SESSION NAME Ambulatory Supplement For AORN Perioperative .
SESSION NAMEAmbulatory Supplement for AORN Perioperative Standardsand Recommended PracticesSPEAKERSJan Davidson, MSN, RN, CNOR, CASCTerri D. Link, MPH, BSN, RN, CNOR, CICMary J. Ogg, MSN, RN, CNORSESSION NUMBER0001DATE/TIMESunday, March 30, 2014, 8-9amREPEAT SESSIONS0111, 0167REPEAT DATE/TIMESunday, March 30, 2014, 10:30-11:30amMonday, March 31, 2014, 7-8amCONTACT HOURS (CH)1.0SESSION OVERVIEW:The fastest growing segment of the AORN membership is ambulatory surgery center (ASC) registerednurses. In many states ASCs outnumber hospitals. In order to meet the needs of its members and becauseof the unique challenges freestanding ASCs have, AORN now has an Ambulatory Division with a specificambulatory focus on AORN Standards and Recommended Practices (RPs). Though AORN RPs areapplicable to all procedural areas in both inpatient and outpatient settings, how they are put into practicevaries. Because ASCs should follow the same evidenced-based recommended practices, theirconsiderations were incorporated into the 2014 AORN RPs. Ease of use and navigation of a detailedmanual were considered when developing these RPs. In order to best use the 2014 RPs with specificambulatory information, an educational component is needed. This session will include a guide to the use ofambulatory implications. Case studies will be incorporated into this presentation.OBJECTIVES:1.Identify the need for Ambulatory Interpretive guidelines in AORN Standards and RecommendedPractices.2.Describe how AORN Standards and Recommended Practices with Ambulatory Interpretive Guidelinescan be used in an ambulatory setting.3.Discuss the challenges of Ambulatory Surgery Centers in interpreting perioperative RecommendedPractices.
SPEAKER BIOGRAPHIES:Jan Davidson, MSN, RN, CNOR, CASC, has been involved in nursing and physician education in variousroles throughout her career. In addition to her years of perioperative experience, she has been employed inprofessional liability, risk management, and patient safety roles. This has provided her the opportunity tooffer education to both nurses and physicians on a variety of clinical and ethical issues. Jan was the clinicaldirector of a start-up free-standing ambulatory surgery center where her role included management of theclinical staff, staff education and training, risk management, and infection prevention. Jan serves as the staffliaison to the Joint Commission's Ambulatory Professional Technical Advisory Committee (PTAC) and is anAORN representative on the ASC Quality Collaboration Committee. She was most recently appointed as amember of the Technical Expert Panel (TEP) with the Agency for Healthcare Research and Quality (AHRQ)along with other health care professionals nationwide who will provide guidance on nationally implementingthe adoption of both clinical and safety culture interventions. She is on the board of directors for theAccreditation Association for Ambulatory Healthcare (AAAHC), as well as a patient safety coalition andpublic awareness campaign in Denver called Think About it Colorado. Jan is also an ambulatory surgerycenter surveyor for AAAHC. She is currently a staff member at AORN where her role is Director of theAmbulatory Division. She is an active member of AORN, ASCA, and ASHRM.Terri D. Link, MPH, BSN, CNOR, CIC, is currently Ambulatory Education Specialist at AORN. She has over15 years in ambulatory surgery experience and prior to working at AORN was perioperative patient safetyspecialist at University of Colorado Hospital. While at University of Colorado Hospital Terri interned with theinfection prevention department while completing her MPH. Terri obtained her diploma in nursing atClarkson in Omaha, Nebraska, her BSN from Regis University, Denver, Colorado, and her MPH in 2008from the University of Northern Colorado. Terri is an ambulatory liaison to the Recommended PracticeAdvisory Board and partners with Nursing Practice in developing the ambulatory supplement for AORNStandards and Recommended Practices. Terri is board certified in infection control (CIC).Mary J. Ogg, MSN, RN, CNOR, is a perioperative nursing specialist at AORN where her responsibilitiesinclude providing professional, technical, and management consultative services regarding perioperativenursing practice to AORN members, specialty assemblies, the Board of Directors, national committees, andhealth care organizations. She is responsible for creating products and education materials that support theperioperative professional's safe workplace practice. Mary managed the development of AORN tool kits forsharps safety, surgical smoke evacuation, workplace safety, and safe patient handling and movement in theperioperative setting. She has authored several recommended practices, including Managing the PatientReceiving Moderate Sedation/Analgesia Recommended Practice, Electrosurgery, and Lasers, and SharpsSafety in the Perioperative Setting. Mary has authored "Clinical Issues" columns and other articlespublished in AORN Journal and other professional publications. Mary has practiced in multiple settings,including hospital based ORs, ambulatory surgery centers, and office-based OR in management andclinical practice roles. Prior to employment at AORN, Mary was the ambulatory surgical services managerat Inova Surgery Center in Falls Church, Virginia. Mary has worked as a staff nurse and RN first assistant inCalifornia, Maryland, Virginia, Florida, Hawaii, Kentucky, New Mexico, and Colorado. Mary graduated with adiploma in nursing from Jewish Hospital School of Nursing in Cincinnati, Ohio, and is certified as a CNOR.She holds bachelor's in health science from Chapman University in Orange, California; and a masters inscience in nursing administration from George Mason University, Fairfax, Virginia.Page 2 of 3
SPEAKER CONTACT INFORMATION:Jan Davidson, MSN, RN, CNOR, CASCDirector, Ambulatory DivisionAORN-Nursing Education2170 South Parker Road #300Denver, CO 80231-5711jdavidson@aorn.orgTerri D. Link, MPH, BSN, RN, CNOR, CICAmbulatory Education SpecialistAORN-Nursing Education2170 South Parker Road #300Denver, CO 80231-5711tlink@aorn.orgMary J. Ogg, MSN, RN, CNORPerioperative Nursing SpecialistAORN-Nursing Practice2170 South Parker Road #300Denver, CO 80231-5711mogg@aorn.orgFACULTY DISCLOSURE:Jan Davidson: 7. No conflict.Terri Link:7. No conflictMary Ogg:7. No conflictPage 3 of 3
3/5/2014AORN Ambulatory Division 38% of AORN’s 45,000 members work in anambulatory surgery environment Ambulatory Surgery Division launched inJanuary 2013 We clearly understand the needs of freestanding ASCs/office-based surgery centersare much different than our peers in acutecare facilitiesAmbulatory Specific Content At the request of our ambulatory members,specific ambulatory content was added to theAORN Perioperative Standards and RecommendedPractices which specifically address the uniquechallenges of an ASC1
3/5/2014Ambulatory Specifics All recommended practices were reviewed by ASCexperts for ambulatory-specificsAdditional content was identified for seven of theRecommended PracticesAmbulatory RP information was developed using aninterdepartmental approach (Ambulatory SurgeryDivision & Nursing Practice Department)Ambulatory supplemental information was reviewed byoutside ambulatory practitioners.Ambulatory-Specifics Ambulatory Supplements have been written toprovide additional considerations for theperioperative RN working in a free-standingASC or physician office-based surgery center Supplemental information is designated withinthe text of the RP to indicate there is additionalASC-specific information in the ambulatorysupplement following the actual document2
3/5/2014Ambulatory-Specific Content1)2)3)4)5)6)7)Medication SafetyEnvironment of CarePrevention of Transmissible InfectionsReducing Radiological ExposurePrevention of Retained Surgical ItemsSurgical Tissue BankingSpecimen Care and Handling3
3/5/2014Finding the Ambulatory Supplements4
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3/5/2014Recommended PracticesRecommended Practices Applicable to all procedural areas in both inpatient andoutpatient settings ASCs should follow same evidenced-based standards andrecommended practices Facility policies and procedures reflect variations inpractice settings and how the recommendations areimplemented ASC considerations were incorporated into theRecommended Practices for 20146
3/5/2014Recommended PracticesRecommended Practices-Format IntroductionPurpose StatementEvidence ReviewRecommendation (I)Intervention (I.a)Activity (I.a.1)GlossaryReferences7
3/5/2014Introduction The following Recommended Practices forPrevention of Transmissible Infections havebeen approved by the AORNRecommended Practices Advisory Board. They were presented as proposedrecommendations for comments by membersand others. These recommended practices are intended asachievable recommendations representingwhat is believed to be an optimal level ofpractice.Purpose Why is this recommended practice important? Description of the intent and scope of thedocumentExampleThese recommended practices are intended to guideperioperative RNs in implementing standard precautionsand transmission-based precautions (i.e., contact, droplet,airborne) to prevent infection in the perioperative practicesetting.8
3/5/2014Evidence ReviewHow was the literature searched?– What databases were used?– What search terms were used?ExampleA medical librarian conducted a systematic review of MEDLINE ,CINAHL , Scopus , and the Cochrane Database of SystematicReviews for meta-analyses, randomized and nonrandomized trials andstudies, systematic and nonsystematic reviews, guidelines, case reports,and opinion documents and letters.Recommendation Broad “should” statements in a bold font“Must” statements if it is a regulatory requirementDesignated by a Roman numeral ( I )RationaleExamplesRecommendation IV (Transmissible Infections) Airborne precautions should be used when providing careto patients who are known or suspected to be infected withmicroorganisms that can be transmitted by the airborneroute.Recommendation I (Sharps Safety) Health care facilities must establish a written bloodbornepathogens exposure control plan9
3/5/2014Rationale Why? Summary of evidence that supports therecommendationExample Airborne transmission can occur when small particlesthat contain infectious agents that remain infective overtime and distance are inhaled.The use of airborne precautions can help minimizetransfer of diseases that are spread by the airborneroute (e.g., Mycobacterium tuberculosis [TB], rubeola,Varicella zoster)Intervention Steps or actions needed to complete therecommendation statement Designated by a Roman numeral followed by alower case letter ( I.a ) Evidence rating Rationale10
3/5/2014InterventionExampleIV.h. Elective surgery should be postponed for patientswho have suspected or confirmed TB until the patientis determined to be noninfectious. If surgery cannot bepostponed, perioperative personnel should followairborne precautions and consult with an infectionpreventionist. [1:Strong Evidence]Activity More specific steps or actions needed to complete theintervention statement.Designated by a Roman numeral, a lower case letter,and an ordinal number. ( IV.h.1 )ExampleIV.h.1. A single-use, disposable bacterial filter should beplaced between the anesthesia circuit and the patient’sairway.11
3/5/2014References Each reference is appraised and scored.Scores are noted in brackets after each citationExample54. Bassetti S, Bischoff WE, Walter M, et al. Dispersal ofStaphylococcus aureus into the air associated with a rhinovirusinfection. Infect Control Hosp Epidemiol. 2005;26(2):196-203.doi:10.1086/502526. [IIB]GlossarySpecialized terms with their definitions related to thedocumentExampleAirborne infection isolation: The isolation of patients infectedwith organisms spread via airborne droplet nuclei 5 μm indiameter.12
3/5/2014Developing Policies & ProceduresPolicy Use an intervention statement as a basis foryour policy statement.– II.c. Medications should be stored accordingto manufacturer’s medication storagerequirements. The “should” becomes a “must” in the policystatement.– Medications must be stored according tomanufacturer’s medication storagerequirements.13
3/5/2014Procedure Use an activity statement as a basis for yourprocedure statement.– VI.d.1. Goggles should fit snugly, especially at thecorners of the eye and across the brow, beindirectly vented, and have anti-fog properties. The “should” becomes a “must” in theprocedure.– Goggles must fit snugly, especially at the cornersof the eye and across the brow, be indirectlyvented, and have anti-fog properties.Using the Recommended Practices Index– Search for a specific topic (eg, restricted area)– Updated & improved– Located at the end of the book Implementation articles– AORN Journal Webinars– Highlights new and changed content– Recoded and available on the website Recommended Practices Summaries– AORN Journal– Highlights important points2814
3/5/2014Medication Safety Contracted pharmacy services Ordering, procuring, and administration ofmedications in an ASC Safe injection practices Compounding medications Tracking of controlled substances15
3/5/2014Compounding Pharmacies Drug Quality and Security Act, signedNovember 2013 Gives FDA oversight in compoundingpharmacies Will oversee mass producing pharmacies May register with FDA – though not mandatory Smaller compounding pharmacies whocompound for individual patients will continueto be regulated by state boards of pharmacy16
3/5/2014Ambulatory Supplement:Transmissible Infections Designated facility Infection Preventionist Risk assessment Screening of patients and family for infectious diseases Isolation precautions in a ASC Staff education Policies and Procedure development Surveillance and outbreak investigationsAn ASC that is certified by the Centers for Medicare& Medicaid (CMS) must designate a staff member trainedin infection prevention to lead the facility’s infectionprevention program.(This is a regulatory requirement which makes it a “must”statement.)17
3/5/2014InterventionIV.h. Elective surgery should be postponed for patients whohave suspected or confirmed TB until the patient is determinedto be noninfectious. If surgery cannot be postponed,perioperative personnel should follow airborne precautions andconsult with an infection preventionist. [Recommended for Practice ]Personnel in an ASC that provides care to patient withconfirmed or suspected TB should follow recommendation IV.Unless the facility has the capability of establishing anegative pressure room, patients with suspected or confirmedcases of TB should be transferred to or rescheduled at a facilitywith a negative pressure room.Transmissible Infections Scenario A 66 year-old patient - cataract procedure - patient’sfirst language is Spanish – speaks and understandslimited EnglishSeveral family members are in attendanceSon is acting as interpreterThe previous day the center attempted to contact thepatient to obtain a history but were unsuccessfulA nurse enters the preop room and introduces herself18
3/5/2014Scenario - continued While the nurse is interviewing the patient the sister hasa coughing spell and the nurse notices blood on hertissue. She asks if she has been sick.The son tells the nurse she was being treated in Mexicofor tuberculosis though now was feeling much betterand thought she no longer needed to take hermedication since it was very expensive.The son also told the nurse his mother had lived withher sister for many years in Mexico.Scenario – Discussion Questions What should the nurse do first? Is isolation appropriate? If so, for whom andwhat kind? Should the surgeon be notified? Would the facility guidelines infectionprevention program indicate the best response? Should the preop nurse consult with the facilityInfection Preventionist? Would this require notification to the statedepartment of health?19
3/5/2014Scenario-Retained Surgical Item It is 5:30pm and the ASC is just finishing thelast procedure of the day – an excision of aganglion cyst under local anesthesia. The circulating nurse and scrub tech are doingthe final count and a sponge is missing. Noradiology personnel are on site. The surgeon doing the procedure is anorthopedic surgeon who has been credentialedand is privileged to operate and interpretfluoroscopy studies for orthopedic procedures.Scenario-Discussion Questions Should the surgical team call a radiologytechnician in to do an x-ray? If so, should the skin closure be delayed untilthis occurs? Would it be appropriate for the surgeon totake a picture using fluoroscopy to determinethe presence of a retained sponge? Is it appropriate for the surgeon to read andinterpret the fluoroscopic study?20
3/5/2014Evidence-based Reference 2014 AORN Perioperative Standards andRecommended Practices4221
SESSION NAME Ambulatory Supplement for AORN Perioperative Standards and Recommended Practices SPEAKERS Jan Davidson, MSN, RN, CNOR, CASC Terri D. Link, MPH, BSN, RN, CNOR, CIC Mary J. Ogg, MSN, RN, CNOR SESSION NUMBER 0001 DATE/TIME Sunday, March 30, 2014, 8-9am REPEAT SESSIONS 0111, 0167 REPEAT DATE/TIME Sunday, March 30, 2014, 10:30-11:30am Monday, March 31, 2014, 7 -8am
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