Leaving OR doors open; sterilizing wood; national patient safety goals; bioburden; mercury thermometers - Clinical Issues - operating room doors

AORN Journal,  March, 2003  

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Question: I just started working at a different hospital, and I am concerned that the OR doors frequently are left open after sterile supplies have been opened. Most of the time the doors are left open after the procedure is set up, while the circulating nurse goes to get the patient. The rationale is that leaving the doors open makes it easier to transport the patient into the room. I am concerned about this practice and believe we are increasing the patient's risk of infection. I need to provide some sound rationale to my colleagues for keeping the doors closed. What does AORN recommend and why?

Answer: The doors to the OR should be kept closed except during movement of patients, personnel, supplies, and equipment to maintain the correct ventilation, air flow, and air pressure. (1) Ventilation in the OR should be kept at a positive air pressure in relation to the corridors and adjacent areas. The positive pressure prevents air flow from moving from less clean areas into more clean areas. Air should be introduced at the ceiling and exhausted near the floor, creating a downward directional flow. (2)

When OR doors are left open, the ambient air pressure is disrupted, and the resulting turbulent air flow can increase airborne contamination. Air is a potential source of microorganisms and can contain microbialladen dust, lint, skin squames, or respiratory droplets. (3) Altering the ventilation increases the risk of contaminating the sterile field and, thus, the patient's risk of infection. The OR doors should be closed except for the very short time it takes for a person to enter the room or transport the patient, supplies, or equipment through the door.

Question: An orthopedic surgeon at our facility wants to use an ordinary lead pencil to mark bone during a surgical procedure. Can wood be sterilized? Is it acceptable to sterilize a pencil for use during surgery?

Answer: Wood is a porous product that cannot be cleaned thoroughly, making sterilization a problem. The sterilant also may not penetrate the wood completely. There is conflicting information in the literature. A perioperative nursing textbook suggests that wood can be steam sterilized. (4) One study, however, demonstrates that wood pencils should be sterilized only with dry heat at 160[degrees] C (320[degrees] F) for 18 hours because steam sterilization of wood fails 37% of the time. (5)

The Association for the Advancement of Medical Instrumentation, the recognized authority on sterilization, makes no recommendations for sterilizing wood products. Based on the lack of recommendations and conflicting information, sterilizing ordinary wood pencils is not advised. Products used during surgery must have validated processes that demonstrate the efficacy of the selected sterilization procedure. As with any product, the manufacturer's specific written instructions for sterilization must be followed to sterilize wood products. Wood products should not be reused because they cannot be cleaned. AORN recommends using a marking device specifically designed for use during surgery only after obtaining validated sterilization procedures for that item.

Question: We recently heard that the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has new patient safety standards. Can you tell me more about this? When do these standards go into effect?

Answer: The Joint Commission has developed national patient safety goals to aid in the prevention of medical mistakes. The national patient safety goals went into effect Jan 1, 2003, and apply to all JCAHO accredited organizations and those facilities seeking accreditation. Previous sentinel event alert recommendations form the foundation for the goals. There are six goals with a maximum of two recommendations for each goal, all of which are based on evidence or expert opinion. The Joint Commission plans to update the goals each year. Some goals will be replaced and others may continue, but only six goals will be enforced each year.

Beginning Jan 1, 2003, facilities will be surveyed for compliance with the patient safety goals and their associated requirements. (6) Patient safety is a priority of every health care provider. The Joint Commission's national patient safety goals provide a method for facilities to focus on specific areas of concern regarding patient safety. See Table 1 for the national patient safety goals, or for more detailed information visit the JCAHO web site at http://www .jcaho.org.

Question: The term bioburden is used In many different ways. Some people refer to bioburden as blood and tissue, although others refer to it as microorganisms. Can you clarity this and provide a clear definition of bioburden?

Answer: The term bioburden frequently is misused in the surgical setting because it is referred to as organic material on surgical instruments and equipment. This is confusing and needs further clarification. The accurate definition of bioburden is the amount of microorganisms (ie, microbial load) on an item. (7) A contaminated instrument may contain both organic material (eg, blood, tissue, mucous, other body fluids) and bioburden. Organic material contaminating instruments may contain pathogenic microorganisms, including bacteria, fungi, or viruses.