Association of periOperative Registered Nurses of Alameda County, California

AORN Alameda County

Vendor Policy - AORN of Alameda County


Vendors

In The

Operating Room

 

 

 

 

 

 

 

 

 

 

Association of periOperative Registered Nurses

Alameda County Chapter (#0501)

2001

Table of Contents

Page 1 of 2

Page

Objectives 4

Instructions 4

  1. Aseptic Technique
    1. Definition 5
    2. Surgical Conscience 5
    3. Sterile versus Non-Sterile Personnel 5
    4. The Sterile Field 6
    5. Talking in the Surgical Suite 6
    6. Traffic Patterns 6
    7. Ventilation, Temperature and Humidity 7
  1. Surgical Attire
    1. Scrub Suit 8
    2. Hair Coverings 8
    3. Shoe Covers 8
    4. Masks 9
    5. Jewelry 9
  1. Potential Hazards in the Operating Room
    1. Fire 10
    2. R.A.C.E. 10
    3. Fire Plan and Internal Disaster Policy 11
    4. Laser Safety 12
    5. Electrical Safety 13
    6. Electrical Outages 14
    7. Miscellaneous Safety 14
  1. Radiation Safety
    1. General Information 15
    2. Radiation Safety Policy 15
  1. Handwashing 17
    1. Handwashing Technique 18
    2. Fingernails 18
  1. Back Safety
    1. Exercise 19
    2. Proper Lifting and Carrying 20

Table of Contents

Page 2 of 2

Page

  1. Infection Prevention

A. Standard Precautions 21

  1. B. Tuberculosis 21
  2. C. Human Immunodeficiency Virus (HIV)/AIDS/Hepatitis A, B, & C 23

D. HIV/AIDS/Hepatitis Information 1998 23

  1. E. Methods of Transmission in the Operating Room 24

F. Specific Questions & Answers 24

  1. Confidentiality 28

IX. References 29

  1. Appendix
  2. Policy and Guidelines for Vendors 31

    XI. Vendor Agreement 33

  3. Section Review Quizzes
    1. Aseptic Technique 34
    2. Surgical Attire 35
    3. Potential Hazards in the Operating Room 36
    4. Radiation Safety 38
    5. Handwashing 39
    6. Back Safety 40
    7. Infection Prevention 41

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Objectives

Following completion of the self-directed learning module, the Vendor will be able to:

1. Classify various areas within the surgical suite, (e.g., restricted, semirestricted and unrestricted).

2. Describe proper surgical attire.

3. Describe proper handwashing technique and its importance.

4. Compare and contrast the communicability of HIV, HAV and HBV.

5. Describe steps to follow during a fire in the operating room.

6. Describe basic procedure during electrical outage.

7. Name plans for prevention of tuberculosis exposure.

 

Instructions

This self-directed learning module is designed for easy progression through the sections without assistance from perioperative personnel.

There is a knowledge assessment quiz for each section. Please complete each quiz signing your name and entering the date.

In addition to the quizzes, please complete the Vendor Agreement form.

Return all quizzes and the Vendor Agreement form to the individual who you received the packet from.

 

 

 

 

 

 

 

 

 

 

 

 

I. Aseptic Technique

Aseptic technique is essential in all operating rooms. It should be considered the "law of the land". If breached, the consequences can be far-reaching and potentially devastating to the patient and the reputation of the hospital involved. The patient is particularly at risk for invasion of exogenous bacterial infections because the most significant protective barrier (the skin) is interrupted during surgery. Therefore, this is one of the most important sections in this module.

A. Definition

The term Aseptic Technique infers absolute cleanliness, without contamination, and in fact, prevention of contamination. This not only addresses personal performance of medical staff members, hospital employees and visitors, but also the methods used for sterilization and processing of instruments and equipment used within the operating room as well as maintaining an impeccably clean environment.

B. Surgical Conscience

All patients have the right to expect and receive exceptional and ethical care. It is the patient that we, in health care, work for. Operating room personnel are keenly aware of the potential for harm to the patient. While in the operating room, the patient is generally unable to provide self-protection. The patient may be partially or completely impaired due to anesthetic needs. It is personal moral values and professional ethics that guide health care professionals to carefully and vigilantly protect their patients.

When there is a breach in aseptic technique or when it is noticed that instruments are contaminated, this must be reported so corrective action can take place immediately, regardless of personal consequences or embarrassment. A delay in reporting such incidents unnecessarily places the patient at great risk. Placing of the patient's well being above personal/professional embarrassment demonstrates good surgical conscience.

C. Sterile versus Non-sterile personnel

Surgeons, assistants, and perioperative personnel who have performed a surgical hand scrub and donned sterile gowns and gloves should be considered a sterile. Care must be taken to avoid inadvertent contamination of these team members. The surgical gown is considered sterile in the front from axilla to waist level, from hands to just above elbows and from side to side. Although the back of the gown is considered unsterile, it is poor technique and inappropriate to touch a scrubbed team member on the shoulder or back. If you need to gain the attention of the surgeon or member of the sterile team, it is highly recommended that you enlist the assistance of the circulating nurse in charge of the room.

Non-scrubbed personnel in the room include the anesthesiologist or nurse anesthetist and the circulating nurse. All are typically dressed in the standard surgical attire of pants, tunic top and warm up jacket.

D. Sterile Field

The sterile field consists of those areas in the operating suite that are covered with sterile drapes as well as personnel wearing sterile gowns. Generally speaking these areas are:

· the patient

· the back table

· the Mayo stand

· the microscope

· radiological equipment

· the surgeon, assistant, scrub person

The sterile field is constantly monitored by the personnel in the room. You should maintain an area around the sterile field of no less than one foot. This is an adequate comfort zone.

All items within the sterile field should be sterile. All items placed upon or within the sterile field should be sterile. When presenting items to the sterile field there are a variety of things to be checked, proper packaging, package integrity, and sterile indicators are a few. Although presentation of supplies to the sterile field is not a difficult skill to master, it is one that requires practice to become proficient. Therefore, sales representatives will not engage in this activity.

E. Talking in the Surgical Suite

Talking in the surgical suite should be kept to conversations that are pertinent and essential. The patient should always be the focus of your attention. During induction of and emergence from anesthesia, it is always courteous to the anesthesia provider and the patient, to refrain from talking. There have been studies that indicate patients may experience some awareness while under anesthesia. This is one reason why conversations within the surgical suite should be pertinent, essential, and always professional. Another reason talking should be kept to a minimum is the surgical mask itself. Once saturated with moisture, the mask lacks effective filtration properties. Human breath is laden with moisture that is expelled while breathing, talking, sneezing, and coughing. The mask is a protective barrier that benefits both the wearer and the patient, when worn properly. Masks are covered more in-depth in the Surgical Attire section of this module.

F. Traffic Patterns

Movement in and around the surgical suite should be limited to that which is absolutely necessary only. Air turbulence is created with movement that in turn increases the likelihood of bacterial fallout from the skin and

lint from draping materials to contaminate the sterile field and wound.

When it is necessary to move around a functioning operating room, you should face the sterile field at all times. This may require some unusual pathways. However, one should never take a pathway between two sterile fields. Sterile fields consist of any two objects that have draped with sterile materials and have sterile supplies and or instruments/ equipment on them. Some possibilities are personnel, patients, furniture, equipment, or instrument tables. It is the responsibility of the entire surgical team to monitor and protect the sterile field and the integrity of the room. Entry into and exit from a surgical room should be done only when absolutely necessary.

G. Ventilation, Temperature, and Humidity

Operating rooms are held to extremely high standards when it comes to ventilation. A typical surgery suite employs a ventilation system that produces anywhere from 15-25 air exchanges per hour. Basically this means the air within the surgical suite is completely replaced 15-25 times each hour. Filtration in the system is also important. The air is filtered prior to return into the room for ultra clean air. Surgical suites also are equipped with a positive air pressure environment. Thus, when a door that leads out of the surgical suite is opened, whether to the main corridor or a substerile room, the air within the surgical suite is pushed out to prevent less clean air from entering the suite. Therefore, it is important that the doors remain closed except when patients or equipment are moving in or out. The temperature and humidity of the surgical suite varies from room to room, institution to institution. Typically you will find operating rooms anywhere from 65° -75° F and 45%-60% humidity. The level of comfort for the scrubbed personnel versus the safety of the patient is always a struggle. An environment that is too cold would subject the patient to increased potential for hypothermia. And an environment that has too much humidity (moisture in the air) creates one that can affect the sterility of items packaged in cloth or paper. There are guidelines set by the federal and state governments dictating ranges for temperature, humidity, and air exchanges in surgical suites. It is important that they are followed.

 

 

 

 

 

II. Surgical Attire

Although surgical attire was introduced in the early 1900's for the purpose of reducing the microorganisms shed into the environment, this practice did not firmly take hold until the 1930's and 40's. This is when the surgical gown, cap, and mask replaced the traditional nurse's uniform on a more consistent basis.

Today, the purpose of surgical attire is multipurpose. Not only do operating room personnel wear surgical suits, gowns, and masks, they also wear sterile gloves and OSHA approved eyewear to protect against transmission of blood borne pathogens and other hazardous materials.

A. Scrub Suit

Proper surgical attire lends to environmental control within the operating room. The standard surgical suit consists of a two piece pants suit with a tunic top (made of a closely woven fabric). It is important when dressing to assure that clothing does not come into contact with the floor. This would enable contaminants from the floor to be transported into the operating room, exposing patients to undue risk. Tunic tops that do not fit closely to the body should be tucked into the scrub pants. Scrub pants with draw string ties, should have the ties tucked in to prevent accidental contamination of the surgical field. Long sleeved jackets should be worn by nonscrubbed personnel and be completely snapped closed when in the operating room. This will lessen the likelihood of contaminating the sterile field when moving close to the sterile field. Long sleeved jackets are also useful for nonscrubbed personnel to keep warm. Remember that the average temperature in operating room is between 65° -72° F.

B. Hair Coverings

Hair coverings come in a variety of styles. The most prudent one to wear is the bouffant type hair covering. Shedding hair and dandruff can be a major source of bacteria in the environment. Therefore, all hair should be covered. Hair coverings are required when entering a semi restricted area of the operating room. Due to the nature of prosthetic implant cases, a hood should be worn with a bouffant, to confine and contain the hair. Persons with beards should cover facial hair.

C. Shoe Covers

Historically, the purpose of shoe covers was to keep the shoes of the surgical team clean and also assist in house cleaning tasks by reducing the tracking of blood throughout the surgical suite. In today's environment of deadly blood borne pathogens, the shoe cover has taken on an additional significance, that of personal protective equipment (PPE). It should be noted that not all shoe covers are impervious. Recently it has been accepted practice for shoe covers to be optional in the surgical arena. This means the responsibility of self-protection has fallen on the individual team member. It is highly recommended that all components of

protective attire be worn when the risk of exposure to blood and or body fluids is likely.

D. Masks

Masks are required in restricted areas of the operating room when sterile supplies are open. The filtration ability of masks varies depending on brand and specification of design. If possible, choose a mask with at least 95% filtration. Particulate matter that is aerosolized during a surgical procedure, typically 10 microns or larger, is easily filtered by the standard surgical mask. A standard surgical mask filters particles anywhere from 0.1 to 0.6 microns. This is adequate protection for the wearer. Of course, the application of the mask must be proper to reap the benefits. To don a mask properly the fit should be snug. The top tie should be tied high up on the back of the head and the lower ties should be tied at the base of the neck. There should be a no gapping on the sides of the mask. Gapping allows respiratory contaminants to escape, unfiltered, into the clean surgical environment. Respiratory contaminants increase a patient's risk to post surgical wound infection. For occasions when the patient has possible or active tuberculosis, it is important to wear a High Efficiency Particulate Air (HEPA) respirator. This mask filters down to .03 microns and is optimal for filtering out tuberculosis bacilli. This mask fits differently than the standard surgical mask. There are several sizes available and each mask must be "fit tested" to the individual wearer. Masks are not to be left hanging around the neck, placed on top of the head or stored in a pocket for future use. Once worn, masks are contaminated with respiratory expiration and should be discarded. The life of a mask is limited to approximately 1-1/2 to 2 hours. The mask should be changed after each case or when soiled. When removing a mask, handle it by the strings only. Immediately wash hands after handling a soiled mask to avoid cross contamination of patients, staff members and equipment. Hand washing is the single most important thing you can do to ensure the best patient outcome and maintain your own health. This concept will be covered further in the Handwashing section.

E. Jewelry

It is preferable that all jewelry be removed prior to entering the operating room. Rings, watches and bracelets can harbor harmful microorganisms. If jewelry is worn within the operating room, it should be confined and contained. There should be no dangling jewelry outside of the scrub suit. It is unacceptable practice to attach jewelry to the exterior of the scrub suit. This creates the possibility of the item falling into the sterile field.

III. Potential Hazards in the Operating Room

A. Fire

Equipment used on a routine basis during a surgical procedure can be a source of possible combustion, given the oxygen-enriched atmosphere. Electrosurgical devices, fiber optic light sources or laser all have the potential for combustion. Linen or nonwoven surgical drapes can serve as sources of fuel. Oxygen serves as the supporter of combustion. All are essential for fire to exist. All of these items are present during any surgical procedure in any operating room. Although fire in the operating room is a rare occurrence, it is always a possibility. A typical fire retardant drape will burn very slowly in a normal atmosphere. However, in an oxygen-enriched atmosphere, there seems to be nothing fire-retardant about the drape. The drape will burn and it will burn fast.

B. R.A.C.E.

If a fire should start in the surgical suite, the first concern is always for the safety of human life, the patient's, visitors, and OR personnel. You may or may not be directly involved in the rescue of patients or personnel. However, preparation for emergency situations is necessary. The R.A.C.E. mnemonic may help prevent panic by aiding memory for effective steps to a fire emergency.

R - Rescue those in immediate danger

A - Activate the nearest fire alarm

C - Confine and contain the fire, if possible, without endangering yourself

or others

E - Evacuate the room, wing, floor or department

If deemed necessary, the patient should be removed from the room. Due to the production of toxic gases from burning materials in the OR, time is essential. Gases such as carbon monoxide and carbon dioxide compete for the oxygen receptor site on the hemoglobin, therefore displacing the oxygen molecule. Acidic fumes (created by some burning plastics) are extremely irritating to the eyes and respiratory tract. If the patient is under anesthesia, the entire OR table should be moved in the interest of time and to prevent injury to the patient and staff.

Know the locations of all fire alarms within the department and where the nearest alarm is to your location. Should a fire break out within your surgical suite, you can be of great assistance by simply initiating the fire alarm. Fire alarms go directly to the fire department for the service area. This enables the fire personnel to know the exact location of the fire within the hospital.

It is preferable, but not always possible, to extinguish the fire in the room.

The operating room personnel will more than likely perform two or more of the following tasks simultaneously:

· Irrigation from the field or damp towels are used on the fire should it involve drapes or other combustibles on the patient

· Oxygen source is turned off by Anesthesiologist

· Drapes may be removed from the patient in order to extinguish the fire

· The room alarm may be activated and/or fire alarm is pulled and the fire department is notified

· The fire extinguisher in the room should be used if the field irrigation is insufficient to extinguish the flames or if it involves electrical/computer equipment.

Know where the fire extinguishers are within the department you are servicing. Always know where the closest fire extinguisher is to your location. There is a fire extinguisher in every surgical suite. Proper application of the device is imperative to the personal safety of the operator and other personnel within the vicinity. Another mnemonic to help with this is PASS.

P - Pull the pin from the handle

A - Aim the delivery device at the base of the flame

S - Squeeze the handle of the fire extinguisher

S - Sweep. Deliver the contents of the extinguisher in a sweeping motion

over the base (bottom) of the fire.

Incorrect application may cause the fire to splash back and injure the operator of the fire extinguisher. Once evacuated from the room, close the door. Operating rooms have 2-hour firewalls between them. This means, the fire within a room should be contained for approximately two hours. The fire department will reach the facility before the firewall would fail.

As mentioned earlier, toxic fumes are of great concern in a fire. All persons within the affected surgical suite should be evacuated. If the fire is too large to be extinguished with a fire extinguisher, smoke and fumes will likely seep out into the common OR corridor. This may require the evacuation of the department. Know the quickest way out of the department and out of the building. You should not bring in supplies and place them where they would block an exit.

C. Fire Plan and Internal Disaster Policy

In the event of a fire, each nursing unit within the hospital has duties that are specific to its nursing function and location. These responsibilities are in addition to those outlined in the hospital's fire plan. These guidelines are an effective means to provide and maintain a safe environment for patients, visitors, and staff.

POLICY:

  1. 1. All staff and vendors will be familiar with and follow the hospital fire plan.
  2. 2. All fires will be reported to the Charge Nurse.
  3. 3. If injury to a patient occurs, and the physician is not present, he/she will be
  4. notified.

PROCEDURE

ACTION/RESPONSIBILITIES

RATIONALE

  1. Participate in fire drills when in the facility.
 
  • Know the location of the nearest fire alarm and fire extinguishing equipment.
  •  
  • Know the evacuation routes for patients.
  • C. Avoid disruption of patient care.

    IN THE EVENT OF A FIRE OR INTERNAL DISASTER YOU MAY BE DIRECTED TO:

     
    1. Remove any patients, visitors and/or personnel who are in immediate danger.
     
  • Call the front desk for help, use the
  • emergency call button if staff are

    available in the department, or pull the

    nearest fire alarm.

     
  • Turn off oxygen and other gas supply. Disconnect electrical equipment in immediate area if safe to do so.
  •  
  • Close door(s). Staff members will manually close doors when an alarm is announced if automatic doors do not close.
  • D. Closed doors help contain fire to a

    portion of the building and minimize

    the spread of smoke from one area to

    another.

  • Extinguish fire, if it can be done safety.
  •  
  • Remain near fire location until help arrives.
  •  

     

    D. Laser Safety

    Lasers are used in a variety of surgical procedures. Generally, the atmosphere in a laser case is one of extreme caution. Many safety procedures are meticulously followed. The eyes, skin and respiratory tract should be protected as fire is a potential in all laser cases.

    The facility will provide you with laser safety glasses or goggles to wear while attending a surgical case that involves laser. Regular prescription glasses do not have the necessary wave length protection to adequately protect your eyes from damage and should not be relied upon for protection.

    The possibility of stray laser beams damaging your skin does exist. Wearing a long sleeved warm-up jacket will help in this area.

    High filtration surgical masks, specific for laser use, are available. There is some controversy whether the laser masks are more effective than a standard surgical mask. Both filter to a very small particle size. When in question always error on the side of safety.

    Stray laser beams can create a fire hazard. When not in use the laser is on stand by. You will hear the circulating nurse, scrub person and surgeon communicating the status of the laser frequently during the case. The laser will not be left in the "on" position unless being used. The surgical team is constantly monitoring the field and the room for possible problems. Saline or sterile water is a standard component of all surgical fields and is readily available should the need arise to extinguish a fire.

    E. Electrical Safety

    Voltage, resistance and current are the three boundaries of electricity. These boundaries all flow along an electron pathway.

    · Voltage refers to the force that is used to move the electrons along the pathway. The number of volts is proportional the directness of the pathway.

    · Resistance is exactly what its name implies, the opposition to the flow of electrons. Insulators have great resistance and conductors support the flow of electrons. To put this into prospective for you using examples of items commonly found in operating rooms, the human body and metal are conductors for electricity. Surgical gloves and plastic are insulators.

    · Current refers to how quickly the electrons are flowing through an item.

    · Ground is earth. This term refers to the layout of all electrical systems that employ three prong outlets. The third wire is the ground. This allows for any stray leakage of current to be collected and delivered to ground. Within the hospital setting all electrical outlets are equipped with a grounding system.

    Just about every device used in modern ORs is electrical. With so much equipment in operation at one time, the source and type of system becomes important. The length of the electrical cords also is an important safety feature. Electrical cords draped across the floor and equipment have the potential for great injury to personnel and visitors. Electrical cords should be contained and should not be attached to extensions.

    Typically the electrical system in the operating room is isolated from the electrical main of the hospital. This means electrical current remains in the circuit and does not seek ground. Within operating rooms are line isolation monitors (LIM). Their purpose is to continuously monitor the relation between the capacity and resistance in the two lines and the ground. Therefore, should degradation of electrical equipment used with an isolated electrical system occur and leakage of current goes to ground, the LIM warning system will alarm. This warning alerts OR personnel to a potentially dangerous situation. Generally, the initial course of action is to unplug the last piece of equipment plugged in. If this is unknown,

    equipment is unplugged in a systematic fashion until the offending article is located. If the offending article happens to be a piece of equipment you are demonstrating, try another plug. If it is the outlet, your equipment will work satisfactorily in another one. If your equipment is faulty, the LIM will alarm. The article is then removed from service until the biomedical engineers can examine it and make needed repairs. Faulty outlets require maintenance to make the necessary repairs. Until this has been accomplished the outlet will be tagged as "Out of Order" to prevent inadvertent usage while faulty.

    Assure the integrity of your equipment prior to in-service and operation within the department. Cords and plugs should be intact without evidence of fraying. Check the plug/outlet compatibility. If you need an adapter, it is handy for the OR staff to know this in advance of your arrival. All equipment must be checked by the biomedical department before being brought to the O.R.

    F. Electrical Outages

    Electrical outages in the hospital setting can be quite disruptive. During a surgical procedure with so many critical electrical devices the OR team cannot function without electricity. All hospitals have a back-up generator(s) for emergency electrical supply. When there is an interruption of the commercial electrical supply to the hospital, the generator automatically begins supplying electricity within 10 seconds. The generator will continue supplying energy until commercial power is restored. During the 10 seconds of darkness in the OR suite, it is important to refrain from movement. Doing so could result in injury or contamination of the sterile field. Inability to visualize the surgical site can be life threatening for the patient and create extreme tension for the surgeon. Many ORs have battery operated spot lights that light up immediately with interruption of electrical power.

    G. Miscellaneous Safety

    There are many structural and equipment hazards in an OR. IV poles (weighted or plain), prep stands, air hoses (attached to wall or tank source), electrical cords, lifts/steps/stools/stands, electrical and medical gas booms that hang from the ceiling, etc. can create hazardous surroundings for visitors of the operating room. For this reason you must be aware of your surroundings at all times.

    IV. Radiation Safety

    A. General Information

    Radiography is common in the operating room setting. From surgical orthopedic cases to laparoscopic cholecystectomy to neurosurgical cases, x-rays are utilized to visualize structures within the body that cannot be seen without assistance. Cumulative effects of radiation exposure have been linked to a variety of health problems and birth defects. To lessen your likelihood of over or inadvertent exposure to radiation remember that time, distance, and shielding are all factors to be considered.

    · Time - Length of exposure is always a determining factor for risk. Whenever possible, limit your time to radiation exposure. If this is not possible, attempt to employ the following two factors; both reduce exposure significantly.

    · Distance - There are monitoring devices (dosimeters) that measure the amount of radiation you are exposed to. The report that is generated will indicate the quantity of radiation you have been exposed to. Occupational exposure is measured in millirems (mrem).

    Radiation scatters when it hits the patient but only travels a short distance. There is a significant exponential decrease in radiation exposure with increased distance. The dose is decreased by the square of distance from the source. For example: if you are 2 feet from the source of radiation, the exposure is approximately 1 mrem. If you increase the distance to 4 feet from the source of radiation, the exposure is decreased dramatically (4-2) to .16 mrem.

    · Shielding - When you know you are going to participate in a surgical procedure that involves radiation exposure (x-rays or fluoroscopy), it is important to wear a lead apron or other supplied shields. When exposed to radiation, you should always face the source. This will provide the maximum amount of protection that the lead apron has to offer. Lead absorbs approximately 95%-99% of the scattered radiation and is an excellent source of protection. Lead doors are used in the OR. During cases that require one to several x-rays, staff members may stand behind the lead door for protection from radiation. It is not recommended that sterile personnel leave the surgical suite because of decreased air quality outside the room.

    B. Radiation Safety Policy

    1. Definition and Purpose:

    Radiation has the ability to modify molecules within body cells. Personnel should protect themselves and patients from radiation scatter and nonessential direct exposure. Operating room

    personnel may assist with invasive and non-invasive intraoperative use of ionizing radiation.

    2. Policy:

    All precautions for patient and personnel safety from hazards of radiation exposure must be observed when x-rays are taken, fluoroscopy is used, or during implantation of radioactive material.

    PROCEDURE

    ACTION

    RATIONALE

    1. All personnel should be protected from

    unnecessary exposure to x-ray and the length

    of time of exposure.

     

     

    1. Non scrubbed personnel who can safely
    2. leave the operating room during single x-

      ray film exposure should do so.

    3. During single x-ray film exposure, leaded
    4. shielding will be provided to scrubbed

      personnel and others who cannot leave the

      room.

    5. Personnel (even when protected by aprons
    6. or a leaded shield) should position

      themselves behind or to the side of the x-

      ray beam when possible.

    7. Personnel wearing aprons should always
    8. face the x-ray unit unless the apron wraps

      around the body.

    9. During fluoroscopy, personnel will wear
    10. leaded aprons.

       

    11. For optimum protection during fluoroscopy,

    personnel within two meters should wear a

    thyroid shield.

    A. The effect of radiation exposure is directly

    related to amount and practice setting. In

    addition to time and length of exposure,

    shielding, and distance from the radiation

    source are key factors in minimizing exposure.

     

     

     

     

    2. Minimizes exposure to scattered radiation.

     

     

     

    3. Leaded aprons do not totally absorb all ionizing

    rays.

     

     

    4. To afford protection, the leaded apron must be

    between the source of radiation and the body.

     

    5. The potential for exposure to radiation is greater

    during fluoroscopy than direct x-ray due to

    increased scatter and exposure time.

    6. The greatest risk of radiation exposure to

    personnel within a two-meter range are in the

    areas of the head, neck and hands.

    1. It is the responsibility of pregnant or potentially

    pregnant personnel to minimize their exposure

    to radiation sources, especially that of

    intermittent fluoroscopy.

    B. Females should protect their reproductive

    organs from excessive exposure during

    childbearing years. The fetus is highly

    susceptible to ionizing radiation.

    C. Leaded protective devices will be handled

    carefully. Aprons will be laid flat or hung by the

    shoulders when not in use.

    C. Leaded aprons/shields are very susceptible to

    cracking, which can occur when folded. Cracks

    significantly reduce the apron’s effectiveness.

    V. Handwashing

    The majority of hospital acquired (nosocomial) infections could be eliminated with effective hand washing techniques. All persons who come in contact with the patient should do so with thoroughly washed hands. In the operating room arena the patient is further susceptible to infection because of an interruption in their skin integrity. This provides harmful microorganisms with an easy pathway for entry. In addition, many hospitalized patients have weakened immune systems. There are a variety of factors that can contribute to a weakened immune system. Age is one factor. Newborns and infants have underdeveloped immune systems that can be marked with age. Immunosuppression is a consideration with patients who are experiencing chemotherapy or other high dose medication regimens or lengthy illnesses.

    Everyone carries with them resident microorganisms. These are the microorganisms that actually live on our skin without harming us and are found repeatedly when cultured. These microorganisms have seated themselves not only on the surface of our skin, but also securely in the deep epidermal layers of our skin. And although they may not be harmful to us, they can be devastating to another person if transmitted.

    Transient microorganisms are, as their name implies, temporarily on the surface of your skin. You pick up transient microorganisms with everything and everyone you touch. This classification of microorganisms can be easily washed away with proper hand washing techniques.

    Abrasions and cuts on the skin create an optimal environment for infection if not cared for properly. All cuts and abrasions should be covered with an occlusive dressing prior to entering the operating room. Individuals with infected cuts, lesions, lacerations, etc. should not be permitted into the operating room.

    To minimize the potential for retention of harmful microorganisms on your skin, wash regularly with an antimicrobial cleanser, maintain well manicured fingernails, pat hands (do not rub) dry after washing, and apply moisturizing lotion after each washing (this prevents chaffing of skin).

    The Centers for Disease Control (CDC) has issued guidelines for hand washing. Although basically common sense, they are good rules of thumb to follow. Simply stated, wash your hands:

    · prior to and after using the restroom.

    · prior to and after eating.

    · prior to and after smoking or blowing your nose.

    · prior to entering the operating room and after leaving the operating room.

    Gloves are important in today’s world to assist in the protection of both the health care worker and the patient. However, they are not without risk. The integrity of nonsterile exam gloves, as well as sterile surgical gloves are not, nor do they claim to be, 100% without breaks. For this reason it is highly recommended that a thorough hand washing follow the removal of gloves.

    A. Handwashing Technique

    To properly wash your hands, complete the following steps:

    1. Wet hands and as much exposed arm as possible.

    2. Liberally apply antimicrobial soap to your hands and exposed areas of arms.

    3. Lather ALL surfaces for approximately 15-30 seconds. The areas under the fingernails and the cuticle areas frequently culture high for microbes. It is important to note that heavy scrubbing of the skin is of no additional value. The converse is true. Heavy scrubbing will break down the surface of the skin and can cause dermatitis.

    4. Rinse all soap from hands and arms.

    5. Pat dry with paper towel.

    6. Apply moisturizing lotion.

    With each subsequent hand washing of the day, antimicrobial properties will build on the surface dermal layers and superficial epidermal layers of your skin. This leads to residual antimicrobial action that contributes to a decrease of readily available transient and resident microorganisms on the surface of your skin. This will lessen the likelihood of transferring potentially harmful microorganisms to the patient.

    B. Fingernails

    Multiple studies have been carried out in various institutions throughout the world on hand asepsis. A common conclusion is that fingernails should be natural, short, well manicured and free of jagged edges. This aids in the removal of harmful bacteria, both residential and transient, from the hands when washed. Artificial nails may harbor fungi and other microorganisms that can be harmful and potentially life threatening for the patient should this be introduced into an open wound.

    VI. Back Safety

    Your back is an active participant in the normal activities of daily living. You should protect and maintain your back because it is the only back you have. If you think about your daily activities and then think about the role your back plays in those activities, it is clear your back should be protected and strengthened as much as possible.

    Your spine is comprised of a series of vertebrae - seven cervical (neck), twelve thoracic (upper back), five lumbar (lower back), one sacral (five fused, posterior pelvis) and one coccygeal (four fused, "tail bone"). Vertebrae bend, backward and forward and side to side. They rotate very slightly, if at all. The back is a connecting point for many other parts of the body that can also be affected adversely by injury.

    The cervical vertebrae support the skull, which houses the brain. This is the most important reason to protect your spine. The second most important reason to protect your spine is the thoracic vertebrae which support your ribs, house your heart and lungs. Walking is something we tend to take for granted. Your back anchors your hips and legs. Constant pain and disability can be experienced with injury to the lumbar vertebrae.

    Commonly back injuries occur when there is a simultaneous twisting and lifting action. This causes back strain and possibly back injury. Incorrect posture, poor body mechanics while lifting, a large protruding abdomen and constant strain can create back fatigue which can in turn lead to injury. In today’s workforce approximately 80% of the population will develop back problems. The translated cost is estimated to be in the billions of dollars. Costs include: medical expenses, lost time from work, Worker’s Compensation benefits, disability insurance and rehabilitation or retraining into a different job. In addition, constant pain, lost time from work, and permanent disability all have their emotional effect on the injured employee.

    A. Exercise

    The muscles that support the back and abdomen (stomach muscles) should be strengthened and stretched daily. This is easily accomplished with a series of exercises. If done routinely and correctly, these simple back-strengthening exercises will help you to a healthier back.

    1. The pelvic tilt can be done several ways. Lay on the floor, stand against a wall, or position yourself on your hands and knees. The movement is the same in all positions. Press your back against the hard surface, which causes the pelvis to tilt forward. If on your hands and knees, arch your back slowly and gently, this also causes the pelvis to tilt forward.

    2. The half sit-up or crunch. This exercise is targeted at strengthening your abdominal muscles. Lay on the floor (padded if possible), bend your knees while keeping your feet on the ground.

    Cross your hands in front of your chest. Lift your upper body to the

    point where your upper back is off the floor.

    3. The hamstring stretch. This exercise also has several versions to choose from, sitting and standing. The end result is the same in all. Sit on the ground with one or both legs extended. If one leg extended, the other should be bent with your foot beside your corresponding hip area. With your back straight, bend forward with extended arms and attempt to touch your toes. Go only as far as is comfortable. This should not hurt. You should, however, feel a slight pull in the back portion of your upper leg, your hamstring.

    B. Proper Lifting and Carrying

    When it becomes necessary to lift and/or carry heavy objects, there are some simple rules to follow:

    1. Assess the object. Can you grasp it easily and securely?

    2. Review your pathway of travel BEFORE lifting the object.

    3. Do not rush. Rushing may cause an accident.

    4. Position your self correctly:

    - Stand close to the object

    - Feet positioned shoulder-width or comfortable distance apart

    - Knees bent slightly

    - Back is straight

    5. Keep object close to your body.

    6. Slowly stand with straightened knees.

    7. If object is too heavy, GET HELP!

    8. When lifting with someone, coordinate the lift.

    Proper lifting and carrying will require changes for some people. Increase your odds in favor of a healthy back. The changes will be well worth the reward.

    VII. Infection Prevention

    A. Standard Precautions

    Standard Precautions currently recommended by OSHA and the CDC are guidelines for safe practice in the workplace. OSHA and the CDC consider it critical that needle sticks, cuts and blood exposure to mucous membranes be prevented. One should assume that all blood and body fluids are infected and direct contact should be avoided if at all possible. If inadvertent exposure occurs, thorough cleansing of the area should occur as soon as possible. Exposure is defined as a "reasonably anticipated skin, eye, mucous membrane or parenteral contact with blood, blood tinged body fluids or other potentially infectious materials. They include semen, vaginal secretions, pleural fluid, amniotic fluid, saliva, feces, and urine."

    Standard Precautions are divided into three major categories:

    · Barrier precautions

    · Handwashing

    · Sharps precautions

    Gloves are to be worn when there is direct contact with blood and or body fluids, non-intact skin, invasive procedures, when the skin on the practitioner’s hands is interrupted, if working directly with contaminated instruments or situations involving phlebotomy. When gloves are removed, hand washing should occur. If, for some reason, gloves are not used during a potentially contaminated procedure, hand washing should be done as soon as possible afterwards.

    Masks/protective eyewear are to be worn to prevent contact of potentially infectious blood and/or body fluids with mucous membranes of the oral cavity, respiratory tract and/or eyes. Masks should be worn whenever aerosolization or exposure to blood or body fluid is likely.

    Gowns are worn to prevent contact of blood or other body fluids with clothing or skin. These items are to be removed prior to leaving the surgical suite.

    Shoe covers should be worn when involved in procedures that are likely to produce gross contamination, (e.g., orthopedic procedures)

    B. Tuberculosis

    Mycobacterium tuberculosis is the bacteria that causes human tuberculosis infection and disease. Pathogens involve two steps: the acquisition of the infection and the development of the disease after infection. Approximately 10% of infections progress to active disease. The following information is meant to inform you and assist you in making important decisions regarding your health.

    Tuberculosis is primarily spread by airborne transmission and inhalation of aerosolized and airborne bacteria. This occurs when a person with ACTIVE pulmonary disease coughs, talks or sneezes. The risk of contracting TB is equal to the density (or quantity) of organisms and the duration of each exposure.

    Tiny foci of TB bacilli, estimated at 1-5 microns in diameter, are released into the air where they can remain suspended for prolonged periods of time. These tiny aerosol droplets are inhaled and carried to the host’s alveoli where they implant. It is here where the disease process begins. The body’s natural immunity takes over and walls off the offensive organism, or forms tubercles or nodules in the lungs. (It should be noted that although TB is primarily a respiratory disease, it can be located in other organs in the body, e.g., liver, spleen, brain, kidneys, etc.) This individual is now considered a carrier for TB. They will become "active" or capable of transmitting the disease should they suffer a decrease in their immunity and can no longer maintain the wall around the TB organism. Common pulmonary symptoms include cough, sputum production, hemoptysis (blood producing cough), night sweats and chest discomfort.

    The first step in preventing/controlling TB is by blocking host-to-host transmission. One way to accomplish this is with adequate respiratory protection. There are a variety of masks that effectively filter out the airborne TB bacteria. Many facilities supply their employees with HEPA (high efficiency particulate air) respirators. The HEPA respirator is very effective in capturing airborne TB due to its multi layer construction. While aerosolized TB is 1-5 microns, the respirators filter down to 0.3 microns. This offers more than adequate protection.

    High-risk occupational areas include those where there is irrigation of abscesses, endotracheal intubation and suctioning, and bronchoscopies of the patient with active pulmonary TB. These procedures generate droplet nuclei, which expose health care workers to TB. The operating room, respiratory therapy, emergency departments, and bronchoscopy suites are all considered high-risk occupational areas.

      1. Tuberculosis Exposure
      2. If you are exposed to a patient that has or is suspected of having TB, you should get a Mantoux skin test, sometimes referred to as a PPD (purified protein derivative), within a day or two. If your test is negative, you should repeat the test in 10-12 weeks. If your initial test is positive, you have been exposed at some time in the past. Exposures that produce positive Mantoux tests require sufficient quantities of airborne TB to cause the development of antibodies. This will be seen in the 10-12 week Mantoux follow-up. If this is the case, there are recommendations that are prudent to adhere to. You should see a physician right away. There are a few

        procedures that he/she may want to carry out. A chest x-ray may be taken and additional tests may be done before a decision is made toward drug therapy.

        The CDC recommends "suspected and/or diagnosed patients with TB be placed in atmospheric isolation". How does that relate to us in the OR? The patient must be wearing a mask when transported from their room to the OR. In the operating room, employees that occupy the surgical suite where the patient is wear HEPA respirators. Traffic into and out of the room is limited to that which is absolutely essential. Upon completion of the procedure, the room is considered "exposed" and closed for a period of not less than one hour.

        It is the responsibility of the patient’s physician to promptly evaluate symptoms that may suggest TB, and to communicate this to the nursing staff. Communication unfortunately does not always occur in a timely fashion. Therefore, it is good practice to ask the OR personnel you will be working with if the patient has any communicable diseases.

        2. Multi-drug Resistant Tuberculosis (MDRTB)

        Currently this is one of the great concerns of the 1990s. Strains of TB have developed over the past forty years that have grown resistant to the drugs most commonly used. Treatment of MDRTB includes rigorous drug therapy of three to five medications daily for a period of 9-18 months. Noncompliance is a problem given the amount and frequency of drug administration required over a long period of time.

        C. Human Immunodeficiency Virus (HIV)/AIDS/Hepatitis A, B & C

        In today’s health care field we have many concerns. Some are overwhelming. Several concerns that continue to weigh heavily on the mind of every health care worker are the threat of contracting HIV, AIDS or Hepatitis. Within the operating room this threat is significant due to the fact there is blood and/or body fluid exposure on almost every case. How we deal with this exposure is of utmost importance. In this section, you will be provided with enough information to assist you in your everyday and professional life.

        D. HIV/AIDS/Hepatitis Information 1998

        If you sustain a puncture type injury while in the OR:

        1. Wash the exposed area thoroughly.

      3. Notify the charge nurse.
      4. File an injury report.
      5. Follow the facility’s formal procedure/protocol.

    The CDC estimates that HIV is 100x less virulent than the Hepatitis B virus (HBV). For example, in one milliliter of blood containing HIV, there may be a few hundred to 10,000 viral particles. This may seem high. However, when you compare the exposure and transmissibility of HBV there are more than 100 million viral particles. This is a significant difference. Your chance of contracting hepatitis is far greater than HIV. There are ways to protect yourself. Standard precautions should be followed at all times to protect yourself.

    Several studies indicate that transmission of HIV by a single percutaneous exposure to HIV infected blood is 0.3% to 0.4%. The exposures in the studies were hollow core needle sticks (e.g., IV or hypodermic needles). The risk of HIV transmission with a solid core needle stick (e.g., atraumatic or suture needle) is much less. Another determining factor in this equation is the viral load of the patient in question. Logically, with an increased viral load the patient’s blood becomes a more significant occupational exposure.

    E. Methods of Transmission in the Operating Room

    HIV is found in blood, semen, and vaginal secretions of carriers. These substances can be found in the typical operating room during various procedures. There have been documented transmissions after skin was exposed (no further explanation as to whether the skin was abraded or impaired) or mucous membranes were exposed. Precautions have recently been applied to feces, saliva, nasal secretions, sputum, or vomitus. The rationale is that there is a possibility these substances may contain blood, yet may not be visible to the naked eye.

    Orthopedic procedures in the OR expose personnel to high-speed drills and sharp instrumentation as well as blood exposure with potential for aerosolization of bloody fluid. Sharp bone fragments, K-wires, and drills all pose additional hazards to the orthopedic surgical team.

      1. Specific Questions and Answers

    Suggestions to make your work environment safer include:

    · Take your time.

    · Check the integrity of your gloves before handling items contaminated with blood or body fluids. In a 1988 study the overall perforation rate for surgical team members was 48% for surgeons and 42% for scrub personnel.

    · Wear eye protection. Goggles with front and side protection, not prescription glasses, are considered proper eye guards by OSHA. Eye protection should protect the wearer from exposures from the side as well as from the top.

    1. Is there potential for aerosolization of HIV from lasers, ESUs, drills, saws, etc?

    It is important to distinguish between true airborne transmission due to respirable infectious particles (aerosolization) and that due to droplets. Infectious particles are measured as less than 10 microns. Droplets are relatively large particles, greater than 10 microns. Transmission due to droplet can be intercepted by way of protective barriers. The standard surgical mask, OSHA approved eyewear, and face shields are all considered effective barriers. Protection against transmission due to true aerosolization would require the use of respirators with self-contained breathing apparatus. Due to the cost involved, self-contained breathing apparatuses are unlikely to be seen in many ORs. There has not, to date, been any documented case of HIV transmission via aerosolized exposure.

    2. How should instruments be cleaned and sterilized in the hospital today?

    Standard sterilization techniques are adequate to sterilize and disinfect instruments that have been contaminated with blood and body substances. Processing instruments using a modern washer decontaminator (a rotating high water pressure, high temperature "dishwasher") is optimal. If not available, processing contaminated instruments through a washer sterilizer is also acceptable. If instruments are not cleaned manually prior to being placed in the washer sterilizer, the blood and body tissue may "bake" on the metal surfaces of the instrumentation during the drying cycle. Consequently, it requires a great deal of time and effort to remove the baked on bioburden from the instruments. Nothing is as effective in decontamination as manual handwashing of instruments. However, this is not considered the safest practice.

    3. What is your risk for HIV and HBV, HCV seroconversion with exposure?

    The CDC estimates 12,000 health care workers are exposed to HBV annually. The exposure of HIV in health care workers is not currently available. After a single needle stick your exposure to:

    - HBV ranges from 1.9% to less than 40%

    - HCV ranges from 2.7% to 10%

    - HIV is approximately 0.3% to 0.44%. (It is slightly more

    from a patient with a high viral load of HIV).

    Between 5% and 10% of persons with acute HBV become chronic carriers; 15% to 25% of carriers will eventually die of liver cancer or cirrhosis. Every year 150 to 250 health care workers die from complications of occupationally exposed HBV. This grim statistic is preventable with the HBV vaccine. The vaccine is available for a nominal fee. Check with your family physician. Also, check with your employer. There is always the possibility your employer will provide the vaccination to your at no cost.

    Recent indications for surface longevity for HBV is one week, possibly longer. Whereas with HIV, drying causes a 90-99% reduction in HIV concentration within several hours.

    HIV seroconversion will most likely occur within the first 6-12 weeks after exposure. Although, within 24-48 hours HIV invades the T lymphocytes and is massively reproduced. After five days virus can be detected in the blood.

    4. Is there risk of HIV seroconversion after mucous membrane exposure?

    Yes, there have been reported cases of HIV seroconversion due to mucous membrane exposure. The estimated risk factor is 0.3%-0.44%. Mucous membranes include eyes, nares, and mouth.

    5. What should health care workers use for appropriate barrier precautions to prevent skin and mucous membrane exposures?

    Gloves should be worn when touching bloody surfaces, non-intact skin, or mucous membranes. Gloves should be changed after each patient contact and hands should be washed immediately after removal of gloves. Rubbing your eyes or nose with contaminated hands is a risk you must avoid. There are studies that have revealed a permeability of 10%-30% of latex gloves when exposed to "fluid and mechanical stress similar to conditions encountered in surgery." This permeability allows for the potential passage of bacteria and viruses to the health care worker from the patient and vice versa.

    6. What are some of the highest risk surgical activities?

    It is important to identify those surgical procedures and techniques that have the potential for percutaneous and exposure to blood. One study found that over half of percutaneous exposures to blood occurred when the suture needle or tissue being sutured was held with the surgeon’s fingers, during manipulation of the suture needle in the needle holder, and/or during passage of sharp instruments. Cases found to be at high risk were:

    · lengthy in duration,

    · emergencies,

    · obstetric,

    · gynecologic,

    · trauma,

    · burn,

    · cardiothoracic,

    · orthopedic,

    · vascular, and

    · those associated with extensive patient blood loss.

    1. Confidentiality

    The issue of patient confidentiality is of utmost importance. Every patient who enters any hospital facility has the right to the expect privacy. This means, very plainly, you must never divulge a patient’s name and situation to anyone who is not directly involved with their care. For example, it is not acceptable to discuss the cases you are involved with in the hospital elevator, cafeteria, lobby, hallways, or anywhere else where a lack of privacy may be an issue. You never know who can overhear your conversation and/or what their relationship is to the patient involved. This type of poor judgement has happened in the past with unfortunate results.

    Along with the confidentiality of their medical care, the patient has the right to expect their medical record will also be held in confidence. This is a tremendously important issue. In most states, a patient whose medical information has been unlawfully used or disclosed, and who has sustained an economic loss or personal injury, may recover compensatory damages and the costs of litigation. This could be devastating for all parties involved.

     

     

     

     

     

     

     

     

     

     

     

     

     

    IX. References

    Association of Operating Room Nurses, Inc. 1999 Safety in the Perioperative

    Setting, Denver, CO. (CD-ROM)

    Association of Operating Room Nurses, Inc. 2001 Standards &

    Recommended Practices, Denver, CO.

    Atkinson, Lucy Jo RN, BSN, MS, & Fortunato, Nancymarie Howard, RN, BSN,

    BA, Med, RNFA, CNOR. 2000. Berry & Kohn’s Operating Room Technique,

    Ninth Edition. St. Louis, MO. Mosby-Year Book, Inc.

    Ballinger, Phillip W., M.S., R.T., Merrill’s Atlas of Radiographic Positions and

    Radiologic Procedures, 7th Ed. Mosby, 1991.

    Bell, David M., M.D., Shapiro, Craig N., M.D., & Holmberg, Scott D., M.D.

    Surgical Practice in Hospitals: HIV and the Surgical Team Today’s O.R. Nurse November 1990

    Bushong, Stewart, Physics PhD., Radiation Science for Technologists: Physics

    Biology and Protection, Mosby, 1997

    Centers for Disease Control and Prevention 45:22. Provisional public health

    service recommendation for chemoprophyslaxis after occupational exposure to

    HIV, June 7, 1991.

    ECRI. Operating Room Risk Management, Chapter 14 Education/Credentialing.

    Plymouth Meeting, PA, 1998.

    Fuller, Joanna Ruth, CST. 1994. Surgical Technology: Principles and Practice,

    Third Edition. Philadelphia, PA. W.B. Saunders Company

    Girard, Nancy J., RN, MSN, CNOR, CS Aseptic Technique: Stressing the

    Fundamentals, 1990 Association of Operating Room Nurses, Inc. Denver, CO

    HCV greatest bloodborne threat expert says. OR Manager, June 1997 Vol 13,

    No 6. OR Manager, Inc., Boulder, CO

    Meeker, Margaret Huth, RN, BSN, CNOR, & Rothrock, Jane c., RN, DNSC,

    CNOR. 1999. Alexander’s Care of the Patient in Surgery, 11th Edition.

    St. Louis, MO: Mosby.

    News Briefs. December 1994. The Surgical Technologist.

    Recommendations for Preventing Transmission of Human Immunodeficiency

    Virus and Hepatitis B Virus to Patients During Exposure-Prone Invasive

    Procedures. Morbidity and Mortality Weekly Report Recommendations and

    Reports U.S. Department of Health and Human Services, Centers for Disease

    Control. Atlanta, Georgia. 40:RR-8 pg. 1-9. July 12, 1991

    Reeter, Alan K., MSEE, CCE Operating Room Fire Medfilms, Inc. 1991 Tucson,

    AZ

    Reeter, Alan K., MSEE, CCE & Richard Jensen, MSEd, Hand Washing

    Medfilms, Inc. 1987 Tucson, AZ

    Rodts, Mary Faut, MS, RN, ONC & Benson, Daniel R., M.D., HIV Precautions for

    Prevention in the Workplace Orthopaedic Nursing,11 51-57. September/

    October 1992

    Schall, Bridget, RN, CNOR, Proper Surgical Attire: Fashion vs Function, 1992

    Association of Operating Room Nurses, Inc. Denver, CO

    Seerem, Euclid, R.T., M.S., Radiation Protection, 1st Ed., Lippincott, 1997

    Sharbaugh, Robert J., Ph.D., Bloodborne Infections: A Practical Guide to OSHA

    Compliance Professional Education Division of Johnson & Johnson Medical,

    Inc. 1992

    Statkiewicz-Shere, Mary Alice, R.T,; Paul Visconti, PhD.; E. Russi Ritinour,

    PhD., Radiation Protection in Medical Radiography, 2nd Ed Mosby, 1993.

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

    X. Appendix

    Policy and Guidelines for Vendors

    In order to preserve the safety and privacy of surgical patients the following policies and guidelines have been established.

    ANY ALAMEDA COUNTY HOSPITAL

    OPERATING ROOM POLICIES AND PROCEDURES

    Title: VENDORS

    Page 1 of 2

    Date Implemented:

    Date Reviewed/Revised:

    Authorized Approval:

     

     

    Definition

    A vendor is any person providing contractual services to the facility and/or physician or any person representing a manufacturer of products.

    Purpose

    1. To protect the privacy of the patient undergoing surgical intervention.

    2. To decrease the risk of infection by limiting the number of people entering the operating room.

    1. To inform the vendor of the conditions by which he/she is admitted to the Operating

    Room Suite and of the policies and procedures to be complied with.

    Policy

    1. The vendor’s presence and purpose should be prescheduled and approved by the OR

    management and surgeon.

    2. A system is in place to document that the vendor has completed, at a minimum,

    instruction in asepsis, fire and safety, infection prevention, bloodborne pathogens and

    patients’ rights.

    3. The vendor must agree to respect the privacy and confidentiality of patients, physicians and facility employees at all times.

    4. The vendor must wear identification while in the facility.

    5. The Biomedical Department must check all electrical equipment brought in by the vendor before use.

    6. Vendors may not operate, control, or touch any equipment being used on a patient. At the request of the attending physician and for the sole purpose of ensuring patient safety, they may troubleshoot, offer advice if equipment malfunctions, calibrate or program equipment, and provide any other technical support needed to ensure that equipment functions safely.

    7. The vendor with specialized training may perform remote calibration (e.g. pacemakers,

    laser).

    8. Vendors may NOT:

    a. scrub on procedures,

    b. open sterile supplies, or

    c. sterilize instruments or equipment.

    9. The presence of the vendor will be documented in the intraoperative nurse’s notes.

    1. The registered nurse should direct the vendor’s activities.

     

     

     

    Title: VENDORS

    Page 2 of 2

    Vendor Guidelines

    1. The patient should be informed that the vendor will be in the OR.

    2. The vendor:

    a. Should exhibit professional behavior at all times.

    b. Should be "in good health" (e.g. no fever, cough or runny nose).

    c. Should be physically oriented to the OR.

    d. Should sign in and out of the facility for safety and security purposes.

    e. Is limited to the operating room and case for which they have been requested.

    f. May contact only those personnel for which authorization has been granted.

    g. Is strongly discouraged from soliciting business in the OR Suite.

    h. May not use department telephones for making personal calls or for making

    other sales contacts.

    i. Should not bring outside baggage into the OR. Carts and unsterile equipment must be wiped with a disinfectant before entering the OR.

    3. The number of vendors in any one OR may be restricted.

    4. Any member of the OR team may direct the vendor to leave the OR at any time.

     

     

     

     

    XI. Vendor Agreement

      1. I have read the information in Vendors in the Operating Room packet.
      2. I have completed and returned the quiz for each section to the individual I received the packet from.
      3. I have read and agree to abide by the conditions presented in the Vendors policy and guidelines.

     

     

     

    Name of Representative: ___________________________________

    (Please Print)

     

    Signature of Representative: ___________________________________

     

    Name of Company: ___________________________________

     

    Local Mailing Address ___________________________________

    ___________________________________

     

    Local Telephone Number ___________________________________

     

    Date: ___________________________________

     

     

     

     

     

     

     

     

     

     

     

     

     

    Aseptic Technique Review Name ____________________

    Date ____________________

    1. Aseptic technique:

    a. is essential in the operating room

    b. the prevention of contamination

    c. infers absolute cleanliness

    d. all of the above

    2. Should there be a breach in aseptic technique, it is a professional's ___________that leads them to correct the problem in spite of any personal embarrassment it may cause:

    a. supervisors

    b. surgeon

    c. department policies and procedures

    d. surgical conscience

    3. An example of sterile personnel is the:

    a. Surgical assistant

    b. Circulating nurse

    c. Anesthesiologist

    d. Operating Room Aide/Orderly

    4. Placing sterile supplies onto the sterile field is:

    1. a. an acceptable practice for the sales representative with more than five

    years of experience

      1. something that requires knowledge of asepsis and significant practice and therefore should only be performed by perioperative personnel

    c. performed by the nearest person to the field

    d. none of the above

    5. Talking during a surgical procedure should be:

    a. engaged in freely

    b. between the surgeon and scrub person only

    c. prohibited always

    d. pertinent and essential to the surgical case in progress

    6. When it becomes necessary to move around a surgical suite you should:

      1. limit your movement to that which is absolutely necessary and never travel

    between two sterile fields

    b. face the wall and travel the perimeter of the room

    1. c. take the most direct path even if it means you travel between two sterile fields

    d. take the path of least resistance

     

     

     

     

     

    Surgical Attire Review Name ____________________

    Date ____________________

    1. Today, the generally accepted purpose of surgical attire is:

    a. protection against transmission of blood borne pathogens

    b. protection from hazardous chemicals

    c. reducing microorganisms shed into the environment

    d. all of the above

    2. The purpose of the shoe cover is:

    a. for housekeeping purposes

    b. personal protective equipment

    c. keeping the wearer's shoes clean

    d. all of the above

    3. The standard surgical mask filters down to:

    a. 1-6 microns

    b. 3-5 microns

    c. 0.1-0.6 microns

    d. 0.6-10 microns

    4. The proper method of wearing a surgical mask is:

    a. loose around the face to prevent a feeling of claustrophobia

    b. snug around the face to prevent gapping and ventilation of unfiltered respiratory contaminants

    c. ties that crisscross in the back

    d. none of the above

    5. The life of a non-woven surgical mask is approximately:

    a. 4-6 hours

    b. 3-5 hours

    c. 1 and 1/2-2 hours

    d. 30 minutes

    6. Ideally, jewelry should be:

    a. removed prior to entrance into the operating room because it can harbor harmful microorganisms

    b. pinned to the outside of the scrub clothing while in the operating room

    c. cleaned thoroughly prior to being pinned to the outside of the scrub clothing

    d. none of the above

     

     

     

     

     

     

     

    Potential Hazards in the Operating Name ____________________

    Room Review Date ____________________

    Page 1 of 2

    1. Three ingredients are essential for fire. They are potential, fuel and a supporter of combustion.

    a. true

    b. false

    2. Should a fire start in the operating room you are visiting, the first thing you should do is:

    a. rescue those in immediate danger, including yourself

    b. run

    c. scream and run

    d. stop, drop and roll

    3. When visiting various hospitals it is a good idea to locate fire alarms in your location. Should a fire break out in the OR this information is most helpful.

    a. True

    b. False

    4. Time is of the essence in an operating room fire because of:

    a. the impacted surgery schedule

    b. toxic fumes produced by burning materials

    c. the intensity of the fire

    d. firefighters not being allowed in the operating room

    5. To properly apply the contents of a fire extinguisher to a fire you:

    a. pull the pin, sweep the fire with the contents, and call the fire department

    b. aim toward the fire and pull the pin

    c. pull the pin from the handle, aim at the base of the flame, squeeze the handle, and disburse the contents in a sweeping motion at the base of the fire

    d. scream and run

    6. Stray laser beams can:

    a. create an interesting visual display in a dimly lit operating room

    b. create a fire hazard

    c. increase the heat in the room

    d. none of the above

    7. Isolated electrical power is:

    a. the force of electrons along the pathway

    b. grounded to earth

    c. the boundaries of electricity

    d. retained in a "circuit" and does not seek ground

     

     

     

     

    Potential Hazards in the Operating Room Review

    Page 2 of 2

    1. The Line Isolation Monitor (LIM) sounds after you plug in your equipment to demonstrate. This generally means:
      1. there is a degradation of the electrical system, in either your equipment or the electrical outlet
      2. the electricity is about to go out
      3. a fire is impending
      4. none of the above

    9. When there is an electrical outage in the operating room:

    a. the hospital generators will activate within 10 seconds

    b. it is important to remain calm and refrain from movement for your safety

    c. it can be disruptive to the surgery

    d. all of the above

    10. Structural hazards in the operating room are many. Items to be aware of are:

    a. lifts

    b. electrical cords

    c. IV poles

    d. air tanks or air hoses

    e. all of the above

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

    Radiation Safety Review Name ____________________

    Date ____________________

    1. Cumulative effects of radiation exposure have been linked to a variety of health problems.

    a. True

    b. False

    2. Three items that lessen your likelihood of overexposure to radiation are:

    a. time, distance, and shielding

    b. time, distance, and moving

    c. movement, water, and shielding

    d. none of the above

    3. With distance:

    a. radiation particles fall to the ground

    b. radiation scatters and decreases exponentially

    c. radiation is neutralized

    d. none of the above

    4. Acceptable methods of shielding used in operating rooms are:

    a. portable lead doors

    b. aprons and thyroid shields

    c. leaving the room during radiation exposure

    d. all of the above

    5. Lead is an important shielding material for radiation exposure because:

    a. it absorbs scattered radiation and is an excellent source of protection

    b. it neutralizes radiation upon contact

    c. it repels radiation

    d. none of the above

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

    Handwashing Review Name ____________________

    Date ____________________

    1. The majority of nosocomial infections can be eliminated with:

    a. an appropriate mask

    b. wide spectrum antibiotics

    c. effective hand washing

    d. physician attendance

    2. Microorganisms that are repeatedly cultured from the skin are identified as:

    a. resident microorganisms

    b. transient microorganisms

    c. water soluble microorganisms

    d. stubborn microorganisms

    3. Abrasions and cuts should be covered prior to entering the operating room because they:

    a. present an unsightly appearance

    b. can bleed on the patient

    c. create an optimal environment for infection

    d. none of the above.

    4. According to guidelines set forth by the CDC, hand washing should occur:

    a. prior to and after using the restroom.

    b. prior to and after eating

    c. prior to and after smoking or blowing your nose

    d. prior to entering the operating room and after leaving the operating room

    e. all of the above

    5. After removing gloves from your hands, it is a good practice to:

    a. wash your hands with an antimicrobial soap

    b. fold them and put them in your pocket for future use

    c. give them to a coworker to use

    d. none of the above.

    6. In the operating room, it is most desirable to have:

    a. attractive, long acrylic finger nails

    b. well manicured, natural finger nails

    c. silk tips with nail polish

    d. none of the above.

    7. Washing your hands with antimicrobial soap is beneficial because:

    a. it can be purchased in bulk

    b. it is readily available

    c. it has antimicrobial properties that build in the dermal layers leading to residual killing action

    d. none of the above.

     

    Back Safety Review Name ____________________

    Date ____________________

    1. The vertebrae have free mobility and can rotate approximately 180 degrees.

    a. True

    b. False

     

    2. Back strain and pain are commonly caused by:

    a. simultaneous lifting and twisting

    b. touching your toes

    c. sleeping wrong

    d. none of the above.

    3. What percent of today’s workforce will develop a back injury?

    a. 20%

    b. 40%

    c. 60%

    d. 80%

    4. The injured employee may suffer from:

    a. constant pain

    b. lost time from work

    c. permanent disability

    d. all of the above.

    5. ___________________can lead to back injury.

    a. Incorrect posture

    b. A large protruding abdomen

    c. Poor body mechanics

    d. all of the above.

    6. Circle two exercises that help strengthen the back and abdominal muscles.

    a. pull-ups

    b. pelvic tilt

    c. side twists

    d. half sit-ups

    7. When lifting heavy objects, which of the following is a good rule to follow for safety?

    a. keep your back rounded

    b. keep the object close to your body

    c. keep your feet close together

    d. none of the above.

    8. If an object is too heavy for you to lift, get help.

    a. True

    b. False

    Infection Prevention Review Name ____________________

    Date ____________________

    Page 1 of 2

    1. What type of mask personnel in the OR should wear in the event a patient is suspected of having TB?

    a. cloth

    b. cone

    c. standard surgical mask

    d. High Efficiency Particulate Air (HEPA) respirator

    2. How long can mycobacterium tuberculosis remain airborne?

    a. prolonged periods of time

    b. 8 hours

    c. long enough for a thorough room turnover between cases

    d. 24 hours

    3. Identify two signs and symptoms of TB.

    a. night sweats

    b. day sweats

    c. bloody sputum produced with coughing

    d. blurred vision

    4. What is the primary method of TB transmission?

    a. hand to hand contact

    b. oral-fecal route

    c. respiratory

    d. blood borne pathogen

    5. What is the schedule for PPD tests for a recent exposure?

    a. immediately and again within three months

    b. three days and again in three weeks

    c. it is not important to follow up an exposure of you feel OK

    d. within a few days of exposure and again in 10-12 weeks

    6. Standard Precautions refers to:

    a. methods of safe practice and self-protection against infectious diseases in the workplace.

    b. standard operating procedures

    c. wearing gloves without holes in them

    d. good hand washing techniques

    7. When there is a reasonable chance of skin, mucous membrane, or parenteral contact with blood or bloody fluids you should wear:

    a. mask

    b. gloves

    c. eye protection

    d. all of the above

    Infection Prevention Review

    Page 2 of 2

    8. Fluids that may fall into the category of potentially infectious materials are:

    a. blood & bloody saliva

    b. semen & vaginal secretions

    c. amniotic & pleural fluid

    d. feces & urine

    e. all of the above

    9. HIV is 100 times more virulent than Hepatitis B.

    a. True

    b. False

    10. A single percutaneous HIV exposure via a hollow bore needle, produces a transmission rate of:

    a. .3%-.4%

    b. 0.2%-4.0%

    c. 1%

    d. 25%

    11. The standard surgical mask offers adequate protection from droplet exposure.

    a. True

    b. False

    12. There are an estimated _________health care workers exposed to Hepatitis B annually.

    a. 500

    b. 12,000

    c. 700

    13. With exposure to the Hepatitis B virus, the risk of transmission is:

    a. 1.9% to < 40%

    b. 10% to 20%

    c. 1.8% to 3.6%

    d. 7% to > 30%

    14. HIV can be transmitted via a blood splash to the eye (mucous membrane).

    a. True

    b. False

    15. There is a vaccination to prevent hepatitis B.

    a. true

    b. false

     

     

     

     

     

    Answer Key

    Aseptic Technique Infection Prevention Overall Scores

    1. d (6/6=100%) 1. d (15/15=100%) 57/57 = 100%

    2. d (5/6=83%) 2. a (14/15=93%) 56/57 = 98%

    3. a (4/6=67%) 3. a,c (13/15=87%) 55/57 = 97%

    4. b (3/6=50%) 4. c (12/15=80%) 54/57 = 95%

    5. d (2/6=33%) 5. d (11/15=73%) 53/57 = 93%

    6. a (1/6=17%) 6. a (10/15=67%) 52/57 = 91%

    7. d (9/15=60%) 51/57 = 90%

    Surgical Attire 8. e (8/15=53%) 50/57 = 88%

    1. d (6/6=100%) 9. b (7/15=47%) 49/57 = 86%

    2. d (5/6=83%) 10. a (6/15=40%) 48/57 = 84%

    3. c (4/6=67%) 11. a (5/15=33%) 47/57 = 83%

    4. b (3/6=50%) 12. b (4/15=27%) 46/57 = 81%

    5. c (2/6=33%) 13. a (3/15=20%) 45/57 = 79%

    6. a (1/6=17%) 14. a (2/15=12%) 44/57 = 77%

    15. a (1/15=7%) 43/57 = 75%

    Potential Hazards In 42/57 = 74%

    The O.R. 41/57 = 72%

    1. a (10/10=100%) 40/57 = 70%

    1. a (9/10=90%) < 40/57 = Failure
    2. a (8/10=80%)
    3. b (7/10=70%)
    4. c (6/10=60%)
    5. b (5/10=50%)
    6. d (4/10=40%)
    7. a (3/10=30%)
    8. d (2/10=20%)
    9. e (1/10=10%)

    Radiation Safety

    1. a (5/5=100%)
    2. a (4/5=80%)
    3. b (3/5=60%)
    4. d (2/5=40%)
    5. a (1/5=20%)

    Handwashing

    1. c (7/7=100%)
    2. a (6/7=86%)
    3. c (5/7=71%)
    4. e (4/7=57%)
    5. a (3/7=43%)
    6. b (2/7=29%)
    7. c (1/7=14%)

    Back Safety

    1. b (8/8=100%) 6. b,d (3/8 = 38%)
    2. a (7/8=88%) 7. b (2/8 = 25%
    3. d (6/8=75%) 8. a (1/8 = 13%)
    4. d (5/8=63%)

    5. d (4/8=50%)

    Test Scores

    Name Date

    Name of Company

     

    Aseptic Technique

    Surgical Attire

    Potential Hazards in the O.R.

    Radiation Safety

    Handwashing

    Back Safety

    Infection Prevention

     

     

     

     

    Sales Representative Agreement Signed ? Yes ? No

    Sales Representative Agreement Attached ? Yes ? No

     

     

    Verified By

    Title

     

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    Created 13 August 2001

    Association of periOperative Registered Nurses, Alameda County, California

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