Updates to AORN Guidelines for Perioperative Practice

ObjectivesDefine the numbering process for the AORN Guidelines

Describe how must, an action verb, and may are used in the guidelines

State three recommendations in the new guidelines that will impact your practice.

State three changes in the revised guidelines that will impact your practice

Guidelines UpdatesFORMATGuideline for SterilizationGuideline for Safe Environment of CareGuideline for Sterile TechniqueGuideline for Transmission Based PrecautionsGuideline for Safe Patient Handling And MovementGuideline for the Design & Maintenance of the Surgical Suite Guideline for Surgical Attire Guideline for Prevention of HypothermiaIn: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

Format

Regulatory Recommendation Conditional No recommendation

Standardized terminologyRationales

Guideline Structure

RevisedIntroductionPurposeEvidence Review1. Topic Header

1.1. Recommendation [Rating]1.1.1. Activity [Rating]

GlossaryReferences

CurrentIntroductionPurposeEvidence ReviewI. Recommendation

I.a. Intervention [Rating]I.a.1. Activity [Rating]

GlossaryReferences

Guideline Update: Sterilization

Reusable semicritical items that are manufacturer-validated for sterilization should be sterilized if possible.

Spaulding classification

Sterilization should be performed in an area intended, designed, and equipped for sterilization processes

Personnel with documented competency

Physical spaceEquipment and supplies

Traffic patterns and functional workflow

Quality assurance measures

Organizations should have standardized process and oversight for off-site sterilization

Consistent standard of care

Standardized process

Multisite coordination

Oversight

Phacoemulsification hand pieces should be steam sterilized in an upright orientation

Steam sterilization

Vertical position

Narrow channel

Free drainage

The organization should monitor and control the steam supply to all steam sterilizers

Wet load investigations

Monitor steam utility supply for large sterilizers; water quality supply to table-top sterilizers

Any changes of steam routing or to equipment connected to steam supply

Upon installation and repairs

Failed loads: Investigation and Correction

Determine patient risk, exposed patients

Recall and quarantine

Reporting and patient follow-up needed?

Communicate and inform –chain of command

Corrective action depends on investigative

findings

The health care organization should assess the environmental impact of sterilization processes and equipment

Energy consumption, emissions, toxicity

Shutting down idle sterilizers

Chemical steriliants: discussion of environmental toxicity, exposure limits, and potential health effects

Hydrogen Peroxide

Peracetic Acid

Ozone

Ethylene Oxide

Leadership in sterilization

Knowledgeable about sterilization science, issues, regulatory compliance, processes, equipment

Qualifications

Quality programs, safe working conditions, staffing, regulatory compliance, procurement of equipment and materials, facility design

Responsibilities

Guideline Update: A Safe Environment of Care

• Perioperative team members’ roles • Communication procedures• Methods of prevention• Processes for safely managing different fire scenarios• Alarm activation procedures • Methods to extinguish a fire• Preferred routes and levels of evacuation • A description of the facility’s fire prevention protocol• The required content for and frequency of fire safety education • The frequency of and procedures for fire drills

Fire Prevention & Management Plan

Assessment OLD

Fire RiskNEW

Fire Prevention

A. Is an alcohol-based skin antiseptic or other flammable solution being used preoperatively?Yes No

B. Is the operative or other invasive procedure being performed above the xiphoid process or in the oropharynx?

Yes No

C. Is open oxygen or nitrous oxide being administered?Yes No

D. Is an electrosurgical unit, laser, or fiber-optic light being used?Yes No

E. Are there other possible contributors (eg, defibrillators, drills, saws, burrs)?Yes No

Fire Prevention Assessment Tool

• No longer 130° F (54.4° C) maximum • Interdisciplinary team to decide proper temperature.

Blanket warmer temperature

Guideline Update: Sterile Technique:

.

Table CoveringTables should be covered during unanticipated delays or during periods of increased activityIf the sterile field is in use, the portion of the field that will not be used immediately may be covered

Measures for preventing contamination to covered sterile fields include:

– A communication process for notifying personnel where a covered sterile table is located

– Limiting traffic in locations with covered sterile tables– Direct observation

Monitoring Covered Sterile Tables

Two-“Cuffed”-Drape Method of Table Covering

Unidirectional Ultraclean Air DeliveryWhen using a unidirectional ultraclean air delivery system, position the surgical site and instrument tables within the air curtain of the system.

• HEPA filtered air directed over the instrument table or the surgical incision site• When a fixed unidirectional ultraclean air delivery system is not available or is not large enough to cover the entire sterile field

Portable Unidirectional Ultraclean Air Delivery Systems

• Interdisciplinary team evaluation of perioperative PAPR use when sterile fields are present• If PAPR use is allowed, a standard plan for • protecting the sterile field from contamination should be in place

PAPRs: Powered Air-Purifying Respirators

https://www.ncbi.nlm.nih.gov/books/NBK294223/https://www.osha.gov/Publications/3352-APF-respirators.pdf

Gloving Name Update

Assisted gloving with gown cuffs at the fingertips

Assisted gloving with gown cuffs at the wrists

Open assisted glovingClosed assisted gloving

• “Doors to the operative or invasive procedure room should be kept closed as much as possible except during entry and exit of patients, required personnel, and necessary equipment.”

Door OpeningVII.dVII.d.1

• Use when entering the gastrointestinal (GI) or biliary tract• Recommended by:

– World Health Organization– Society for Healthcare Epidemiology of America– Infectious Diseases Society of America

Wound Protectors

Open Items Close to Time of Use

Wound Classification Decision Tree

2019 Guideline - Figure 7

Welc

Guideline Update: Transmission-Based

Precautions

Standard Precautions

1. Hand hygiene2. Clean environment3. Personal protective equipment (PPE)4. Respiratory hygiene5. Safe injection practices6. Clean reusable equipment

Contact Precautions

• Draining abscess• Infectious wounds• Clostridium difficile• Acute viral infection• Methicillin-resistant Staphylococcus aureus (MRSA)• Vancomycin-resistant Enterococci (VRE)• Vancomycin-intermediate/resistant S aureus (VISA/VRSA)• Extended-spectrum beta-lactamase (ESBL)• Multidrug-resistant organism

• Cover or contain the infected or colonized areas of the patient’s body.• Remove and dispose of contaminated personal protective equipment (PPE) and perform hand hygiene before transporting the patient.• Don clean PPE to handle the patient at the transport destination.

• Use standard precautions• Wear gloves whenever touching the patient’s skin or items that are in close proximity to the patient.• Wear a gown when it can be anticipated that clothing will come into contact with the patient or contaminated environmental surfaces.• Don a gown upon entry into the room. Remove the gown and perform hand hygiene before exiting.

• Hold the patient in a single-patient room if possible; otherwise keep ≥ 3 ft separation between patients.

• Clean the room immediately after patient use. Focus on frequently touched surfaces.

Type of Organism/Disease TransportProtection for Unscrubbed Personnel* Preoperative Area Environmental Measures

Droplet Precautions

• Diphtheria• Haemophilus influenzae type b• Seasonal influenza• Pandemic influenza• Meningococcal disease• Mumps• Mycoplasma pneumonia• Group A streptococcus• Pertussis• Adenovirus• Rubella

• Instruct the patient to wear a mask and follow respiratory hygiene and cough etiquette.• The transporter is not required to wear a mask.

• Use standard precautions• Wear a mask upon entry into the room.

• Hold the patient in a single-patient room if possible; otherwise keep ≥ 3 ft separation between patients.• Draw a privacy curtain between beds to minimize the opportunity for close contact. • Routine

Type of Organism/Disease TransportProtection for Unscrubbed Personnel* Preoperative Area Environmental Measures

Airborne

Type of Organism/Disease TransportProtection for Unscrubbed Personnel* Preoperative Area Environmental Measures

• Mycobacterium tuberculosis• Disseminated herpes zoster• Rubeola Monkeypox• Smallpox• Varicella zoster• Chicken pox

• Instruct the patient to wear a mask and follow respiratory hygiene and cough etiquette.• Cover and contain affected skin lesions.• The transporter is not required to wear a mask.

• Use standard precautions• Wear a fit-tested N95 or higher level respirator that is approved by the National Institute for Occupational Safety and Health.

• Place the patient in an airborne infection isolation room (AIIR), if possible.• Provide at least 6 (existing facility) or 12 (new construction/renovation) air changes per hour.

• Consult an infection preventions before patient placement to determine the safety of an alternative room that does not meet AIIR requirements.• If an AIIR is not available, the OR should remain vacant postoperatively for sufficient time to allow for a full exchange of air, generally 1 hour.

Transmission Risk: Personnel

• See occupational health:– Infections– Exudative lesions– Nonintact skin

• Report exposures ASAP• TB screening

CDC Guidelines: Infection Control in Personnel (1998) & TB (2005)

Guideline Update : Safe Patient Handling and Movement

• The health care organization and the perioperative team should collaborate to establish and sustain a culture of safety that incorporates the principles of SPHM.

Recommendation I

• The health care organization and the perioperative team should establish a formal, systemized SPHM program.

Recommendation II

• The health care organization and the perioperative SPHM program team should incorporate ergonomic design principles in the planning and design of the surgical suite.

Recommendation III

• The health care organization and the perioperative team should collaborate in the selection, installation, and maintenance of safe patient handling technology into the perioperative setting.

Recommendation IV

• The health care organization and the perioperative team should collaborate to establish education, training, and competency verification in safe patient handling techniques and equipment.

Recommendation V

• The perioperative team should assess the patient and the perioperative environment and develop a plan for SPHM.

Recommendation VI

• The health care organization and the perioperative SPHM team should provide an injured employee with reasonable accommodations for post-injury return to work.

Recommendation VII

• The perioperative SPHM program team should establish a quality assurance and performance improvement program.

Recommendation VIII

New Guideline: Design and Maintenance of the Surgical Suite

• I. Interdisciplinary team• II. Perioperative suite• III. Preoperative area• IV. Intraoperative area• V. Hybrid OR • VI. Postoperative area• VII. Support areas

• VIII. Sterile processing• IX. Procedure rooms • X. Preventing contamination during construction• XI. Utility failure• XII. Monitoring and maintaining surfaces and HVAC system performance

Document Layout

Zones Sterile

Admissions Processing

Waiting room PACU Supply

PACU Phase I Storage Decon Clean

Phase 2 SSPD

NS OR 1

Soiled Locker rooms

OR2 1 floor below

Clean

Pre-op OR 3

Pharmacy OR 4

Zones of Protection• General areas accessible to the public at all times• General areas restricted to the public during non-

visiting hours, periods of lesser activity, or other periods of increased vulnerability

• Screened public areas • Staff and accompanied public areas• General staff-only areas• Areas for designated staff with appropriate

clearance

Zones within the OR

Postoperative areas

Ice-making equipmentStorage for belongings

Patient care stations

Other support areas

Bathrooms for patients and personnel

Medication safety zone

Nourishment area Hand washing stations

Support AreasInclude

Locker roomsThe nurse stationClean equipment storage areasSoiled workroomEnvironmental services roomSupply breakout area/roomSterile processing departmentAdministrative areas

May include

Information systems control roomMedical records storage areasMultipurpose roomsPatient waiting roomsSpecimen holding areasMedical gas storageSatellite laboratorySatellite pharmacySatellite sterile processing area

Part of the surgical suite YES or NO ? Satellite sterile processingYES or NO ?

Sterile Processing

Two-Room Satellite Sterile Processing

• Perform construction site and infection control barrier monitoring and periodically

• Barriers (eg, solid fiberboard or sheetrock walls, sealed plastic walls)

Construction safety and infection control measures

Utility Failure

Electrical HVAC Sewage Vacuum Plumbing

Medical Gases

Boiler . Steam Water Communication

GeneratorAnd Fuel

Immediate actions

Reschedule or redirect

Delay elective

Emergency only Close

NOTHING

Coming to the Facility Reference Center: July 1Coming to the book: 1-1- 2020

HYPOTHERMIA

• Who• How• When

Temperature Measurement

• Who • How • When• Prewarming

Hypothermia prevention

Coming to the Facility Reference Center: July 1Coming to the print book: 1-1- 2020

SURGICAL ATTIRE

Laundering

• a health care-accredited laundry facility,• the health care organization according to state regulatory requirements, or• the health care organization according to Centers for Disease Control and Prevention recommendations for laundering in the absence of state requirements.

Launder scrub attire after each daily use at

Remove scrub attire

Before leaving the facility

Personal Clothing

NoRecommendation

Establish a process:• the type of fabrics (eg, nonlinting) that may be worn under scrub attire, • the amount of fabric that may extend beyond the scrub attire (eg, a crew neck collar under V-neck scrub attire),• laundering frequency (eg, daily), and • laundering method (eg, facility laundering, home laundering).

Antimicrobial Scrubs

No Recommendation

Long Sleeves

Arms MAY be covered during performance of preoperative patient skin antisepsis. No recommendation can be made for wearing long sleeves in the semi-restricted and restricted areas.

Head Coverings

Beards

Shoes

Guidelines Being Updated for Publication in 2021 book

Guideline for Surgical Attire Guideline for Prevention of HypothermiaGuideline for TourniquetsGuideline for Environmental CleaningGuideline for PackagingGuideline for Sharps Safety Currently up for Public CommentGuideline for Autologous TissueGuideline for Energy Generating Devices (Laser and ESU)

AORN LinksEvidence Modelhttps://aorn.org/guidelines/about-aorn-guidelines/evidence-ratingEvidence Tableshttps://www.aorn.org/guidelines/about-aorn-guidelines/evidence-tables

Public Commentinghttps://www.aorn.org/Aorn-org/Events/Public-Comments

Guidelineshttps://aorn.org/guidelines/about-aorn-guidelines

Toolkits

https://aorn.org/guidelines/about-aorn-guidelines