AORN Journal
Volume 92, Issue 2 , Pages 228-232, August 2010

Clinical Issues—August 2010

Perioperative Nursing Specialist, AORN Center for Nursing Practice

Article Outline

This Month 

Wearing shoe covers and appropriate footwear in the OR

Key words: fluid-resistant shoe covers, OR footwear.

Use of fabric head coverings

Key words: fabric OR caps; laundering OR caps, OR head coverings.

Proper equipment storage in perioperative services

Key words: perioperative equipment storage, OR utility room.

Performing a traditional surgical hand scrub

Key words: hand hygiene practices, hand washing, hand rub solutions.

 

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Wearing shoe covers and appropriate footwear in the OR 

Question 

In our OR, we have stopped wearing shoe covers to save money. Is there any reason for wearing them other than to keep our shoes clean? If we do not have to wear shoe covers, what types of shoes are recommended for wear in the OR?

Answer 

The Occupational Safety and Health Administration requires that fluid-resistant shoe covers be worn during procedures in which the possibility of exposure to fluids that contain blood or other body fluids exists.1 Fluid-resistant shoe covers decrease the risk of exposure and possible transmission of potentially infectious microorganisms through nonintact skin.1, 2 Personnel participating in procedures such as orthopedics, obstetrics (eg, cesarean births), and trauma are required to wear fluid-resistant shoe covers. Shoe covers that become wet, torn, or soiled should be discarded in a designated container and replaced. Personnel should remove shoe covers that have been exposed to fluids containing blood or other body fluids and place them in a hazardous waste container.1

Shoes that provide protection must be worn in the perioperative environment. The Occupational Safety and Health Administration requires the use of protective shoes in areas where there is a danger of foot injuries from falling objects or objects piercing the soles.3 Shoes with closed toes, low heels, nonskid soles, and no perforations on the tops should be chosen for the perioperative environment.

A study that measured the resistance of shoes to penetration by scalpels showed that of the 15 pairs of shoes studied, only six pairs were made of material that was sharps resistant; these included

■sneaker suede,

■suede with inner mesh lining,

■leather with inner canvas lining,

■nonpliable leather,

■rubber with inner leather lining, and

■thicker rubber.3

Scalpel injuries may be more than a laceration or a deep cut. The injury may result in exposure to hepatitis B, hepatitis C, or HIV.3

Members of the perioperative team should take responsibility for protecting themselves from the risk of exposure to blood and body fluids and the potential for injuries from sharps. Administrators and managers in perioperative environments should facilitate an environment of accountability for safety in the workplace.

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Use of fabric head coverings 

Question 

Fabric head coverings are worn in our perioperative area. This adds color and variety to head coverings and everyone enjoys them, including our patients. Some of the head coverings, however, do not completely cover the person's hair or scalp. Furthermore, some staff members wear the same head covering for a week at a time. Is this appropriate? How often should head coverings be laundered?

Answer 

Fabric head coverings should cover the hair and scalp completely. Head coverings that are worn correctly help contain skin squames from the head and scalp. Preventing skin squames from falling onto a sterile field is important and may help prevent surgical site infections (SSIs).1, 2

Human hair can be the site of pathogenic bacteria, including methicillin-resistant Staphylococcus aureus. Uncovered hair acts as a filter and collects bacteria in proportion to its length, waviness, and oiliness. Studies have shown that S aureus and Staphylococcus epidermidis have a tendency to colonize on hair, skin, and the nasopharynx.3 In one case, an outbreak of group A β-hemolytic streptococcus found on the scalp of perioperative personnel was identified as the same pathogen in 20 patients who developed SSIs.4 Although group A streptococcus is isolated in only 1% of SSIs, an SSI caused by group A streptococcus is severe and difficult to treat.4 One study reported that washing the hair with a neutral shampoo that contained no antimicrobial component had no bactericidal effect on the hair.3

Head coverings should be designed to contain hair and scalp skin to minimize microbial dispersal.5 A bald or shaved head also must be covered to prevent shedding of skin squames. Skullcaps do not contain the side hair above or in front of the ears or hair at the nape of the neck.

Fabric head coverings should be laundered daily in a health care-approved or accredited laundry. Studies have shown that staphylococci can survive on textiles from 56 to 90 days, and enterococci can survive on textiles for up to 11 days.6 Another study tested fungal survival and found that Candida, Aspergillus, Mucor, and Fusarium, which can cause health care-associated infections, survived on fabrics and plastics for one day and often for weeks.7 These textiles and plastics may serve as reservoirs or vectors for fungi.7 The practice of wearing a disposable bouffant cap over a fabric cap is acceptable if the fabric cap is freshly laundered. It is unacceptable to wear a disposable cap over a fabric cap if the fabric cap has been worn more than one day. Disposable caps are discarded in designated containers after use.

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Proper equipment storage in perioperative services 

Question 

We have limited space for equipment in our perioperative storage area. Can we place clean equipment in a dirty utility room?

Answer 

To prevent cross-contamination from dirty to clean equipment, clean equipment should not be mixed with dirty items in a dirty utility room or workroom. Equipment and supply storage rooms are used for clean equipment and clean surgical supplies.1 Storage space should be designated as equipment or supply storage.

The dirty utility workroom and the equipment and supply storage rooms all should be located in the semirestricted area, but the dirty utility workroom should be physically separated from the equipment and supply storage rooms. The clean storage areas should have a minimum of 150 sq ft for three or fewer ORs, and the floor space should be increased by 50 sq ft per room for more than three ORs.2 Equipment stored in storage rooms may include items such as x-ray equipment, stretchers, warming devices, and auxiliary lamps.1

An OR designated for special services may require adjacent storage, such as a pump room for cardiac surgery and storage for larger pieces of equipment for orthopedic or neurosurgery procedures. Equipment should not be left in corridors where it could obstruct traffic.

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Performing a traditional surgical hand scrub 

Question 

In reviewing AORN's new “Recommended practices for hand hygiene”1 in the 2010 edition of Perioperative Standards and Recommended Practices, we noticed that there is no longer a recommendation for a traditional surgical hand scrub using a brush at the beginning of the day. We have done this for years and wondered why it was deleted. Should we continue doing this since this policy is in place in our perioperative suite, or can we adapt the new hand hygiene practice?

Answer 

A traditional, standardized, surgical hand scrub, which includes the use of a soft bristle brush or sponge at the beginning of the shift, is no longer required. A hand wash should be performed at the beginning of the shift on arrival at the health care organization. The purpose of hand washing is to

■remove soil, organic matter, and transient microorganisms from the fingernails, hands, and forearms;

■decrease the resident microorganism count; and

■inhibit the rebound of microorganisms.1, 2

The effectiveness of the hand washing is determined by
■technique,

■application of the product,

■length of exposure to the product, and

■correct concentration of the product.

 Health care personnel may not be aware that they may have contaminated their hands after petting the cat, taking out the trash, or stopping by the grocery store on the way to work. Personnel should wash their hands
■on entry into the perioperative environment,

■before and after every patient contact,

■before putting on gloves or other personal protective equipment,

■after removing gloves or other personal protective equipment,

■any time there has been contact with blood or other potentially infectious materials or surfaces,

■before and after using the restroom,

■before leaving the health care facility, and

■any time hands are visibly soiled.1, 3

Hand rub solutions may be used if there is no visible soil on hands or arms. Personnel should wash their hands between every surgical procedure, following the manufacturer's directions for use of the product and application of the hand rub solution. Hands should be rubbed until dry, including the webs between the fingers.1, 3

Hand washing remains one of the most important measures for maintaining patient and health care personnel safety. Using good hand hygiene practices prevents the transmission of infection and reduces the risk of health care-associated infections.1

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Learner Evaluation. Continuing Education Program 

0.8 

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: #10055; Session: #4019 Fee: Members $4, Nonmembers $8

The deadline for this program is August 31, 2013.

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

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References 

    Wearing shoe covers and appropriate footwear in the OR
  1. Occupational exposure to bloodborne pathogens—OSHA (Final rule). Fed Register. 1991;56(235):64004–64182
  2. Barr J, Siegel D. Dangers of dermatologic surgery: protect your feet. Dermatol Surg. 2004;30(12 Pt 1):1495–1497
  3. Watt AM, Patkin M, Sinnott MJ, Black RJ, Maddern GJ. Scalpel safety in the operative setting: a systematic review. Surgery. 2010;147(1):98–106
    Use of fabric head coverings
  1. Summers MM, Lynch PF, Black T. Hair as a reservoir of staphylococci. J Clin Pathol. 1965;18:13–15
  2. Dineen P, Drusin L. Epidemics of postoperative wound infections associated with hair carriers. Lancet. 1973;2(7839):1157–1159
  3. Mase K, Hasegawa T, Horii T, et al. Firm adherence of Staphylococcus aureus and Staphylococcus epidermidis to human hair and effect of detergent treatment. Microbiol Immunol. 2000;44(8):653–656
  4. Mastro TD, Farley TA, Elliott JA, et al. An outbreak of surgical-wound infections due to group A streptococcus carried on the scalp. N Engl J Med. 1990;323(14):968–972
  5. Friberg S, Ardnor B, Lundholm R, Friberg B. The addition of a mobile ultra-clean exponential laminar airflow screen to conventional operating room ventilation reduces bacterial contamination to operating box levels. J Hosp Infect. 2003;55(2):92–97
  6. Neely AN, Maley MP. Survival of enterococci and staphylococci on hospital fabrics and plastic. J Clin Microbiol. 2000;38(2):724–726
  7. Neely AN, Orloff MM. Survival of some medically important fungi on hospital fabrics and plastics. J Clin Microbiol. 2001;39(9):3360–3361
    Proper equipment storage in perioperative services
  1. Specific surgical services. In: Guidelines for Design and Construction of Health Care Facilities. Washington, DC: American Institute of Architects; 2010;p. 140
  2. Allo M, Tedesco M. Operating room management: operative suite considerations, infection control. Surg Clin North Am. 2005;85(6):1291–1297
    Performing a traditional surgical hand scrub
  1. Recommended practices for hand hygiene in the perioperative setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010;p. 75–89
  2. Boyce JM, Pittet D Healthcare Infection Control Practices Advisory Committee HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Guideline for hand hygiene in health-care settings (Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Society for Healthcare Epidemiology of America/Association for Professionals in Infection Control/Infectious Diseases Society of America). MMWR. 2002;51(RR-16):1–45
  3. Underwood MA. Hand hygiene. In: APIC Text of Infection Control and Epidemiology. Washington, DC: Associational for Professionals in Infection Control and Epidemiology; 2005;p. 191–197

  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 August 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(10)00553-3

doi:10.1016/j.aorn.2010.06.001

AORN Journal
Volume 92, Issue 2 , Pages 228-232, August 2010

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