Banked tissue; correct site surgery; procedure rooms; disaster plans for terrorist activity - Clinical Issues - various articles

AORN Journal,  Feb, 2002  by Dorothy M. Fogg

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Question: Two patients recently experienced two separate incidents of septic joints offer anterior cruciate ligament reconstruction with tendon allografts. The procedures were performed two days apart by different surgeons with different instruments. Different staff members participated in each procedure. There was no commonality in organisms cultured from the joints. The only common factor was the source of the graffs; both grafts were obtained from the some tissue honk. Our facility epidemiologist worked with the tissue honk end discovered that the graffs were from a common donor and that they hod been released for implantation without having received any kind of terminal sterilization. Is this common practice? Is there a requirement for donor screening for infectious diseases?

Answer: The US Food and Drug Administration (FDA) requires all tissue donors to be screened for HIV, hepatitis B, hepatitis C, and other bloodborne pathogens. There are no requirements related to other infectious agents. (1) The American Association of Tissue Banks (AATB) publishes standards for obtaining and processing tissue for implantation. Guidelines address:

* donor screening;

* time limits for retrieval of soft tissue;

* a procedures for tissue preservation, sterilization, preparation, and evaluation; and

* tissue labeling.

Freezing or freeze-drying are the methods most frequently recommended for tissue preservation. (2) The primary methods for sterilization are gamma irradiation or ethylene oxide (EO). Most tissue banks use gamma irradiation, but high doses of gamma irradiation can have an adverse effect on the graft. Ethylene oxide, on the other hand, has limited ability to penetrate tissue, and adverse patient outcomes have occurred following implantation of EO-sterilized gratis. Musculoskeletal tissues (eg, bone-tendon allografts) are being procured and processed aseptically, but the tissues are not terminally sterilized because of concerns about sterilization-related complications. The AATB standards require tissue banks to develop a list of organisms that require graft destruction, sterilization, or disinfection should they be cultured from procured tissue. All tissues, however, are not cultured, and the AATB does not provide a list of such organisms. (3)

A further concern is that close to one-half of existing tissue banks are not accredited by the AATB or inspected by state regulatory agencies. Only two states require licensing and inspection of tissue banks. Tissue banks that are not accredited or licensed need not comply with external standards or quality requirements beyond donor screening for HIV and hepatitis as required by the FDA. (4) With the unfortunate infections experienced at your facility and the information gleaned by your epidemiologist, you might want to consider using a different tissue bank for future needs. Talk with potential tissue bank partners in your area to determine their methods and practices, whether they are licensed or accredited, and, if so, by whom.

Question: I am a perioperative nurse educator responsible for two facilities in one health care system. One of these facilities is on ambulatory surgery center. I would like to develop end implement a policy for identifying the correct surgical site in both facilities. We hove never hod on incident, end nursing staff members in the facility where I work think it could never happen here. They ore not interested in developing a protocol or procedure for identifying the correct surgical site. We identify patients by asking them to state their name, end the surgical site is checked by looking et the OR schedule end the surgical consent. Our circulating nurses think this is sufficient. Last year, I heard a lot about wrong site surgery, but I hove not heard anything lately. Does AORN support having a policy end procedure for correct site surgery or is this no longer a problem?

Answer: AORN does support every facility having a policy and procedure for identifying the correct surgical site. Incorrect surgeries continue to be a serious problem. According to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the number of reported cases of wrong site surgery (ie, the wrong surgery being performed or surgery being performed on the wrong patient or the wrong site) has increased from 15 in 1998 to 150 in 2001. (5) Joint Commission statistics show the following breakdown:

* orthopedics/pediatrics, 41%;

* general surgery, 20%;

* neurosurgery, 14%;

* urology, 11%; and other, 14% in a variety of specialties.

Fifty-eight percent of incidents occurred in ambulatory surgery centers, 29% in inpatient ORs, and 13% in emergency departments and/or intensive care units. Seventy-six percent of incidents involved surgery on the wrong body part or site.

The Joint Commission has identified a number of risk factors contributing to wrong site surgery (ie, incorrect surgeries, incorrect patients, incorrect sites). These include:

* emergency surgeries,