Within the sterile walls of the operating room (OR), a well-rehearsed choreography unfolds with each procedure. Just a like a professional dance troupe, the surgical team is comprised of the finest performers, including perioperative nurses who share center stage alongside the surgeons. Members must know their parts inside and out. There is little room for hesitation or second-guessing. Of course, experience helps fine tune skills and build confidence, but medicine advances at such a frenetic pace that there is an ever-increasing demand for staff to enhance their knowledgebase.

One of the key resources perioperative nurses reach for to keep themselves current is AORN's Perioperative Standards and Recommended Practices (PSRP). This reference book is published annually and details what the organization endorses as best practices in traditional operating rooms, ambulatory surgery centers, physician's offices, cardiac catheterization laboratories, endoscopy suites, and other surgical environs. The 2008 Edition, released in January, offers eight new or revised Recommended Practices (RPs), including Environment of Care, Cleaning and Care of Instruments and Powered Equipment, and Managing the Patient Receiving Moderate Sedation/Analgesia.

Read on for further details on a select few of the revised RPs and the impact they and other Recommended Practices have generated in the workplace.

'We think of the OR as a secured area, but is it?'
Judith (Judi) Goldberg, BSN, RN, CNOR, is a clinical educator of surgical services at The William W. Backus Hospital in Norwich, CT. A nurse for more than 30 years, Goldberg has 23 years of experience in the operating room and has served as a clinical educator for her organization for the past 10 years. As current chair of the AORN Recommended Practices Committee, she spearheaded the 2008 Edition revisions and looks forward to developing nine documents this year for the 2009 Edition.

Whether carrying out circulating or scrubbing duties, perioperative nurses handle a myriad of tasks that require extreme focus. The last thing they want to worry about when overseeing patient care is their own personal security. Staff members want reassurances that they will be protected while on the job.

"As a nation,"offers Judi Goldberg, "we are becoming more and more concerned with issues of security. We think of the OR as a secured area, but is it? Professionals use their badges to enter, but can someone follow them in? We all know HIPAA like the backs of our hands, but when it comes to security, what should we do? We need to make sure we all understand how we can help to improve security--and patient and provider safety--in our work settings."

In answer to this need, Goldberg--primary author of the latest Recommended Practices for a Safe Environment of Care--reorganized and refined existing data to make it more readily accessible to nurses and administrators. The RP now includes guidelines that clearly explain what AORN believes are some of the must-have elements to any OR security policy. For example, it states there should be a quick and visible method to distinguish authorized personnel from visitors: "Access to the perioperative environment should be limited to those who have authorized access verified by proper identification."1 The RP also specifies that the ID should be worn on the upper body and be clearly visible.

Another aspect is that unidentified individuals should not be able to effortlessly blend in with those who belong on the floor. "Staff members need to be aware of the people around them and whether they should or should not be in the OR," says Goldberg. "We want to make sure the nurses understand how critical it is that if they see an unfamiliar face, do not just assume that person has permission to be there."

Implementation of these advisements and others that recommended electronic surveillance monitors, for instance, is up to individual organizations, but sometimes is affected by hospitals' physical and fiscal capabilities. "We have had people post comments to the AORN Web site like, 'We do not have photo badges,' or, 'We cannot afford surveillance cameras,'" notes Goldberg. "The RPs are best practices. Administrators should incorporate what they can within the realm of their situations."

Clean and clear. Other RPs, however, may be better suited for quick enforcement. A case in point is how Goldberg's staff established a new policy for determining when instruments are "clean" versus "dirty."

Obviously used equipment must undergo complete cleaning and sterilization. The gray area occurs when instruments are opened but not used, regardless of whether a patient enters the sterile field. The 2008 RP states, "All instruments opened in the operating or procedure room should be decontaminated whether or not they have been used."

"As of February, we now function under the assumption that if instruments are in an open OR, they are contaminated and must be sent to central processing for re-sterilization," states Goldberg, "Whenever the instrument cart is wheeled out of the OR, we have instructed our nurses to flip its placard to the biohazard side, thus eliminating any questions about its clean status. We are still trying to work out the logistics, but it has worked pretty well. For the most part, management supports such changes because we have the documentation to back up our decision. AORN's guidelines are respected because we take the time to perform the literature and standards searches for evidence-based practice."

'We enhance our credibility.'
Victoria Steelman, RN, PhD, CNOR, FAAN, an advanced practice nurse at University of Iowa Healthcare Hospitals and Clinics in Iowa City, has 29 years of experience in OR nursing. This former chair of the AORN Research Committee and the AORN Recommended Practices Committee has received two AORN Outstanding achievement awards as well as served as guest editor for the evidence-based practice edition of Perioperative Nursing Clinics. In 2007, Steelman was inducted as a Fellow of the American Academy of Nursing. In 2008, she received the highest award in perioperative nursing, the AORN Award for Excellence.

Over the past few years, Victoria Steelman has been intricately involved with the RP updating process. Indeed, she has been the primary author of nine RPs and a contributor on another 22. For the current edition, Steelman's efforts focused on the Recommended Practices for Perioperative Patient Skin Antisepsis.

Based upon user feedback, this RP includes a chart comparing the effectiveness, uses, and implications for various prep agents. "We strengthened the recommendation for not shaving with a razor, which is consistent with other national initiatives."

Another important change dealt with eight precautions that must be taken into account when using a flammable prep agent. "The use of these materials has increased," explains Steelman, "so we needed to address the issue of minimizing the risk of surgical fires." She continues, "While some perioperative nurses have noted that the change may be a challenge to implement, they recognized the need to prevent surgical fires is paramount."

Perhaps the most significant revision in this RP is the addition of prepping patients for surgical procedures below the chin with two showers with chlorhexidine gluconate (CHG) for maximum antiseptic benefits. According to the text, "One preoperative shower with 4% CHG was found to be twice as effective in reducing skin bacterial flora as showering with nonmedicated soap. Two showers with 4% CHG were found to result in lower microbial counts than showers with boar soap, medicated soap, or povidone-iodine."2

"Our goal is to minimize the microbial count on the skin before surgery, and CHG showers effectively decolonize the patient's groin," Steelman explains. "Implementation of this best practice has resulted in lower surgical site infections in three settings of which I am familiar. While these cases are not part of a formal research study, and should not be considered proof of cause and effect, they do provide further support for this approach."

Doubling up. Steelman and her colleagues have already improved patient care through implementation of other RP recommendations. The University of Iowa Healthcare Hospitals and Clinics reduced staff sharps injury rates and subsequent exposure to blood and other body fluids by nearly one-fourth by implementing this change. She states, "We experienced a 23.5% reduction in sharps injuries, which has been sustained for more than two years."

How? By enacting the Recommended Practices for the Prevention of Transmissible Infections in the Perioperative Practice Setting. This calls for the routine use of double gloves, and formally states, "A systematic review of 18 clinical trials of gloving practices clearly demonstrates that double-gloving minimizes the risk of exposure of health care workers to blood during invasive procedures." 3

Asserts Steelman, "Whenever we use evidence-based resources to clearly articulate our rationale for perioperative practices, we enhance our credibility among administrators and other healthcare disciplines. Focusing on mutual goals also facilitates buy-in. National emphasis is being placed on prevention of surgical site infections, as well as prevention of surgical fires. Demonstrating how AORN recommendations are in alignment with the Surgical Care Improvement Project, CMS core measures, and public reporting should garner the support needed for change."

'There have not been any adverse events.'
Cecil A. King, RN, MS, CNOR, a perioperative advanced practice nurse-clinical nurse specialist at Sinai Hospital of Baltimore, has 24 years of nursing experience--22 as a perioperative nurse and 12 of those as a CNS. He also serves as a legal nurse consultant and president of ssCecil Consulting Firm. King currently sits on the AORN Recommended Practices Committee and the Competency & Credentialing Institute's Research Committee and Portfolio Task Force and is a an alternate to the ANA Standards and Guidelines Committee. He is the 2006 recipient of the AORN Award for Outstanding Achievement in Perioperative Academic Nursing Education.

From routine surgeries to complicated, potentially life-threatening procedures, sedation is always a top concern in the OR. While full anesthesia is administered by anesthesiologists or certified registered nurse anesthetists, there are cases when qualified perioperative nurses can perform moderate sedation or analgesia, in all 50 states and Washington, DC. As the circumstances under which this takes place must be clearly defined, it is only logical that the very first advisement in the Recommended Practices for Managing the Patient Receiving Moderate Sedation/Analgesia expresses a directive that nurses must "practice within the scope of nursing practice defined by his or her state and should be compliant with state advisory opinions, declaratory rules, and other regulations that direct the practice of registered nurse."4

To aid nurses in this role, the revised RP includes the American Society of Anesthesiologists (ASA) Physical Status Classification and the Fasting Guidelines. These provide quick reference for the variations of patients' health, for example, as well as timing for food consumption prior to surgery. Cecil A. King, who served as the content specialist, says, "Some of the change was prompted by our objective to bring the RP in line with the ASA 2002 Practice Guidelines for Sedation and Analgesia by Non-anesthesiologists. Also, representatives from the American Society of Anesthesiology, American Association of Nurse Anesthetists, and the American College of Surgeons were involved in developing this revision.

"The AORN Recommended Practices," he continues, "articulates the content and outlines the knowledge and skill sets required to provide care in a safe, cost-effective, and evidence-based process."

Other noteworthy changes include incorporation of the Perioperative Nursing Data Set, risk factors of difficult mask ventilation, recommendations for patients with sleep apnea, and more definitive best practices for determining discharge criteria from the recovery area.

An ounce of prevention. The PSRP pertains to all aspects of surgical environments, including the seemingly simplistic details because if even a minor component is overlooked, the result could be potentially dangerous.

"Over the past 12 years, I have worked in two facilities that had implemented AORN Recommended Practices to the letter by incorporating them into facility policies and procedure. One of the most important deals with medication administration in the OR." When King arrived at his current facility two years ago, he observed that the perioperative nurses had taken steps to label all medications on the sterile field. "The staff was already doing a good job."

However, he still saw room for improvement. "There have been reports of patient deaths associated with medication mix-ups, albeit not at this hospital," adds King. "For example, one container may hold an antiseptic and another a saline prep solution. If the antiseptic was accidentally used for irrigation, the patient could experience negative reactions. That is unacceptable, especially when prevention of such incidences is easily attainable through proper labeling of all items. By following the AORN prescribed Recommended Practices for labeling medications both on and off of the sterile field, we have yet another safety mechanism in place. During my tenure in my current position thus far, there have not been any adverse events related to medication errors because we are doing 100% labeling."

'You cannot change everything in one day.'
Charlotte Guglielmi, RN, BSN, MA, CNOR, is a perioperative nurse specialist at the Beth Israel Deaconess Medical Center in Boston, where she has been employed for 31 of her 37 years in nursing. A member of AORN since 1985, she has held many offices at the state and national levels and recently completed her term as vice president of the organization. Guglielmi is also an AORN representative to the American College of Surgeons' Perioperative Care Committee and the Council for Surgical and Perioperative Safety. She received the AORN Award for Outstanding Achievement in Perioperative Clinical Practice in 2001.

The sheer magnitude of the latest PSRP may be a bit overwhelming. Although only eight Recommended Practices were revised or added this year, some of them underwent substantial overhauls, and sifting through all the details takes time. Then, comes the matter of implementing the changes into individual practice sites. "This has to be done in stages," advises Charlotte Guglielmi. "You cannot change everything in one day. It is hard to synthesize all of the information quickly. But it is critical for us to use evidence-based information to promote care--and to provide staff with adequate resources. With many best practices, we now have the evidence behind RPs to defend the expense of operating under increased vigilance such as adopting the 'gold standard' for sterilization monitoring that is highlighted in the new RP for Sterilization."

The approach she assumes in her OR is to examine the RPs as just step one in a multistep process. "We use them as the center of our focus and move outward from there. Everybody looks to the RPs for ways to change our practice to bring it to the highest level. We use the RPs as one major driver in the development of our quality assurance indicators."

Time is of the essence. Perhaps one of the most convenient methods to execute the RPs is by adopting AORN's Perioperative Orientation Resources program, including the Perioperative 101 course. Basically, this initiative is a guide on how to orient new nurses to the OR, and includes such steps as naming specific competencies, selecting preceptors, and creating retention strategies.

"One of the benefits of using this program is that the RPs are embedded into 27 different modules of the Perioperative 101," says Guglielmi. "Nurses learn how to apply RPs into practice settings from the start. I think this is a huge benefit because it is the opportunity for new nurses to get to know the standards very early on in their careers."

In today's competitive environment, having a training tool like Perioperative 101 can prove to be effective in many ways. Guglielmi explains, "Nurses will be attracted to those facilities that offer it as part of their orientation programs. We have used the Perioperative 101 here for about five years and have seen improvements in retention. Also, even though my facility is a Level I trauma center and a major teaching hospital, the average OR nurse finishes the orientation process in just nine months. They are officially allotted a full year, but I think having the RPs explained in the curriculum has helped us to get them functioning independently in a shorter amount of time."

Raising the bar
If the surgical team performs a high-tech choreography with each procedure, then PSRP could be considered the musical score. It notes the particulars of how each element of the OR should be played. And while it is truly a classic resource to have at hand, it is an ever-evolving one, striving to present the most current and pertinent data so perioperative nurses can continue to deliver outstanding performances on the job.

"In the course of a regular work day, nurses can only do so much, so we as educators have to make sure we give them the right tools," concludes Goldberg. "Everything in this book is geared toward good patient outcomes. When nurses know their organizations are using safe practices, and providing the tools they need to do their jobs, they tend to be more satisfied with their career choice and their employers, aiding recruitment and retention efforts--two important objectives in this time of severe shortage."

The Process
Each year, the Perioperative Standards and Recommended Practices (PSRP) features new or revised Recommended Practices (RPs) in accordance with a preset rotation. New RPs may be developed because of emerging practice issues and/or new research supporting a practice change. "The Recommended Practices Committee uses specific criteria when considering a new RP by asking: Does it support AORN's mission, does it promote perioperative nursing practice, and what are the desired patient outcome(s)," explains Cecil A. King, RN, MS, CNOR, a perioperative advanced practice nurse-clinical nurse specialist at Sinai Hospital of Baltimore. Additional changes or topics may be incorporated because there has been repeated requests or inquiries on a subject made by nurses in the specialty.

"If a large percentage of our membership is asking the same questions, then we need to incorporate that information into the new documents," says Judi Goldberg, BSN, RN, CNOR, clinical educator of surgical services at The William W. Backus Hospital in Norwich, CT.

The AORN Recommended Practices Committee also is charged with making existing RPs current. Basically, committee members compare the information against the most recent research and literature. States Goldberg, "We have to make sure research supports every change made."

Gathering public comments is the final step. The AORN posts the recommended revisions and additions on its Web site for commentary by its membership via an online form. "We encourage all members to actively participate by sharing their experiences and suggestions," says Charlotte Guglielmi, an educator at Beth Israel Deaconess Medical Center in Boston. "I think nurses today are more astute to those types of opportunities."

Plus, the committee confers with healthcare organizations, such as the U.S. Centers for Disease Control and Prevention and the American Society of Anesthesiologists for their input as well as regulatory bodies to ensure that the RPs fall into full compliance. "While input is welcomed," reminds Victoria Steelman, RN, PhD, CNOR, FAAN, an advanced practice nurse at University of Iowa Healthcare Hospitals and Clinics in Iowa City, "these recommendations are not based upon individual institution's practices, but rather the best evidence available and then consensus about what best practices should be in place."

When everything is compiled, confirmed, and completed, the new book is made available for purchase by individuals, facilities, schools, and other healthcare organizations. Says Goldberg, "It is a concise reference, the one place where organizations and members can determine how to meet local, state, and federal regulations."