By Don Sadler
Earlier this year, the Association of periOperative Registered Nurses (AORN) published revisions to eight of the 35 guidelines included in the AORN Guidelines for Perioperative Practice. These guidelines represent AORN’s official position on questions regarding perioperative practice.
The AORN Guidelines for Perioperative Practice are based on a comprehensive, systematic review of research and non-research evidence. The individual references are appraised and scored, and the recommendations are rated according to the strength and quality of the evidence supporting each recommendation.
Each guideline is reviewed and updated on a five-year cycle and posted for a 30-day public comment period. If research indicates that a change in practice is needed, the guidelines will be updated sooner than the five-year cycle.
“I believe AORN guidelines should be reviewed annually and revised when necessary based on evidence and research,” says Pat Thornton, MD, RN, CNOR, RNFA, Dermatology Institute. “The guidelines are geared toward patient safety first. Perioperative nursing care evolves through process improvement and patient outcomes.”
“The AORN Guidelines for Perioperative Practice are the premier resource in our tool kit,” says Sharon A. McNamara, RN, BSN, MS, CNOR. In her role as a perioperative consultant with OR Dx + Rx Solutions for Surgical Safety, McNamara and her team perform team-oriented safety and quality assessments across surgical services at hospitals across the country.
“These guidelines have traditionally been the patient care Bible for perioperative nurses, supporting both patient and worker safety,” say McNamara. “In a culture of safety, if you do not have a safe environment for the workforce, you do not have a safe environment for patient care.”
There are 35 guidelines in the 2023 edition of the AORN Guidelines for Perioperative Practice. Following are highlights from the guidelines that were updated this year.
Flexible Endoscopes
The updated AORN “Guideline for processing flexible endoscopes” provides guidance for teams who participate in flexible endoscope processing. It is intended to help prevent patient infections and outbreaks associated with endoscopes.
“The problem of infections and outbreaks is a long-standing one and many people are working to find solutions,” says Erin Kyle, DNP, RN, CNOR, NEA-BC, editor in chief, Guidelines for Perioperative Practice, AORN. “The complexity of both the devices and the process are complex, which makes achieving success in processing endoscopes challenging.”
According to Kyle, successful endoscope processing begins with interdisciplinary planning and pre-purchase evaluation. “There is a new section in the guideline that addresses elements to consider during this pre-purchase evaluation,” she says.
There is also a new recommendation to select and use flexible endoscopes that have manufacturer-validation for sterilization, and to sterilize these endoscopes whenever possible.
“Sterilization gives us the greatest margin of safety and greater assurance that we have eliminated more potential pathogens than we can with HLD,” says Kyle.
The updated guideline also includes new recommendations on cleaning verification, inspection, drying and point of use treatment and transport, with sections dedicated to each of these topics.
Information Management
The updated AORN “Guideline for patient information management” provides guidance on assessing health information technology (HIT), designing patient health care record (HCR) information systems and tools, documenting care and using patient information management to deliver safe care.
Patient information management systems include paper and electronic health care record systems and tools that facilitate safe patient care, such as HIT and clinical decision support applications.
“It’s important that documentation practices integrate with the perioperative nurse’s workflow to strike a balance between direct patient care and documentation,” says Kyle.
The updated guideline includes a new section dedicated to HIT with recommendations for selecting and implementing certified systems that use standardized vocabularies and provisions to keep protected patient information secure.
“The section on patient care records has been organized to assist perioperative RNs when determining what the essential elements to be documented are,” says Kyle.
There is also a new section on perioperative record design with recommendations to include perioperative RNs and nurse informaticists when designing, editing and customizing patient information management systems and tools.
The updated guideline addresses the distinction between the informed consent process and documentation of informed consent verification, which Kyle says are two different things. It also addresses documentation burden, which can be a real problem in poorly designed documentation systems and tools.
“Recommendations in the updated guideline support a smooth integration of workflow and documentation activities to support efforts for a reduced documentation burden,” says Kyle.
Positioning the Patient
The updated AORN “Guideline for positioning the patient” provides guidance for perioperative teams that participate in patient positioning for operative and other invasive procedures. New and updated practices in the guideline focus on improving awareness of potential positioning risks to mitigate injury.
“When these risks are acknowledged as a team, safe practices to prevent positioning injuries are easy to put into place,” says Kyle.
There are new recommendations for including interventions that should be implemented to prevent positioning injury during the preoperative briefing. The guideline emphasizes the value of neurophysiological monitoring to identify potential positioning injuries intraoperatively so repositioning can occur to minimize patient injury.
There is also a new communication recommendation to establish who is responsible for continually monitoring the patient after the safety strap comes off to help minimize the risk of the patient falling from the OR bed.
“We found in the research literature that lack of clear communication about this responsibility is a contributing factor to patient falls,” says Kyle.
The update recommends against using shoulder braces in the Trendelenburg position because of overwhelming evidence of injury to the brachial plexus resulting from compression over the acromion when shoulder braces were used.
“We also found significant evidence in research literature about postoperative vision loss due to positioning-related increased intraocular pressure that compromises blood flow to the optic nerve,” says Kyle.
Product Evaluation
The updated AORN “Guideline for medical device and product evaluation” provides guidance intended to optimize patient care by engaging the correct professionals in product evaluation. The literature that emerged for this update was centered around technology, quality and cost-savings initiatives.
One of the major updates is around who should be included in the interdisciplinary team responsible for evaluating medical devices and products. The guideline emphasizes the importance of including health information technology professionals on the interdisciplinary team when medical devices and products that have a technology component are being evaluated.
“Many medical devices are interconnected and share patient information across systems,” says Kyle. “IT professionals in the organization have direct insight into the kinds of systems that are in place and what systems can work well together to streamline patient information sharing.”
As part of the guidance to perform a financial impact analysis for medical devices and products under evaluation, a new recommendation was added that medical devices and products being considered for purchase due to cost-savings should have clinical performance assessed.
“When teams make decisions about substituting a product or device for one that’s less expensive, it’s important that users be confident that the lower-cost item can perform well in the clinical setting,” says Kyle.
There’s also a new recommendation to include a review of FDA safety information as part of the quality assurance and performance improvement processes. The guideline offers a list of FDA databases that users will find useful in this evaluation.
“Overall, this guideline update is heavy on ensuring safety related to medical devices and including the right evaluation criteria and people when considering products and medical devices,” says Kyle.
Hand Hygiene
The updated AORN “Guideline for hand hygiene” provides guidance on performing hand hygiene and surgical hand antisepsis to promote safety and decrease the risk of health care–associated infections (HAIs).
“Hand hygiene is essential as a first-line defense against SSIs in the perioperative environment because of its fast pace and high task density,” says Kyle.
The update includes recommendations for fingernail and hand condition, including nail coatings. There are also two new recommendations that encourage organizations to determine policies and procedures for what kind of jewelry may be worn, by whom and under what circumstances.
New recommendations were also added that address sinks, faucets and drains.
“These were added based on research on bacterial growth and contamination,” says Kyle. “They provide the interdisciplinary team with considerations related to water flow rate, the holding water temperature, the complexity and composition of the internal faucet components and the location and volume of the water mixing chamber.”
Another addition to this guideline focuses on research related to the irritant potential of different hand hygiene products that might lead to skin irritation. This can be measured as transepidermal water loss on the user’s skin and is related to the extent of skin damage that could be attributed to the hand hygiene product.
“Ultimately, we would hope that by using this guideline, facilities can prevent transmission of pathogens and reduce HAIs,” says Kyle.
Minimally Invasive Surgery
The updated AORN “Guideline for minimally invasive surgery” provides guidance on creating a safe environment of care during minimally invasive surgery. It includes information regarding:
- Distention media used during endoscopic procedures
- Hybrid ORs, including those with intraoperative MRI capabilities
- Computer-assisted navigation procedures
- Robotic-assisted surgery
Much of the new and updated content in this guideline focuses on assessment of the patient, collaboration between members of the perioperative team and management of unanticipated or emergent situations.
New recommendations were added that an assessment should be performed preoperatively to identify patients at risk of complications related to MIS. Also, before the patient arrives in the OR and during the preoperative briefing, perioperative team members should collaborate to identify resources that could be needed for conversion of endoscopic procedures to open procedures.
This guideline update also goes into more detail about identifying risk factors and monitoring for complications related to gas distention media, such as venous and arterial gas embolism. In addition, the guideline addresses risks related to fluid distention media, such as fluid overload related to excess fluid absorption.
New recommendations for anticipating and responding to computer-assisted navigation and robotic procedures complications are also included in this update.
“Another not-to-miss update is around implementing a comprehensive safety program that is used in intraoperative magnetic resonance imaging,” says Kyle.
Pressure Injury Prevention
The new AORN “Guideline for prevention of perioperative pressure injury” includes specific interventions for preventing pressure injury in the perioperative setting. Recommendations for preventing these types of injuries were previously included in the AORN “Guideline for positioning the patient” but they’re now being published for the first time in a separate guideline.
New and updated recommendations in this guideline address PI prevention practices, risk assessment and skin tone considerations. The guideline recommends establishing an interdisciplinary team that has the authority to establish policies and procedures related to the prevention of perioperative pressure injury.
“Pressure injuries frequently originate in the OR but often are not discovered until many hours later, which means the OR may not be notified about the injury,” says Kyle. “With increased awareness of PI incidences through participation in a PI prevention program, the OR can have the incidence data to develop quality improvement activities designed to mitigate PI risk.”
The guideline also recommends using a comprehensive, structured risk assessment tool that’s specific to the patient’s age when conducting the preoperative pressure injury risk assessment. These tools are listed in the guideline as validated or they have been demonstrated to be reliable for this assessment.
The guideline also has new recommendations for selecting and using support surfaces that provide pressure redistribution and provide for the lowest peak interface pressure and highest skin contact area to mitigate pressure injury risk. And the guideline includes new recommendations for using prophylactic materials such as dressings to prevent pressure injury.
The guideline also addresses understanding the unique assessment practices that should be used based on the patient’s skin tone.
“There are technologies that can be used to identify injury to darkly pigmented skin by detecting changes in skin temperature and the presence of edema even before it becomes visible,” says Kyle.
Venous Thromboembolism
The updated AORN “Guideline for prevention of venous thromboembolism” provides recommendations on creating and implementing a protocol to prevent venous thromboembolism in the perioperative setting by using mechanical and pharmacologic prophylaxis. It also provides guidance on preventing pulmonary embolism resulting from deep vein thrombosis.
The guideline update includes new recommendations regarding nurse-driven protocols as part of the health care organization’s VTE protocol. It also includes new recommendations for using a validated VTE risk assessment tool such as the Caprini VTE risk assessment tool.
In addition, the guideline recommends that bleeding risk should be assessed in conjunction with assessing VTE risk in order to select and implement interventions that are safe for each patient and their unique situation. The guideline includes new recommendations about the importance of education on VTE prevention for patients and their support persons in advance of the procedure to increase patient knowledge and adherence to preventive strategies in the postoperative period.
Design and Maintenance
The updated AORN “Guideline for the design and maintenance of the surgical suite” includes new recommendation sections for planning construction projects, renovations and technology updates and construction-related environmental contamination. There are also expanded strategy recommendations for the surgical suite including the design of rooms and areas, safety risk assessment and mitigation and regular maintenance and utility disruption.
In addition, there are specific recommendations for pediatric and critical access hospitals based on the current Facility Guidelines Institute (FGI) recommendations.
“These are the gold standard for health care design standards,” says Mary Alice Miner, Ph.D., RN, CNOR, senior perioperative practice specialist, AORN.
Another revision to this guideline is the focus on inpatient operating room space and HVAC requirements based on the FGI and the American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) 170 Standard recommendations.
AORN recommendations have expanded related to HVAC system operations and maintenance, such as collaborating to maintain the system and implementing a schedule to clean and disinfect the HVAC system.
According to Miner, there is a new federal mandate that requires federal buildings to use filters with a Minimum Efficiency Reporting Value (MERV) of 13 to increase the quality of the indoor air in public buildings.
“This federal mandate for public spaces does not include health care settings,” says Miner. “However, AORN is collaborating with health care design and construction experts and engineers regarding these air quality requirement changes.”
“We are alert to and anticipating that a review in the next few years of overall HVAC parameters that influence indoor air quality might result in updates to information provided in the guideline,” says Miner.
Note: This updated AORN guideline was newly released to online subscribers in June and will publish in the 2024 print edition of AORN Guidelines for Perioperative Practice.
“I could not do a thorough, comprehensive assessment of a perioperative service without the AORN Guidelines for Perioperative Practice,” says McNamara. “Having evidence-based guidelines to standardize care processes supports building a culture of safety to keep patients and workers safe.”
OR Today readers can obtain the updated AORN Guidelines for Perioperative Practice by visiting eGuidelines+ at aornguidelines.org.
