CONTINUING EDUCATION

Clinical Issues 1.7 www.aorn.org/CE

SHARON A. VAN WICKLIN, MSN, RN, CNOR, CRNFA(E), CPSN-R, PLNC; SCOTT A. BRUBAKER, CTBS

Continuing Education Contact Hours Approvals indicates that continuing education (CE) contact hours are This program meets criteria for CNOR and CRNFA recerti- available for this activity. Earn the CE contact hours by fication, as well as other CE requirements. reading this article, reviewing the purpose/goal and objectives, and completing the online Learner Evaluation at http:// AORN is provider-approved by the California Board of www.aorn.org/CE. Each applicant who successfully completes Registered Nursing, Provider Number CEP 13019. Check this program can immediately print a certificate of completion. with your state board of nursing for acceptance of this activity for relicensure. Event: #15532 Session: #0001 Fee: Members $13.60, Nonmembers $27.20 Conflict-of-Interest Disclosures The contact hours for this article expire September 30, 2018. Sharon A. Van Wicklin, MSN, RN, CNOR, CRNFA(E), Pricing is subject to change. CPSN-R, PLNC, and Scott A. Brubaker, CTBS, have no declared affiliations that could be perceived as posing a po- fl Purpose/Goal tential con ict of interest in the publication of this article. To provide the learner with knowledge of AORN’s guidelines The behavioral objectives for this program were created by related to surgical wound classification; storing and using Helen Starbuck Pashley, MA, BSN, CNOR, clinical editor, small, prefilled containers of formalin in the OR; latex-free with consultation from Susan Bakewell, MS, RN-BC, direc- environments for tissue recovery and organ procurement tor, Perioperative Education. Ms Starbuck Pashley and Ms procedures; covering facial hair in semirestricted and restricted Bakewell have no declared affiliations that could be perceived areas; and covering ears in semirestricted and restricted areas. as posing potential conflicts of interest in the publication of this article. Objectives 1. Discuss practices that could jeopardize safety in the peri- operative area. Sponsorship or Commercial Support 2. Discuss common areas of concern that relate to perioper- No sponsorship or commercial support was received for this ative best practices. article. 3. Describe implementation of evidence-based practice in relation to perioperative nursing care. Disclaimer Accreditation AORN recognizes these activities as CE for RNs. This AORN is accredited as a provider of continuing nursing ed- recognition does not imply that AORN or the American ucation by the American Nurses Credentialing Center’s Nurses Credentialing Center approves or endorses products Commission on Accreditation. mentioned in the activity.

http://dx.doi.org/10.1016/j.aorn.2015.06.002 ª AORN, Inc, 2015 www.aornjournal.org AORN Journal j 299 CLINICAL ISSUES

1.7 www.aorn.org/CE

THIS MONTH Surgical wound classification Key words: wound classification, documentation, surgical site infection. Storing and using small, prefilled containers of formalin in the OR Key words: formalin, formaldehyde, eyewash stations, Occupational Safety and Health Administration. Latex-free environments for tissue recovery and organ procurement procedures Key words: allografts, organ donation, tissue recovery, latex sensitivity, latex-free environment. Covering facial hair in semirestricted and restricted areas Key words: facial hair, beards, surgical masks. Covering ears in semirestricted and restricted areas Key words: ears, pierced earrings, surgical head coverings.

Surgical wound classification

QUESTION: ANSWER: We are having disagreements at our facility about how Perioperative RNs should assign surgical wound classifica- certain procedures should be classified when using the tion collaboratively with the surgeon after a careful assess- Centers for Disease Control and Prevention (CDC) sur- ment of the specific factors associated with each surgical gical wound classification system. Can you discuss the procedure. According to the CDC, surgical wounds should wound classifications that should be assigned to some be classified based on the likelihood and degree of wound common procedures? contamination at the time of surgery.1 The following are

300 j AORN Journal www.aornjournal.org September 2015, Vol. 102, No. 3 Clinical Issues FPO = print & web 4C Figure 1. Surgical Wound Classification Decision Tree.

the CDC’sdefinitions of the four surgical wound closed, and if necessary, drained with closed drainage [eg, bulb classifications: drain]. Operative incisional wounds that follow non- penetrating (blunt) trauma should be included in this category [Class I] Clean wounds: These are uninfected operative if they meet the criteria. wounds in which no inflammation is encountered and the respiratory, alimentary, genital, or uninfected urinary tracts [Class II] Clean-contaminated wounds: These are operative are not entered. In addition, clean wounds are primarily wounds in which the respiratory, alimentary, genital, or

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Table 1. Wound Classifications for Specific Procedures Cesarean section with long labor or ruptured membranes A cesarean section should be classified as Class II (clean-contaminated) because the uterus is entered to deliver the child. Cesarean deliveries with or without ruptured membranes or long labors are Class II procedures unless there is a specific reason (eg, presence of meconium representing spillage from the fetal gastrointestinal [GI] tract) to assign a Class III (contaminated) rating. Class IV (dirty or infected) would be assigned if an existing clinical infection were present, evidenced by the presence of purulence. Circumcision A circumcision does not enter the genitourinary (GU) tract; therefore, the wound classification should be Class I (clean). Coronary artery bypass grafting Coronary artery bypass grafting does not enter the respiratory tract and should be classified as Class I (clean). Hepatectomy Within the liver is a network of fine tubular channels known as bile capillaries that collect and carry bile. These capillaries merge to form the bile ducts and eventually become the hepatic duct; therefore, a procedure where the liver is completely or partially removed transects the biliary tract, which is a part of the GI tract, and should be classified as Class II (clean-contaminated). Laparoscopic Nissen fundoplication with esophagogastroduodenoscopy In a laparoscopic Nissen fundoplication, the upper curvature of the stomach is wrapped around the esophagus and sutured into place. If the patient has a hiatal hernia, this is also repaired. The GI tract is not entered. For this reason, a laparoscopic Nissen fundoplication is a Class I (clean) procedure. There is no classification for the esophagogastroduodenoscopy because there is no surgical wound. Orchiectomy An orchiectomy procedure should be classified as Class II (clean-contaminated) because the spermatic cord is severed. Orchiopexy An orchiopexy procedure enters the inguinal canal but not the GU tract. It should be classified as Class I (clean). Pancreatectomy The pancreas is part of the GI tract; therefore, a procedure in which the pancreas is completely or partially removed should be classified as Class II (clean-contaminated). Parotidectomy The salivary glands (parotid, submandibular, sublingual) produce saliva and are part of the GI tract. For this reason, surgical procedures involving the salivary glands should be classified as Class II (clean-contaminated). Penile prosthesis A procedure in which a penile prosthesis is inserted enters the erection chambers but not the GU tract. For this reason, it should be classified as Class I (clean). Penrose drain A surgical wound that is closed with a Penrose drain should be classified as Class III (contaminated). According to the CDC, “clean wounds are primarily closed, and if necessary, drained with closed drainage.”1(p109) A Penrose drain is a form of open drainage; therefore, a procedure in which a Penrose drain is placed cannot be classified as Class I. Class II (clean-contaminated) procedures are those where the respiratory, GI, or GU tracts are entered; unless these tracts are entered, the procedure cannot be classified as Class II. The definition of a Class III (contaminated) procedure includes an “open, fresh wound.”1(p109) When a Penrose drain is placed and the surgical wound is closed, the portion of the incision where the drain is inserted remains partially open. This fresh, open wound increases the potential for postoperative infection, so Class III is the correct classification. If the drainage from the wound is purulent, it is Class IV (dirty or infected). Pilonidal cyst If no inflammation or infection is present, the excision of a pilonidal cyst should be classified as Class I (clean). If acute inflammation is present, it should be classified as Class III (contaminated); if existing clinical infection (ie, purulence) is present, it should be classified as Class IV (dirty or infected). Portacaval shunt In this procedure, the hepatic vein is connected to the inferior vena cava. The GI tract is not entered. For this reason, a portacaval shunt should be classified as Class I (clean). Thoracoscopy and thoracotomy When thoracoscopy and thoracotomy procedures are performed, the pleural space is entered but the respiratory tract is not entered. These procedures should be classified as Class I (clean). Vasectomy During a vasectomy, the vas deferens, a part of the GU tract, is severed. For this reason, a vasectomy should be classified as Class II (clean-contaminated).

Reference 1. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guidelines for prevention of surgical site infection, 1999. Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee. Am J Infect Control. 1999;27(2):99-134.

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urinary tract is entered under controlled conditions and members to the correct wound classification. Examples of without unusual contamination. Specifically, operations procedures that may cause confusion regarding their correct involving the biliary tract, appendix, vagina, and oropharynx wound classification are addressed in Table 1, and a rationale for are included in this category, provided no evidence of infection how the Surgical Wound Classification Decision Tree has been or major break in technique is encountered [eg, spillage from used is provided. gastrointestinal tract].

[Class III] Contaminated wounds: These include open, fresh, Sharon A. Van Wicklin, accidental wounds, operations with major breaks in sterile MSN, RN, CNOR, CRNFA(E), technique [eg, procedure performed with unsterile instruments] CPSN-R, PLNC, is a perioperative or gross spillage from the gastrointestinal tract, and incisions in nursing specialist in the Nursing which acute, nonpurulent inflammation is encountered. Department at AORN, Inc.

[Class IV] Dirty or infected wounds: These include old traumatic wounds with retained devitalized tissue and those that involve existing clinical infection or perforated viscera. This definition print & web 4C/FPO suggests that the organisms causing postoperative infection were present in the operative field before the operation.1(p109)

AORN developed the Surgical Wound Classification Decision Tree (Figure 1) as a tool to assist perioperative RNs in accurately classifying surgical wounds using the CDC surgical wound References classification system. This tool, included in the 2015 “Guideline ”2 1. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guidelines for prevention of transmissible infections, can also be found on for prevention of surgical site infection, 1999. Centers for Disease the AORN web site at http://www.aorn.org by searching for Control and Prevention (CDC) Hospital Infection Control Practices “Surgical Wound Classification Decision Tree.” The decision Advisory Committee. Am J Infect Control. 1999;27(2):99-134. tree is an algorithm that has organized, directed wound 2. Guideline for prevention of transmissible infections. In: Guidelines classification questions designed to lead perioperative team for Perioperative Practice. Denver, CO: AORN, Inc; 2015:419-451.

Storing and using small, prefilled containers of formalin in the OR

QUESTION: posted signs warning of formaldehyde use, the active Is it acceptable to store and use small, prefilled containers ingredient in formalin; of formalin in a procedure room or the OR? eyewash stations available within the immediate area; and ventilation systems with adequate capacity to maintain formaldehyde levels below the permissible exposure limits ANSWER: (ie, eight-hour total weighted average of 0.75 ppm or 15- Formalin, including formalin in small, prefilled containers, minute short-term exposure limit of 2.0 ppm).2 should be stored or used in an area other than a procedure Warning signs and adequate ventilation systems are necessary room or the OR unless ignition sources are not used and the because formaldehyde is a potential carcinogen that can cause regulatory requirements for the locations for use and storage acute and chronic health conditions, including sensitization have been met. Formalin is a combustible liquid, and ignition leading to asthma and contact dermatitis. Formalin, even sources (eg, electrosurgery) should not be used in the stor- 1 when stored in small, prefilled containers, can be absorbed age area. through the skin and nasal passages, splashed in the eyes, or Storage and use of formalin is regulated by the Occupational ingested. Exposure can result in irritation, burns, or allergic Safety and Health Administration (OSHA) and other federal reactions.1-4 Formalin in a 10% buffered solution, as is and state health regulatory agencies.2,3 Locations where commonly used in the OR, contains approximately 4% formalin is used or stored must have formaldehyde.4 Eye and skin contact with liquids containing

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1% or more formaldehyde must be prevented by the use of face shields and eye protection according to OSHA Sharon A. Van Wicklin, MSN, RN, CNOR, 2 requirements. CRNFA(E), CPSN-R, PLNC, is a perioperative nursing specialist in the Nursing Department at AORN, Inc. Eyewash stations are necessary to provide emergency treatment in the event that a perioperative team member splashes formalin into his or her eyes. Eyewash stations located in the References immediate area means that travel time from the site of chemical exposure to the eyewash station is no greater than 10 1. NIOSH Pocket Guide to Chemical Hazards. DHHS (NIOSH) Publi- cation No. 2005-149 ed. Cincinnati, OH: National Institute for seconds.5 The eyewash station also should be located on the Occupational Safety and Health; 2007. same level as the formalin, and the travel route to the 2. xCFR 1910.1048: Hazardous substances. Formaldehyde. eyewash station should be free of obstructions that may Occupational Safety and Health Administration. https://www.osha.gov/ delay the immediate use of the eyewash station.5 When pls/oshaweb/owadisp.show_document?p_id¼10075&p_table¼ walking at a normal pace, the average person covers a STANDARDS. Accessed May 8, 2015. distance of 55 feet in 10 seconds5; however, a person who 3. OSHA Fact Sheet: Formaldehyde. 2011. Occupational Safety and has experienced a chemical splash to the eyes or face may be Health Administration. https://www.osha.gov/OshDoc/data_General_ visually impaired, in discomfort or pain, and in a state of Facts/formaldehyde-factsheet.pdf. Accessed May 8, 2015. 4. Material Safety Data SheetdFormalin 10%. 2013. American panic. For this reason, it is prudent to consider the physical Master Tech. http://www.americanmas-tertech.com/PDF/SSFX and emotional state of a person in these circumstances and BFO.PDF. Accessed May 8, 2015. the availability of assistive personnel in the immediate area 5. ANSI/ISEA Z358.1-2009: American National Standard for Emergency when determining the location of eyewash stations in Eyewash and Shower Equipment. New York, NY: American National relation to areas where formalin is used or stored.5 Standards Institute; 2009.

Latex-free environments for tissue recovery and organ procurement procedures

QUESTION: protein that might adhere to an allograft when recovered in an One of the surgeons I work with has asked that we provide environment where latex gloves were worn. They calculated 2 a latex-free environment during procedures where tissue is that up to 90 mcg/dm of latex protein could be transferred to recovered and organs are procured. Is this necessary? an allograft during the recovery procedure. Based on the researcher’s conservative assumption that approximately 10% ANSWER: of leachable latex protein would remain adherent to the Currently there are no recommendations from any professional allograft after processing, they estimated that the total amount organization for providing a latex-free environment during tissue of latex protein remaining on a single allograft would be 2 1 recovery and organ procurement; however, there is a potential approximately 10 mcg/dm . This amount is much lower ’ for tissue and organs to acquire latex protein deposits if not than the 2001 ASTM International s recommended limit of 2 recovered in a latex-free environment. Organ transplantation, 200 mcg/dm for medical devices that are to be labeled latex- 2 where fresh, refrigerated, viable, and functional cells are desired, free, including latex-free surgical gloves. and allograft tissue transplantation, where a highly processed nonviable matrix is the norm, are substantially different pro- In December 2014, the US Food and Drug Administration cedures. There are no reports of latex-induced anaphylactic (FDA) provided guidance for labeling products made with “ shock associated with transplantation of allograft tissues. natural rubber and recommended that products be labeled Not made with natural rubber latex”3(p4) with the explanation that Researchers at one tissue bank evaluated the potential for latex residue on finished tissue allografts and found it to be within [The] FDA is concerned that statements submitted for inclu- acceptable limits of exposure (ie, 200 mcg/dm2).1 In this study, sion in medical product labeling, such as “latex-free,”“does not the researchers approximated the maximum amount of latex contain natural rubber latex,” or “does not contain latex,” are

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not accurate because it is not possible to reliably assure that environment to reduce the risk of anaphylactic shock in a there is an absence of the allergens associated with hypersen- recipient with unknown latex allergy. sitivity reactions to natural rubber latex in the medical prod- Preoperatively, the RN should assess both donor and recipient uct. Use of these terms may give users allergic to natural rubber 3(p1) patients for risk factors for latex sensitivity. Organ procure- latex a false sense of security when using a medical product. ment and tissue recovery professionals use donor risk assess- Although the FDA recognizes that the complete absence of ment forms when evaluating the donor’s medical condition all natural rubber latex allergens may not be necessary for and history. These forms may include assessment questions ’ fi the safe use of medical products by individuals with natural regarding the donor s speci c allergies. Uniform donor risk assessment interview forms are available from the American rubber latex allergies,3(p4) it is impossible to know how Association of Tissue Banks at http://www.aatb.org/DRAI much exposure to natural rubber latex might cause a -Documents.6 Early recognition of risk factors for latex fi reaction in any speci c person. Researchers have not been sensitivity may prevent the progression of anaphylaxis. able to establish that allograft processing procedures are fi able to completely destroy or eliminate any latex proteins Based on a consideration of the bene ts versus potential harms associated with this practice question, it seems that the benefits of that might be present in the allograft. Thus, the question providing a latex-free environment during tissue recovery and organ of whether allograft tissue recovered in a non-latex-free procurement procedures outweigh the potential harms. Recom- environment is safe for transplantation into latex-sensitive mendations for providing a latex-free environment are provided in or latex-allergic patients remains unanswered. the AORN “Guidelineforasafeenvironmentofcare,part1.”7

Case reports in the literature describe latex-induced anaphylactic Acknowledgment: The authors thank Eric J. Davis, MS, RN, 4,5 4 shock during organ transplantation procedures. Shinoda et al CNOR, clinical nurse consultant, at Molnlycke Health Care, reported the case of a 33-year-old female liver donor who Norcross, GA, for his assistance in writing this response. developed intraoperative latex-induced anaphylactic shock during surgery for living donor transplantation. During the procedure, her blood pressure dropped and her face and upper extremities Sharon A. Van Wicklin, MSN, RN, CNOR, became warm and flushed. After treatment with epinephrine, she CRNFA(E), CPSN-R, PLNC, is a perioperative nursing seemed to recover and the procedure was continued; however, specialist in the Nursing Department at AORN, Inc. she went into shock again within a few minutes. The surgical team suspected latex-induced anaphylactic shock. They administered epinephrine and hydrocortisone, changed to latex- free gloves, and replaced the patient’s urinary catheter with a Scott A. Brubaker, CTBS, is latex-free catheter. The patient recovered a second time, but the senior vice president of Policy at procedure was discontinued because an intraoperative x-ray the American Association Of revealed mild pulmonary edema. Postoperative IgE-RAST Tissue Banks, McLean, VA. (immunoglobulin E radioallergosorbent test) blood levels showed a strong positive result, suggesting that the anaphylactic reaction was induced by latex. The authors recommended that latex

allergy should be considered as a potential donor risk. Although print & web 4C/FPO the authors did not recommend using a latex-free environment for organ recovery procedures, a hypothetical case could be made that implementing latex precautions during this procedure might have prevented the anaphylaxis.

5 Jacmarcq et al reported the case of a young man who developed References anaphylactic shock during a kidney transplantation procedure. 1. LifeNet HealthTM. Frequently Asked Questions: What Is the Risk That No latex-containing materials were used during the procedure; an Allograft That Is Implanted Into a Patient Contains Latex?. Virginia however, the authors concluded that latex contamination in the Beach, VA: LifeNet Health; 2014. donor organ was the cause of the anaphylaxis. The authors 2. ASTM D3578-01e1. Standard Specification for Rubber Examination strongly recommended procuring donor organs in a latex-free Gloves. West Conshohocken, PA: ASTM International; 2001.

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3. Recommendations for Labeling Medical Products to Inform Users latex-induced anaphylactic shock. Int Surg. 2012;97(4): That the Product or Product Container Is Not Made With Natural 356-359. Latex. Guidance for Industry and Food and Drug Administration 5. Jacmarcq O, Karila C, Carli P. Latex-induced anaphylactic shock Staff. Rockville, MD: US Department of Health and Human Services, following graft reperfusion during renal transplantation. Ann Fr Food and Drug Administration; 2014. http://www.fda.gov/ucm/ Anesth Reanim. 2005;24(5):547-550. groups/fdagov-public/@fdagov-meddev-gen/documents/document/ 6. Uniform DRAI Documents. American Association of Tissue Banks. ucm342872.pdf. Accessed May 9, 2015. http://www.aatb.org/DRAI-Documents. Accessed May 9, 2015. 4. Shinoda M, Tanabe M, Nagao K, et al. Discontinuation of 7. Guideline for a safe environment of care, part 1. In: Guidelines for living donor liver transplantation due to donor’s intraoperative Perioperative Practice. Denver, CO: AORN, Inc; 2015:239-263.

Covering facial hair in semirestricted and restricted areas

QUESTION: or her cheek using a sterile culture swab while holding a blood Why does the current AORN “Guideline for surgical agar Petri dish 30 cm below the face. The researchers designed attire”1 recommend that perioperative team members this test to simulate the bacterial shedding that might occur cover facial hair when in semirestricted and restricted from the health care worker onto a sterile field or a patient areas? Does longer facial hair present a greater risk of during patient care. Notably, researchers considered the surgical site infection than shorter facial hair? shedding test positive only if the same species of bacteria grew in the Petri dish as grew on the culture swab from the health care worker’s face. ANSWER: The results of the study showed that although health care The AORN recommendation1 for covering facial hair is based workers with and without facial hair shed bacteria at high rates on a nonexperimental study that examined dispersal of (42% overall), those with facial hair shed bacteria at a higher bacteria by men with and without beards and by women. rate (50.8%) than those without facial hair (33.5%). The re- McLure et al2 placed blood agar plates 15 cm below the lips searchers emphasized the importance of all health care workers of 30 seated subjects: 10 clean-shaven men, 10 bearded completely covering their faces during invasive procedures men, and 10 women. The subjects wore surgical masks for performed under sterile conditions. The benefit of covering two 90-minute periods. Researchers placed an additional facial hair in restricted and semirestricted areas is that it may agar plate 15 cm below the subjects’ lips to control for decrease patients’ exposure to microorganisms shed from the environmental conditions. Following exposure, they skin and hair of perioperative personnel and thus reduce their incubated the agar plates for 24 hours and a microbiologist, risk of surgical site infection.1 blinded to the study sequence, counted and identified the number of bacterial colonies present. The results of the fi study showed there was signi cantly more bacterial shedding Sharon A. Van Wicklin, MSN, RN, CNOR, by bearded men than by clean-shaven men or by women, CRNFA(E), CPSN-R, PLNC, is a perioperative nursing even when a mask was worn. The researchers suggested that specialist in the Nursing Department at AORN, Inc. beards may act as a reservoir for bacteria and dead organic material. The researchers did not specifically explore the amount of bacterial shedding from longer beards compared References with shorter beards; however, they theorized that shorter 1. Guideline for surgical attire. In: Guidelines for Perioperative Practice. beards would disperse less bacteria than longer beards. Their Denver, CO: AORN, Inc; 2015:97-120. recommendation was that bearded men working near sterile 2. McLure HA, Mannam M, Talboys CA, Azadian BS, Yentis SM. The fields should consider beard removal. effect of facial hair and sex on the dispersal of bacteria below a masked subject. Anaesthesia. 2000;55(2):173-176. 3 In a quasi-experimental study, Wakeam et al investigated the 3. Wakeam E, Hernandez RA, Rivera Morales D, Finlayson SR, facial bacterial shedding of 408 health care workers: 199 with Klompas M, Zinner MJ. Bacterial ecology of hospital workers’ facial facial hair and 209 without facial hair. Each subject rubbed his hair: a cross-sectional study. J Hosp Infect. 2014;87(1):63-67.

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Covering ears in semirestricted and restricted areas

QUESTION: negate the effect of differences in individual skin bacterial Why does the current AORN “Guideline for surgical loads. The researchers found that bacterial counts were 21 attire”1 recommend that perioperative team members times greater on the skin behind the earrings worn by the cover their ears when in semirestricted and restricted areas? perioperative team members. The benefitofcoveringthe ears, regardless of whether they are pierced or not, in ANSWER: restricted and semirestricted areas is that it may decrease ’ The AORN recommendation1 for covering ears is based on a the patient s exposure to microorganisms shed from the nonexperimental study that examined the source of bacteria ears of perioperative personnel and thus reduce the ’ 2 shed by perioperative team members from exposed areas of patient s risk of surgical site infection. the face not covered by surgical attire or personal 2 protective equipment. Owers et al systematically cultured Sharon A. Van Wicklin, MSN, RN, CNOR, the foreheads, eyebrows, and ears of 20 surgical team CRNFA(E), CPSN-R, PLNC, is a perioperative nursing members. The researchers found that there was specialist in the Nursing Department at AORN, Inc. significantly more bacteria isolated from the ears than from the foreheads and eyebrows of the surgical team members and recommended that the ears be covered by surgical References head covers during surgery, particularly if the team 1. Guideline for surgical attire. In: Guidelines for Perioperative Practice. member has pierced ears. Owers et al2 emphasized the 3 Denver, CO: AORN, Inc; 2015:97-120. need for covering ears, and Bartlett et al recommended 2. Owers KL, James E, Bannister GC. Source of bacterial shedding in fi that pierced ears speci cally be covered. In this quasi- laminar flow theatres. J Hosp Infect. 2004;58(3):230-232. 3 experimental study, the researchers measured bacterial 3. Bartlett GE, Pollard TC, Bowker KE, Bannister GC. Effect of jewellery counts on the earlobes of surgical team members wearing on surface bacterial counts of operating theatres. J Hosp Infect. pierced earrings. Each subject acted as their own control to 2002;52(1):68-70.

www.aornjournal.org AORN Journal j 307 LEARNER EVALUATION Continuing Education:

Clinical Issues 1.7 www.aorn.org/CE

his evaluation is used to determine the extent to 5. To what extent were your individual objectives met? which this continuing education program met Low 1. 2. 3. 4. 5. High your learning needs. The evaluation is printed There for your convenience. To receive continuing education 6. Will you be able to use the information from this article credit, you must complete the online Learner Evaluation at in your work setting? http://www.aorn.org/CE. Rate the items as described below. 1. Yes 2. No 7. Will you change your practice as a result of reading this PURPOSE/GOAL article? (If yes, answer question #7A. If no, answer question #7B.) To provide the learner with knowledge of AORN’s guidelines fi related to surgical wound classi cation; storing and using 7A. How will you change your practice? (Select all that apply) fi small, pre lled containers of formalin in the OR; latex-free 1. I will provide education to my team regarding why environments for tissue recovery and organ procurement change is needed. procedures; covering facial hair in semirestricted and restricted 2. I will work with management to change/implement areas; and covering ears in semirestricted and restricted areas. a policy and procedure. 3. I will plan an informational meeting with physicians OBJECTIVES to seek their input and acceptance of the need for change. To what extent were the following objectives of this 4. I will implement change and evaluate the effect of continuing education program achieved? the change at regular intervals until the change is 1. Discuss practices that could jeopardize safety in the incorporated as best practice. perioperative area. 5. Other: ______Low 1. 2. 3. 4. 5. High

2. Discuss common areas of concern that relate to periop- 7B. If you will not change your practice as a result of erative best practices. reading this article, why? (Select all that apply) Low 1. 2. 3. 4. 5. High 1. The content of the article is not relevant to my practice. 3. Describe implementation of evidence-based practice in 2. I do not have enough time to teach others about the relation to perioperative nursing care. purpose of the needed change. Low 1. 2. 3. 4. 5. High 3. I do not have management support to make a change. 4. Other: ______CONTENT 4. To what extent did this article increase your knowledge 8. Our accrediting body requires that we verify the time of the subject matter? you needed to complete the 1.7 continuing education Low 1. 2. 3. 4. 5. High contact hour (102-minute) program: ______

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