AORN Journal
Volume 91, Issue 5 , Pages 627-631, May 2010

Clinical Issues—May 2010

AORN Center for Nursing Practice

Article Outline

This Month 

Keeping blood-soaked sponges on the sterile field

Key words: blood-soaked sponges; bloodborne pathogens; counting sponges.

Staff members wearing casts in restricted and semirestricted zones

Key words: casts in perioperative areas; splints in perioperative areas; infection prevention measures; bloodborne pathogens; reassignment to administrative duties.

Washer decontaminator/disinfector cleaning validation

Key words: mechanical disinfectors; washer/disinfectors; mechanical instrument washers; washer decontaminators; mechanical cleaning; instrument processing.

 

Back to Article Outline

Keeping blood-soaked sponges on the sterile field 

Question 

Some of our scrub personnel prefer to keep blood-soaked sponges on the field rather than drop the sponges into a kick bucket or count technology container. What does AORN say about this practice?

Answer 

It is considered best practice to contain blood-soaked sponges and remove them from the sterile field as soon as possible to prevent bloodborne pathogen hazards, unplanned retained sponges, and compromise of the sterile field. Although a review of the literature did not reveal specific evidence on this topic, AORN has three recommended practices that relate to confining and containing blood and other potentially infectious materials: “Recommended practices for prevention of transmissible infections in the perioperative practice setting,”1 “Recommended practices for cleaning and care of surgical instruments and powered equipment,”2 and “Recommended practices for prevention of unplanned retained items.”3

Bloodborne pathogens and other potentially infectious materials should be contained using engineering controls that isolate or minimize bloodborne pathogen hazards (eg, kick buckets, sponge bags). Bloodborne pathogens are present in human blood and can cause disease in humans. The Occupational Safety and Health Administration defines other potentially infectious materials as

semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, any body fluid that is visibly contaminated with blood, and all body fluids in situations where it is difficult or impossible to differentiate between body fluids.4

Infectious agents can be transmitted via direct and indirect contact, respiratory droplets, and airborne aerosols.1(p277) During long procedures, the airflow across sponges contaminated with potentially infectious materials may increase the likelihood of bacterial growth and airborne dispersal with handling.

Blood-soaked sponges should be contained to preclude unnecessary contact with instruments and other sterile supplies. Blood and body fluids are highly corrosive. Corrosion, rusting, and pitting occur when blood and debris are allowed to dry in or on surgical instruments. Dried blood and debris can be difficult, if not impossible, to remove from all surfaces during the decontamination process; therefore, subsequent disinfection or sterilization may not be achieved.2(p423)

Accurately accounting for sponges throughout a surgical procedure should be a priority of the surgical team to minimize the risks of retained sponges. Use of a pocketed bag or other system for separating used sponges facilitates visualization and accounting for sponges during the procedure. When sponges are wadded up and allowed to adhere together, a miscount may occur. Separating sponges after use minimizes the risk of errors that could be caused by adherent sponges.3 When the sponges are removed from the sterile field, the circulating nurse can prepare for closing counts by separating the sponges, containing them in a pocketed bag, or reconciling them using other counting technologies.

Back to Article Outline

Staff members wearing casts in restricted and semirestricted zones 

Question 

Last month, a surgeon wanted to perform surgery while wearing a volar splint that extended from midpalm to the antecubital fossa. Recently, one of our circulating nurses required an arm cast after falling and breaking her arm. Can they continue to provide direct patient care in the OR?

Answer 

Health care personnel wearing casts or splints should not provide direct patient care because of infection control and performance issues that may create undue risk to surgical patients and other personnel. There is little research regarding staff members working while wearing a cast or splint. Infection control is the pervasive issue because casts and splints cannot be cleaned or disinfected adequately. As a result, health care providers with splints or casts should avoid patient care areas as well as areas where instruments, supplies, and equipment are processed.1 Health care providers wearing splints or casts cannot perform adequate infection prevention measures (eg, hand washing, hand scrubs), and this inability puts the patient at risk for surgical site infections and renders the person with a cast or a splint unable to adequately deal with exposure to bloodborne pathogens.2, 3 Aseptic technique will be compromised because it is nearly impossible for a surgical team member to don a gown and gloves over a cast without creating breaks in technique. When the gown and glove barriers are compromised, the risk of surgical site infection increases.2, 3

Facility leaders should consult the health care organization's occupational health personnel and may consider temporarily reassigning the injured staff member to administrative duties until he or she can perform patient care responsibilities without risking further injury to himself or herself, other personnel, and patients. A surgeon operating with limited capacity may create risk for the health care organization. Consult local and state practice guidelines to determine details of restrictions for physical incapacity.

A policy addressing this situation should be developed by a multidisciplinary team consisting of risk management, infection prevention, medical and nursing surgical leadership, occupational health, and quality assurance personnel. Careful observance of policy and administrative reassignment of personnel to more suitable non-patient care tasks are appropriate management interventions.

Back to Article Outline

Washer decontaminator/disinfector cleaning validation 

Question 

We recently opened a new ambulatory surgery center. We process our instruments using a washer decontaminator or disinfector. What are the requirements for testing the efficacy of the washer/disinfector cleaning process? Are there products available that assist in assessing the cleaning process?

Answer 

Testing automated or mechanical washer decontaminators or disinfectors on a regular basis is an integral component of quality assurance. Periodic testing verifies that the equipment is functioning properly and identifies opportunities for corrective action. Mechanical instrument washer decontaminators/disinfectors should be tested for proper functioning before initial use, weekly during service, and after major maintenance. Commercial products are available to verify the effectiveness of washer decontaminator/disinfector cleaning processes.1, 2

The initial, important steps for processing instruments are cleaning and decontamination. Mechanical methods and equipment are preferred over manual methods. Monitoring and verifying the cleaning process are essential elements of quality assurance that decrease the risk of surgical site infection. According to AORN's “Recommended practices for cleaning and care of surgical instruments and powered equipment,”

Adequate cleaning of surgical instruments is essential to remove or destroy microorganisms and eliminate endotoxins. Automated cleaning and decontamination of equipment is recommended because it provides a high level of cleaning that is difficult to consistently replicate using manual methods.1(p442)

Mechanical cleaning of surgical instruments should be accomplished by ultrasonic cleaners, washer decontaminators/disinfectors, or washer sterilizers.1(p428)

Mechanical cleaning is preferred because it removes soil efficiently and provides consistent washing and rinsing parameters during the process.1(p428)

Washer decontaminator cycles are intended to process instruments and equipment to a level that renders them safe to handle by persons who will inspect and prepare them for terminal sterilization.1(p429)

According to the Association for the Advancement of Medical Instrumentation,

To ensure that mechanical cleaning equipment is working properly, and according to manufacturer's specifications, health care personnel may perform verification tests as part of the overall quality assurance program. This verification may include the use of test devices that monitor the functionality of the cleaning equipment in cleaning surfaces and that ensure adequate fluid flow in equipment that has adaptors for lumened devices.2(p83)

The effectiveness of washer decontaminator/disinfector cleaning processes can be verified with available commercial products.1 One such product is designed to mimic dried blood; it parallels worst-case scenarios of instruments (ie, unclean and blood saturated) being processed in mechanical cleaning equipment and monitors the ability of the machine to remove bioburden. After the cycle is completed, personnel inspect the monitor for residual bioburden. The presence of residue is a clear indication that all of the parameters needed for cleaning have not been achieved.3 The commercial monitoring product is similar to a biological indicator used for quality assurance in sterilizers. Just as biological monitors are used to monitor the process but do not prove sterility, this product monitors the process but does not prove the cleanliness of instruments.3 Members can access AORN's OR Product Directory online at http://www.orpd.org/search.php for additional resources.

Back to Article Outline

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 in relation 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 the 0.8 continuing education contact hour (48-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: #10021; Session: #4009 Fee: Members $4, Nonmembers $8

The deadline for this program is May 31, 2013.

Each applicant who successfully completes this program can immediately print a certificate of completion.

Back to Article Outline

References 

    Keeping blood-soaked sponges on the sterile field
  1. Recommended practices for prevention of transmissible infections in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010;p. 277–287
  2. Recommended practices for cleaning and care of surgical instruments and powered equipment. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010;p. 421–445
  3. Recommended practices for prevention of unplanned retained items. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010;In press
  4. Occupational Safety and Health Administration. Regulations (Standards–29 CFR) Bloodborne pathogens–1910.1030. http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=10051Accessed January 25, 2010
    Staff members wearing casts in restricted and semirestricted zones
  1. Fogg DM. Setting up before scrubbing, working with a cast, counting sponges on the floor affect infection control [Clinical Issues]. AORN J. 1986;44(4):644–646
  2. Recommended practices for maintaining a sterile field. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010;p. 91–99
  3. Harvey CK. Surgeon operating with arm in cast compromises asepsis. AORN J. 1982;35(5):860
    Washer decontaminator/disinfector cleaning validation
  1. Recommended practices for cleaning and care of surgical instruments and powered equipment. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010;p. 421–445
  2. Comprehensive Guide to Steam Sterilization and Sterility Assurance in Health Care Facilities ANSI/AAMI ST79:2006 and A1:2008 and A2:2009. Arlington, VA: Association for the Advancement of Medical Instrumentation; 2009;A:1
  3. Central Service Technical Manual. 7th ed.. Chicago, IL: IAHCSMM; 2007;

  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 May 31, 2013.

 The author of this column has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.

PII: S0001-2092(10)00252-8

doi:10.1016/j.aorn.2010.02.008

AORN Journal
Volume 91, Issue 5 , Pages 627-631, May 2010

Article Tools