AORN JOURNAL

SEITEMBER 1992, VOL 56, NO 3

care institutions in today’s uncertain economy, tion to the area under the tape. If the colorhospital reputation and physician loyalty are coded tape chips or peels off during surgery important considerations, but physician satisand the instruments have not been sterilized for faction should be promoted through progresthe appropriate amount of time, the instrument sion, not regression. Rather than promote a may not be sterile. physician bonding system, we should promote MARYO’NEALE,RN, BS, CNOR a system of collaboration in which the knowlPERIOPERATIVE NURSE SPECIALIST edge, skills, and clinical competence of health CENTERFOR PRACTICE care professionals are mutually valued and respected. If nurses allow this professional Surgical Masks socialization to continue, it will result in a loss of autonomy and a change in the interpretation am quite concerned about the viewpoint presented by William C. Beck, MD, FACS, and expectation of nursing roles. FIES, in the April 1992 guest editorial, “The ROSETROJKoVIcH, RN, CNOR STAFFNURSE/NEUROLQGY surgical mask: Another ‘sacred cow’?” Dr Beck reports on “an excellently designed ENGLEWOOD (NJ) HOSPITAL and executed study on 3,088 consecutive Flash Sterilization patients.” He explains when masks were used and noted that patients were excluded if they he article “Flash sterilization: Is it safe for were undergoing open heart, orthopedic, neuroroutine use?” is good overall. I was dislogic, or outpatient procedures. The study found turbed, however, when I read that the author a postoperative wound infection rate of 4.7% flash sterilizes articles with instrument tape on when masks were worn and a 3.5% postoperathem for only three minutes. I thought the use tive infection rate when no masks were worn. of instrument tape required that the flash sterilFrom these results, the researchers conclude that ization time increase from three minutes to 10 masks provide no benefit for the patient. minutes and that only metal instruments with I am an orthopedic surgeon; thus, my no tape could be flash sterilized for three minpatients would have been excluded from this utes. study. It is my opinion that infection rates of CLARENCE FENTON, RN, BS, CNOR 3.5% and 4.7% are totally unacceptable in CLINICAL NURSE EDUCATOR/OR, ASU, PACU modem operating rooms. Proper asepsis is part technique and part attiBRIGHTON MEDICAL CENTER PORTLAND, ME tude. I do not perform surgery in an atmosphere that would be considered jovial, I believe the Response. The recommended exposure time surgical team’s number one concern is the pergiven by the Association for Advancement of son lying on the OR bed. I am not there to have Medical Instrumentation for metal instruments a good time but to perform a job and perform it only (ie, no porous items or items with lumens) well. I do believe in every standard set by is three minutes at or above 270 O F (132.2 “C) AORN concerning sterile technique, including in a gravity-displacement sterilizer. Examples the recommendations for space around tables of porous items are rubber, towels, plastics, and and the proper wearing of masks, gowns, and colored tape. When nonporous items and gloves. I even believe in “space suits’’ when porous items are combined, the minimum expoperforming total joint replacements. There is no sure time is 10 minutes at or above 270 OF room for slack in an OR. As a surgeon, I am truly the “captain of the (132.2 “C) in a gravity-displacement sterilizer. Instruments with color-coded tape are conship.’’ When an infection occurs and one of my patients is faced with a markedly altered sidered porous and require longer exposure lifestyle, it is I who must sit a few feet from the time to ensure steam penetration and steriliza-

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patient and his or her family members and explain what happened. This is not pleasant; it makes me feel that I should do everything within my power to prevent catastrophic complications and outcomes. In my last 1,718 cases, I have had two infections. One was in a diabetic patient, and the other was in a patient who had severe rheumatoid arthritis and was taking prednisone. I have had no infections in the last 394 total joint replacements I have performed. My overall infection rate is 0.12% while wearing masks or space suits. I believe this is nearly the lowest rate possible, and the approach I use is the kind of approach I would like the surgeon to use when I am the one lying on the OR bed. Dr Beck and I do agree on one point: that face shields are useful. I, however, believe they should be worn over masks. 1 don’t mind the extra effort that it takes to breathe through a mask, and my patients appreciate my approach to their health. In conclusion, I find this editorial illogical and unsettling. Masks are but a small part of the overall picture of sterile technique. Along with wearing a mask properly, one should limit talking and laughing in the OR, eliminate traffic to and from the room, and provide an atmosphere where work is done precisely with no need to rush or to waste time. JOHNG. SULLIVAN, MD ORTHOPEDIC SURGEON ORTHOPEDIC SPECIALISTS TARPON SPRINGS, FLA Author’s response. Dr Sullivan is to be congratulated not only for his superb infection rate, but for the obvious discipline of his team and his ability to limit his practice to “clean” cases. Several decades ago, it was demonstrated that prohibiting talk, in the operating room was invaluable. As one researcher said, keeping one’s mouth shut makes masks unnecessary. It is important to remember that statistics demand proper interpretation. The Tunevall study excluded only open heart cases. The obvious reason for this is that infection might place such patients’ lives at risk-an unaccept426

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able hazard for such a study. The orthopedist

Sir John Charnley led the way to ensuring successful joint replacements by adding total silence, laminar flow, and antibiotics to infection control. It could be that Dr Sullivan’s infection rate could be as good without his wearing a mask, but I agree that he and other orthopedists should not tamper with their fine results. I do not recommend giving up the surgical mask. I do suggest, however, that further studies be completed to see if the mask could be replaced by the more comfortable splash shield or whether masking of those not scrubbed could be avoided. WILLIAM C. BECK,MD PRESIDENT EMERITUS FOUNDATION FOR THEGUTHRIE MEDICAL RESEARCH SAYRE, PA The AORN Journal welcomes letters f o r its “Letters to the Editor” column. Letters must refer to Journal articles or columns published within the preceding two months. All letters are subject to editing. Authors of articles or columns referenced in the letter to the editor are given the opportunity to respond. Letters that are to be included in the “Letters to the Editor” column must contain the reader’s name, credentials if applicable (eg, RN, BSN, CNOR),position or title, employer, and employer’s address. Submit all correspondence to AORN Journal, Letters to the Editor, 10170 E Mississippi Ave, Denver, CO 80231.

Surgical masks.

AORN JOURNAL SEITEMBER 1992, VOL 56, NO 3 care institutions in today’s uncertain economy, tion to the area under the tape. If the colorhospital repu...
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