Guidelines in Practice: Preoperative Patient Skin Antisepsis.

Surgical site infections (SSIs) frequently involve resident bacteria (eg, Staphylococcus aureus) on the patient's skin. Strategies to help prevent SSIs include removing soil and transient microorganisms from the skin before surgery. Preoperative decolonization, preoperative bathing, and application of an effective skin antiseptic at the surgical site are components of a multimodal approach to reducing microorganisms to subpathogenic levels. As members of an interdisciplinary team, perioperative RNs are essential in the development and implementation of SSI prevention bundles to promote patient safety. This article discusses recommendations from the AORN "Guideline for preoperative patient skin antisepsis" for decolonization protocols, preoperative bathing, and selection of surgical site antiseptics. A scenario describes the process a facility team uses to determine components of an SSI prevention bundle after recognizing an increase in infections from multidrug-resistant organisms.

Guidelines in Practice: Specimen Management.

Specimen management is a complex process that involves multiple steps and numerous health care personnel. Preventable specimen-related errors are common and can occur during any phase of the specimen management process. Perioperative nurses manage specimens during the preanalytical phase before specimens are delivered to the laboratory for analysis. Errors in the preanalytical phase may include mislabeling, miscommunication, loss of a specimen, improper fixation of the specimen, and transport failures. The AORN "Guideline for specimen management" provides guidance for managing specimens collected during surgical and other invasive procedures, including recommendations for handling specific types of specimens. This article discusses the guideline recommendations for intraoperative team communication, transfer from the sterile field, containment, transport, and quality. A scenario describes a facility team's use of a root cause analysis and a failure modes and effects analysis tool to assess the risk and effects of specimen errors and create a process improvement plan.

Guidelines in Practice: Instrument Cleaning.

Care of surgical instruments and devices is a multifaceted process that begins with an interdisciplinary team's prepurchase determination that the facility has the resources to correctly process the items. Processing encompasses point-of use removal of organic and inorganic material, transport to the processing area, use of chemicals and equipment to clean and decontaminate the item, and inspection for cleanliness and function. Failure to correctly clean and decontaminate surgical instruments can impede subsequent sterilization processes and place patients at risk for developing surgical site infections. The AORN "Guideline for care and cleaning of surgical instruments" provides general guidance for care of reusable medical devices. When processing instruments, perioperative team members should use the guideline in conjunction with the instrument manufacturer's validated instructions for use. This article discusses the guideline recommendations related to prepurchase evaluation, point-of-use treatment, transport, cleaning and decontamination, and education; it also includes a scenario to illustrate these topics.

Guidelines in Practice: Electrosurgical Safety.

Surgeons routinely use electrosurgical devices to cut and coagulate tissue during surgical procedures. However, hazards associated with electrosurgery (eg, burns, electrical shock, fire) can place patients or personnel at risk. Perioperative nurses should standardize processes, preoperatively assess the risks for electrosurgical injuries, and participate in education activities on electrosurgical safety to help prevent injuries from occurring. The AORN "Guideline for electrosurgical safety" provides guidance to perioperative personnel for safe use of electrosurgical units, electrocautery devices, and argon-enhanced coagulators. This article discusses prevention of electrosurgical unit injuries, including those that can be caused by electrosurgical accessories. A scenario describes how a team investigating two incidents related to use of electrosurgery uses an assessment tool to identify risks for injury and includes a report of these risks in the surgical briefing. Perioperative RNs should review the entire guideline for additional information when creating and updating policies and procedures for electrosurgical safety.

Guidelines in Practice: Environmental Cleaning.

All perioperative personnel are responsible for providing a clean environment for patients undergoing operative or other invasive procedures. A contaminated environment can contribute to the incidence of surgical site infections when a patient's skin contacts a contaminated surface or personnel touch a contaminated surface and then transmit microbes to the patient. Airborne contaminants may settle on the sterile field or in the surgical wound. The AORN "Guideline for environmental cleaning" provides guidance on cleaning product selection, cleaning procedures, personnel education, competency verification, and monitoring cleanliness through performance improvement processes. This article discusses guideline recommendations for cleaning procedures and cleaning of operating and procedure rooms. A scenario describes how an ambulatory surgery center team identifies gaps in cleaning processes and modifies the cleaning checklist to improve these processes. Perioperative RNs should review the entire guideline for additional information when creating and updating policies and procedures for environmental cleaning.

Guidelines in Practice: Autologous Tissue Management.

During a surgical procedure, the surgeon may remove tissue to be preserved and stored for replantation or autotransplantation on or in the same individual during a subsequent procedure. The AORN "Guideline for autologous tissue management" provides guidance to perioperative personnel for preserving and handling autologous tissue (eg, cranial bone flaps, parathyroid tissue, skin, vessels) that will be replanted or autotransplanted in the same facility in which the tissue was surgically removed. This article discusses guideline recommendations on packaging, labeling, storing, and disposing of autologous tissue. A scenario describes how an interdisciplinary team uses the AORN guideline and Guideline Essentials to identify recommendations and tools to incorporate into their policy and procedures after their facility receives a citation during a regulatory site visit. Perioperative RNs should review the entire guideline for additional information when creating and updating policies and procedures on autologous tissue management.

Guidelines in Practice: Sharps Safety.

Perioperative personnel are at risk for sharps injuries when using devices with sharp points and edges and therefore are at risk for infection from exposure to blood and other potentially infectious body fluids. The Occupational Safety and Health Administration bloodborne pathogens standard is the regulatory document that health care employers must follow to protect personnel who are at risk for sharps injuries. The AORN "Guideline for sharps safety" provides guidance to perioperative personnel for identifying sharps hazards and implementing best practices to prevent injuries. This article discusses the guideline recommendations for developing and implementing work practice controls and administrative controls for handling sharps. A scenario describes an interdisciplinary team's efforts to decrease specific sharps injuries and develop policies and procedures based on the identified risks and practice changes. Perioperative RNs should review the entire guideline for additional information when creating and updating policies and procedures for sharps safety.

Guidelines in Practice: Sterilization Packaging Systems.

Sterile processing personnel use sterilization packaging systems to sterilize reusable medical devices and protect them from contamination until perioperative nurses deliver the items to the sterile field. The AORN "Guideline for sterilization packaging systems" provides guidance for evaluating and selecting appropriate packaging systems based on compatibility with the items to be sterilized and the sterilization method, preparing items for sterilization, and verifying achievement of sterilization parameters. This article discusses the guideline recommendations for selecting and using packaging systems and educating personnel about their use. A scenario provides an example in which a perioperative educator uses an audit tool to determine sterile processing and perioperative team members' educational needs related to packaging systems and to evaluate the outcomes after an education session and competency verification activities. Perioperative RNs should review the entire guideline for additional information and guidance when creating and updating policies and procedures on use of sterilization packaging systems.

Guidelines in Practice: Hypothermia Prevention.

All patients are at risk for unplanned hypothermia in the perioperative practice setting. Adverse outcomes attributed to hypothermia include myocardial events, surgical site infections, poor wound healing, increased blood loss, and prolonged postanesthesia care unit stays. The AORN "Guideline for prevention of hypothermia" includes recommendations for measuring the patient's body temperature, selecting methods for prevention of unplanned hypothermia, and implementing the selected insulation and warming interventions. This article discusses guideline recommendations related to using a consistent temperature measurement method through all phases of perioperative care, assessing risk for hypothermia in all patients, and prewarming perioperative patients. A scenario provides an example in which an interdisciplinary facility team uses a gap analysis and a risk assessment to determine the process for implementing recommendations from this guideline. Perioperative RNs should review the entire guideline for additional information and for guidance when creating and updating policies and procedures related to unplanned hypothermia.

Guidelines in Practice: Surgical Attire.

Surgical attire provides a barrier to microorganisms shed from health care workers' skin and hair to help protect patients and promote a clean environment. The AORN "Guideline for surgical attire" includes recommendations for selecting, wearing, and cleaning surgical attire that are based on the highest-quality evidence available. Recommendations are rated as Regulatory Requirement, Recommendation, Conditional Recommendation, or No Recommendation according to the level of evidence, an assessment of the benefits versus harms of implementing specific interventions, and consideration of resources required to implement the interventions. This article discusses guideline recommendations related to laundering surgical attire, wearing long-sleeved attire, and wearing head coverings. A scenario provides an example in which an interdisciplinary facility team uses a gap analysis and a risk assessment to prioritize process changes for implementing the guideline. Perioperative personnel should review the entire guideline for additional information and for guidance when creating and updating policies and procedures.

Guideline Implementation: Transmission-Based Precautions.

Transmission of an infectious agent requires a source of infection, a mode of transmission, and a vulnerable host. The most important interventions for preventing infection transmission are hand hygiene and use of standard precautions for all patients. Other precautions are based on how an organism is transmitted; these include contact, airborne, and droplet precautions. The cornerstone of transmission-based precautions is appropriate use of personal protective equipment to protect personnel and patients from infection. This article discusses key takeaways from the "AORN guideline for transmission-based precautions," including using standard precautions; wearing personal protective equipment when exposure to blood, body fluids, or other potentially infectious materials is anticipated; and using contact precautions during care of patients known or suspected to be infected or colonized with pathogens transmitted by direct or indirect contact. Perioperative RNs should review the complete guideline for additional information and for guidance when writing and updating policies and procedures.

Guideline Implementation: Sterile Technique.

Establishing and maintaining a sterile field to help prevent surgical site infections requires specific knowledge and skills and is among the most important responsibilities of the perioperative RN. Perioperative RNs should remain vigilant in monitoring the sterile field, communicate when a break in sterile technique occurs, and collaborate with other surgical team members to correct the break in technique. The AORN "Guideline for sterile technique" provides guidance to perioperative personnel on the principles and processes of sterile technique. This article elaborates on key takeaways from the guideline, including using sterile technique when donning sterile gowns and gloves, delivering sterile items to the sterile field, using drapes to establish a sterile field, and maintaining the sterile field. Perioperative RNs should review the complete guideline for additional information and for guidance when writing and updating policies and procedures.

Guideline Implementation: A Safe Environment of Care.

The OR can be a hazardous environment for both patients and personnel. Low lighting, fluid on the floor, combustible and noxious chemicals, multiple pieces of equipment with cords, the fast pace, and numerous distractions are only some of the factors that can lead to an accident or injury. The AORN "Guideline for a safe environment of care" provides guidance to perioperative personnel on identifying hazards and implementing processes to mitigate risks in the perioperative setting. This article elaborates on key takeaways from the guideline, including precautions to reduce the risk of OR fires; occupational injuries associated with slips, trips, and falls; and handling, storing, and using hazardous chemicals. Perioperative RNs should review the complete guideline for additional information and for guidance when writing and updating policies and procedures.

Guideline Implementation: Sterilization.

Ensuring that reusable surgical instruments and medical devices have been sterilized is an important factor in preventing surgical site infections. The sterilization method for a particular device is based on the device design, material, packaging, compatibility with the sterilant, load limitations, and safety requirements. Perioperative team members must review the manufacturer's instructions for cleaning, packaging, and sterilizing the device to determine the correct sterilization process. The AORN "Guideline for sterilization" provides guidance for processing reusable medical devices for use in perioperative and procedural settings. This article elaborates on key takeaways from the guideline, including processing a device based on the intended use of the item, protecting sterile items during transport, reprocessing by immediate-use steam sterilization when certain conditions can be met, and educating personnel who perform sterile processing activities. Perioperative RNs should review the complete guideline for additional information and for guidance when writing and updating policies and procedures.

Guideline Implementation: Design and Maintenance of the Surgical Suite.

The primary considerations for any health care facility construction or renovation project are the design and function of the new areas, assessment of environmental risks for airborne contamination, and containment of dust and moisture created during construction activities. Disruptions created by construction inside or outside a health care facility can increase airborne organisms, such as Aspergillus, that can lead to infections; thus, infection prevention and control are integral parts of construction planning. The AORN "Guideline for design and maintenance of the surgical suite" provides guidance to perioperative team members for developing a functional program to guide the construction/renovation project, use of evidence-based design principles, measures to contain construction-related dust and debris, and maintenance of utilities after planned or emergent utility failures. Perioperative nurses should review the complete guideline for additional information and for guidance when writing and updating policies and procedures.

Guideline Implementation: Safe Patient Handling and Movement: 1.8 www.aornjournal.org/content/cme.

Physical stressors that occur with patient and equipment handling in the OR (eg, moving or lifting patients, carrying heavy instrument sets, prolonged standing) can contribute to musculoskeletal disorders for perioperative personnel. In addition to increasing patient safety, safe patient handling and movement (SPHM) programs have been shown to reduce the risk and severity of injuries, workers' compensation costs, and personnel fatigue and to increase health care workers' morale and quality of life. The AORN "Guideline for safe patient handling and movement" provides guidance for implementing an SPHM program. This article discusses key takeaways from the guideline, including forming an interdisciplinary team to oversee the SPHM program, selecting safe patient handling technologies and equipment, and assessing the unique needs of each patient to develop an individualized plan for SPHM. Perioperative RNs should review the complete guideline for additional information and for guidance when writing and updating policies and procedures.

Guideline Implementation: Manual Chemical High-Level Disinfection: 1.5 www.aornjournal.org/content/cme.

The Spaulding system recommends sterilization or, at minimum, high-level disinfection for semicritical medical items (ie, items that come into contact with mucous membranes or nonintact skin). High-level disinfection deactivates all types of microorganisms except bacterial spores and prions. If high-level disinfection is not performed correctly, however, contaminated medical or surgical devices could transmit pathogens to patients. Reusable semicritical items may be processed using manual methods when manual chemical high-level disinfection is the only processing method recommended by the manufacturer. The AORN "Guideline for manual chemical high-level disinfection" provides guidance to health care personnel for performing effective manual chemical high-level disinfection and preventing injury associated with the use of high-level disinfectant chemicals. This article focuses on key points of the guideline that address preparation of items for high-level disinfection, use of high-level disinfectants, health care personnel safety, and documentation. Perioperative RNs should review the complete guideline for additional information and for guidance when writing and updating policies and procedures.

Guideline Implementation: Team Communication: 1.8 www.aornjournal.org/content/cme.

The perioperative environment is fast paced and complex. Competing responsibilities, noise and distractions, and reluctance of team members to speak up when they are aware of a potential patient safety issue are all barriers to effective communication in the perioperative setting. Communication breakdowns among health care providers can lead to medical errors and patient harm. Accurate and complete communication about the patient and the patient's care can contribute to improved efficiency, better patient outcomes, and fewer adverse events. The new AORN "Guideline for team communication" provides guidance on using standardized processes and tools to improve the quality of team communication. The key points address hand overs between phases of perioperative care; a briefing to share the surgical plan; a time out to verify the correct patient, procedure, site, and side; and a debriefing to discuss what was learned and how to improve. Perioperative RNs should review the complete guideline for additional information and for guidance when writing and updating policies and procedures.

Guideline Implementation: Prevention of Venous Thromboembolism: 1.6 www.aornjournal.org/content/cme.

Venous thromboembolism (VTE) is a serious and costly complication of surgery. Many cases of health care-associated VTE could be prevented with the use of evidenced-based interventions. Perioperative nurses are in a position to advocate for patients by assessing each patient's risk for VTE and implementing preventive measures, such as administering anticoagulants as ordered and correctly applying graduated compression stockings and intermittent pneumatic compression devices. The updated AORN "Guideline for prevention of venous thromboembolism" provides guidance to perioperative team members for developing and implementing a protocol for VTE prevention. This article focuses on key points of the guideline that address preoperative patient assessment for VTE and bleeding risk, safe use of pharmacologic and mechanical prophylaxis, patient education on prevention and signs and symptoms of VTE, and a quality management program to evaluate VTE prophylaxis outcomes and protocol compliance. Perioperative nurses should review the complete guideline for additional information and for guidance when writing and updating policies and procedures.