AORN Journal
Volume 91, Issue 3 , Pages 399-406, March 2010

Clinical Issues—March 2010

  • Bonnie Denholm, RN, BSN, MS, CNOR (Perioperative Nursing Specialist)
    • ,
  • Mary Ogg, RN, MSN, CNOR (Perioperative Nursing Specialist)
    • ,
  • Mary Ogg, RN, MSN, CNOR (Perioperative Nursing Specialist)

AORN Center for Nursing Practice

Article Outline

This Month 

Flash sterilization

Key words: flash sterilization, routine sterilization cycles, drying time, cooling time, rigid sterilization containers.

Eye protection

Key words: protective eye wear, goggles, standard precautions, bloodborne pathogens.

Reusing medication syringes and tubing

Key words: single-use devices, reusing syringes, multidose vials, infection prevention.

 

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Flash sterilization 

Question 

Our facility uses a dynamic air removal steam sterilization process and rigid containers. When we need an instrument immediately, we use the same sterilization cycle times that are used for the routine dynamic air removal process. Is this considered flash sterilization? Do we still need to count this as flash sterilization in our log?

Answer 

According to AORN's “Recommended practices for sterilization in the perioperative practice setting,” the definition of flash sterilization is “a process designed for the steam sterilization of patient care items for immediate use.”1(p668) Although the flash sterilization exposure times may be similar to those used in the dynamic air removal steam sterilization process, flash steam sterilization cycles do not include drying and cooling times. When an item is not used immediately after a flash steam sterilization cycle, there is an increased risk of condensation on the item because no drying time is included or the drying time has been abbreviated. When an item is used immediately, there is an increased risk of burns to the patient or perioperative team members because no cooling time is included. Items that have been sterilized in a cycle that does not include drying or cooling times should be included in a flash sterilization log.

Rigid sterilization container systems are designed and validated for specific uses. A rigid container system designed for flash steam sterilization cycles should not be used for routine cycles and vice versa. The rigid sterilization container system manufacturer should be able to provide the scientific data that support the use of the container for either flash or routine sterilization. The manufacturer should also provide information on the cycle parameters and the process challenge device that is appropriate.2

If an item has been processed through a sterilization cycle that does not include drying and cooling times and that is not used immediately, then it should not be stored in the autoclave or on the shelf for use at a later time unless the manufacturer specifies otherwise.2 If the item it not delivered to the sterile field for immediate use, it should still be included in a flash sterilization log and then broken down to undergo regular processing for long-term storage. Including this entry in the log will help to reconcile the number of flash cycles run with the flash sterilization log. It also helps to determine whether the health care organization needs to purchase additional instruments and to analyze the time spent decontaminating and running flash sterilization cycles for items that do not end up being used.

Flash steam sterilization cycles should be used only when there is insufficient time to process an item by the preferred wrapped or container method.

■Flash sterilization should not be used as a substitute for sufficient instrument inventory.

■All steps in the sterilization process should be performed consistently and in a conscientious manner (Figure 1).
  • View full-size image.
  • Figure 1. 

    AORN and the Association for the Advancement of Medical Instrumentation recommend performing the complete sterilization process for sterilizing all surgical instruments in all practice settings. Recommended practices are applicable to all practice settings where surgical and other invasive procedures are performed.

Reprinted from Practicing the complete sterilization process. AORN Connections. 2009;7(5):10, with permission from AORN, Inc, Denver, CO.


■Flash sterilization should not be used for implantable devices.

AORN discourages the practice of flash sterilization because the process may be associated with increased risk of infection to patients. This increased risk may be caused by pressure on personnel to eliminate one or more steps in the cleaning and sterilization process and the possibility of contamination when uncovered items are delivered to the point of use. Perioperative personnel who are sterilizing instrument sets in rigid containers should consider ways to add in drying and cooling times to eliminate the need for flash sterilization cycles. Analyzing which instruments often are sterilized separately in flash sterilization cycles to see if they could be kept available in peel packs also may help reduce the number of flash sterilization cycles.

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Eye protection 

Question 

What is considered eyewear protection: goggles, personal glasses, face shields? Does the circulating nurse need to wear eye protection in the OR?

Answer 

Health care workers should use standard precautions when caring for all patients in the perioperative setting.1 Personal protective barriers are required when it can be reasonably anticipated that the health care worker will be exposed to blood or body fluids or other potentially infectious materials.1, 2 Eye protection devices are goggles or glasses with solid side shields.2 Eye protection must be worn “whenever splashes, spray, spatter, or droplets of blood or other potentially infectious materials may be generated and eye, nose, or mouth contamination can be reasonably anticipated.”2 All perioperative personnel should wear protective eyewear because everyone in the OR, not just the scrubbed members of the perioperative team, is at risk for exposure to blood and other potentially infectious fluids.

Where there is the possibility of an occupational exposure, Occupational Safety and Health Administration regulation requires the employer to provide eye protection, excluding prescription eyewear,3 to the employee at no cost. Furthermore, the employer must ensure that the employee is using the appropriate personal protective equipment (PPE).2

The Centers for Disease Control and Prevention standard precautions, which include the use of eye protection depending on the anticipated exposure, applies in all health care settings and when caring for all patients regardless of their suspected or confirmed infection status. Standard precautions are based on the “principle that blood, body fluids, secretions, excretions except sweat, non-intact skin, and mucous membranes may contain transmissible infectious agents.”4

A number of studies demonstrated the risk to the surgical team of exposure to bloodborne pathogens by splatter and spray from the surgical field. In one study, researchers used a simulation model to measure the conjunctival contamination on a mannequin's head during a femoral osteotomy.5 Five types of eyewear were tested to determine their ability to prevent conjunctival splash contamination. The five types were modern prescription glasses, standard surgical loupes, hard plastic contoured glasses, disposable plastic glasses, and a combination face mask and eye shield. No protection was used as the control. The modern prescription glasses provided no benefit (ie, was the same as no protection). All the other eye protection devices were more effective than the prescription glasses (Table 1). The results of this experiment suggest that prescription glasses should not be considered protective eyewear.5

TABLE 1. Percent Reduction in Conjunctival Contamination with Protective Eyewear Compared to No Eye Protection1
Protective devicePercent reduction
Modern prescription glasses0
Standard loupes40
Combination face mask-shield64
Hard plastic contoured glasses80
Disposable plastic glasses96

1Mansour AA, Even JL, Phillips S, Halpern JL. Eye protection in orthopaedic surgery. An in vitro study of various forms of eye protection and their effectiveness. J Bone Joint Surg Am. 2009;91(5):1050-1054.

Whereas blood splatters and infectious material spray are often associated with orthopedic and vascular surgery, there is inherent risk in all surgeries. In a prospective study conducted in the United Kingdom, the mask and goggles of a single surgeon were examined preoperatively and postoperatively after all procedures in which he participated as the main surgeon or assistant during a one-year time frame. There was an overall risk of 45% for blood and fluid splatters on the protective wrap-around goggles. The highest incidence occurred during vascular procedures followed by endocrine, laparoscopic, and breast procedures. The longer the procedure, the greater the incidence of blood splatters. The surgeon and assistant were equally at risk.6

Blood splash injury from laparoscopic and endoscopic urology procedures was studied in Scotland. The face masks with combined eye shields of the surgeon, assistant, and scrub person were examined for visible and nonvisible blood exposure. The surgeon's mask-face shield showed the highest rate of contamination, at 48.5%, followed by that of the scrub person. The contamination rate during

■laparoscopic nephrectomies was 84.2%,

■pyeloplasties was 66.7%, and

■flexible ureteroscopies was 58.3%.

The results showed that perioperative personnel involved in laparoscopic procedures are at risk for bloodborne disease transmission from microscopic and macroscopic blood spray.7

An Irish study included a telephone survey of otolaryngologists and otolaryngologists-in-training about the routine use of eye protection and the potential for blood splash during tonsillectomy procedures.8 None of the respondents wore eye protection other than their prescription glasses when performing tonsillectomies. The respondents all agreed that the potential for blood splatter during tonsillectomy procedures was minimal. The second phase of the study examined the goggles worn by the otolaryngologists during tonsillectomies. There were splash events in 22% of the procedures, with an event more likely during adult tonsillectomy.8

The incidence of blood splashes to the goggles of the surgeon, assistant, and scrub person during cesarean deliveries was studied in Nigeria.9 The rate of blood splashes was 63.2% on the goggles of the surgeon, 38.9% on the goggles of the assistant, and 16.0% on the goggles of the scrub person.

The results of a surveillance study of occupational blood exposures conducted to identify risk patterns in the OR showed the susceptibility of the eyes to blood contact.10 Eye exposures accounted for 45.3% of the mucocutaneous incidents. The number of exposures was almost the same for the circulating nurses as for the scrub personnel in this study.

Anecdotally, it has been noted that when the hepatitis or HIV status of a patient is known, the perioperative team compliance rate increases for using PPE (ie, protective eyewear, double gloves). The patient's HIV or hepatitis status is not always known, however. The Centers for Disease Control and Prevention estimated that 232,700 (21%) of people living with HIV infection were undiagnosed in the United States in 2006.11

Hepatitis and HIV may be transmitted across the mucocutaneous membrane.8, 10 The eyes are an entry portal for infectious material. Wearing appropriate PPE reduces the risk of exposure, thereby reducing the risk of transmission. Eye exposure to infectious material in the perioperative environment is a risk that can be avoided by wearing the appropriate eye protection.

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Reusing medication syringes and tubing 

Question 

My staff had a disagreement with a temporary anesthesia care provider regarding changing the tubing on a large syringe of propofol on a medication infusion device. The anesthesia care provider wanted to use a 100-mL bottle of propofol and the same syringe and tubing for multiple patients undergoing pain procedures. Can syringes and tubing be reused?

Answer 

Single-use tubing, syringes, and needles should only be used one time and then discarded.1, 2 Patients are placed at increased risk of infection if multidose vials are re-entered with used needles and syringes.1

During a 10-year period from 1998 to 2008, 35 documented outbreaks of hepatitis occurred in nonhospital health care facilities (eg, pain clinics, endoscopy clinics, hemodialysis centers). The outbreaks were traced to

■reuse of syringes on multiple patients,

■contamination of anesthesia medication vials, and

■improper hand hygiene.3

An outbreak of hepatitis C (HCV) in 2007 at an endoscopy center revealed that five of the six infected patients underwent procedures on the same day. Direct observation of the center's personnel demonstrated that they inappropriately reused syringes and used single-person medication vials on multiple patients. Clean needles and syringes were used to withdraw medication from a single-use bottle of propofol. The medication was injected through the patient's IV access. If more propofol was needed, the same syringe with a clean needle was used to withdraw more medication. Potentially, backflow from the patient's IV or the needle may have contaminated the syringe with HCV, thereby contaminating the vial. The remaining medication was used on subsequent patients. This scenario is demonstrated in Figure 2.4

Reprinted from MMWR Mortal Morb Wkly Rep. 2008;57(19):513-517. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5719a2.htm. Accessed October 7, 2009.

The Oklahoma State Department of Health investigated an unexplained outbreak of HCV in 2002. All the patients had been treated for pain at the same outpatient clinic. The health department was able to test 795 (87.6%) of the patients who had been treated since the clinic opened. There were 71 cases of HCV and 31 cases of hepatitis B during 2002. Interviews with staff members regarding injection practices revealed that a single needle and syringe were used for three different sedation medications. The same needle and syringe were used to administer the medications to all of the patients treated that day. Results of the investigation suggest that the infection was transmitted from patient to patient after a contaminated syringe and needle were used on subsequent patients. The outbreak stopped when the practice of reusing syringes and needles stopped.5

Adhering to basic principles of aseptic technique can decrease the possibility of contamination and transfer of infectious disease from patient to patient. Safe injection practices include but are not limited to the following:

■Do not use the same syringe to administer medication to more than one patient.2, 6, 7

■Do not reuse a syringe for the same patient.6, 7

■Do not reuse a needle on the same patient; it is considered contaminated if it entered or was connected to the patient's IV.2, 6, 7

■Do not access a medication vial or bottle with a used syringe or needle.2, 6, 7

■Do not use the same infusion or IV sets for multiple patients.2, 7

■Always adhere to aseptic principles when preparing and delivering medication.2, 6

Every patient deserves a clean, sterile needle, syringe, infusion set, and medication vial every time. Decreasing the cost per patient or speed of turnover are not excuses for compromising patient care.

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Learner Evaluation. Continuing Education Program 

Clinical Issues 

This evaluation is used to determine the extent to which this continuing education program met your learning needs. The evaluation is printed here for your convenience. To receive continuing education credit, you must complete the Learner Evaluation online at http://www.aorn.org/CE. Rate the items as described below.

Purpose/Goal 

To educate perioperative nurses about providing safe nursing care throughout the perioperative continuum.

Objectives 

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

1.Discuss practices that could jeopardize safety in the perioperative area. Low 1. 2. 3. 4. 5. High

2.Discuss common areas of concern that relate to perioperative best practices. Low 1. 2. 3. 4. 5. High

3.Describe implementation of evidence-based practice related to perioperative nursing care. Low 1. 2. 3. 4. 5. High

Content 


4.To what extent did this article increase your knowledge of the subject matter? Low 1. 2. 3. 4. 5. High

5.To what extent were your individual objectives met? Low 1. 2. 3. 4. 5. High

6.Will you be able to use the information from this article in your work setting? 1. Yes 2. No

7.Will you change your practice as a result of reading this article? (If yes, answer question #7A. If no, answer question #7B.)
7A.How will you change your practice (Select all that apply)
1.I will provide education to my team regarding why change is needed.

2.I will work with management to change/implement a policy and procedure.

3.I will plan an informational meeting with physicians to seek their input and acceptance of the need for change.

4.I will implement change and evaluate the effect of the change at regular intervals until the change is incorporated as best practice.

5.Other:


7B.If you will not change your practice as a result of reading this article, why? (Select all that apply)
1.The content of the article is not relevant to my practice.

2.I do not have enough time to teach others about the purpose of the needed change.

3.I do not have management support to make a change.

4.Other:



8.Our accrediting body requires that we verify the time you needed to complete this 1.3 continuing education contact hour (78-minute) program:

This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements.

AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.

AORN recognizes these activities as continuing education for registered nurses. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity.

AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure.

Event: #10010; Session: #4002 Fee: Members $6.50, Nonmembers $13

The deadline for this program is March 31, 2013.

Each applicant who successfully completes this program will be able to print a certificate of completion.

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References 

    Flash sterilization
  1. Recommended practices for sterilization in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010;p. 457–480
  2. In: ANSI/AAMI ST79: 2006 and A1: 2008—Comprehensive Guide to Steam Sterilization and Sterility Assurance in Health Care Facilities. Arlington, VA: Association for the Advancement of Medical Instrumentation; 2006;p. 73;75
    Eye protection
  1. Recommended practices for prevention of transmissible infections. In: Perioperative Standard and Recommended Practices. Denver, CO: AORN, Inc; 2010;p. 277–287
  2. Regulations (Standards—29 CFR) (Bloodborne pathogens—1910.1030.(d)(3)(x): masks, eye protection, and face shields). Occupational Safety and Health Administration http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=10051#1910.1030(d)(3)Accessed October 7, 2009
  3. Employer payment for personal protective equipment; final rule. 72(220) Fed Regist. (November 15, 2007) 64341-64430. Occupational Safety and Health Administration http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=FEDERAL_REGISTER&p_id=20094Accessed October 7, 2009
  4. Standard precautions. Centers for Disease Control and Prevention http://www.cdc.gov/ncidod/dhqp/gl_isolation_standard.htmlAccessed October 7, 2009
  5. Mansour AA, Even JL, Phillips S, Halpern JL. Eye protection in orthopaedic surgery (An in vitro study of various forms of eye protection and their effectiveness). J Bone Joint Surg Am. 2009;91(5):1050–1054
  6. Davies CG, Khan MN, Ghauri AS, Ranaboldo UK. Blood and body fluid splashes during surgery: the need for eye protection and masks. Ann R Coll Surg Engl. 2007;89:770–772
  7. Wines MP, Lamb A, Argyropoulos AN, Caviezel A, Gannicliffe C, Tolley D. Blood splash injury: an underestimated risk in endourology. J Endourology. 2008;22(6):1183–1187
  8. Keogh IJ, Hone SW, Colreavey M, Walsh M. Blood splash and tonsillectomy: an underestimated hazard to the otolaryngologist. J Laryngol Otol. 2001;115(6):455–456
  9. Aisien AO, Ujah IA. Risk of blood splashes to masks and goggles during cesarean section. Med Sci Monit. 2006;12(2):CR94–CR97
  10. Jagger J, Bentley M, Tereskerz P. A study of patterns and prevention of blood exposures in OR personnel. AORN J. 1998;67(5):979–987
  11. HIV prevalence estimates—United States, 2006. MMWR Morb Mortal Wkly Rep. 2008;57(39):1073–1076http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5739a2.htmAccessed October 7, 2009
    Reusing medication syringes and tubing
  1. Dangers associated with shared multidose vials. Pa Patient Saf Advis. 2008;5(2):68;http://www.psa.state.pa.us/ADVISORIES/AdvisoryLibrary/2008/Jun5(2)/Pages/68.aspxAccessed October 7, 2009
  2. APIC position paper: safe injection, infusion and medication vial practices in healthcare. Association for Professionals in Infection Control http://www.apic.org/Content/NavigationMenu/GovernmentAdvocacy/PublicPolicyLibrary/Safe_injection_policy_paper_06_2009.pdfAccessed October 7, 2009
  3. Healthcare-associated outbreaks of hepatitis, 1998-2008. HONOReform http://67.228.183.132/∼hardtime/HONOR/occurrences.htmlAccessed October 7, 2009
  4. Acute hepatitis C virus infections attributed to unsafe injection practices at an endoscopy clinic—Nevada, 2007. MMWR Morb Mortal Wkly Rep. 2008;57(19):513–517http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5719a2.htmAccessed October 7, 2009
  5. Comstock RD, Mallonee S, Fox JL, et al. A large nosocomial outbreak of hepatitis C and hepatitis B among patients receiving pain remediation treatments. Infect Control Hosp Epidemiol. 2004;25(7):576–583http://www.journals.uchicago.edu/doi/pdf/10.1086/502442?cookieSet=1Accessed October 7, 2009
  6. Siegel JD, Rhinehart E, Jackson M, Chiarello L Healthcare Infection Control Practices Advisory Committee. 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. Atlanta, GA: Centers for Disease Control and Prevention; 2007;http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Isolation2007.pdfAccessed October 7, 2009
  7. Position statement number 2.13 (Safe practices for needle and syringe use). American Association of Nurse Anesthetists http://www.aana.com/WorkArea/showcontent.aspx?id=18966Accessed October 7, 2009

  indicates that continuing education contact hours are available for this activity. Earn the contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Learner Evaluation at http://www.aorn.org/ce. The contact hours for this article expire March 31, 2013.

 The authors of this column have no declared affiliations that could be perceived as potential conflicts of interest in publishing this article.

PII: S0001-2092(09)00973-9

doi:10.1016/j.aorn.2009.12.009

AORN Journal
Volume 91, Issue 3 , Pages 399-406, March 2010

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