By Don Sadler
The Association of periOperative Registered Nurses (AORN) has issued new and updated Guidelines for Perioperative Practice in 2025 that all perioperative personnel should be aware of. These guidelines are the gold standard in evidence-based recommendations to deliver safe perioperative patient care and achieve workplace safety.
How Are the Guidelines Drafted?
The Guidelines for Perioperative Practice are drafted by the AORN Guidelines Advisory Board, which is comprised of a chairperson, at least eight perioperative nurse members and liaisons from other professional associations.
The first step in drafting the guidelines is a literature search. Next, the level and quality of each piece of evidence (both research and non-research) is appraised using AORN’s evidence-based appraisal tools, with an appraisal score of I-V and A, B or C assigned. Very low levels of evidence are not accepted.
The research is then translated into recommendations and the guidelines’ required elements are confirmed: introduction, purpose, evidence review, recommendation (rating), glossary and references. Each recommendation is rated using AORN’s evidence rating model:
- Regulatory requirement
- Recommendation
- Conditional recommendation
- No recommendation
The draft guideline is posted on the AORN website for a 30-day public comment period. All submitted comments are reviewed and action is taken on each: accept, accept with modification or not accept. The draft is then amended in collaboration with the editor-in-chief before the final draft is submitted to the Guidelines Advisory Board for final approval before the guideline is published. Each guideline is reviewed and updated on a five-year cycle.
Following is an overview of the new and updated AORN guidelines issued in 2025.
New Enhanced Recovery After Surgery Guideline
The Enhanced Recovery After Surgery (ERAS) guideline is a new guideline focused on how to implement this evidence-based model of care. “We believe that ERAS is the standard of care that should be implemented in all patients undergoing surgery,” says Lisa Spruce, DNP, RN, CNS-CP, EBP-C, CNOR, ACNS, ACNP, FAAN, AORN Senior Director of Evidence-Based Perioperative Practice.
According to Spruce, the ERAS guideline offers guidance on preoperative screening of patient risk factors, optimizing the patient’s health prior to surgery and comprehensive education for patients in an ERAS program.
“Preoperative preparation includes preparing the patient for surgery by appropriate fasting guidance, conducting risk assessments, implementing a surgical site infection prevention bundle, warming the patient, and preparing for multi-modal pain management by strategically targeting various physiological pathways,” says Spruce. “Multimodal analgesia aims to optimize pain control while minimizing the adverse effects associated with narcotic pain medications.”
The most important recommendations in the postoperative period are encouraging early patient mobilization and early return to a normal diet. “If a patient happens to have an indwelling catheter or drain placed, it’s important to remove these as soon as possible,” says Spruce.
One common obstacle to ERAS program implementation is variation in care driven by physicians’ strong personal preferences. “If organizations base their protocols on the best available evidence, they shift the focus toward the patient’s well-being and away from historical provider preferences,” says Spruce.
According to Karen Reiter, national vice president of ASC operations for TriasMD, ambulatory surgery centers (ASCs) started using ERAS before hospitals identified it as a tool for better patient outcomes.
“Our centers perform complex spine surgeries and all patients go home in less than 24 hours,” says Reiter “We train our team members to keep their eye on discharge – every decision they make is to work toward an earlier discharge. In complex cases, patients are managed almost like they’re in the ICU. They are not ‘tucked in and lights out’ unless there is a doctor’s order that they are staying overnight for observation or extended care.”
Educating patients and their families “early and often” is the key to achieving successful patient outcomes with ERAS, says Reiter.
“Upon admission, the family is present for education, and expectations around mobilization and discharge are reemphasized at this time. A family member remains with the patient throughout the duration in the ASC,” Reiter adds.
Reiter stresses the importance of getting surgeons onboard with ERAS. “Surgeons have to understand that we are keeping their patients moving through,” she says.
Spruce believes that ERAS will lead to a number of patient benefits, including shorter hospital stays, fewer postoperative complications, faster recovery, reduced readmission rates, lower costs and higher levels of patient satisfaction.
“Research around ERAS is ongoing and I think we will see more pediatric and special populations research coming out, in addition to more specialty specific protocols,” says Spruce. “ERAS is growing around the world so there’s a lot to learn about implementation efforts in other countries as well.”
Surgical Attire Guideline Update
According to Karen deKay, MSN, RN, EBP-C, CNOR, CIC, FAPIC, AORN Senior Perioperative Practice Specialist, updates were made to the surgical attire guideline to determine what are the best practices for surgical attire in the perioperative setting, as well as how surgical attire influences other factors that can lead to better or worse patient outcomes.
deKay lists the following primary changes to the surgical attire guideline:
- Form an interdisciplinary team to determine circumstances that may require perioperative personnel to change surgical attire when returning to the OR or procedural area after being in other areas of the building or outside building for short periods of time.
- Form an interdisciplinary team to determine if lanyards will be used in the perioperative setting. If so, develop and implement a process and schedule for routine disinfection.
- Develop and implement staff education to increase compliance with cleaning and disinfection of stethoscopes, cell phones and personal communication devices.
- Perform frequent hand hygiene when handling communication devices throughout the workday.
“By implementing these guidelines, healthcare facilities can reduce the introduction of potential pathogens into the perioperative environment from surgical attire, stethoscopes and personal items,” says deKay. “This will minimize a patient’s exposure to microorganisms that can contribute to an SSI.”
These guidelines will also prevent the introduction of pathogenic organisms that may adhere to scrub apparel during the workday from being brought into public places or the homes of perioperative personnel, adds deKay.
Sharps Safety Guideline Update
New research on sharps injuries and changing regulatory requirements, along with advancements in safety devices, led to a review and update of the sharps safety guideline.
“Sharps safety remains of particular importance to all members of the surgical team because everyone is at risk,” says Emily Jones, MSN, RN, CNOR, EBP-C, AORN Senior Perioperative Practice Specialist. “Unfortunately, the data show that sharps injuries continue to occur in the perioperative setting.”
The new elements in the updated guideline for sharps safety include a new section about creating and sustaining an organizational sharps safety program to support safety throughout the organization where all members have a role to play.
“Experts agree that the institution has a responsibility to be fully engaged in a culture of sharp safety,” says Jones. “Leaders can support a non-punitive environment that creates a psychologically safe atmosphere to improve reporting of sharps injuries.”
In addition, there are new recommendations related to the process of selecting sharps disposal containers. At a minimum, sharps disposal containers must be:
- Closable,
- Puncture resistant,
- Leak proof on the sides and bottom,
- Labeled according to OSHA biohazard labeling requirement,
- Easily accessible,
- Located as close as possible to the immediate work area,
- Maintained in an upright position throughout use, and
- Replaced at a frequency to reduce overfilling.
To overcome potential resistance to changing how sharps are handled in the operating room, Jones recommends that leaders include surgical staff members as part of an interdisciplinary team to identify achievable solutions toward sustaining change. “For example, leaders can involve direct care staff members during device evaluation, implementation of sharps safety initiatives or competency verification activities,” she says.
“We recognize that surgery is ever evolving,” Jones adds “With this evolution, perioperative team members must remain vigilant in maintaining a culture of sharps safety to protect ourselves and one another.”
Patient Temperature Management Guideline Update
Updates were made to the patient temperature management guideline to prevent inadvertent patient hypothermia. For example, a new section was added to support facilities and teams in developing a patient temperature management plan for how they are going to tackle the issue of periop normothermia that includes prevention of hypothermia and malignant hyperthermia.
“We also created a sample Periop Normothermia Bundle so facilities don’t have to reinvent the wheel and start from scratch if they don’t already have this in place,” says Renae Wright, DNP, RN, CNOR, EBP-C, AORN Senior Perioperative Practice Specialist. “In addition, we revised the recommendation language around active warming, prewarming and passive insulation to reinforce that active warming is more effective than passive insulation for raising patient temperature and treating hypothermia.”
Two new recommendations were also added to this guideline: to implement intraoperative warming according to the patient temperature management (PTM) plan, and to continue warming into the postoperative period while minimizing interruptions to warming. “These were added because we saw in the literature that inconsistent intraop warming practices and lengthy pauses in warming contributed to hypothermia,” says Wright.
Wright notes that the incidence of periop hypothermia reported in the literature ranges between 2% to more than 80% among different patient populations, depending on the degree of warming measures implemented.
“High-quality evidence supports using one or more active warming methods to prevent and treat hypothermia,” says Wright. “Which type or combination of active warming methods is most effective is still unclear because there’s a lot of variation in study methodology and results.”
“Remember that the purpose of this guideline isn’t so much to educate and inform or dispel misconceptions, but to make recommendations for practice,” says Wright.
Packaging for Sterilization Guideline Update
A review and update of the packaging for sterilization guideline was prompted by the need to incorporate ergonomic concerns about packaging defects caused by personnel discomfort, as well as concerns about the use of peel pouches and the presence of holes in sterilization wrap and filters.
“In addition, there is a growing body of evidence on the use of quality improvement initiatives to identify and remove underutilized instrumentation from sets,” says Amber Wood, MSN, RN, CNOR, CIC, EBP-C, FAPIC, AORN Senior Perioperative Practice Specialist. “The goal of the updated guideline is to guide perioperative teams on evaluating and using sterilization packaging systems in a manner that protects the integrity of the sterilized contents until delivery to the sterile field.”
When selecting and using packaging materials, perioperative teams should incorporate ergonomic features into the design of the sterile processing area.
“For example, work surfaces should be at a comfortable height, lighting should be adequate, anti-fatigue flooring or mats and adjustable seating (such as sit-stand stools) should be used, and there should be adequate space for the performance of tasks,” says Wood.
All single-use sterilization wrap and filters should be inspected for defects before use. “There is also new guidance for using quality improvement initiatives to identify and remove underutilized instrumentation from sets,” says Wood.
In addition, recommendations for the use of peel pouches were enhanced to emphasize the correct use of pouches.
“This includes verifying that all seals are completely closed and smooth without gaps, folds, bubbles or wrinkles, and using heat sealers according to the manufacturer’s instructions for use,” says Wood.
The updated packaging for sterilization guideline is expected to highlight important recommendations to reduce the risk of packaging defects that could compromise the sterility of the package and increase patients’ risk for infection.
“As new sterilization technologies and materials are developed, this guideline will continue to evolve and update perioperative teams on the latest developments and evidence-based practices for selection and use of sterilization packaging systems,” says Wood.
Sterilization Guideline Update
A review and update of the sterilization guideline was prompted by the need to incorporate guidance for sterilizing devices produced by additive manufacturing (e.g., 3D printing), the practice of short-cycle sterilization, procedures for transportation of sterilized items between facilities, and updated recommendations for water quality monitoring in ANSI/AAMI ST108:2023.
According to Wood, the updated sterilization guideline is intended to help perioperative teams achieve more effective and reliable sterilization processes that will reduce the patient’s risk for infection.
The update adds a definition for short-cycle sterilization: “A sterilization method for a wrapped or contained load that is sterilized in accordance with the device, sterilizer and packaging manufacturer’s instructions for use; includes a dry time; and is packaged in a sterile barrier that permits storage for use at a later time.”
“This addition was needed to address this as a commonly used term and practice in ophthalmology centers,” says Wood. “It aligns with the CMS definition.”
Wood says the updated sterilization guideline continues to stress the importance of using physical monitors and chemical and biological indicators to monitor sterilization processes. “We added a table based on a request during public comment to help readers quickly identify the recommended frequencies for routine sterilizer efficacy testing for various sterilization methods,” she says.
The update also adds a new recommendation, in alignment with ANSI/AAMI ST108, for routinely monitoring the quality of water systems that supply steam generators (e.g., boilers). “This is important because the quality of the incoming water supply is a major factor influencing steam quality and purity,” says Wood.
To learn more about the Guidelines for Perioperative Practice, including purchase and subscription options, visit https://info.aorn.org/GuidelinesBook2025.
