Body piercings in the OR; tabletop sterilizers; Joint Commission initiative; West Nile virus; home laundering - Clinical Issues

AORN Journal, Feb, 2003 by Dorothy Fogg

Question: One of our OR staff members had his nose pierced lost weekend and now wears a stud through the skin and into the nares. He does not want to remove the stud as he believes the hole/track will heal closed if the stud is removed. This person functions primarily in the scrub role and covers the jewelry with a surgical mask when at the sterile field. Some other staff members do not want to work with him as they believe the nose jewelry poses an increased infection-control threat. Is this type of jewelry acceptable in the OR? Is there an increased infection-control concern?

Answer: Ideally, all jewelry should be removed when a staff member is working in the OR. At a minimum, jewelry that is not removed should be confined fully. If the staff member is unable or unwilling to remove the stud, it should be confined under the mask at all times, including when the person is not scrubbed. The mask should be changed approximately every two hours to avoid' a build up of exhaled organisms, and the person should be assigned to procedures of shorter duration so the mask can be changed at appropriate intervals. If the pierced track has any type of serous drainage or weeping, the employee should be excused from work until the drainage or weeping subsides.

According to AORN "Recommended practices for surgical attire," jewelry should be confined or removed. Rings, bracelets, and watches may harbor organisms that cannot be removed during hand washing, hand hygiene practices, or the surgical scrub. These items, therefore, should be removed. (1) To date, there is no evidence that other jewelry increases bacterial shedding, but studies of newly pierced body parts have not been performed. A certain amount of friction occurs between the skin and the surgical mask because the nose is in contact with the mask. The jewelry stud will suffer some manipulation due to normal breathing and talking from behind the mask. This manipulation and constant friction between nose and mask may lead to increased bacterial shedding or dispersion of organisms from inside the nares.

Contact your employee health service for assistance in determining when the pierced track is healed sufficiently for removal and reinsertion of the jewelry stud. After the track has healed, the employee should remove the stud before working in the OR environment, and at that time, a mask needs to be worn only according to your facility policy for masks in the OR.

Question: I work in an office-based surgery practice where we use a tabletop steam sterilizer to process supplies. We often use peel pouches and sometimes put small items inside a pouch and place the pouch Inside another pouch to help contain the items. Only the outer pouch is sealed. Recently, a representative of the sterilizer's manufacturer questioned this practice, Is it acceptable practice to place a pouch within a pouch for sterilization? We sometimes also place a pouch of small items inside a tray of instruments in the sterilizer. Is this acceptable practice?

Answer: Whether the double peel pouches or the pouches within wrapped goods can be sterilized depends on the sterilizer you are using. Only the manufacturer can provide the information you seek. According to the US Food and Drug Administration (FDA), the sterilizer manufacturer is required to provide you with very specific information about the product you purchased. You should receive instructions on correct packaging, sterilizer loading, drying time, and cooling time, among other things. The manufacturer is required to validate sterilization of items by the sterilizer being sold. Most, but not all, tabletop steam sterilizer manufacturers have not validated sterilization of either double peel pouches or peel pouches within wrapped goods. If the sterilizer you are using has not been validated for these configurations, your practice would be considered unacceptable because you have no assurance that the sterilizer is capable of sterilizing the items in the peel pouches.

Question: I recently heard that the Joint Commission on Accreditation of Healthcare Organizations Is changing the accreditation process again. We are not due for a survey until 2004, but we wonder what we should be expecting and planning for. We would prefer not to wait until the last minute to prepare for the survey. What does AORN know about any impending Joint Commission changes?

Answer: The new Joint Commission initiative, Shared Visions-New Pathways, is intended to be the next step after the Agenda for Change initiated in 1987. (2) According to Russell Massaro, MD, vice president for accreditation operations, the initiative is intended to shift the focus from survey preparation to continuous operational improvement in the facility. As a part of the Shared Visions-New Pathways initiative, the Joint Commission is streamlining standards in its various programs. Standards common to all programs have been identified and will appear in all manuals and in the same language. Program-specific standards appear in individual program manuals. In addition, the standards format has been reconfigured. Presently the format consists of standards followed by intent statements, after which examples of performance are presented. Only standards and intent statements are scored, and the assumption exists that all standards will be surveyed during the site visit.