If you feel weighed down by rules, regulations and guidelines you believe are unnecessary, ambiguous, wasteful, often poorly supported and occasionally archaic, you're not alone. Our recent reader survey suggests that common sense is being steamrolled by too many surgical do's and don'ts.
With recommendations coming from a variety of sources AORN, CMS, CDC, the Joint Commission, as well as surgical, anesthesia and infection-prevention groups the volume of guidance can be both overwhelming and frustrating. Many of our survey respondents say they struggle with what they perceive as unwelcome and unjustified departures from common sense.
"I feel that many recommendations are generated by those sitting behind a desk trying to justify their job somehow," says Kamille Livingston, RN, director of nursing at the St. George (Utah) Surgical Center. "They're not on the front line dealing with the day-to-day stresses of the job and do not realize how much these regulations actually tie our hands and prevent us from giving the quality patient care that we would like."
Readers mentioned dozens of issues, but the 5 that drew the strongest ire are surgical attire, home laundering of scrubs, OR temperatures, immediate-use steam sterilization and NPO guidelines.
"Does it really matter if you wear your own designer scrub cap?" asks Jonathan Kaplan, MD, owner of Pacific Heights Plastic Surgery in San Francisco, referring to the AORN recommendation that reusable cloth caps, if worn, be covered with single-use disposable caps.
"More hair is contained with the cloth hats than the cheap thin paper ones," says Kristin Gillard, MSN, GI lab nurse manager at the Loma Linda (Calif.) VA. Many question the recommendation. Others dismiss it as borderline absurd. "Everyone has been wearing cloth hats in the OR for decades," says an OR manager from Kansas. "If this was really an infection issue, it would have been figured out a long time ago."
So where is the recommendation coming from? "Arbitrary ideas and local lore guide the creation of rules, especially as related to attire and NPO," says Catherine Cooper, MD, an associate professor at Virginia Commonwealth University in Richmond. "There's no evidence on personal scrub hats; there are (just) strong opinions."
Some even question AORN's interpretation of available evidence. "I have gone to and looked up the evidence myself in the original sources and often have found that AORN extrapolates info they want, to make the case they want," says a clinical educator from Indianapolis. "I agree with many of the AORN recommendations on attire and jewelry, but their references are so outdated it's very hard to defend."
And it isn't just the guidance about surgical caps that elicits contempt. "My favorite most ridiculous rule is shoe covers," says Dr. Kaplan. "How does a shoe cover protect a patient?"
AORN's recommendation that perioperative staff wear long sleeved warm-up jackets also evokes deep skepticism. "The theory is that it will capture desquamation, which makes sense," says Ken Warnock, CST/SFA, CRCST, supervisor of central sterile processing at Beaumont Hospital-Dearborn (Mich.). "But epidemiologically, I haven't seen any studies linking desquamation to infection."
"I disagree with the need to wear long sleeves," adds a nurse manager from Maine. "Based on studies and anecdotal reports, it seems that we are at greater risk of direct contamination of sleeves by wearing jackets while we position patients and turn over rooms. Then we prep patients while wearing the same jacket. Shedding of squamous cells seems like far less of a risk."
AORN's recent decision to strengthen the force of its recommendation against home laundering of scrubs has infuriated some in the field who insist that the rationale is flawed. "There is no evidence that this is necessary," says Keri Ortega, DNAP, CRNA, associate director of doctoral education at Wolford College in Naples, Fla. "'Evidence' that does exist does not meet the rigorous standards of evidence-based practice. Studies were biased and therefore cannot be used as evidence."
Dr. Ortega says the pronouncement may have the opposite of the desired effect: "Many times we take hospital-provided scrubs and they smell sour. How is this better than scrubs I know that I washed? Also, locker rooms are not clean where the scrubs are stored and we change into the provided scrubs."
AORN says the benefit of healthcare-accredited laundering is that it may protect the patient from exposure to pathogens remaining on the attire after home laundering and may prevent transmission of pathogens from the attire worn in the healthcare facility into the home or community. AORN further states that home laundering is not monitored for quality, consistency or safety, and that home laundering may not reliably kill all pathogens and the pathogens may survive in the form of biofilms within the washing machine.
The director of anesthesia at a Colorado medical center scoffs at the idea that home laundry facilities can't adequately disinfect scrubs: "My water temperature is much greater at home than the facility we currently use." Adds another reader: "In 40 years of being in the OR, I've never heard of washing scrubs at home causing an infection to patient or provider."
A perceived double standard doesn't help. Many readers say laundering rules aren't uniformly enforced. "Surgeons and anesthesia providers wear their scrubs in from home 95% of the time, and it does not affect the infection rates," says a Texas director of nursing. Chuck Dawson, BSN, RN, MBA, agrees. "Show me a study that provides evidence that home laundering scrubs results in demonstrably higher infection rates," says Mr. Dawson, the director of surgery at Iberia (La.) Medical Center.
How strong is the evidence is to support the many recommendations and guidelines you're asked to follow?
- Very strong 14%
- Moderately strong 46%
- Not very strong 32%
- Not strong at all 8%
Have you ever seen 2 or more facilities interpret and handle the same guideline differently?
- Yes 92%
- No 8%
Do you think there are any guidelines or recommendations that need to be updated that may have seemed appropriate at one time, but that no longer do?
- Yes 75%
- No 25%
Do you ever feel as if your facility is wasting time or money by trying to comply with overreaching or unnecessary rules and recommendations?
- Yes 74%%
- No 26%%
SOURCE: Outpatient Surgery Magazine reader survey, November 2015, n=360.
Feeling the heat
AORN's recommendation that ORs be kept between 68 ? and 75 ?F is another guideline that gets practitioners steamed, with many arguing that uncomfortably hot surgeons in hot gowns are more dangerous to patients than a cooler environment would be.
"Our surgeons cannot operate at the temperatures AORN recommends," says Patricia Huber, MA, RN, nurse manager at Jack C. Montgomery VAMC in Muskogee, Okla.
"The OR temperature has a significant impact on the surgeon's comfort level in the room," agrees Beth Hurley, BSN, RN, CASC, administrator of the Phoenix (Ariz.) Children's Surgery Center. "I would rather ensure the temperature in the room is cooler, the surgeon isn't sweating profusely and the patient is warmed by heated air."
The recommendation doesn't take into account surgical team members' clothing and gowns, says a perioperative educator from Indiana. "You cannot have team members passed out from heat!" she says. Indeed, adds a clinical education coordinator from California. "Often surgeons are sweating profusely, which is a greater risk than a temperature of 66 ?F."
Many respondents don't see the sense in the recommendation that immediate-use steam sterilization terminology that has evolved from what used to be called "flashing" be avoided if at all possible.
Those doing ophthalmological procedures tend to be especially skeptical. "It is more than adequate for eyes, since we have good data to show it does not lead to increased infections," says Jon Weston, MD, owner of the Weston Eye Center in Roseburg, Ore. "These guidelines were well-intentioned, but not science-based initiatives."
A Las Vegas director of nursing agrees. "Infection rates haven't changed one iota from when it was common practice to flash cataract trays to now," she says.
The distinction seems arbitrary to those in other specialties, as well. The idea that flashing "is only OK in an emergency," strikes Jeffrey Blank, DPM, as nonsensical. "Sterile is sterile," says Dr. Blank, of the Dundee Foot & Ankle Center in Wheeling, Ill. "If flashing is ever acceptable, then it should always be acceptable."
Concerns about the logic echoed from as far away as Australia. "A flash sterilizer is better than waiting for an hour or so to get a dropped instrument re-sterilized," says Ian Skinner, MBBS, FRACS, FAOA, of the Orthopaedic Surgery Institute of Western Australia. "In my view, the time spent with the patient anesthetized and (with the) wound open is a greater risk of infection and/or complication than the threat of a flash sterilizer. Even if the instrument is hollow, what chance is there that the interstices were contaminated when it was dropped?"
NPO guidelines have been evolving in recent years. but as William Landess, CRNA, MS, JD, notes, "some cling to the old standards." The nothing-after-midnight proclamation was based on "old, questionable research," says Mr. Landess, the corporate director of anesthesia at Palmetto Health in Columbia, S.C. How old? "The guidelines were established more than 150 years ago for patients in labor," says Gary Lawson, MD, chief medical officer for Quantum Anesthesia Services in Naples, Fla.
If guidelines are evolving, but patients are still being told to fast for 8 hours or more, who's to blame? "It seems that patients are kept NPO for surgeon convenience," says a nurse manager from Kentucky, "in case the procedure can be done earlier than planned. The rule is actually bad for patients. That's what bothers me the most."
Patients who take clear carbohydrate liquids up to 3 hours pre-operatively recover faster, have less PONV, spend less time in PACU and have greater satisfaction, says Kris Sabo, RN, executive director and administrator of Pend Oreille Surgery Center in Ponderay, Idaho, echoing a widely held view. "In my opinion, that outweighs the NPO after midnight for the convenience of the provider."
"NPO status is too rigid, especially for the frail and elderly," says a Washington state RN. "Patients arrive so dehydrated, it makes IV starts impossible."
When it comes to NPO, it all adds up to a need for more, or at least better, guidance, says Teresa Smith, RN, director of Forsyth Plastic Surgery in Winston-Salem, N.C. "There will always be variables, especially if you're dealing with pediatrics or patients not receiving a general anesthetic," she says. "But it would be nice to come together and develop some evidence-based guidelines surrounding NPO status."