AORN Alameda County, CA
Research Committee

September 4, 2002 Clinical Question
October 2002 Newsletter



18 Responses – Participating Facilities: Summit, San Ramon, Washington, ValleyCare, Kaiser Pleasanton, Eden, Kaiser Oakland, Washington Outpatient.

1. You are circulating for a patient who is undergoing an abdominal hysterectomy. The surgeon has ordered an abdominal prep, a vaginal prep, and placement of a oley catheter. In what order do you perform these activities?

A. Abdominal prep, vaginal prep, foley insertion - 7
B. Abdominal prep, foley insertion, vaginal prep - 0
C. Vaginal prep, foley insertion, abdominal prep - 3
D. Vaginal prep, abdominal prep, foley insertion - 0
E. Foley insertion, abdominal prep, vaginal prep - 0
F. Foley insertion, vaginal prep, abdominal prep - 8
Rationale for "A" – "Clean" to "Dirty"
Rationale for "C" – Potential contamination of abdomen if vaginal prep and foley are done second. Bacterial count at urethral orifice will be decreased if vagina is prepped first.
Rationale for "F" – Potential contamination of abdomen if vagina prep and foley are done second. Foley before vaginal prep because foley is going into "sterile" bladder. Prep for abdomen last because it should be "most sterile" at incision site.
Note: Practice varies between individuals at a particular facility.

2. Do you use one (1) prep set-up or two (2) to complete the activities listed above?
A. One - 6
B. Two - 12

3. Do you use one (1) pair of gloves for all three (3) activities or two (2) pair?
A. One - 1
B. Two - 16

4. Would you say that the majority of time, your facility removes hair at the incision site by:
A. Shaving with a razor before arriving in the OR - 2
B. Shaving with a razor in the OR -11
C. Clipping -5

April 3 Clinical Question
June 2002 Newsletter


Name of facilities : Eden, Kaiser Oakland, Kaiser Pleasanton, San Leandro Surgery Center, San Ramon, Summit, The Surgery Center Oakland, Washington Outpatient Surgery Center.

1. Which of the following do you consistently document with regard to implants? (Check all that apply.)

11- Location
13 - Name
13 - Manufacturer
13 - Lot #
13 - Serial #
12 - Type
13 - Size
7- Expiration Date
0 - Other (describe)

2. Do you flash implants? (Check the box that best describes the practice at your facility.)

0 - Frequently
4 - Occasionally
6 - Seldom
3 - Never

3. If you flash implants, do you (Check all that apply.)

10 - Run a biological monitor with the load?
0 - Quarantine the device until negative biological monitoring is obtained?
3 - N/A – we don’t flash implants

4. Do you allow sales representatives to open implants onto the sterile field? (Check the box that best describes the practice at your facility.)

0 - Frequently
0 - Occasionally
1 - Seldom
12- Never

By Kathie Shea


February 2002 Clinical Question – Positioning
April 2002 Newsletter


Name of Facilities: Eden, Kaiser Oakland, Kaiser Pleasanton, San Leandro Surgery Center, San Ramon, Summit, The Surgery Center Oakland, Washington Outpatient Surgery Center

1. The patient should be assessed for positioning needs before transfer to the OR bed. Circle the word that best describes how frequently you routinely assess your patient for each of the following factors:

a. Age
Always-15
Frequently-2
Seldom

b. Height & weight
Always-13
Frequently-4
Seldom

c. Nutritional status
Always-8
Frequently-7
Seldom-2

d. Preexisting conditions
Always-13
Frequently-4
Seldom

e. Physical/mobility limits
Always-17
Frequently
Seldom

f. Type of planned anesthesia
Always-16
Frequently-1
Seldom

g. Length of surgery
Always-14
Frequently-3
Seldom

h. Position required
Always-17
Frequently
Seldom

2. You are gathering the necessary equipment and supplies to position your patient in lithotomy position for an extensive GYN procedure scheduled to take three hours. In general, which of the following criteria will be met by the positioning equipment you will use at your facility? (Circle the letters of all that apply)

a. Available in a variety of appropriate sizes and shapes-8
b. Durable material and design-14
c. Ability to maintain normal capillary interface pressure (23-32mmHg)-11
d. Resistant to moisture and microorganisms-10
e. Fire resistant-8
f. Non-allergenic to the patient-12
g. Easy to use-14
h. If non-disposable, easy to clean/disinfect-13
i. Easy to store and handle-11

3. Which of the following do you routinely document with regard to positioning? (Circle the letters of all that apply)

a. Assessment-14
b. Type and location of positioning and/or padding devices-16
c. Names and titles of persons positioning the patient-9
d. Postoperative outcome evaluation-11

By Kathie Shea


Clinical Question for November 2001
December 2001 Newsletter

What type of tourniquet cuffs do you usually use ?
Disposable - 0
Reusable - 8

If you use reusable cuffs do you usually COVER (3) or CLEAN (5) them?

If you clean them, who is usually responsible for the cleaning?
Circulating Nurse - 1
Scrub Person
Surgical Orderly/Aide - 3
Housekeeper
Central Supply/Sterile Processing - 2
PACU - 1

If you clean them, what product(s) do you use?
Amphyl or whatever is being used to clean the OR. Germicide.
Don’t know - 3

"If using a disposable tourniquet, discard after use unless the manufacturer recommends that it can be resterilized. Reusable cuffs and bladders should be cleaned, rinsed, and dried according to the level of contamination and the manufacturers’ instructions. If the bladder is removable, care must be taken to prevent introducing water into the bladder through the ports. All the connecting tubing should be wiped with a hospital-grade chemical germicide and dried before storage. Water in the port can cause microbial growth…All connecting tubing should be wiped with a hospital-grade chemical germicide that is not deleterious to the rubber or the polyethylene substance. Manufacturers’ written instructions for drying should be followed. The cuff and bladder should be thoroughly rinsed because detergent residue may increase the chances of allergic reactions and decrease the life of the rubber bladder. The tourniquet cuff should be protected adequately from contamination during surgery; therefore, washing is the only decontamination procedure indicated. If blood or other body fluids come in contact with the tourniquet components, however, more intensive cleaning with an enzymatic detergent is necessary. The tourniquet may be a source of contamination, even though the skin area under the tourniquet may be protected by use of various padding materials."
Source: AORN Recommended Practices, 2001 – Pneumatic Tourniquet

Submitted by Kathie Shea


Clinical Question for October 2001
December 2001 Newsletter


1. Does your facility have a policy that requires patients to remove their jewelry prior to surgery?
8 Yes 1 No

2. If yes, does this policy address body-piercing jewelry?
5 Yes 3 No

3. What do you do if patients cannot remove their jewelry (e.g., rings)?

A. Leave the jewelry on uncovered
B. Cut off the jewelry (1)
C. Leave the jewelry on and place a barrier (e.g., gauze or tape) between the jewelry and the patient’s skin (8)
D. Other (please list) Depends on what type of surgery if it is a procedure that the hands might swell and cut of circulation to finger, rings are cut off. Only our open-heart patients or those having surgeries where 3rd spacing is anticipated have their rings removed. If we cannot remove the rings with our tricks, they will be cut off. Otherwise, rings that cannot be removed are taped.

4. What do you do if the patient can remove their jewelry but refuses to do so?
Explain the risks – tape. Tape rings. Speak to physician. Tape, if operative site, refer to surgeon/anesthesiologist and must be removed. Document on nurse’s notes and try to cover to protect from burns. Tape over and explain that if it is necessary to save the extremity or digit, it will be cut off. Explain the risk they are assuming by leaving it on and do as above (3 C). I do not know if this has happened. We have had patients refuse but when we tell them about burns, they usually concede.

5. Have you ever removed body-piercing jewelry in your O.R.?
7 Yes 4 No
(20 on one patient)

6. Do you have specialized tools to remove body-piercing jewelry in your O.R.?
3 Yes 7 No

7. Where do you document that the patient had jewelry on during surgery?
Preop Notes (4) / OR Nurse’s Notes (4) / Nurses Notes (1) / Valuables Form (1)

Submitted by Kathie Shea

Clinical Question for September 2001
December 2001 Newsletter


Facilities surveyed: East Bay Surgery Center, Eden, Kaiser Oakland, San Ramon, Summit, UCSF

Warming Cabinets


1. What do you store in your Operating Room/PACU warming cabinets? (check all that apply)
11 Blankets 8 IV Solutions
10 Irrigating Solutions (water/saline) 0 Prep Solutions


2. What is the temperature range your warmers are set at?
IV = 94-104 F (2) ? (1) 40 C (1)
Irr = 120-150 F (3) < 130* F (1)

3. Do you monitor the temperature of your warming cabinets? 8 Yes 4 No

4. If you answered "Yes" to #3, how to do monitor the temperature?
5 Visual check of internal thermometer
3 Recording graph attached to the warmer

Please answer these questions only if you place solutions in your warmer.

5. Do you date your solutions when placing them in the warmer?
4 Yes 7 No

6. Do you know the maximum amount of time that your solutions manufacturer (e.g. Baxter, McGaw) recommends that their solutions be stored in the warmer?
5 Yes 6 No
If yes, how long is this time? IV = 2 weeks (3) 4 weeks (1)
Irr = 8 weeks (3) 4 weeks (1)

7. Do you know the maximum temperature that your solutions manufacturer (e.g.
Baxter, McGaw) recommends that their solutions be stored at in the warmer?
4 Yes 7 No
If yes, what is this temperature? IV = 104 F (3) Irr = 150 F (3)
40 C (1) Can’t remember (1)




Manufacturer’s Guidelines for Solutions Placed in Warming Cabinets


Call your manufacturer for written documentation for your files.

Abbott
Recommendations – IV Solutions
Store up to 2 weeks at 104 F or less. Once removed, use within 24 hours or discard.

Recommendations – Irrigating Solutions
Store up to 60 days (semi-rigid containers) at 150 F or less. Once removed, use within 24 hours or discard.

Baxter
Recommendations – IV Solutions
Store up to 2 weeks at 110-115 F.

Recommendations – Irrigating Solutions
Store for a maximum of 72 hours at 150 F or less. Once removed, they cannot be rewarmed.

McGaw
Recommendations – IV Solutions
Store up to 4 weeks at 40 C. Once removed they must be discarded.

Recommendations – Irrigating Solutions
Store up to 4 weeks at 40 C. May be stored at temperature not to exceed 150 F for a maximum of 16 hours. Once removed they must be discarded.

Submitted by Kathie Shea

Vendor Packets Now Available!
August 2001

This year your Research Committee conducted a Delphi study to develop a standardized policy and procedure for vendors in the operating room and a credentialing packet for vendors to complete before entering the operating room.

Our goal was to develop these documents for use by all facilities in Alameda County. The objective was to provide a consistent standard that all of our facilities could implement. We felt that this would create a win-win situation for both our facilities and our vendors.

The facilities would win because they could feel confident that the same “rules” applied to all the vendors we share in our geographic location. The facilities would also be assured that the vendors entering their operating rooms had received the same information regarding aseptic technique, surgical attire, potential hazards in the O.R., radiation safety, hand washing, back safety, and infection control. Facilities could call, fax, or e-mail other facilities to ascertain successful credentialing of a vendor or they could administer the credentialing program to vendors who were new to the area or served only that facility. An additional benefit of this credentialing was that it exceeded regulatory and accreditation body regulations and standards.

The vendors would win because they would not have to learn the “rules” of each facility; they would be basically the same wherever they traveled within the county (this translates into about 23 different facilities). They would also feel confident that they had the knowledge needed to access and provide effective services within the operating room.

We began the project by developing the Vendors in the Operating Room policy and procedure template. Chapter members were active in the first two rounds of the Delphi study ranking the most important components to be included. Two more rounds followed this by the Research Committee. Lastly, the language was edited and reviewed by the Risk Managers of two facilities.

The second phase was the credentialing packet. The Research Committee chair had a packet she had developed and used successfully for two years. The committee reviewed the packet to determine which topics to keep, delete and/or add. This was based on a review of current JCAHO standards and information obtained from ECRI (the first and only independent organization committed to the improvement of the safety, efficacy, and cost-effectiveness of health care technology) and AORN. Once this was determined the committee reviewed the content and updated it to reflect the most current practice.

This fall we hope to get each facility a copy of the policy and procedure template and one complete copy of the credentialing packet with a cover letter describing in detail how to use the documents. In addition, it’s also on our web site at the Vendor Policy page.

Thanks to all of you who helped in this potentially invaluable resource!

Submitted by Kathie Shea

Research Committee Meeting Minutes
December 2000

Date/Time: September 19, 2000, 6 - 8 p.m.
Location: Eden Medical Center
Present: Donna Benotti, Ann Ceasri, Beth Mar, Kathie Shea, Sophie Taylor

1. The committee work plan was reviewed and adopted.
2. Kathie shared results of a literature search regarding the sales reps in the OR.
3. Components for a survey of chapter members regarding activities of sales reps in the OR were identified. The survey will be distributed at the October chapter meeting (October survey results).

Date/Time: October 25, 2000, 6 - 8 p.m.
Location: Eden Medical Center
Present: Donna Benotti, Ann Ceasri, Beth Mar, Kathie Shea

1. Summarized results of the October chapter meeting survey were reviewed (October survey results).
. Kathie called all facilities in Alameda County that were not represented at the October meeting to secure their input. Responses from a total of 21 facilities were incorporated into the survey.
2. The committee adopted the survey as a standard of practice in the community.
3. A copy of the summarized survey will be sent to Mary Ritchie for inclusion in the chapter newsletter.
4. Consensus was reached on which components from the survey and literature search should be included in a November survey of chapter members. The purpose of this survey is to determine which components should be included in a policy, a guideline, or not at all.

Date/Time: November 14, 2000, 6 - 8 p.m.

Location: Eden Medical Center

Present: Denise Bickert, Donna Benotti, Ann Ceasri, Beth Mar, Kathie Shea

1. Denise was introduced and welcomed as a new member of the committee.
2. Summarized results of the November chapter meeting survey were reviewed (November survey results).
. Consensus was reached on components for inclusion in a policy or guideline and those that would be excluded.
3. The components for policy and guideline were then placed in a preliminary sequence in which committee members felt they occurred.
4. Kathie will send each member a worksheet listing all components for each document - policy and guideline (November survey results).
. Members will write language they believe is appropriate for each component. This will be brought to the next meeting (January 23, 2001).

Submitted by Kathie Shea

Research Committee - Sales Reps. in the O.R.
October 2000

"Don’t get too close to the sterile field." "We’re taking an x-ray, you’ll have to leave the room for a moment." "I’ll open that." Do you ever wonder what training your sales representatives receive before they enter your OR? In talking with several reps, I have discovered that some have extensive training and others very little, mostly on-the-job from other reps.

This year you have the opportunity to develop a standardized credentialing process and a policy & procedure template for all facilities in Alameda County to use when admitting manufacture’s representatives to the operating room. It’s a classic win-win situation. The reps win because they have the opportunity to receive the most current information and know what the expectations are in all of our facilities. Perioperative nurses win because the reps will be knowledgeable not only about their products, but will be better prepared to enter our ORs and will allow us less time to monitor their activities and more time to devote to our patients.

If this sounds like something you might enjoy being a part of, contact Kathie Shea (W) 925-275-8485 or (W e-mail) Kathie.Shea@tenenthealth.com. We plan to meet about 1-1.5 hours once a month this year. Your voice and that of your facility is important!! Contact Kathie today!

Submitted by Kathie Shea

Research Committee
October 1999

Your Research Committee did not take a summer vacation this year! Members of this dedicated committee spent the summer developing a pilot of the Universal Perioperative Nursing Record. After many hours of discussion (you know how detail-oriented perioperative nurses are) we reached enough consensus to proceed. The committee conceeds that the record is not perfect, but that it does reflect the minimum documentation. Committee members will begin a one-month pilot of the record during the month of October. Stay tuned for details!

By Kathie Shea

May 1999 Clinical Question
Sterilization in the Practice Setting

Sterilizers
The recommended practice (IV) states that steam sterilizers should open into each room.

Eighteen participants in the survey stated that they do not have sterilizers that open into each room, and only one person said that they do.

Implants
Fifteen people said that they flash sterilize implants only if absolutely necessary, three said that they never sterilize implants.

If flash sterilization was used for implants, eight participants stated that their facility does not require them to quarantine the implants pending the outcome of the biological monitoring, eight stated that they are required to quarantine them, and three said it was not applicable since they do not flash sterilize implants.

Parameters
The three physical parameters for adequate steam sterilization are:
Time (depends on the type of instrument being flashed)
Temperature (270 degrees)
Pressure (30 lbs)

Thirteen participants said that their facility uses Cidex, and fourteen use paracetic acid (Steris). Eight facilities use both.

Steris
It is recommended that when Steris is being used, the contents are sterilized immediately before the case. Some facilities do so, but there is a wide range. The range was from immediately prior to a case, up to two hours. One comment was that it doesn't quite matter when Steris is run if the container remains in the Steris unit with the lid shut until it is needed.

Thank you to all who participated.

By Sophie Taylor

Research Committee
June 1999 Newsletter

Research - Interesting? (Sort of) Fun? (Huh?) Exciting and Rewarding? You bet! Congratulations are in order for you and your 1998-99 Research Committee.

Phase I of the project is now complete. Results of the joint project with the Kansas City chapter were brilliantly put together in a research poster displayed at this year's AORN Congress. The poster was one of five award-winning displays presented. Let's summarize the results of the project this far:

  1. 127 interventions were taken from the Data Elements Committee Perioperative Nursing Nomenclature (PNN) document. Consensus was achieved on 75 as required for minimum documentation on all perioperative patients. 47 of these were reduced to 15 because of duplication. The end result was that a total of 44 interventions (75-47+15) were confirmed.
  2. 29 outcomes were taken from the PNN document. Consensus was achieved on 15 as required for minimum documentation. These were collapsed into 5 outcome groups.
  3. Procedural times taken directly from the American Society of Anesthesiologists (ASA) Glossary were considered and seven were accepted as essential at a minimum for all patients. These were PIF (patient in facility), PA (patient available), PIR (patient in room), PST (procedure/surgery start time), PF (procedure/surgery finish), POR (patient out of room) and arrival in PACU/ICU.

The most exciting events that occurred while our project was underway were:

  1. The PNN was accepted and officially recognized by the American Nurses Association (ANA) as the language for perioperative nursing. Its new official name is the Perioperative Nursing Data Set (PNDS).
  2. The model we used for our study was officially recognized by AORN as the nursing model for perioperative nursing.

These two factors lend enormous credibility to our study and historically make it the first study to be conducted using the PNDS and the Perioperative Nursing Model.

What's next? Phase II of course! The Research Committee will be working over the summer with the Kansas City chapter to develop an actual perioperative nursing record using the interventions and outcomes identified in Phase I. The record will be pilot tested in our chapter facilities in September, November and January (2000). Results of the pilot will be presented at next year's Congress.

Who says research isn't exciting!

By Kathie Shea

There were no March and April 1999 Clinical Questions

February 1999 Clinical Question
Recommended Practices for Skin Preparation of Patients

There were 17 respondents.

Does your facility routinely shave patients?
Yes - 6
No - 8
Depends on:
Procedure - 12
MD preference - 10
MD orders - 8

Where is hair removal performed?
In patient's room - 3 (in-house cardiac patients may be shaved on unit)
Preop holding area - 14
In O.R. - 7 (All cranis - 1, Sometimes - 1, Male hernia patients - 1)

Who routinely performs hair removal?
MD - 7
RN - 12
Nursing assistant - 7
Comments: MDs and RNs do shaves in the ORs - 2

Hair removal is accomplished by:
Depilatory cream - 0
Shaving (wet - 3, dry - 5)
Disposable safety razor - 6
Straight razor - 0
Clippers with disposable or reusable head for cranis in OR - 1
In holding area - 10

The following refer specifically to the patients having craniotomies.
Answers tabulated from seven respondents. Nine respondents don't do cranis in their facilities.

The majority of hair removal is done:
In the holding area - 1
In the OR - 6
By the MD - 5
By the RN - 0
Using clippers first - 5
Disposable safety razors next - 2

The patient's dignity is preserved by:
Drawing curtains around patient's bed in holding area and transporting patient to OR with head wrapped in towel - 0
With bouffant cap in place - 1

Close shave is performed:
Yes - 5
No - 2
In holding area - 0
In OR - 5
By MD - 3
By RN - 0

Using disposable razor doing:
Dry shave - 0
Wet shave - 1
Before patient is positioned - 0
After patient is positioned - 5
Before patient is anesthetized - 0
After patient is anesthetized - 5

Note: This research question was posed at the request of a chapter member. If you have questions regarding community practice, submit your request to the chairman of the Research Committee - Kathie Shea at 925-275-8485(w).

Remember - inquiring minds want to know!

By Donna Benotti

January 1999 Clinical Question
Reducing Radiologic Exposure in the Practice Setting

For cases involving x-ray do you:

  1. Wear a lead apron?
    always (8) sometimes (5) never (0)
  2. Leave the room while the x-ray is taken?
    always (4) sometimes (7) never (1)
  3. Wear a thyroid collar?
    always (1) sometimes (8) never (4)
  4. Wear x-ray glasses?
    always (0) sometimes (0) never (13)
  5. Wear an x-ray badge?
    always (7) sometimes (4) never (2)

The following questions pertain to the Fluoroscan (or equivalent):

  1. Does your institution have a Fluoroscan (or equivalent)?
    Yes (12) No (1)
  2. Do you have a policy specific to the Fluoroscan?
    Yes (6) No (5)
  3. Are you required to wear a lead apron?
    Yes (5) No (7)
  4. Do you wear a lead apron?
    always (4) sometimes (2) never (5)

Facilities Represented in this Clinical Question Survey:
Alta Bates, Eden, Kaiser Hayward, Kaiser Oakland, St. Rose, San Ramon Regional, Summit, The Surgery Center Oakland, Washington Hospital, Washington Outpatient Surgery Center.

By Kathie Shea

December 1998 Clinical Question


Recommended Practices for Safe Care Through Identification of Potential Hazards in the Surgical Environment

Recommended Practice II: Potential hazards associated with controlling the patient's temperature should be identified, and safe practices should be established.

The greatest decrease in body temperature occurs during the immediate preoperative phase and continues throughout the intraoperative phase. What measurers are utilized on a routine basis at your institution for this potential hazard? (Check all that apply)

Recommended Practice IV: Potential hazards associated with the use of electrical equipment in the practice setting should be identified and safe practices should be established.

Device cord length should be appropriate for intended use of equipment. Extension cords should be avoided. Are extension cords used in your perioperative setting?

(10) Yes (5) No

By Kathie Shea

October 1998 Clinical Question:
Endoscopic Minimal Access Surgery

  1. In your institution do you sterilize your endoscopic instruments or use a high level disinfectant such as gluteraldehyde?

    High level disinfect - 1
    Sterilize - 14
    Identified methods (not asked in the question but provided by several respondents): Steris - 8 : Steam - 1 : Gas - 1

  2. In your institution when doing endoscopic surgery do you use a hydrophobic filter with your insufflator?

    Yes - 11
    No - 5

By Kathie Shea

October 7, 1998 Meeting Research Committee Report

By Kathie Shea
Research Committee Chairman

Research Committee
October 1998

The September meeting started the 1998-1999 year off with a bang! Dr. Susan Kleinbeck flew out from Kansas to give an encore presentation of her 1998 Congress program, "You Can Walk the Walk, but Can You Talk the Talk?" She spoke about the importance of using the standard language of the Perioperative Nursing Data Set (PNDS) and how a standard language will make it possible communicate what has been done to effect patient outcomes, including a means to determine the effectiveness and cost of perioperative patient care.

Making History

She also discussed the research grant and how our chapter and the Kansas City Chapter are working together using the Delphi method of research, to determine which data elements perioperative nurses believe should be included in the patient record. Those attending the September meeting had the opportunity to participate in a survey which measured if the respondents believed that certain data elements should be included in each patient record. (Those nurses completing the survey tool at the meeting received a Symphony candy bar!) As there were many nurses from different practice settings who completed those surveys, it will be interesting to see which elements will be present for the next go-round.

Information Sharing

This information will be assembled into a research poster for the 1999 Congress. It will be interesting to see all the information come together, to see if it's even possible to develop a document that can be used nationwide. There are already some differ- ences. Dr. Kleinbeck noted that many of the Research Committee members who had completed the first three surveys, kept referring to "something called a standardized care plan or a standard of care." This is something different than in middle America.

There will be two more opportunities to participate in such ground breaking research. Do plan to attend the November and January meetings. Take advantage of your professional organization at the local level and make a contribution to perioperative nursing!

By Donna Benotti

September 1998 Clinical Question
Documentation of Perioperative Nursing Care

Total Responses: 17

I. Which of the following areas are currently reflected in your facility's perioperative record?

A. Assessment
Yes - 16 No - 0
B. Nursing Diagnosis
Yes - 11 No - 6
C. Outcome Identification
Yes - 13 No - 3
D. Implementation
Yes - 14 No - 2
E. Evaluation
Yes - 13 No - 3

II. Which of the following are currently documented on your facility's perioperative nursing record?

  1. Identification of persons providing perioperative patient care. Yes - 17 No - 0
  2. Description of patient's overall skin condition on arrival and discharge. Yes - 13 No - 4
  3. Placement of the ESU dispersive pad and ESU settings used. Yes - 16 No - 1 (Note 1)
  4. Placement of EKG electrodes, blood pressure cuff, oximeter, temperature probes, and other invasive and non-invasive monitoring devices. Yes - 13 No - 4
  5. Patient specimens and cultures taken during surgery. Yes - 16 No - 1
  6. Location of skin prep including solutions used. Yes - 15 No - 1 (Note 2)
  7. Location and type of drains, catheters, wound packing, casting material, and dressings used. Yes - 16 No - 1 (Note 3)
  8. Placement and location of implants including name of the manufacturer, lot and serial numbers, type and size of implant, and expiration dates. Yes - 15 No - 0 (Note 4)
  9. Use of intraoperative x-rays and fluoroscopy Yes - 15 No - 1
  10. Wound and anesthesia classifications. Yes - 13 No - 4 (Note 5)
  11. Time and patient status at discharge, disposition of patient, method of transfer. Yes - 16 No - 1 (Note 6)
  12. Presence and/or disposition of sensory aids and prosthetic devices. Yes - 13 No - 3
  13. Patient's positioning/repositioning devices and supports, and/or restraints. Yes - 17 No - 0
  14. Use of temperature regulating devices including identification of unit and documentation of patient's body temperature. Yes - 11 No - 6 (Note 7)
  15. Administration of blood or blood products, medications, irrigations, and solutions. Yes - 17 No - 0 (Note 8)
  16. Placement of tourniquet cuffs including identification of unit, pressure setting, and inflation and deflation times. Yes - 15 No - 2
  17. Placement of radioactive implants including time, number, location, and type of material. Yes - 8 No - 9
  18. Sponge, sharp and instrument counts. Yes - 16 No- 0 (Note 9)
  19. Use of lasers including identification of the unit, support staff members, type of laser used, the lens used, length of time used and wattage. Yes - 9 No - 2 (Note 10)
  20. Any significant or unusual occurrences pertinent to perioperative patient outcomes. Yes - 14 No - 3

III. Do you practice in a facility located in Alameda County? Yes - 16 No - 1

Notes

Note 1. ESU Settings not documented x 5
Note 2. Location not documented x 2
Note 3. Location not documented x 1. Dressings not documented x 2
Note 4. Not all things listed are documented x 2. Listed on separate sheet x 2
Note 5. Anesthesia classification not documented x 4
Note 6. Status at discharge not documented x 4. Method of transfer not documented x 2
Note 7. Documented on anesthesia record only x 1
Note 8. Administration of blood not documented x 5
Note 9. Instrument count not done x 5. Sharps count not documented x 1
Note 10. Do not use laser x 1. Documented on separate sheet x 4

By Kathie Shea

June 1998 Clinical Questions

  1. Does your facility use auto transfusion devices (cell savers)?
    Yes (11)
    No (2)

  2. If your answer to #1 was yes, who is primarily responsible for operating cell savers in your facility?
    Registered Nurse - 1
    Surgical Technologist - 0
    Outside agency - 8
    Other Unlicensed Assistive Personnel - 3

  3. Does your facility provide education and training in the use of the cell savers for employees?
    Yes (6)
    No (5)

  4. If yes, who is responsible for this education and training?
    Manufacturer (4)
    OR RN (1)
    PACU RN (1)

  5. How many hours is this cell saver education and training?
    Two to three days (1)
    Four hours (3)
    One hour (1)

  6. Are newly trained employees proctored?
    Yes (6)
    No (0)

  7. By whom are they proctored?
    Manufacturer (2)
    RN (3)
    Unknown (2)

  8. How long are these employees proctored?
    Four to six cases (1)
    Two to four cases (2)
    Unknown (3)

  9. If you use an outside agency for cell saver, how are these individuals credentialed by your facility?
    Unknown (7)
    Provide documentation of successful completion of a cell saver course and experience (1)
    Under direction of the perfusionist (1)

Submitted by Kathie Shea

Research Committee
June 1998

The Data Elements Coordinating Committee (DECC) challenged local chapters and AORN members to embrace the new Perioperative Nursing Nomenclature at the 1998 Congress. Incoming Chapter Research Chairman, Kathie Shea, believing this challenge would lend itself to a chapter research project got the ball rolling. Our chapter and the Greater Kansas City (MO) chapter have developed a collaborative plan to research what data elements from the Perioperative Nursing Nomenclature nurses would recommend for use on a standardized patient record. We have applied for and will soon receive a research grant from the AORN Foundation.

The Research Committee met May 28 to gain knowledge of the research project, terms of the research grant, establish a timeline for the project, and complete the initial interventions identification. The committee will be working through the summer.

The September chapter meeting will feature Dr. Susan Kleinbeck, who is serving as the nurse scientist and principle investigator for our project. I know every member will want to attend this meeting to learn more about the Data Elements, the project, and how each one of us can contribute to data collection. Our research project will make its official debut as a poster session at the 1999 Congress in San Francisco! Stay tuned for more details!

Submitted by Donna Benotti

May 1998 Clinical Questions
"Our Members Want to Know"

Facilities that replied: Alta Bates, Eden, Summit, Kaiser Pleasanton, Alameda, St. Rose, Washington, TriValley Surgery Center, East Bay Medical Surgical Center, Kaiser Hayward, and Surgery Center of Healthsouth

  1. Does your facility require ACLS certification?

    All of the above facilities responded that ACLS was not required in the OR (although it is highly recommended that nurses who monitor conscious sedation patients be able to interpret EKGs). Units that require ACLS certification were GI, PACU, and SDS.

  2. What do you like about our chapter?

    Friendships, education, team work, strong leadership, committed people, our accomplishments, pacesetter, keeping abreast of new legislation affecting nurses, newsletter, networking, meetings are close to home, and an opportunity to hear about national issues - that we are not alone.

  3. What do you not like about our chapter?

    High fat-high calorie dinners, apathy among members, meeting day, our inability to attract new members - I think we have a "marketing problem," and too many raffles.

  4. Any suggestions on improving the chapter?

    Perhaps once a month , we should make a concentrated effort with a particularly appealing speaker; each member should try to bring someone new to the meetings; somehow get more people interested and active; "think tank"; focus on all the members; raffles; allowing one AORN member to attend Congress without using the point system; continue meetings in one place; more food options; we need some exciting and stimulating projects and ways and means to earn money and at the same time have fun; online newsletters and information sent to all OR nurses in Alameda County (it will save on postage); and more Saturday CEU workshops.

    Submitted by Debbie Tung

    Editorial comment by Mary Ritchie: We do have an online newsletter! It was started May 2, 1997. The newsletter is the foundation of our web site. The web site contains information from 1996-1998 newsletters plus up-to-date information that doesn't appear in the newsletters. The web site has been written about in the newsletters and the address of the web site appears in each issue in the return address area. From surveys we've conducted at the meetings, very few of our members (at the meetings) have internet access. It's also been a struggle getting e-mail addresses from members!
    I'd like to invite any member to please suggest a "particularly appealing speaker" to our education committee or president. They have a difficult job and would welcome your assistance.

    There was no April meeting due to Congress

    March 1998 Clinical Question
    "Is there a future for perioperative nurses?"

    Alta Bates
    Currently has at least one RN position vacant, looking for RN with pediatric experience willing to work flexible hours, primarily on the 7-3:30p shift.
    The RN:tech ratio is 60:40.
    Alta Bates does not offer an in-house perioperative training program but they have offered it in the past.
    Alta Bates precepts nursing students in perioperative nursing from Cal State Hayward for two-four days. The students mainly observe the activities in the OR.

    Eden
    Currently has one vacant RN position for nights.
    Eden's RN:tech ratio: Nocs 1:1; PMs 1:1; and Days 3:1
    Eden does not offer an in-house perioperative nursing training program.
    Eden precepts nursing students from 3 different schools. The preceptorship lasts 3 months.

    Washington
    Currently does not have any vacancies. Washington recently hired 3 full-time RNs and one per diem RN (who was offered a full-time position).
    Washington's RN:tech ratio: 2:1.
    Washington does not offer an in-house perioperative training program.
    Washington has precepted nursing students in the past (Debbie Tung is an alumni). They are currently precepting an OR tech student.

    Summit
    It is anticipated that there will be 19 RN positions available as soon as Kaiser brings their inpatients to Summit.
    Summit's RN:tech ratio: 60:40.
    Summit does not offer an in-house perioperative training program.
    Summit precepts nursing students from Samuel Merritt College; junior students: 2 days; senior students: 3 months. Ohlone Community College students follow patients through surgery.

    Hospital Consortium Education Network
    Currently looking for a nurse educator.
    This facility offers a 10 month perioperative training program for nurses and techs.
    This facility is looking for clinical sites for their students (any volunteers?).

    Kaiser Vallejo
    Currently has 2 RN positions available.
    Kaiser Vallejo's RN:tech ratio: 2:1.
    Kaiser Vallejo OFFERS a perioperative nursing training program!
    This facility does not precept nursing students.

    Kaiser Martinez
    Currently has no available positions.
    Kaiser Martinez's RN:tech ratio: 1:1.
    Kaiser Martinez does not offer a perioperative training program and they do not precept nursing students.

    East Bay Medical Surgical Center
    Currently has no available positions.
    This facility's RN:tech ratio: 1:1.
    East Bay Medical Surgical Center does not offer a perioperative training program and they do not precept nursing students (yet).

    Mt. Diablo Medical Center
    Currently has available positions.
    Mt. Diablo's current RN:tech ratio: 20:3
    Mt. Diablo has offered an in-house perioperative training program in the past and does not precept students.

    Kaiser Pleasanton
    Currently has no available positions.
    Kaiser Pleasanton's RN:tech ratio: 1:1.
    Kaiser Pleasanton does not offer an in-house perioperative training program.
    This facility precepts Cal State Hayward students for half a day occasionally.

    Kaiser Oakland
    Currently has four RN positions available.
    Kaiser Oakland's RN:tech ratio: 2:1.
    Kaiser Oakland does not presently have an in-house perioperative nursing training program. From their last program (lasting 3 months), they have hired two nurses.
    This facility does not precept students.

    Valley Care Medical Center--Pleasanton
    Currently has no available positions.
    Valley Care's RN:tech ratio: 2:1.
    Valley Care does not offer an in-house training program.
    This facility precepts nursing students for 12 weeks.

    CPMC (California Pacific Medical Center)
    Currently has no available positions.
    CPMC's RN:tech ratio: Days: 70:30 PMs: 1:1.
    CPMC does not offer an in-house training program.
    CPMC will be working with the San Francisco Consortium next year.
    Currently they have students from USF for one day who scrub and circulate and students from SF State who observe for one day.

    Submitted by Debbie Tung

    February 1998 Clinical Questions
    "Our Members Want to Know"

    Please note: Some of the Clinical Questions relate to specific facilities. When answering the clinical questions, it would be helpful to indicate the facility in order for the reply to be utilized. Although many responses were received in February, the facilities’ names were not included and rendered the responses useless.

    Kaiser Pleasanton
    This facility does not have an OR educator.
    Their OR schedule is coordinated by a scheduler at the Walnut Creek facility.
    This facility does not have service lead RNs.

    Kaiser Hayward
    This facility does not have an OR educator.
    Their OR schedule is coordinated by their RN manager.
    This facility does not have service lead RNs.

    St. Rose
    This facility does not have an OR educator.
    Their OR schedule is coordinated by their RN manager.
    This facility does not have service lead RNs.

    Alta Bates
    This facility does not have an OR educator.
    Their OR schedule is coordinated by their charge RN.
    This facility has three charge RNs that also have the role of service lead RNs - one RN is in charge of vascular, neuro, & cardiac; one RN is in charge of ortho, plastics, & ENT; one RN is in charge of general & GYN.
    These charge/service leads are paid extra for their work.

    Summit
    This facility does not have an OR educator. There is a posted position that has not be filled.
    Currently, Donna Benotti, RN, CNOR, Clinical Nurse IV, is Interim OR educator. Among other projects, she plans and implements an inservice program once a month, oversees the senior surgical technologist program, and coordinates the perioperative experience for the Merritt nursing students. (You go, Donna!)
    Their OR schedule is coordinated by their RN manager. Normally, this is done by a charge RN but this is also a vacant position (any takers?) This facility has service lead RNs who are paid extra for their work.

    Here are the names of postgraduate OR programs in California:
    Stanford, San Mateo Consortium, Sonoma State, UCSF, and the College of San Mateo.

    Most facilities STILL use Cidex in addition to Steris, Sterrad, and dry sterilization.

    Submitted by Debbie Tung

    January 1998 Clinical Questions
    Laser Safety in the OR

    Facilities that responded: Alta Bates, Kaiser Pleasanton, Summit, St. Rose, Eden, Washington

    1. Do you have a laser safety officer in your facility?

      Yes--Alta Bates, Eden, and Washington
      No--Summit and St. Rose

    2. According to the American National Standards Institute, Inc., surgical consents for laser procedures should state what type of laser will be used during surgery. Do your surgical consents state what type of laser will be used during surgery?

      Yes--Alta Bates
      No--St. Rose, Summit, Washington, and Eden

    3. Are eye exams performed annually on staff members who are part of the laser team?

      Yes--Alta Bates
      Maybe--Eden
      No--St. Rose, Summit, and Washington

    4. Is a fire extinguisher or basin of water or saline readily available for each laser case?

      All facilities responded yes.

    Submitted by Debbie Tung

    December 1997 Clinical Questions
    Anything Related to Packs

    Facilities that responded: Alta Bates, Summit, Eden, Kaiser Oakland, Washington

    1. Besides standard sterile packs (e.g. back table packs, GYN packs, laparoscopy packs), does anyone use an unusual pack? What's it called?

      Most facilities have the basics. It was interesting to read that Eden had a shoulder pack, upper extremity pack, lower extremity pack, arthroscopy pack, total knee pack, and a total hip pack. That's a lot of different ortho packs.
      Summit has heart pack A, B, C. Is that three packs and three back tables? (Ed. note: A and B are back table packs. C is a circulator pack with prep tray, foley, and lines).
      Kaiser Oakland has a back pack (cute name) used for spinal fusion.

    2. How are your packs wrapped?

      Most replied one-step with plastic.

    3. Does your facility use disposable linens?

      Yes--Eden and Washington
      No--Alta Bates, Summit, Kaiser Oakland

    4. Does your facility use disposable instrument trays?

      All replied no except Alta Bates has disposable suture removal tray for the floors. The tray has a clamp, scissors, and forceps.

    5. In your sterile packs, are prep sets included?

      At Washington and Summit they are but at Alta Bates, Eden, and Kaiser Oakland, the prep sets are not included in the packs.

    6. Are dressing sets included in your sterile packs?

      Eden was the only facility that doesn't include dressings in their packs.

    7. At Alta Bates, when we flash sterilize, we no loner use indicators placed in the pan. Instead, we rely on the printout generated by the autoclave. After each flash sterilization, the circulator checks the printout for the time elapsed and the temperature used. This is the only indication that the pan is sterile. Does anyone else out there follow this practice?

      What a surprise!!! No other facility practices this way. Alta Bates is leading the way toward a new community standard. (Ed. note: This is sarcasm!)

    Submitted by Debbie Tung

    November 1997 Clinical Questions
    Malpractice Insurance

    Facilities that responded: Alta Bates, Alameda, St. Rose, Washington, Kaiser Oakland, Kaiser Pleasanton, Summit, East Bay Surgical Center, Eden, Cal. State Hayward.

    1. Does your facility provide malpractice insurance for staff RNs?
      Of the facilities that responded, the facilities that do not provide malpractice insurance for staff RNs were: Eden, Cal. State Hayward, Summit, Kaiser Oakland, and Kaiser Pleasanton.

    2. Do you carry your own malpractice insurance?
      Of the facilities that responded, 65% of the nurses carry their own malpractice insurance while 35% do not.

    3. How much do you pay for your malpractice insurance?
      The price of malpractice insurance paid by the nurses who responded ranged from $80 - $389.

    4. Have you ever been sued?
      Of the facilities that responded, no individual nurse has been sued. A few nurses have given depositions. A few nurses were involved in cases where the plaintiff sued the hospital thereby involving the OR nurse. One nurse stated that she was used as an expert witness.

      How prepared are you if you were to become involved in ligation? Is there a lawyer at your facility who would provide guidance? Do you think of the possibility of being sued as an individual nurse?

      Submitted by Debbie Tung

      October 1997 Clinical Question
      *Dietary Supplements: Helpful, Harmful, or Hype?

      Here are some dietary supplements and their purported effects:

      1. Ginkgo Biloba: fights memory loss
      2. DHEA: a fountain-of-youth pill that boosts energy and immunity, prevents heart disease, enhances sex drive, and decreases body fat
      3. Ginseng: boosts energy and sexual stamina; reduces stress and stimulates the immune system
      4. Folic Acid: prevents neural-tube birth defects if taken by the mother
      5. Saw Palmetto: offers relief from symptoms of an enlarged prostate
      6. Vitamin E: reduces the risk of cardiovascular disease

      *Reader's Digest July 1997

      I make a motion that Ginkgo Biloba and DHEA be passed out at each AORN meeting. Any seconds?

      Submitted by Debbie Tung

      September 1997 Clinical Question
      Organize & Coordinate Supplies, Equipment, and Team Members

      The perioperative nurse’s organization and coordination of patient care activities improves the effectiveness of the health care team, saves money, and enhances the quality of patient care.

      Choose the best answer:

      1. When a patient is to have a craniotomy in the sitting position, the nurse should ensure the availability of which of the following pieces of equipment to monitor for potential complications related to this procedure?

        a. Arterial line, EEG, EKG
        b. Doppler, CVP line, left atrial line
        c. Hypothermia unit, temperature probe
        d. Blood gas kit, lumbar puncture tray

      2. A critically injured patient requires immediate surgery, but all unassigned personnel have limited operating room experience. In this situation, the charge nurse should:

        a. assist the available personnel in caring for the patient
        b. reassign experienced personnel to the emergency procedure
        c. personally assume care for the critically injured patient
        d. call in additional personnel to handle the emergency

      3. A patient is scheduled to have laser-assisted balloon angioplasty by percutaneous approach under local anesthesia. In addition to coordinating all equipment and supplies for laser and fluoroscopy, the nurse should take care to ensure that:

        a. earphones are available for the conscious patient, to help allay fear and anxiety
        b. an epidural setup is available in case the local anesthetic is inadequate for the angioplasty
        c. a traffic pattern is clear for radiological personnel
        d. a surgical setup is available for bypass in case the angioplasty is unsuccessful

        The correct answers according to the CNOR 1993 Study Guide are: b, b, d.

        Submitted by Debbie Tung

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        Updated September 13, 2002

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