AORN Journal
Volume 91, Issue 6 , Pages 779-786, June 2010

Clinical Issues—June 2010

Perioperative Nursing Specialist, AORN Center for Nursing Practice

Perioperative Nursing Specialist, AORN Center for Nursing Practice

Article Outline

This Month 

Measuring radiation exposure levels

Key words: measuring radiation levels, radiation dosimeters, radiation monitoring, radiation exposure, radiology, workplace safety.

Defining major and minor surgical procedures

Key words: major surgical procedures, minor surgical procedures.

Comparative evaluation for purchasing new products or equipment

Key words: purchasing process, prepurchase requirements, ongoing product evaluation.

Selecting replacement items for discontinued products

Key words: product selection process, replacement product selection, discontinued products, unavailable products.

 

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Measuring radiation exposure levels 

Question 

I work in an ambulatory surgery center (ASC), and we are considering changing our policy on wearing dosimeters. Is it true that members of the surgical team do not need to wear dosimeters if they have limited exposure to radiation? Where can I find information about measuring radiation levels for health care workers?

Answer 

Although federal regulations state that external radiation dose monitoring is not necessary if a radiation dosimeter evaluation reveals a radiation dose less than 10% of the specified 5 rems per year,1 state or local regulations may have stricter requirements, and the strictest requirements must be followed. AORN recommends that personnel who are in frequent proximity to radiation wear radiation monitors or dosimeters as determined by the radiation safety officer.2 The radiation safety officer should be knowledgeable about state regulations concerning monitor placement and the American College of Radiology guidelines for overseeing personnel who routinely are involved in fluoroscopic procedures.3

Assessment of the need for monitoring should be based on the exposure conditions at the specific facility only, not on exposure conditions that appear to be similar at another facility. The decision to monitor should be made independently. If an individual's assignment changes from an area of low exposure to an area suspected to exceed 10% of the limit, the radiation safety officer is obligated to monitor that person's radiation exposure and record the amount of exposure. Conversely, if a monitored individual's anticipated annual occupational dose is likely to fall below 10% of the limit, monitoring can be discontinued; however, the radiation safety officer should record the radiation exposure levels for the period during which monitoring was done.1 Radiation monitoring devices or dosimeters should be removed and stored at the facility at the end of every work day. These devices should not be taken home because the device will collect ionizing radiation from other sources (eg, sun, soil). Documentation of the readings of the dosimeters should be kept in the facility's safety office.2

In ASCs, if exposure levels are lower than those specified by the strictest requirements, the decision not to wear dosimeter badges may be made by the radiologist in charge of the ASC's radiology program, risk management personnel or advisors, and members of the ASC governing body. The Occupational Safety and Health Administration alliance is a source for information on radiation safety, which can be accessed at http://www.osha.gov/SLTC/etools/hospital/clinical/radiology/radiology.html#Radiation. For guidance on evaluating the need to monitor radiation exposure levels, refer to the US Nuclear Regulatory Commission 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/index.html.

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Defining major and minor surgical procedures 

Question 

In my role as a team leader, I have been asked to classify all procedures as major or minor. What determines whether a procedure is major or minor?

Answer 

The definition and use of the terms major and minor are determined in each health care organization. These terms were historically used by the Medicare reimbursement schema, but the Centers for Medicare & Medicaid Services has replaced them with the diagnosis-related group coding system.1 Health care organizations use these terms in various ways, such as to determine the level of staffing required, specify the acuity of a procedure, and conduct statistical analyses. The definitions used by some organizations include one or a combination of the following criteria:

■number of instruments,

■number of staff members,

■type of anesthesia,

■procedural location,

■type of sterilization or disinfection of instruments, and/or

■postprocedure disposition (Table 1).
TABLE 1. Examples of Criteria That Could Be Used to Classify Minor Versus Major Surgical Procedures
CriterionExamples, minor procedureExamples, major procedure
Number of instrument traysMinor trayMajor tray
Number of staff membersTwo nursing staff membersThree nursing staff members
Type of anesthesiaLocal, regionalGeneral
Procedure locationAmbulatory surgery setting, procedure roomOR
Type of sterilization or disinfection of instrumentsLow- or high-level disinfected instrumentsSterile instruments
Postprocedure dispositionThe patient is discharged homeThe patient is admitted to an inpatient setting

Some health care organizations use an additional criterion to help clarify the classification (eg, if any one of the criteria from the major case definition is met, the major definition will be used). The health care organization may also derive the definitions from any of the established medical dictionaries.

■Minor
■Dorland's: “surgery restricted to management of minor problems and injuries.”2(p1835)

■Mosby's: “surgical procedure for minor problems or injuries that are not considered life-threatening or hazardous.”3(p1200)

■McGraw-Hill: “any surgical procedure that can be performed in a brief period of time–usually [less than] 1 hour under local anesthesia; does not, under normal circumstances, constitute a major hazard to life or function of organs or body parts; does not generally require hospitalization and may be performed electively, usually by a general–board-certified surgeon in a secondary-care hospital setting.”4(p421)


■Major
■Dorland's: “surgery involving the more important, difficult, and hazardous operations.”2(p1835)

■Mosby's: “a surgical procedure that is extensive, involving removal of organs, and/or life-threatening.”3(p1129)

■McGraw-Hill: “1. A surgical operation within or upon the contents of the abdominal, pelvic, cranial, or thoracic cavities; or 2. A procedure which, given the locality, condition of patient, level of difficulty, or length of time to perform, constitutes a hazard to life or function of an organ or tissue.”4(p393)


These terms should not be used for benchmarking or statistical analysis because there is no consistent definition, and the existing definitions are very vague. Another weakness of using these terms is that the same procedure may be listed as a major or minor procedure based on patient assessment or physician preference. The variability of these factors may skew any data analysis that uses these terms. The definition of major and minor also should not include criteria describing levels of aseptic technique because any invasive surgical procedure in which the mucosal barrier is broken requires the use of aseptic/sterile technique.5

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Comparative evaluation for purchasing new products or equipment 

Question 

My facility is considering purchasing a robotic surgical system, and my manager has requested that I begin the process. What steps should we follow in making this decision?

Answer 

All health care organizations should have processes to evaluate purchases of new products. The same or a very similar process should be used for capital equipment and supplies. The process should be developed by a multidisciplinary team consisting of representatives of all end users and other stakeholders (eg, infection control, finance, facilities). The person requesting the new product should complete a “new product request form” to initiate the process. This form should contain all of the information required by the team (eg, the name of the requestor; the preferred vendor; the product name and description; where the product will be used; budgetary information, when required). The team then uses this information and the answers to the following questions to determine the prepurchase requirements.

■What are the product performance requirements?

■Is the product on the health care organization's list of standardized products?

■Is a product comparison required or is this the only product on the market that meets the requirements?

■What is the environmental impact?

■What is the financial impact?

■Which option is best suited to the health care organization if the product is available as a single-use, reusable, or reposable product?

■If the product is labeled as a single-use device, may it be reprocessed?

After determining the prepurchase requirements, the team should create an individualized comparative evaluation plan. The evaluation plan should describe

■the number of products considered;

■whether the product can be reused and, if so, how many times;

■departments involved;

■costs;

■length of time for the evaluation; and

■the desired patient outcomes.

As a portion of the evaluation plan, the team should design an evaluation tool that measures product compliance with the prepurchase requirements. This tool assists with consistent evaluation of each product being compared and reduces potential evaluator bias.

When a purchasing decision has been finalized, the team should complete an implementation plan. This plan should include required user education and credentialing, steps defining how the product will be introduced into the organization, and a process to notify all involved departments. The final step for the team is to create a plan for ongoing product evaluation. This evaluation answers the questions “Is the product meeting the requirements?” and “Is the product still being used or used at the predetermined or estimated rates?”

The entire process should be documented to provide information for ongoing product evaluation and to facilitate future decisions involving the product. The length of time the documentation should be retained is an organizational decision and may be determined by how long the product is used, how often ongoing product evaluation occurs, and any contractual agreements that may affect the selection process. For more information on product selection, review AORN's “Recommended practices for product selection,” which was published electronically in March 2010.1

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Selecting replacement items for discontinued products 

Question 

We have received notices from our purchasing department that some products we have used for several years are no longer available. What is the process for replacing these products?

Answer 

When a product is no longer available, health care organization personnel should follow the process that guides product selection with some additional steps.1 In this situation, product is defined as a supply, piece of equipment, medication, or any item purchased for patient care. Following are the steps of the purchasing process for replacing a product that is no longer available:

1.Determine the reason the product is no longer available. This explanation should contain components that dictate the actions necessary to handle the products already in stock, the time frame allowed to handle these products, and the steps for possible resolution of the situation. Examples of the explanation may include but are not limited to the following:
a.The product has been recalled. The recall may be restricted to specific lot numbers or the entire quantity of the item on hand.
■Actions: Return the product to the manufacturer, destroy the product, or arrange for repair.

■Time frame: Often, the time frame is immediate, but it may be limited to a specific number of days or weeks.

■Resolution: If the recall is restricted to a certain lot number, a reorder may be sufficient to obtain new products with lot numbers that are not involved in the recall. If the recall involves the entire stock of a product on hand, then a new product needs to be found immediately or unaffected product needs to be reordered, if possible. If a repair is required, arrangements should be made for the repair, which usually requires the item to be out of service for a period of time.


b.The product is no longer stocked at the vendor or at the supplier because of a company decision and not because of a regulatory agency decision.
■Actions: Continue to use the existing stock until a new product is found or inventory is exhausted.

■Time frame: The time frame depends on the quantity of stock on hand, usage, and the amount of notice provided by the vendor or supplier.

■Resolution: Locate a different vendor, supplier, or new product, or order directly from the manufacturer.


c.The product is no longer being manufactured because of a company decision and not because of a regulatory agency decision.
■Actions: Continue to use existing stock until a new product is found or inventory is exhausted.

■Time frame: The time frame depends on the quantity of stock on hand, usage, and the amount of notice provided by the vendor or supplier.

■Resolution: Locate a new product or another manufacturer of the same product.


d.A regulatory agency has issued a notice of regulatory status and actions to be taken by the health care organization. The notice may include a time frame during which the product can continue to be used, which allows the health care organization to locate an alternative product in a timely fashion.
■Actions: The appropriate actions depend on the requirements expressed in the notice.

■Time frame: The time frame depends on the time frame expressed in the notice, which may vary from immediate to months.

■Resolution: Locate a new product or repair the current product if allowed by the notice.



2.Determine the amount of time available before a replacement product is required. This time frame is determined by assessing the required response and time frame expressed in the explanation, the effect on patient safety, and the predicted usage pattern. The description of the effect on patient safety can be determined by each health care organization and may use terms such as high, medium, and low. “High effect on patient safety” may indicate that it is not safe to perform a surgical procedure without the product, so any scheduled and future surgical procedures will need to be canceled until a satisfactory replacement can be purchased. The assessment to determine the usage pattern should include the current frequency of use, stock on hand, current users, reasons for current use, and alternative products used previously or by other specialties in or outside the organization. If the discontinued product was a replacement for another product when it was originally purchased, the reasons for the previous change (eg, required more time or more manpower, was less convenient compared with the item currently used) also should be examined. The previously replaced alternative may be considered for use until a new alternative can be found or if a newer alternative is not available. Table 2 provides an example of the usage pattern assessment. In this scenario, the predicted time frame would be between three months and one year based on stock on hand and the regulatory requirement. If necessary, the general surgeons could use the same product used by the orthopedic surgeons, thereby creating a need for increased inventory of that product. This would prolong the time frame for replacement if the decision were made to continue to stock two products.
TABLE 2. Example of the Usage Pattern Assessment
Reason the product is no longer available: A notice of regulatory status stating the product must be removed from use within the next year
Frequency of use: Daily
Impact on patient safety: Low
Stock on hand: Three-month supply
Current users: General surgeons only
Reasons for current use: Surgeon preference and lower cost
Alternative: An equivalent product is used by the orthopedic surgeons
Reason for change: Economics

3.Present the reason for the need for a product change, usage pattern assessment, and the predicted time frame for replacement to the multidisciplinary product selection committee.

When supplied with information containing all of the factors for consideration, the committee can help complete the steps described in the health care organization's process to guide product selection. The committee should be able to recommend an appropriate action at the completion of this entire process.1

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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 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 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 1.5 continuing education contact hour (90-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: #10048; Session: #4012 Fee: Members $7.50, Nonmembers $15

The deadline for this program is June 30, 2013.

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

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References 

    Measuring radiation exposure levels
  1. Regulatory Guide 8.34 – Monitoring criteria and methods to calculate occupational doses (US Nuclear Regulatory Commission). http://www.nrc.gov/reading-rm/doc-collections/reg-guides/occupational-health/active/8-34/index.htmlAccessed March 23, 2010
  2. Recommended practices for reducing radiological exposure in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010;p. 257–268
  3. ACR technical standard for management of the use of radiation in fluoroscopic procedures (American College of Radiology). http://www.acr.org/SecondaryMainMenuCategories/quality_safety/RadSafety/RadiationSafety/standard-manage-radiation.aspxAccessed March 23, 2010
    Defining major and minor surgical procedures
  1. Diagnosis-related groups. Centers for Medicare & Medicaid Services. http://www.cms.hhs.gov/apps/glossary/default.asp?Letter=D&Language=EnglishAccessed March 23, 2010
  2. Dorland's Illustrated Medical Dictionary. In: 31st ed.. Philadelphia, PA: Elsevier, Inc; 2007;p. 1835
  3. Mosby's Dictionary of Medicine, Nursing, and Health Professions. In: 8th ed.. St Louis, MO: Elsevier Inc; 2009;p. 1129;1200
  4. McGraw-Hill Concise Dictionary of Modern Medicine. In: New York, NY: McGraw-Hill Companies, Inc; 2006;p. 393;421
  5. Recommended practices for maintaining a sterile field Perioperative Standards and Recommended Practices. In: Denver, CO: AORN, Inc; 2010;p. 91–99
    Comparative evaluation for purchasing new products or equipment
  1. Recommended practices for product selection in perioperative practice settings. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010;p. e1–e10
    Selecting replacement items for discontinued products
  1. Recommended practices for product selection in perioperative practice settings. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010;p. e1–e10

  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 June 30, 2013.

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

PII: S0001-2092(10)00330-3

doi:10.1016/j.aorn.2010.03.007

AORN Journal
Volume 91, Issue 6 , Pages 779-786, June 2010

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