CONTINUING EDUCATION Implementing AORN Recommended Practices for Prevention of Transmissible Infections

3.3

MARCIA R. PATRICK, MSN, RN, CIC; RODNEY W. HICKS, PhD, RN, FNP, FAANP, FAAN

www.aorn.org/CE Continuing Education Contact Hours

Approvals

indicates that continuing education (CE) contact hours are available for this activity. Earn the CE contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Examination and Learner Evaluation at http://www.aorn.org/CE. A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answers. Each applicant who successfully completes this program can immediately print a certificate of completion.

This program meets criteria for CNOR and CRNFA recertification, as well as other CE requirements. AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure.

Event: #13536 Session: #0001 Fee: Members $19.80, Nonmembers $39.60

Ms Patrick and Dr Hicks have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article. The behavioral objectives for this program were created by Liz Cowperthwaite, senior managing editor, and Rebecca Holm, MSN, RN, CNOR, clinical editor, with consultation from Susan Bakewell, MS, RN-BC, director, Perioperative Education. Ms Cowperthwaite, Ms Holm, and Ms Bakewell have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article.

The CE contact hours for this article expire December 31, 2016. Pricing is subject to change.

Purpose/Goal To provide the learner with knowledge specific to implementing precautions to prevent infection in perioperative practice settings.

Conflict of Interest Disclosures

Objectives 1. 2. 3. 4.

Identify components of the chain of infection. Identify types of transmission-based precautions. Explain methods by which pathogens are transmitted. Describe ways to implement transmission-based precautions. 5. Discuss ways health care providers can protect themselves against transmissible infections.

Accreditation AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

Sponsorship or Commercial Support No sponsorship or commercial support was received for this article.

Disclaimer AORN recognizes these activities as CE for RNs. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity.

http://dx.doi.org/10.1016/j.aorn.2013.08.018


AORN, Inc, 2013

December 2013

Vol 98 No 6


AORN Journal j 609

RECOMMENDED PRACTICES Implementing AORN Recommended Practices for Prevention of Transmissible Infections 3.3 MARCIA R. PATRICK, MSN, RN, CIC; RODNEY W. HICKS, PhD, RN, FNP, FAANP, FAAN

www.aorn.org/CE

ABSTRACT Preventing infection in the perioperative setting is a critical element of patient and health care worker safety. This article reviews the recommendations in the AORN “Recommended practices for prevention of transmissible infections in the perioperative practice setting.” The recommended practices are intended to help perioperative nurses implement standard and transmission-based precautions (ie, contact, droplet, airborne), including use of personal protective equipment as well as interventions to prevent surgical site infections and exposure to bloodborne pathogens. Additional recommendations cover vaccination programs and how to manage personnel who require work restrictions. Hospital and ambulatory patient scenarios are included to help perioperative nurses apply the recommendations in daily practice. AORN J 98 (December 2013) 610-625.
AORN, Inc, 2013. http:// dx.doi.org/10.1016/j.aorn.2013.08.018 Key words: transmissible infections, health careeassociated infections, bloodborne pathogens, standard precautions, transmission-based precautions.

P

rotecting patients and health care personnel from infectious agents is one of the many important roles of perioperative nurses. Fundamental to infection prevention is breaking the chain of infection (ie, the elements required for an infection to occur): a pathogen source, a susceptible host, and a method of transmission. This article provides an overview of the updated AORN

“Recommended practices for prevention of transmissible infections in the perioperative practice setting,”1 an evidence-based document developed to help guide perioperative patient care. Health care personnel who use these recommendations should be better equipped to align their facility’s infection prevention program goals and priorities with the requirements of regulatory and accrediting bodies.

http://dx.doi.org/10.1016/j.aorn.2013.08.018

610 j AORN Journal




December 2013

Vol 98 No 6


AORN, Inc, 2013

RP IMPLEMENTATION GUIDE: TRANSMISSIBLE INFECTIONS For a full understanding of each of the recommendations, along with the corresponding review of evidence, readers are encouraged to read the full recommended practices (RP) document. WHAT’S NEW The RP document was updated in 2012 using an evidence-based approach. The lead author and a team of evidence appraisers reviewed relevant literature and used an appraisal tool to assign appraisal scores. The appraisal score depicts the strength and quality of the evidence in an individual article. The collective evidence that supports each intervention statement was then rated using a rating schema. This helps perioperative providers understand the best evidence available for infection prevention practices. The content of the document has been rearranged and expanded. Increased information is included about standard and transmission-based precautions, including explanations of the evidence for each practice recommendation. Personal protective equipment (PPE) plays a role in each type of transmissible infection precaution, and one section of the updated RP document focuses specifically on PPE. Classification of surgical wounds is important in the risk stratification used to report surgical site infections. A Surgical Wound Classification Decision Tree is included to provide a tool for correct documentation of the surgical wound class. The recommendation related to vaccination includes the current immunizations that the Centers for Disease Control and Prevention (CDC) recommends for health care personnel,2 as well as guidelines for when and who to immunize and how to manage occupational exposures to vaccinepreventable diseases. Recommendations for managing personnel with communicable diseases are expanded and include information on exposure management, work restrictions, and medical clearance.2 The section on competency includes more detail about which practices should be included in education and competency evaluation, training

www.aornjournal.org

requirements under the Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens Standard,3 and emergency preparedness. Formal competency evaluation is an important part of this revised RP document that was not included in previous iterations. Collaboration between perioperative nurses and infection preventionists, as well as other professionals, is emphasized throughout the document. RATIONALE Prevention of transmissible infections is a priority in all areas of health care. In operating and procedure rooms, many opportunities exist to introduce pathogens to patients through the surgical site, IV access, and the use of invasive devices. In addition, there have been reports of transmission of bloodborne pathogens to patients through unsafe injection practices.4-6 Health care personnel are at risk for diseases transmitted by infected patients. There are additional risks to health care personnel of exposure to bloodborne pathogens from unsafe handling of contaminated sharps and using sharps that do not have engineered safety protection. Accreditation organizations and Centers for Medicare & Medicaid Services (CMS) surveyors assess compliance with evidence-based best practices to reduce the risk of infection to patients and health care workers. These surveyors are interested in staff participation in quality assurance and performance improvement activities. They look for identification of infection control problems or issues and the steps taken to resolve these and to improve patient outcomes. They also look at compliance with process measures such as standard precautions, transmission-based isolation precautions, hand hygiene, and environmental cleaning and disinfection.7,8 DISCUSSION In addition to standard precautions, the health care team can use transmission-based precautions to disrupt the chain of infection; transmission-based precautions comprise contact precautions, droplet AORN Journal j 611

December 2013 Vol 98 No 6

precautions, and airborne precautions. These precautions can help prevent disease transmission to both patients and health care providers. The RP document includes a table to help health care providers determine which category of precautions is appropriate (Table 1). In addition, health care providers must protect patients from acquiring health careeassociated infections and protect themselves and patients by adhering to the OSHA Bloodborne Pathogens Standard3 and getting immunized against vaccine-preventable diseases. There are many evidence-based practices that can be used in the perioperative environment to reduce the risks of infection transmission to patients and personnel. Perioperative nurses are in a unique position to interrupt the chain of infection and help ensure patient and worker safety. Recommendation I “Standard precautions are the foundation for preventing transmission of infectious diseases.”1(p332) It is rarely the patient who is known to have a communicable disease that causes exposures and transmission; it is the patient who has a transmissible infection that has not been identified.9 Some hospitals have the ability through electronic health records to identify patients who are actively infected with or carrying a multidrug-resistant organism (MDRO). Having a clinical history of the patient can help the perioperative nurse plan the best approach to care to minimize exposure to other patients. However, not every patient with an MDRO infection or colonization will be identified, so strict adherence to standard precautions is necessary. Recommendation I focuses on the use of standard precautions and includes information on hand hygiene practices, PPE, respiratory and cough hygiene practices, and safe injection practices. Frequent hand hygiene, either thorough washing with soap and water for a minimum of 15 seconds or use of a hand rub containing at least 60% alcohol, will help prevent contaminants from spreading from the patient or the patient’s environment to 612 j AORN Journal

PATRICKdHICKS other surfaces and other patients or personnel.10 Perioperative nurses should follow good hand hygiene practices and act as the patient’s advocate by helping to ensure that everyone who comes in contact with the patient or the patient’s environment cleans his or her hands before and after patient contact. Use of PPE is a part of standard and transmissionbased precautions to protect health care providers’ bodies and clothing from exposure to blood and other potentially infectious materials. In addition, when possible, personnel should keep their clothing from touching beds or other patient care surfaces or equipment to help prevent spread of contamination. Respiratory hygiene and cough etiquette are important to prevent transmission of diseases spread by the droplet or airborne routes, including the common cold and influenza, as well as to keep Mycobacterium tuberculosis (TB) out of the air, where it can be breathed in by others and cause infection. Patients and visitors should be instructed to cough or sneeze into a tissue, immediately dispose of it in a waste receptacle, and then clean their hands. This prevents pathogens from contaminating hands and the surfaces hands subsequently touch. Perioperative nurses should educate others and promote compliance with respiratory hygiene and cough etiquette practices. Awareness of safe injection practices facilitates compliance with the CDC Safe Injection Practices11 and the “One and Only Campaign,” which advocates for “one needle, one syringe, one time.”12 In addition, OSHA requires the use of sharps with engineered safety protection (if a safety device is available on the market) and safe handling practices for sharps, including scalpels and other sharp implements.3 The intent of these interventions is to reduce the risk of pathogen exposure to patients caused by unsafe injection practices and to reduce accidental injury to health care workers and the subsequent risk of bloodborne disease transmission (eg, hepatitis B, hepatitis C, HIV). Perioperative nurses have a responsibility to follow safe injection practices, including using aseptic technique during

Type of precaution Contact

Droplet

Type of organism/ disease

Transport n

Diphtheria, Haemophilus influenzae type b, seasonal influenza, pandemic influenza, meningococcal disease, mumps, mycoplasma pneumonia, group A streptococcus, pertussis, adenovirus, rubella

n

n

n

n

Cover or contain the infected or colonized areas of the patient’s body. Remove and dispose of contaminated personal protective equipment (PPE) and perform hand hygiene before transporting the patient. Don clean PPE to handle the patient at the transport destination.

Instruct the patient to wear a mask and follow respiratory hygiene and cough etiquette. The transporter is not required to wear a mask.

Standard precautions plus the following: n Wear gloves whenever touching the patient’s skin or items that are in close proximity to the patient. n Wear a gown when it can be anticipated that clothing will come in contact with the patient or contaminated environmental surfaces. n Don a gown upon entry into the room, and remove and perform hand hygiene before exiting. Standard precautions plus the following: n Wear a mask upon entry into the room.

Preoperative area

Environmental measures

Hold the patient in a single patient room if possible; otherwise keep  3 feet separation between patients.

Clean the room (eg, OR, airborne infection isolation room [AIIR]) immediately after patient use. Focus on frequently touched surfaces.

n

Routine

n

Hold the patient in a single patient room if possible; otherwise keep  3 feet separation between patients. Draw a privacy curtain between beds to minimize the opportunity for close contact.

(table continued)

www.aornjournal.org

AORN Journal j 613

Draining abscess, infectious wounds, Clostridium difficile, acute viral infection, methicillin-resistant Staphylococcus aureus (MRSA), vancomycinresistant Enterococci (VRE), vancomycinintermediate/resistant S aureus (VISA/VRSA), extended-spectrum beta-lactamase (ESBL), and multidrug-resistant pneumonia

Protection for unscrubbed personnela

1

RP IMPLEMENTATION GUIDE: TRANSMISSIBLE INFECTIONS

TABLE 1. Guide for Perioperative Personnel Caring for Patients With Transmissible Infections

Type of precaution Airborne

Type of organism/ disease Tuberculosis, disseminated herpes zoster, rubeola, monkeypox, smallpox, varicella zoster, and chicken pox

Transport n

n n

Instruct the patient to wear a mask and follow respiratory hygiene and cough etiquette. Cover and contain affected skin lesions. The transporter is not required to wear a mask.

Protection for unscrubbed personnela Standard precautions plus the following: n Wear a fit-tested N95 or higher-level respirator that is approved by the National Institute for Occupational Safety and Health.

1

Environmental measures

Preoperative area n n

Place the patient in an AIIR if possible. Provide at least 6 (existing facility) or 12 (new construction/ renovation) air changes per hour.

n

n

Consult an infection preventionist before patient placement to determine the safety of an alternative room that does not meet AIIR requirements. If an AIIR is not available, the OR should remain vacant postoperatively for the appropriate time to allow for a full exchange of air, generally 1 hour.

December 2013 Vol 98 No 6

614 j AORN Journal

TABLE 1. (continued ) Guide for Perioperative Personnel Caring for Patients With Transmissible Infections

a Unscrubbed personnel include anesthesia professionals, the circulating RN, and preoperative and postanesthesia care unit personnel. 1. Siegel JD, Rhinehart E, Jackson M, Chiarello L; the Healthcare Infection Control Practices Advisory Committee. 2007 Guideline for isolation precautions: preventing transmission of infections agents in health care settings. Am J Infect Control. 2007;35(10 Suppl 2):S65-S164.

Infection control professionals should modify or adapt this table according to local conditions and special patient considerations. Reprinted with permission from Perioperative Standards and Recommended Practices. Copyright ª 2013, AORN, Inc. All rights reserved.

PATRICKdHICKS

RP IMPLEMENTATION GUIDE: TRANSMISSIBLE INFECTIONS

www.aornjournal.org

transport bed is pushed to the doorway, the transporter should remove the PPE and sanitize his or her hands. A clean sheet can be draped over the patient, hanging outside the bedrails, to prevent others from coming into contact with contaminated surfaces during transport. Some facilities require the transporter to don a clean gown and gloves for Recommendation II the transport. Because the transporter’s hands will Recommendation II pertains to contact precautions, 9 be on the bed, it is important that he or she not which are used in addition to standard precautions. touch other surfaces. This can be done, for example, Some patients have infections that can be spread by using an elbow to press elevator buttons and by contact with the patient or with items from the automatic door openers.15 Perioperative nurses can patient’s environment. These patients may have support these recommendations by helping ensure open, draining wounds or be infected or colothat personnel entering the room and transporting nized with an MDRO. For years, the most common patients comply with appropriate precautions. MDROs were methicillin-resistant Staphylococcus If the patient is taken to a preoperative holding aureus and, to a much lesser extent, vancomycinarea, the perioperative nurse should help ensure resistant enterococcus. Today, even more viruthat the patient is placed away from the traffic flow lent and dangerous pathogens are being identified, so other personnel are less likely to bump into the including carbapenem-resistant Enterobacteribed or brush against it. Everyone providing care aceae, multidrug-resistant Acinetobacter, and should don a gown carbapenemaseand gloves, and those producing Klebsiella pneumoniae.13 Gowns and gloves should be worn by anyone assisting with patient who enters a room of a patient on contact transfer to the OR Clostridium difficile should wear a gown is not a resistant path- precautions. Contact with the environment alone can result in organisms on staff members’ and gloves until the ogen but one that has clothing and hands. patient is on the OR become increasingly bed and is covered, virulent and prevalent being careful not to and can survive for come into contact with any other surfaces in the months on environmental surfaces, providing an room. The gown and gloves should be removed and ongoing reservoir.14 Recommendation II provides the person’s hands sanitized before contact with information on the use of PPE, hand hygiene any other surfaces, including telephones, pens, practices, and transporting patients. The recomand charts, and before he or she leaves the room mendation also addresses environmental cleaning. or immediate area. Gowns and gloves should be worn by anyone At the end of the surgical procedure, personnel who enters a room of a patient on contact precaushould gown and glove again to remove drapes and tions. Contact with the environment alone can retransfer the patient to the transport bed. Those in sult in organisms on staff members’ clothing and the postanesthesia care unit (PACU) should don a hands.15 Health care personnel should don a gown gown and gloves for any contact with the patient and gloves at the door of the room and remove or the bed. Again, the patient should be placed the gloves and perform hand hygiene after leaving out of the main flow of traffic to prevent others the room. For patients undergoing surgery, the from accidentally coming in contact with the reOR transporter should don a gown and gloves to covery bed. When the patient has recovered from assist the patient to the transport bed. After the all aspects of injection or IV medication administration; not using needles, syringes, or IV fluid bags for more than one patient; and not administering medications from single-dose vials to multiple patients.11

AORN Journal j 615

December 2013 Vol 98 No 6

anesthesia and can be transported back to his or her inpatient room, the perioperative nurse or transporter should drape a clean sheet over the transport bed to prevent unprotected contact during the trip back to the inpatient room.9 If a patient is transported to the OR from the intensive care unit in his or her inpatient bed and the bed is then left in the hallway outside the OR, the perioperative nurse or designee should place a clean sheet over the bed and label the bed (eg, “MDRO” or “Keep Off”) to prevent other personnel from coming in contact with the contaminated bed. This is important because leaning or sitting on the bed may contaminate scrub attire. Thorough cleaning and disinfection of equipment used on the patient and surfaces with which the patient came into contact are essential to preventing the spread of disease.9 “Perioperative nurses should assess and monitor cleaning and disinfection practices.”1(p354) Implementing this recommendation provides an excellent opportunity for nurses to work with the infection preventionist on educating environmental services personnel about cleaning products and practices, such as cleaning surfaces with a 1:10 household bleach solution or a product registered with the Environmental Protection Agency to eradicate pathogens such as C difficile.16 Recommendation III Recommendation III addresses droplet precautions, which are used in addition to standard precautions. Droplet precautions are implemented to reduce the risk of infection spread by close contact with the patient’s respiratory secretions or moist mucosal membranes. Diseases spread via the droplet route include influenza, colds and other upper or lower respiratory infections, pertussis (ie, whooping cough), rubella, and mumps. For droplet precautions, PPE may include using a mask that is sufficient to prevent transmission of large droplets and eye protection to reduce the spread of infectious respiratory secretions. Glasses should have solid side shields; there are goggles and over-glasses 616 j AORN Journal

PATRICKdHICKS that can be used and masks that have built-in eye shields. A full face shield worn with a mask is also acceptable. When possible, patients with a known droplet-spread disease should have their surgery postponed until they are no longer infectious.9 All personnel in the OR who will be within 3 feet of the patient before and during intubation should wear a gown, gloves, mask, and eye protection. Anesthesia professionals should wear a gown and a mask with eye protection during intubation. These should be removed and the anesthesia professional’s hands sanitized after the patient is intubated and the endotracheal (ET) tube is secured. Personal protective equipment should be donned by anyone within 3 feet of the patient’s head for extubation and for moving the patient from the OR bed to the gurney and for transport. This is not necessary if the patient remains intubated and is transported back to a critical care unit. Perioperative nurses should comply with PPE requirements and help ensure that others within the 3-feet zone are wearing appropriate PPE. Personnel in the PACU should wear gowns, gloves, masks, and eye protection when within 3 feet of the patient who requires droplet precautions. The patient should not be any closer than 3 feet from another patient. Patients being treated with droplet precautions should be masked for transport when clinically appropriate to prevent the spread of infection from respiratory secretions. Recommendation IV Airborne precautions, which are used with standard precautions, are the focus of Recommendation IV. Patients with suspected or diagnosed pulmonary or laryngeal TB, varicella (ie, chickenpox), rubeola (ie, measles), or disseminated herpes zoster (ie, shingles) require airborne precautions9 and are not candidates for elective surgical procedures until they are no longer infectious. They should not undergo surgery unless life-threatening conditions direct otherwise.17 Intubation and extubation are high-risk procedures because they often cause patients to cough, producing infectious aerosols.

RP IMPLEMENTATION GUIDE: TRANSMISSIBLE INFECTIONS

www.aornjournal.org

powered air purifying respirator (PAPR) with a The goal of using airborne precautions is to limit loose-fitting hood. These do not require fit testing, risk to the surgeon and other team members. This is just familiarization.18 especially true for TB, for which there is no vacRespirators must be fit checked immediately cine. Varicella and rubeola both have safe, effective before personnel enter the room of a patient who vaccines that are recommended by the CDC for all requires airborne precautions to ensure that the health care workers.2 For varicella, rubeola, or disseminated herpes mask seal is tight to prevent breathing of unfiltered zoster, the period of communicability varies by air around the respirator. The OR manager and disease. For a patient materials management with TB, it may take personnel should enseveral weeks to sure that there is an Personnel who are not able to be fit tested several months of adequate supply of or who cannot tolerate the respirator cannot provide care for surgical patients who are on treatment before the respirators in suffiairborne precautions. patient is noninfeccient types and sizes tious, as determined to accommodate all by three negative personnel. The N95 sputum smears or other criteria in the facility’s respirators should not have exhalation valves bepolicy; however, the surgical procedure only needs cause the exhalation from personnel can contamito be postponed until the patient is noninfectious, nate the surgical field17; PAPRs designed for use in even if the patient is still undergoing treatment the OR may be used with the exhaust aimed down 17 for TB. and away from the OR bed.18 Sometimes surgery cannot be postponed and the There are several options that can be used to patient must be brought to the OR. For these situmanage a patient with TB who must undergo surations, the OR manager must ensure that periopgery. One option is to use local exhaust control erative personnel in the OR wear fit-tested N95 or measures such as a high-efficiency particulate air higher-level (eg, N99) respirators, which necessi(HEPA) filter machine directed near the patient’s tates having a full respiratory protection program mouth and a portable HEPA filter machine in the according to the OSHA Respiratory Protection room during intubation and extubation or for the 18 Standard. Every person who needs a respirator entire procedure if possible. After intubation, the must complete a specific medical screening quesanesthesia professional should place a HEPA filter tionnaire that is reviewed by the employee health on the end of the ET tube to keep TB out of the air nurse or other appropriate provider to ascertain and the anesthesia machine. Personnel should know 18 whether that person can safely wear a respirator. where the HEPA filter machine is kept and how Some people have face shapes or facial hair that it can be accessed, and HEPA filters for ET tubes prevents a tight seal. Some cannot breathe comshould be readily available.18 fortably through a respirator, especially those who A second option that will keep a patient with have asthma, chronic obstructive pulmonary disTB from contaminating the OR air is to move the ease, or other respiratory ailments or those who are masked patient from an inpatient airborne infection claustrophobic.18 Personnel who are not able to isolation room (AIIR) to an AIIR located in either be fit tested or who cannot tolerate the respirator the preoperative area or the PACU for intubation cannot provide care for surgical patients who are if the facility has these specially designed rooms. on airborne precautions. Personnel with beards or The door should be kept closed when the patient mustaches that prevent a tight mask seal may be is in the room, and all personnel present should provided with an alternate respirator, such as a wear N95 respirators or PAPRs. The anesthesia AORN Journal j 617

December 2013 Vol 98 No 6

professional should place a HEPA filter on the end of the ET tube and should mechanically ventilate the patient during transport to the OR. After the surgical procedure is completed, the patient, still intubated with the HEPA filter in place, should be transported to the PACU AIIR and extubated. The door to the AIIR should be kept closed, and all personnel present should wear an N95 respirator or PAPR. When the patient has fully recovered from anesthesia, the perioperative nurse or transporter should place a new surgical mask over the patient’s mouth and nose for transport to the AIIR on the inpatient unit. The third option is similar except intubation and extubation are performed in the inpatient AIIR. For facilities that do not have AIIRs near the OR, this may present the best option, even though a PACU nurse may need to recover the patient in the inpatient AIIR.17 After the patient has been moved, the OR or AIIR should be kept closed until adequate time has passed for 99% of the air volume to have been replaced before the room is entered for cleaning. It is imperative that a written policy be in place before a patient with TB presents for surgery. The OR manager should designate a perioperative staff member to monitor that all the necessary precautions are being taken and the policy is being followed. Because surgery on a patient with TB is probably a rare occurrence at any facility, an infection preventionist should brief personnel, help ensure the process is followed, and note any problems (eg, lack of appropriate respirators, employees who are not fit tested, no HEPA filters for the ET tube, no HEPA machine). Everyone participating in the surgical procedure, particularly anesthesia professionals and surgeons, should be included in the briefing. After the surgical procedure is finished and the patient has been transported for recovery, the OR manager or a designee should conduct a short process review with all participants to determine what went well and what did not and identify any recommendations for improvement. Very 618 j AORN Journal

PATRICKdHICKS importantly, all personnel, including physicians and anesthesia professionals, should be educated about the TB policy, signs and symptoms of TB, and precautions required.17 Facilities must have written policies for managing personnel who are exposed to infectious diseases. The infection preventionist can assist with developing the policies.17,19 When a surgical patient has TB, it is also important to screen everyone accompanying the patient for signs and symptoms to be certain they do not also have TB. Children with TB are almost always infected by an adult in their immediate environment.17 The screening can be performed by the first employees who encounter the patient or by telephone before the patient’s admission. Facility policy should indicate who is responsible for this function. Signs and symptoms of TB include fever, fatigue, night sweats, and weight loss of 10 lb or more within two months; later symptoms include cough, sometimes bloody sputum, and hoarseness (a sign of laryngeal TB, which is generally considered very contagious). Chest x-rays may show cavitary lesions, and sputum smears may be positive for acid-fast bacilli.17 Management of patients who require airborne precautions may be a good subject for a multidisciplinary performance improvement project; it addresses transmission of infection, requires coordination with other departments, and could enhance patient and personnel safety. It encompasses policies and procedures, documentation, performance monitoring, use of equipment and supplies, quality management, infection prevention, employee health, engineering, administration, purchasing, safety, and possibly coordination with the local health department and other external agencies. The perioperative nurse is in an ideal position to initiate such a project. Ambulatory surgery centers (ASCs) should only provide surgical services to patients with airborne diseases, particularly TB, if the facility is equipped to care for patients who require airborne precautions (eg, has AIIRs and personnel fit tested with N95 respirators).18 Personnel should undergo the

RP IMPLEMENTATION GUIDE: TRANSMISSIBLE INFECTIONS same preparation and education as in a hospital setting. If the facility is not equipped to manage these patients, referral to a facility with the appropriate accommodations is the best course.17 There should be a written policy stating that patients with suspected TB, varicella, rubeola, or disseminated herpes zoster will not be admitted but will be referred to a health care facility that has the capability to safely perform surgery on the patient.17 Surgeons who practice at the ASC should be aware of and follow the policy to avoid exposing personnel and other patients and visitors to disease.

www.aornjournal.org

exposure and for enforcing the proper use of PPE and safe work practices. This responsibility includes having an adequate supply of equipment in the correct sizes available to the employee at no cost. Using the PPE, however, is the responsibility of the employee. Perioperative nurses should participate in monitoring for proper use of PPE to contribute to facility and community safety. The OSHA requirements are not guidelines; they are federal law. Failure to follow OSHA standards can lead to significant fines for the organization. More importantly, it puts employees at risk for exposure to bloodborne pathogens.

Recommendations V and VI Recommendation VII Since the early 1980s, awareness of bloodborne Recommendation VII emphasizes that perioperapathogens and prevention programs has grown. tive nurses should take an active role to prevent Some pathogens can cause disease, increase mor3,12 the transmission of health careeassociated infecbidity, and lead to death. Recommendation V tions. Health careeassociated infections are comaims to reduce occupational exposure to such mon20 and expensive, pathogens by emphasizing that personnel and they contribute must follow the significantly to patient The health care employer is responsible for OSHA Bloodborne morbidity and mortalproviding the necessary equipment and attire Pathogens Standard ity. The RP document to reduce workplace exposure to blood, with regard to PPE includes recommenbody fluids, and other potentially infectious and use engineering dations for interorganisms; however, using the personal protective equipment is the responsibility of controls (eg, needleventions to prevent the employee. less systems, selfprocedure-associated sheathing needles) infections, such as and work practice surgical site infeccontrols (eg, a neutral zone for passing sharps, tions, and device-associated infections, including double gloving for all surgical procedures) when central lineerelated bacteremias and catheterthere is a risk of exposure to blood or other porelated urinary tract infections. The document 3 tentially infectious materials. A health care orgaalso addresses prevention of MDROs. Most perioperative nurses are familiar with interventions nization must have a written exposure control plan 3 including sterile technique, clean environments, that is readily accessible to personnel. clean surgical attire, antisepsis at the surgical Recommendation VI addresses use of PPE (eg, site, hand hygiene with appropriate disinfecting gloves, eye protection, masks) when exposure to agents, managed traffic flow, timing of prebloodborne pathogens and to other potentially inprocedural prophylaxis, and adherence to CDC fectious materials, such as semen; vaginal secreguidelines for use of central lines and urinary tions; or amniotic, pleural, pericardial, peritoneal, catheters. cerebrospinal, or synovial fluids, is anticipated.3 This recommendation also promotes multidisciThe health care employer is responsible for proplinary collaboration to prevent various types of viding the necessary equipment and attire to reduce AORN Journal j 619

December 2013 Vol 98 No 6

infections. The infection preventionist can provide data on infections that have origins in the perioperative arena. He or she will be able to assess data for trends or patterns that might indicate a problem or other opportunity for improvement. Comparison of the facility’s infection rates with national benchmarks such as the CDC National Healthcare Safety Network21 or other databases can provide valuable information on reducing infections. Regardless of benchmark data, the goal is always to have no infections. Implementing bundles of best practices has been shown to reduce surgical site infections and other health careeassociated infections and conditions.22 Recommendation VIII Including a vaccination program as part of an organizational infection prevention program is a cost-effective intervention that reduces the likelihood that health care workers will contract an illness. In addition, having a fully vaccinated health care team reduces the risk to patients. Health care providers should be immunized “if they come into contact with patients or infectious material from patients that may put them at risk for exposure and possible transmission of vaccine-preventable diseases”1(p345) (eg, hepatitis B, seasonal influenza, varicella, rubeola, rubella, pertussis). Postexposure treatment guidelines should be understood by all employees, and there should be adequate recordkeeping of exposures and injuries as required by OSHA.3 Perioperative managers should collaborate with the employee health nurse, the infection preventionist, and perioperative personnel to develop, implement, and monitor a robust vaccine program.2 Perioperative nurses should participate in programs to educate health care personnel about the importance of immunization and comply with facility immunization requirements. Recommendation IX Recommendation IX addresses how to manage health care personnel with infections, exudative 620 j AORN Journal

PATRICKdHICKS lesions, or interruption in normal skin integrity and who may need to restrict work activities (eg, direct patient care, handling of surgical instruments). Each of these issues is best handled through consultation with the employee health nurse, the health care worker, and the infection preventionist. In some instances, it may be necessary to involve the employee’s personal physician or a specialist (eg, for conditions such as ongoing hand dermatitis or other skin infections or respiratory infections that persist). Health care personnel with work restrictions should obtain medical clearance before returning to work with patients.18 Organizations should have written policies to address these instances. The Final Four The final four recommendations in each AORN RP document discuss education/competency, documentation, policies and procedures, and quality assurance/performance improvement. These four topics are integral to the implementation of AORN practice recommendations. Personnel should receive initial and ongoing education and should complete competency verification activities as applicable to their roles. Implementing new and updated recommended practices offers an excellent opportunity to create or update competency materials and competency verification tools. AORN’s perioperative competencies team has developed the AORN Perioperative Job Descriptions and Competency Evaluation Tools23 to assist perioperative personnel in verifying competency or developing customized competency evaluation tools and position descriptions. Documentation of nursing care should include patient assessment, plan of care, nursing diagnosis, and identification of desired outcomes and interventions as well as an evaluation of the patient’s response to care. Implementing new or updated recommended practices may warrant a review or revision of the relevant documentation being used in the facility. Policies and procedures should be developed, reviewed periodically, revised as necessary, and

RP IMPLEMENTATION GUIDE: TRANSMISSIBLE INFECTIONS readily available in the practice setting. New or updated recommended practices may present an opportunity for collaborative efforts among nurses and personnel from other departments in the facility to develop organization-wide policies and procedures that support the recommended practices. The AORN Policy and Procedure Templates, 3rd edition,24 provides a collection of 30 sample policies and customizable templates based on AORN’s Perioperative Standards and Recommended Practices.25 Regular quality improvement projects are necessary to improve patient safety and to help ensure safe, quality care. For details on the final four practice recommendations that are specific to the RP document discussed in this article, please refer to the full text of the RP document.

www.aornjournal.org

The signs and symptoms are all compatible with TB, but the patient is not in an isolation room. Nurse M knows that if the patient has TB, personnel and patients could possibly be exposed because intubation and extubation are highrisk procedures. Nurse M relates her concerns to the charge nurse. They call the infection preventionist, who says he will institute airborne precautions for the patient. He recommends that the perioperative nurse contact the surgeon to discuss the possibility that this patient has TB and explain that these patients do not generally come to the OR unless there is a life- or limb-threatening emergency. The charge nurse calls the thoracic surgeon and explains the policy that given the patient’s clinical presentation, he should be tested to rule out TB. The surgeon states he is sure that the patient does not have TB. The OR charge nurse contacts the chief surgeon and asks for her thoughts on the situation. The chief surgeon agrees that the patient should not be taken to the OR, so she calls the thoracic surgeon to obtain a more in-depth understanding of the patient’s clinical picture. The thoracic surgeon believes the patient has lung

HOSPITAL PATIENT SCENARIO Nurse M is a hospital perioperative nurse. In reviewing the day’s surgical schedule, she notes that one of the thoracic surgeons will be performing a bronchoscopy in the OR with the patient under anesthesia. These procedures usually are performed in the pulmonary clinic, so she pulls up the patient’s health record on the computer. She sees that the Educational Resources patient is an older man who has dementia, which is pren AORN Video Library: Prevention of Transmissible Infections in sumably why the surgeon the Perioperative Practice Setting [DVD]. http://cine-med.com/ wants to perform the surgery index.php?nav¼aorn&cat¼all. in the OR (ie, for better airn Sharps Safety Tool Kit. http://www.aorn.org/Clinical_Practice/ way control in a potentially ToolKits/Tool_Kits.aspx. uncooperative patient). n Spruce L. Recommended Practices for the Prevention of The patient is a native of Transmissible Infections in the Perioperative Setting [Webinar]. Mexico and has a history of http://www.aorn.org/Events/Webinars/Previously_Recorded_ a 20-lb weight loss during Webinars.aspx#RPInfectionPrevention. the past three months; fen Spruce L, Chinnes LF, Perz JF, Kirchner B. Infection Prevention vers; night sweats; and chest Series for the Ambulatory Setting. 4-Part Series [Webinars]. pain on coughing, which is http://www.aorn.org/Events/Webinars/Previously_Recorded_ frequent. His sputum often Webinars.aspx. contains blood. A chest x-ray shows upper lobe cavitary Web site access verified September 10, 2013. lesions, suggestive of TB.

AORN Journal j 621

December 2013 Vol 98 No 6

PATRICKdHICKS

that the safest place to perform the bronchoscopy is in the pulmonary clinic AIIR as soon as possible. Nurse M contacts the clinic and discusses the situation with the clinic manager, who says she can schedule the patient to undergo the procedure within the hour. One of the pulmonologists is willing to perform the bronchoscopy because the surgeon is now in the OR with another patient. Nurse M then calls the patient’s nurse on the inpatient unit to give her an update on the situation and also briefs the nursing supervisor. The patient is masked and transported to the clinic. The procedure goes well, and the patient is masked and returned to the AIIR on the inpatient unit. Later that afternoon, the result of the patient’s acid-fast bacillus smear is positive, with identification pending. The next day, it is identified as M tuberculosis. The personnel in the emergency department on the inpatient unit who cared for the patient before he was placed on airborne precautions are scheduled to be screened by the employee health nurse and receive follow-up for exposure to TB. Because the patient was not treated in the OR, no OR team members were exposed. The personnel in Resources for Implementation the pulmonary clinic were not exposed because they n AORN Syntegrity Framework. AORN, Inc. http://www.aorn wore fit-tested N95 respira.org/syntegrity. tors in an AIIR. n ORNurseLinkTM. http://ornurselink.aorn.org. The OR director complin Perioperative Job Descriptions and Competency Evaluation ments Nurse M on her idenTools [CD-ROM]. Denver, CO: AORN, Inc; 2012. http:// tification of the problem and www.aorn.org/JobDescriptions. suggests the group reconn Policy and Procedure Templates [CD-ROM]. 3rd ed. Denver, vene to identify how they CO: AORN, Inc; 2013. http://www.aorn.org/Books_and_ could handle similar situaPublications/AORN_Publications/Policy_and_Procedure_ tions in the future. The group Templates.aspx. agrees that the causes of n The Roadmap to ASC Compliance [CD-ROM]. Denver, CO: the problem were multifacAORN, Inc; 2012. http://www.aorn.org/Education/Ambulatory/ torial. The surgeon was unAmbulatory_Surgery_Center_Resources.aspx. familiar with hospital policy regarding patients with susSyntegrity is a registered trademark and ORNurseLink is a tradepected TB, and the system mark of AORN, Inc, Denver, CO. had not ensured the medical Web site access verified September 10, 2013. staff members were included

cancer, but he agrees to meet with Nurse M, the OR charge nurse, the chief surgeon, the infection preventionist, and the anesthesia professional to discuss the options available. In this facility, bronchoscopies generally are performed in the pulmonary clinic in a negative pressure room with a HEPA filter unit in the exhaust duct. Engineering department personnel check this room monthly, and the room has a pressure monitor on the wall outside the door that will sound an alarm if the pressure and required air exchanges are out of range. Personnel who work in the pulmonary clinic have all been fit tested for N95 respirators and have experience performing bronchoscopies on patients with TB. The anesthesia professional has HEPA filters for the ET tube and is willing to sedate or anesthetize the patient in the pulmonary clinic. The procedure needs to be performed as soon as possible because the blood clots in the patient’s sputum are increasing, which could indicate erosion of a major blood vessel that could cause the patient to hemorrhage and possibly die. The group agrees

622 j AORN Journal

RP IMPLEMENTATION GUIDE: TRANSMISSIBLE INFECTIONS

www.aornjournal.org

he has already drawn up, particularly propofol, which is expensive. Nurse S is uncomfortable with the response, so he seeks out the charge nurse. She concurs and alerts the OR and the anesthesia directors. Because the anesthesiologist did not seem to be convinced AMBULATORY PATIENT SCENARIO or likely to comply after talking with Nurse S, they Nurse S is a perioperative staff nurse in an ASC. decide that a physician-to-physician discussion While setting up for a surgical procedure, he sees about the situation is warranted. The anesthesia the anesthesiologist who is new to the facility draw director speaks to the anesthesiologist, explaining up 10-mL syringes of several different medications. the ASC policy and providing a printed copy. He The anesthesiologist makes it clear that the labels the syringes policy must be folwith the appropriate lowed. He also relates It only takes one person failing to follow the medication name that in 2013, a physiappropriate practices one time to transmit an stickers and places infection to a patient, himself or herself, another cian was convicted staff member, or someone outside the facility. on criminal charges, them on the anesthesia cart. The paincluding secondtient comes in and the degree murder, reanesthesiologist injects the medications into the lated to unsafe injection practices that resulted in patient’s IV line. At the end of the procedure, the patient infections and death.26 patient is transported to the PACU. The syringes Nurse S, the OR director, the OR charge nurse, remain on top of the cart. and the anesthesia director meet informally later Nurse S meets with the anesthesiologist in the in the day. The others compliment Nurse S on rehallway and quietly asks whether those same sycognizing the problem and going up the chain of ringes will be used for the next surgical procedure. command when his efforts with the provider failed. The reply is “yes.” Nurse S knows that the syringes The anesthesia director agrees to work on an orienshould have been discarded as soon as the patient left tation plan for anesthesia providers to avoid similar the room. He voices his concern about transmission issues in the future. of bloodborne pathogens because the contents of the syringes could be contaminated by blood from the CONCLUSION first patient. The anesthesiologist says that because Following infection prevention practices is integral he injected the medications into a port located at least in the perioperative practice setting to protect both 1 foot above the IV site and no blood was visible in patients and health care personnel. Establishing a the IV tubing, it is safe to use the syringes again. He quality assurance and performance improvement also notes that he has done it this way for more than plan can help promote proper practices and should 20 years and never had a problem. include scheduled, formal monitoring for compliNurse S knows that the ASC policy is “one ance with hand hygiene, standard precautions, and needle, one syringe, one time”12 and that transmistransmission-based precautions. It only takes one person failing to follow these practices one time to sion of bloodborne pathogens, including hepatitis transmit an infection to a patient, himself or herself, C, has occurred from the practices the anestheanother staff member, or someone outside the siologist just described. Nurse S relates the facility facility. Results of monitoring should be made policy and rationale. The anesthesiologist responds available to personnel, and goals and objectives that he does not want to waste the medications that in education about this policy. The participants agree that a multidisciplinary team should be formed to address these problems. The team will also include representatives from employee health and administration.

AORN Journal j 623

PATRICKdHICKS

December 2013 Vol 98 No 6

should be established for performance improvement. The OR manager should ensure that regular education on disease transmission and best practices is provided. Written policies and procedures must be available to guide personnel in the care and management of patients with infectious diseases. Importantly, all surgeons, providers, and anesthesia professionals should be given a copy of the policy and procedure to help promote their compliance. The perioperative nurse plays a critical role in protecting patient safety, helping to ensure that standard and transmission-based precautions are implemented to break the chain of infection, and protecting patients and personnel from transmissible infections. Perioperative nurses are in the best position to implement interventions that will improve patient outcomes and safety, as well as the safety of other perioperative team members. The perioperative nurse may be the last line of defense in protecting patients in today’s complex care environments.

8.

9.

10.

11.

12.

13.

14.

References 1. Recommended practices for prevention of transmissible infections in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:331-363. 2. Advisory Committee on Immunization Practices; Centers for Disease Control and Prevention. Immunization of health-care personnel: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2011;60(RR-7):1-45. 3. Occupational Safety and Health Standards, Toxic and Hazardous Substances: Bloodborne Pathogens, 29 CFR x1910.1030 (2012). US Department of Labor. https:// www.osha.gov/pls/oshaweb/owadisp.show_document?p_ table¼standards&p_id¼10051. Accessed August 28, 2013. 4. Perz JF, Thompson ND, Schaefer MK, Patel PR. US outbreak investigations highlight the need for safe injection practices and basic infection control. Clin Liver Dis. 2010;14(1):137-151. 5. Williams IT, Perz JF, Bell BP. Viral hepatitis transmission in ambulatory health care settings. Clin Infect Dis. 2004;38(11):1592-1598. 6. Centers for Disease Control and Prevention. Transmission of hepatitis B and C viruses in outpatient settingsd New York, Oklahoma, and Nebraska, 2000-2002. MMWR Morb Mortal Wkly Rep. 2003;52(38):901-906. 7. State Operations Manual Appendix AdSurvey Protocol, Regulations and Interpretive Guidelines for Hospitals. Rev 89; 2013. http://www.cms.gov/Regulations-and

624 j AORN Journal

15.

16.

17.

18.

19.

20.

-Guidance/Guidance/Manuals/downloads/som107ap_a_ hospitals.pdf. Accessed October 1, 2013. State Operations Manual Appendix LdGuidance for Surveyors: Ambulatory Surgical Centers. Rev 89; 2013. Centers for Medicare & Medicaid Services. http://www.cms. gov/Regulations-and-Guidance/Guidance/Manuals/downloa ds/som107ap_l_ambulatory.pdf. Accessed October 1, 2013. Siegel JD, Rhinehart E, Jackson M, Chiarello L; Health Care Infection Control Practices Advisory Committee. 2007 Guideline for isolation precautions: preventing transmission of infectious agents in health care settings. Am J Infect Control. 2007;35(10 Suppl 2):S65-S164. Boyce JM, Pittet D. Guideline for hand hygiene in healthcare settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Society for Healthcare Epidemiology of America/Association for Professionals in Infection Control/Infectious Diseases Society of America. MMWR Recomm Rep. 2002;51(RR-16):1-45. Safe injection practices: what they are & why follow them? The One and Only Campaign. http://oneandonly campaign.org/content/what-are-they-why-follow-them. Accessed September 25, 2013. One and Only Campaign. Centers for Disease Control and Prevention. http://www.cdc.gov/injectionsafety/ 1anOnly.html. Accessed August 28, 2013. Arnold RS, Thom KA, Sharma S, Phillips M, Kristie Johnson J, Morgan DJ. Emergence of Klebsiella pneumoniae carbapenemase-producing bacteria. South Med J. 2011;104(1):40-45. Mutters R, Nonnenmacher C, Susin C, Albrecht U, Kropatsch R, Schumacher S. Quantitative detection of Clostridium difficile in hospital environmental samples by real-time polymerase chain reaction. J Hosp Infect. 2009;71(1):43-48. Siegel JD, Rhinehart E, Jackson M, Chiarello L; Healthcare Infection Control Practices Advisory Committee. Management of multidrug-resistant organisms in healthcare settings, 2006. Atlanta, GA: Centers for Disease Control and Prevention; 2006. Vonberg RP, Kuijper EJ, Wilcox MH, et al. Infection control measures to limit the spread of Clostridium difficile. Clin Microbiol Infect. 2008;14(Suppl 5):2-20. Jensen PA, Lambert LA, Iademarco MF, Ridzon R; Centers for Disease Control and Prevention. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings, 2005. MMWR Recomm Rep. 2005;54(RR-17):1-141. Occupational Safety and Health Standards, Personal Protective Equipment: Respiratory Protection Standard, 29 CFRx1910.134 (2011). US Department of Labor. https://www.osha.gov/pls/oshaweb/owadisp.show_docu ment?p_table¼STANDARDS&p_id¼12716. Accessed August 28, 2013. Bolyard EA, Tablan OC, Williams WW, Pearson ML, Shapiro CN, Deitchmann SD. Guideline for infection control in healthcare personnel, 1998. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol. 1998;19(6):407-463. Klevens RM, Edwards JR, Richards CL Jr, et al. Estimating health care-associated infections and deaths in

RP IMPLEMENTATION GUIDE: TRANSMISSIBLE INFECTIONS

21.

22.

23. 24. 25. 26.

US hospitals, 2002. Public Health Rep. 2007;122(2): 160-166. National Healthcare Safety Network. Centers for Disease Control and Prevention. http://www.cdc.gov/nhsn/. Accessed September 25, 2013. Surgical site infection. Institute for Healthcare Improvement. http://www.ihi.org/explore/SSI/Pages/default.aspx. Accessed September 25, 2013. Perioperative Job Descriptions and Competency Evaluation Tools [CD-ROM]. Denver, CO: AORN, Inc; 2012. Policy and Procedure Templates [CD-ROM]. 3rd ed. Denver, CO: AORN, Inc; 2013. Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013. Quine M. Guilty verdicts delivered in hepatitis C outbreak trial. Las Vegas Review-Journal. July 1, 2013. http://www.reviewjournal.com/news/crime-courts/guiltyverdicts-delivered-hepatitis-c-outbreak-trial. Accessed September 25, 2013.

www.aornjournal.org

Marcia R. Patrick, MSN, RN, CIC, is an independent consultant in infection prevention, Tacoma, WA. Ms Patrick has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. Rodney W. Hicks, PhD, RN, FNP, FAANP, FAAN, is a professor in the College of Graduate Nursing, Western University of Health Sciences, Pomona, CA. Dr Hicks has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.

This RP Implementation Guide is intended to be an adjunct to the complete recommended practices document upon which it is based and is not intended to be a replacement for that document. Individuals who are developing and updating organizational policies and procedures should review and reference the full recommended practices document.

AORN Journal j 625

EXAMINATION

3.3

CONTINUING EDUCATION PROGRAM

Implementing AORN Recommended www.aorn.org/CE Practices for Prevention of Transmissible Infections PURPOSE/GOAL To provide the learner with knowledge specific to implementing precautions to prevent infection in perioperative practice settings.

OBJECTIVES 1. 2. 3. 4. 5.

Identify components of the chain of infection. Identify types of transmission-based precautions. Explain methods by which pathogens are transmitted. Describe ways to implement transmission-based precautions. Discuss ways health care providers can protect themselves against transmissible infections.

The Examination and Learner Evaluation are printed here for your convenience. To receive continuing education credit, you must complete the Examination and Learner Evaluation online at http://www.aorn.org/CE.

QUESTIONS 1.

2.

Fundamental to infection prevention is breaking the chain of infection, which includes 1. a pathogen source. 2. a method of transmission. 3. a susceptible host. 4. an ignition source. a. 1 and 3 b. 2 and 4 c. 1, 2, and 3 d. 1, 2, 3, and 4 Transmission-based precautions comprise 1. airborne precautions. 2. contact precautions. 3. droplet precautions. 4. standard precautions.

626 j AORN Journal




December 2013

Vol 98 No 6

a. 2 and 4 c. 1, 3, and 4

b. 1, 2, and 3 d. 1, 2, 3, and 4

3.

Clostridium difficile can survive for months on environmental surfaces. a. true b. false

4.

Anyone who enters the room of a patient on contact precautions should wear 1. a gown. 2. a fit-tested N95 respirator. 3. a surgical mask. 4. gloves. a. 1 and 3 b. 1 and 4 c. 1, 2, and 4 d. 1, 3, and 4


AORN, Inc, 2013

CE EXAMINATION 5.

6.

7.

www.aornjournal.org

a. 2 and 3 c. 1, 2, and 3

b. 1 and 4 d. 1, 2, 3, and 4

Diseases spread via the droplet route include 1. hepatitis B. 2. influenza. 3. pertussis. 4. rubella. a. 2 and 3 b. 1 and 4 c. 2, 3, and 4 d. 1, 2, 3, and 4

8.

Patients who require droplet precautions should be placed at least _______ from other patients. a. 6 inches b. 1 foot c. 2 feet d. 3 feet

After a surgical procedure for a patient with tuberculosis, the OR or airborne infection isolation room should be kept closed until ____ of the air volume has been replaced. a. 30% b. 50% c. 75% d. 99%

9.

The health care employer is responsible for providing the necessary equipment and attire to reduce exposure of personnel to bloodborne pathogens at no cost to the employee. a. true b. false

Options for managing a patient with tuberculosis who must undergo surgery include 1. using a portable high-efficiency particulate air (HEPA) filter machine near the patient’s mouth. 2. using a portable HEPA filter machine in the room during intubation and extubation. 3. placing a HEPA filter on the end of the endotracheal tube. 4. intubating and extubating the patient in an airborne infection isolation room.

10.

Vaccine-preventable diseases against which health care providers should be immunized include 1. hepatitis B. 2. seasonal influenza. 3. tuberculosis. 4. varicella. a. 2 and 3 b. 1 and 4 c. 1, 2, and 4 d. 1, 2, 3, and 4

AORN Journal j 627

LEARNER EVALUATION

3.3

CONTINUING EDUCATION PROGRAM

Implementing AORN Recommended www.aorn.org/CE Practices for Prevention of Transmissible Infections

T

his evaluation is used to determine the extent to which this continuing education program met your learning needs. Rate the items as described below.

OBJECTIVES To what extent were the following objectives of this continuing education program achieved? 1. Identify components of the chain of infection. Low 1. 2. 3. 4. 5. High 2. Identify types of transmission-based precautions. Low 1. 2. 3. 4. 5. High 3. Explain methods by which pathogens are transmitted. Low 1. 2. 3. 4. 5. High 4. Describe ways to implement transmission-based precautions. Low 1. 2. 3. 4. 5. High 5. Discuss ways health care providers can protect themselves against transmissible infections. Low 1. 2. 3. 4. 5. High

CONTENT 6. To what extent did this article increase your knowledge of the subject matter? Low 1. 2. 3. 4. 5. High 7. To what extent were your individual objectives met? Low 1. 2. 3. 4. 5. High 8. Will you be able to use the information from this article in your work setting? 1. Yes 2. No

628 j AORN Journal




December 2013

Vol 98 No 6

9. Will you change your practice as a result of reading this article? (If yes, answer question #9A. If no, answer question #9B.) 9A. How will you change your practice? (Select all that apply) 1. I will provide education to my team regarding why change is needed. 2. I will work with management to change/ implement a policy and procedure. 3. I will plan an informational meeting with physicians to seek their input and acceptance of the need for change. 4. I will implement change and evaluate the effect of the change at regular intervals until the change is incorporated as best practice. 5. Other: ________________________________ 9B. If you will not change your practice as a result of reading this article, why? (Select all that apply) 1. The content of the article is not relevant to my practice. 2. I do not have enough time to teach others about the purpose of the needed change. 3. I do not have management support to make a change. 4. Other: ________________________________ 10. Our accrediting body requires that we verify the time you needed to complete the 3.3 continuing education contact hour (198-minute) program: ________________________________


AORN, Inc, 2013