Transcript ppt

ACORN Standard
Perioperative Attire
Australian College of Operating Room Nurses
Copyright © 2014 ACORN
Acknowledgements
ACORN acknowledges the
contribution of the dedicated
perioperative nurses who
contributed to the current and past
review of this standard.
Copyright © 2014 ACORN
Perioperative Attire
Introduction
‘Perioperative Attire’ was the
second standard to be released
in 2014 and followed on
perfectly from the first on
Infection Prevention
Copyright © 2014 ACORN
Perioperative Attire
Introduction
The most common question from
our first and subsequent webinars
has asked ‘how to engage medical
staff, anaesthetists/ surgeons’ in
the standards and how to aid in
their compliance Copyright © 2014 ACORN
Its all about you!
Perioperative Attire
Introduction
My suggestions are;
• Provide not only the hospital policy and the
standard but also the papers that are referenced
in the attire standard and this webinar
• Remind them ‘its all about you’
• Teach medical staff early in their career
Copyright © 2014 ACORN
Perioperative Attire
Introduction
The healthcare environment is everchanging with new multi-drug resistant
pathogens, and viral mutations emerging
regularly (as seen in Hepatitis)
(Di Giacoma-Geffers 2014: Spruce, 2014)
Copyright © 2014 ACORN
Perioperative Attire
Introduction
• It is important to try keep our thinking and
practice ahead of these pathogens and
their mutations
• A clean perioperative environment is of
benefit to both our patients and
perioperative team members Copyright
(Spruce, ©
2014)
2014 ACORN
Perioperative Attire
Introduction
• Whilst there is no evidence actually linking non-sterile
perioperative attire to patient infections, the skin of
staff is known to be a major dispersal source of
bacteria into the air
(McHugh, et al. 2014)
• We also know that mean bacterial counts on non-
sterile perioperative attire do increase significantly
during the course of the day so practices to decrease
bacteria are required
(Hee et al 2014)
Copyright © 2014 ACORN
Perioperative Attire
Background
Although there are no randomised clinical trials
that provide a direct link between surgical attire
and surgical site infections, there are other data
such as case studies and laboratory studies that
reveal the risk of infection to patients when
exposed to skin, mucous membranes and hair
from perioperative team members
(Spruce, 2014)
Copyright © 2014 ACORN
Perioperative Attire
Background
• Example: A nurse anaesthetist with forearm
dermatitis was the carrier of Gordonia
bronchialis in the sternal wounds of three
cardiac surgical patients
• Her house mate was found to be positive
• The bacteria was traced to the washing
machine in the healthcare worker’s home (Wright
2012 as cited in Spruce, 2014)
Copyright © 2014 ACORN
Perioperative Attire
Background
• Human skin is colonised with bacteria
that are continuously shed and dispersed
into the air (Hee, 2014)
• Squames are flakes of skin (up to 80
microns in size) that are shed from the
body
(Clark and De Calcina-Goff 2009)
Copyright © 2014 ACORN
Perioperative Attire
Background
• Dispersal of squames occurs via the natural
convection air flows occurring around the human
body because our body temperature is higher than
ambient air
(Clark and De Calcina-Goff 2009)
• Airborne particles are able to contaminate the
surgical site directly by sedimentation or indirectly
by settling on surgical instruments (ACORN policy)
Copyright © 2014 ACORN
Perioperative Attire
Background
• The scalp can be colonised & skin
shedding from the scalp can carry bacteria
• Staphylococcus aureus & staphlococcus
epidermidis adhered tightly to hair and
could not be removed by routine
shampooing
(Spruce 2014)
Copyright © 2014 ACORN
Perioperative Attire
This presentation will:
• Discuss some new additions to the standard
• Look at the ‘Salient Information’ provided in
this standard
• Discuss some possible controversial issues
• Provide some ideas for implementation of the
‘Perioperative Attire’ standard
Copyright © 2014 ACORN
Perioperative Attire
New information
• There are now 11 statements compared to 9 in the
previous standard
• Expanded information on many aspects of perioperative
attire will be found in this standard
• New information concerned with:
– What constitutes perioperative attire
– Change rooms & locker space
– Tightening up of hair covering
Copyright © 2014 ACORN
Perioperative Attire
New information
Perioperative attire includes;
• Head covers
• Dresses with pantyhose or trousers
• Warm up jackets
• Dedicated footwear
(no more boiler suits)
Copyright © 2014 ACORN
Salient Information
Statement 1
Perioperative attire is correctly donned in a
dedicated change room prior to entering a
semi-restricted or restricted area in the
operating suite
• Wear clean attire daily & change when wet or soiled
• Do not re-wear attire (no hanging in change room or
in lockers)
Copyright © 2014 ACORN
Salient Information
Statement 1
• Only wear undergarments that can be
covered
• Ensure any body hair on the back and neck
are covered
• Prevent perioperative attire coming into
contact with the floor
Copyright © 2014 ACORN
Salient Information
Statement 1
• Wear a fastened long sleeved, cuffed warm up
jacket in restricted areas when not scrubbed
• Refrain from tying jackets around the waist
• Wear a visible name tag (not lanyard) that is
secured to the perioperative attire (e.g.
pocket) and clean this regularly
Copyright © 2014 ACORN
Salient Information
Statement 1
The healthcare facility shall provide a dedicated
change room which provides enough storage
to prevent belongings having to be brought
into restricted areas;
• Briefcases
• Backpacks
• Handbags
• Laptops
Copyright © 2014 ACORN
Salient Information
Statement 2
The scalp, sideburns, facial hair, ears and the nape
of the neck are completely covered by a surgical
head cover to minimise microbial dispersal
• Bacterial contamination of the operative field is
less with appropriate head gear (McHugh et al 2014)
• As skin squames shed in the absence of hair,
healthcare worker without scalp hair should also
wear surgical head covers
Copyright © 2014 ACORN
Salient Information
Statement 2
• Ensure that hairclips and pins are kept to a
minimum and secured particularly when
working in close proximity to the sterile field
• Cloth head covers must cover all hair & meet
Australian standards for textiles, labelling
and laundering (Australian Standards 2003)
Copyright © 2014 ACORN
Salient Information
Statement 2
• Ensure that headwear worn for religious or
cultural reasons is cleaned daily and
completely covered by a balaclava-type
covering
• If woven fabric hats are permitted in your
hospital, please study this standard carefully
with regards to fabrics (tightly woven), sewing
& labelling
Copyright © 2014 ACORN
Salient Information
Statement 3
Perioperative attire is supplied and laundered by
the healthcare facility, or its contractors
• The healthcare facility must;
– meet Australian standards in design & manufacture
– provide sufficient quantities of attire
– ensure laundering is provided in an approved
facility and transported and stored appropriately
Copyright © 2014 ACORN
Salient Information
Statement 4
• As zone conformity contributes to an effective
infection prevention strategy by minimising
introduction of micro-organisms, appropriate
perioperative attire should be worn in
restricted, semi-restricted and non-restricted
areas
• A full breakdown of these areas is provided in
the standard
Copyright © 2014 ACORN
Salient Information
Statement 5
There is expanded information on footwear under both
Australian Standards (2010) and Workplace Health and Safety
guidelines
• This includes;
– foot protection
– foot being fully enclosed
– supportive to the foot
– clean and cleanable
•
Wash hands after handling footwear
Copyright © 2014 ACORN
Salient Information
Statement 5
• The routine use of overshoes is not
recommended as bacterial numbers on hands
are increased when donning and removing
• A connection has been made between the
bacteria of floor origin and the rate of surgical
infections (WHO 2009)
• The function of overshoes is to protect footwear
during gross contaminationCopyright © 2014 ACORN
Salient Information
Statement 6
• Disposable face masks should be worn
correctly to limit droplets arising from
oropharyngeal flora OR to protect the
wearer from blood or body splashes
• Facemasks with 95% bacterial filtration
have a wearer time of 4 hours
Copyright © 2014 ACORN
Salient Information
Statement 7
• Fingernails should be short, clean, and healthy and
free from artificial or acrylic nails or nail additives
• Fungal or other nail infections should be managed by
a staff health process
• No trials have investigated plain nail polish and
surgical site infections, however, accumulated
evidence has shown that artificial nails, or nails
longer than 2mm may harbour bacteria and fungi
Copyright © 2014 ACORN
Salient Information
Statement 8
• Jewellery worn within the perioperative environment is
limited to items that can be contained within the
perioperative attire
• Only sleeper or securely fastened stud earrings should
be worn
• Rings can be caught causing avulsion of the soft tissue
• Neck chains can harbour bacteria and also be grabbed by
patients causing possible injury or breakage
Copyright © 2014 ACORN
Salient Information
Statement 9
Wear personal protective attire according to the activity
or surgery being performed, including, but not limited to;
• Gloves (double gloving)
• Gowns
• Eyewear
• Masks
• Lead aprons
• Thyroid protectors
• Overshoes (if gross contamination)
Copyright © 2014 ACORN
Salient Information
Statement 10
• Provide initial (at orientation) and on-going education
on Perioperative Attire so all staff have an up to date
understanding of the standard
• Have competencies in wearing perioperative attire as
this provides evidence that staff have been provided
with the opportunity to understand the purpose of the
correct wearing of attire
• Assess compliance in wearing perioperative attire
Copyright © 2014 ACORN
Salient Information
Statement 11
• Compliance of perioperative attire will
form part of the auditing process for the
infection prevention standard (NHMRC
2010, ACSQHC 2012)
• Quality indicators for auditing are
provided in this statement
Copyright © 2014 ACORN
Implications for practice
Implementation Ideas
Develop a policy regarding the use of cover
gowns outside theatre
• Whilst there is conflicting evidence regarding
the infection control advantages of cover
gowns (Hee 2014), public perception and
confidence in the ‘standard of care’ may be a
benefit (Landry 2013)
Copyright © 2014 ACORN
Implications for practice
Develop a policy regarding the use
personal woven fabric hats and clothes
• The fabric must be tightly woven
• Bacteria on dispersed epithelial cells can break into
fragments of approximately 20 microns in size and
would pass through some cotton fabrics that have a
pore size of 80 + 100 microns (McHugh 2014)
• The information surrounding this is complex, and needs
to be looked at carefully by the hospital and all the staff
Copyright © 2014 ACORN
Implications for practice
• Organise a system so that appropriate
personal attire owned by individual staff
members can be laundered by the facility
• With at-risk patients such as the
immunocompromised, consider having
facemasks changed after 4 hours of
surgery
Copyright © 2014 ACORN
Implications for practice
• Perform an educational audit on
perioperative attire
• Where needed include this information at
the operating suite orientation process
• Provide in-service education to existing
staff to assist in compliance
Copyright © 2014 ACORN
Possible controversial issues
• Lack of definite evidence linking perioperative
attire and surgical site infections
• A very recent paper published in ‘Anesthesia
2014’ looked at bacterial counts on surgical attire
worn outside the theatre without cover gowns
• They found that visits to the ward and office
respectively did not significantly increase
bacterial contamination of scrub suits (Hee 2014)
Copyright © 2014 ACORN
Possible controversial issues
• This research also showed that all scrub suits
(including the ones that were not soiled or those that
had not left the operating suite) had significantly
higher counts over the course of the day supporting
a possible lunchtime change for everyone (Hee 2014)
• They did not however consider the bacteria they may
have been taking out of theatre to the ward or office
areas!
Copyright © 2014 ACORN
Possible controversial issues
•
This research is interesting however
further research is required
•
This may be a great project for someone
looking for some perioperative research
•
In fact, this entire topic reveals many
research gaps waiting to be filled
Copyright © 2014 ACORN
Perioperative Attire
Strategies for implementation
• At the Monday morning meeting – clean name
tags each week
• AORN 2014 suggests some ideas to help
implementation;
– Be prepared to support the policy with evidence
(there are both nursing & medical references)
Copyright © 2014 ACORN
Perioperative Attire
Strategies for implementation
– Enlist support from the executive team – if
you link this policy to the infection
prevention standard with regards to
accreditation, this may be of assistance
– Emphasise to staff the importance of the
standard for patients, staff and their
families safety
Copyright © 2014 ACORN
Perioperative Attire
Strategies for implementation
– invite team members to discuss and
brainstorm issues to gain ownership &
compliance
– be aware of barriers to practice change, such
as lack of awareness and education
– Send out electronic copies or letters explaining
the standard
(AORN 2014)
Copyright © 2014 ACORN
Perioperative Attire
In conclusion (medical)
A quote from The Surgeon 2014 …
“In a general sense the donning of surgical attire
helps to demarcate the operating theatre
complex from the rest of the hospital indicating a
higher risk zone requiring extra efforts in asepsis
to prevent infection and
Copyright © 2014 ACORN
Perioperative Attire
In conclusion (continued)
by making theatre personnel change to specific
surgical scrubs, shoes and hats before entering
the theatre complex, this ritualistic behaviour
serves as a daily reminder of the importance of
sterility and infection prevention practices in
the operating theatre” (McHugh et al. 2014)
Copyright © 2014 ACORN
Perioperative Attire
In conclusion (nursing)
A quote from AORN Journal 2014 ….
“ It is up to perioperative nurses to protect
patients, themselves and others from the risk of
infection”
It may be challenging to get everyone to adhere to
the attire rules, but perioperative nurses are up to
the challenge if they understand what is at stake’’
Copyright © 2014 ACORN
Perioperative Attire
QUESTIONS ?
Copyright © 2014 ACORN
References
1.
Spruce L. (2014). Back to Basics: Surgical Attire and Cleanliness. AORN
Journal, Vol. 99, No. 1. pp.138-46.
2.
McHugh S, Corrigan M, Hill A, Humphreys H. (2014). Surgical attire,
practices and their perception in the prevention of surgical site
infection. The Surgeon, Vol. 12, No. 1. pp.47-52.
3.
Hee H, Lee S, Chia S, Lu Q, Liew A, Ng A. (2014). Bacterial
contamination of surgical scrub suits worn outside the operating
theatre: A randomised crossover study Anaesthesia, Vol. 69, No. 8.
pp.816-25.
4.
Di Giacomo-Geffers E. (2014). Reviewing requirements for surgical
attire. Briefings on the Joint Commission, Vol. 25, No. 2. pp.7-9.
5.
Landry K, Dornelles A, Hayek G, Deichmann R. (2013). Patient
Preferences for doctor attire: The white coat place in the medical
profession. The Ochsner Journal Vol. 13, No. 3. pp.334-42.
References
6.
Australian Commission on Safety and Quality in Health Care,
(2012) National Safety and Quality Health Service Standards,
Canberra: Commonwealth Government 2012.
7.
World Health Organization, (2009) Guidelines for Safe Surgery.
Department of Human Service, 2009.
8.
Clark R, De-Calcina-Goff M. (2009). Some aspects of the
airborne transmission of infection. Journal of the Royal Society
of Interface, Vol. 6, No. Suppl. 6. pp.S767-S82.
9.
National Health and Medical Research Council. (2010)
Australian Guidelines for the Prevention and Control if
Infection in Healthcare. Commonwealth of Australia; 2010