Insects in the OR; multiple-procedure consent form; sterilizer testing; smoke plume; MRSA/VRE precautions - Clinical Issues

AORN Journal,  July, 2002  by Dorothy Fogg

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Question: Now that the weather has warmed, we are experiencing a problem with insects getting into our OR suites. Some are flying insects (eg, flies, gnats), and others are the crawling type (eg, spiders, ants). Some staff members would like us to purchase an ultraviolet bug light to hang in the OR for the flying insects. Others want chemical strips and saucers of beer to lure the crawling insects. Theoretically, the beer entices the insects, and they become trapped in the liquid. Neither of these options seems like a good idea from an infection control perspective. In addition, trapped insects struggling for their freedom or dead insects lying around the OR are displeasing aesthetically, to say the least. Does AORN have a better suggestion for eliminating these insects?

Answer: The real solution to the problem lies in finding the insects' portals of entry and closing them. Using hanging ultraviolet pest control devices is not recommended because the precipitate from incinerated insects creates a potential infection control hazard in the OR. Chemical strips and saucers of beer are equally unacceptable; however, some liquid pesticides are acceptable for use in OR suites. Any pesticide application in the OR should be performed commercially by people who are familiar with the various pesticides and their characteristics and have the appropriate equipment to perform a controlled application of the chemicals. Pesticides should be applied after all procedures have been completed and OR staff members have left the area. Equipment and supplies should be covered with an impervious material, such as plastic, or moved to another location during the application. If a fogging process is used, supplies must be moved from the area, including items stored in cupboards and closets. Supplies do not need to be removed for floor applications of pesticide chemicals. Regardless of the method used, all pesticide residues must be removed after the designated contact time has elapsed. The entire surgical suite and all equipment not removed from the area must be cleaned thoroughly before the area and equipment can be used.

Question: I am the manager of an ambulatory surgery center in which we maintain an ongoing emphasis on time and efficiency. We recently developed a surgical consent form listing many of the procedures normally performed in our facility. When the patient signs the form, he or she is instructed to cross out everything except the procedure for which he or she is giving consent. The surgeon still is responsible for informing patients about risks and benefits of procedures. The purpose of using this method is to save time by having everything preprinted on the form. Some nurses are uncomfortable with the new form. They insist on using the old form on which the specific surgical procedure is handwritten before the patient provides consent. Is there a problem with using a multiple-procedure consent form? What is AORN's opinion?

Answer: Although there may be nothing legally incorrect about using a multiple-procedure consent form, such a form would seem to provide opportunity for error. Above all, we must put patient safety first. How much time does the preprinted form really save? The patient must initial anything on the form that he or she crosses out, which requires additional time. The patient may not understand or be familiar with procedure names or the medical terminology used; therefore, additional explanation will be required. The potential for error is great with the system you describe. What if something is not crossed out and the oversight is not noted until a later time? Could the patient be subjected to unnecessary and unplanned procedures? How will you know the patient's intent if the oversight is not noted until after the patient is anesthetized? How will you use the consent form as part of the surgical site identification process if the procedure is not specified? How will you determine laterality with a preprinted form? Ideally, the surgical consent form should be signed in the surgeon's office sometime before the day of surgery. This gives the patient an opportunity to ask questions of the surgeon or office staff members. With the time lapse between the office visit and scheduled procedure, patients often have additional questions for the surgeon. If the procedure is written on the form at the time of the office visit, having that information on the form when the patient arrives at your facility provides one more check and balance to ensure correct site surgery.

Question: We have a sterilizer in our facility that can be run on either a gravity or prevacuum cycle. We normally perform biological testing of the sterilizers daily. When we perform this test, is it sufficient to test one mode of operation (ie, gravity versus prevacuum), or is it necessary to test each type of cycle?

Answer: If a sterilizer is designed to be used for more than one type of cycle (eg, gravity, prevacuum,) each sterilization mode should be tested. (1) Testing should be performed upon installation and routinely thereafter. For both gravity and prevacuum cycles, a biological indicator test pack should be used. The test pack should consist of 16 freshly laundered, reusable, absorbent surgical towels with an approximate size of 16 inches by 26 inches. To construct a test pack, fold each towel in thirds and then at the middle to create an approximate 9-inch by 9-inch item. Place the towels in a stack with the folds opposite each other. The stack should measure approximately 9 inches by 9 inches by 6 inches. Place one or more biological indicators containing spores of Bacillus stearothermophilus between the seventh and eighth towels in the center of the pack. Tape the towels together. Do not use a wrapper. Commercially available disposable test packs may be used if manufacturers' data demonstrate equivalency to the defined test pack. Label the test pack with the sterilizer information.