CONTINUING EDUCATION Clinical Issues 1.2 MARY J. OGG, MSN, RN, CNOR; AMBER WOOD, MSN, RN, CNOR, CIC, CPN www.aorn.org/CE Continuing Education Contact Hours Approvals indicates that continuing education contact hours are available for this activity. Earn the contact hours by reading this article, reviewing the purpose/goal, and completing the online Learner Evaluation at http://www.aorn.org/CE. Each applicant who successfully completes this program can immediately print a certificate of completion. This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements. AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure. Event: #13512 Session: #0001 Fee: Members $7.20, Nonmembers $14.40 Conflict of Interest Disclosures The contact hours for this article expire April 30, 2016. Purpose/Goal To provide perioperative nurses with knowledge related to AORN’s recommendation practices for safe laser use and prevention of transmissible infections. Objectives 1. Discuss practices that could jeopardize safety in the perioperative area. 2. Discuss common areas of concern that relate to perioperative best practices. 3. Describe implementation of evidence-based practice in relation to perioperative nursing care. Ms Ogg and Ms Wood have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article. The behavioral objectives for this program were created by Helen Starbuck Pashley, MA, BSN, RN, CNOR, clinical editor, with consultation from Susan Bakewell, MS, RN-BC, director, Perioperative Education. Ms Starbuck Pashley and Ms Bakewell have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article. Sponsorship or Commercial Support No sponsorship or commercial support was received for this article. Disclaimer Accreditation AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. AORN recognizes these activities as continuing education for registered nurses. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity. http://dx.doi.org/10.1016/j.aorn.2013.01.006 480 j AORN Journal  April 2013 Vol 97 No 4 Ó AORN, Inc, 2013 CLINICAL ISSUES 1.2 www.aorn.org/CE This Month Eye examinations for health care personnel using lasers Key words: lasers, eye examinations, laser eye injuries. The difference between a laser safety specialist and a laser safety site contact Key words: laser, laser safety specialist, laser safety site contact, laser safety officer. Isolation precautions during care of a patient with a herpes simplex virus infection of the eye Key words: herpes simplex virus (HSV), herpes, eye infection, ocular infection, contact isolation precautions, standard precautions, personal protective equipment. Environmental cleaning of blood spills on the floor of the OR Key words: OR cleaning, environmental cleaning, blood spills. Eye examinations for health care personnel using lasers QUESTION: Are eye examinations required for health care personnel involved in laser procedures? ANSWER: Based on AORN’s “Recommended practices for laser safety in perioperative practice settings,”1 it is the responsibility of health care organization administrators to determine whether medical surveillance is necessary for health care personnel where class 3B and class 4 lasers are used.1 Medical surveillance includes a baseline eye examination and postexposure injury examination.2-5 Manufacturers classify medical laser systems (ie, class 3B and class 4 lasers) based on their ability to cause damage to the eye and skin.6 Eyes are vulnerable to injury from scattered, diffused, and reflected laser beams as well as direct exposure from misdirected beams and damaged fibers.2,4,7 The part of the eye that is at risk (ie, retina, cornea) depends on the wavelength of the laser used.4 Wavelengths in the ultraviolet (ie, 200 nm to 400 nm), mid-infrared (ie, 1,400 nm to 3,000 nm), and far-infrared (ie, 3,000 nm to 10,600 nm) ranges are absorbed by the anterior segment of the eye, causing damage to the cornea and the lens.3,6 An excimer laser is classified as an ultraviolet laser.8 A carbon dioxide laser is an example of a far-infrared laser.6 Wavelengths in the visible (400 nm to 700 nm) and near-infrared (760 nm to 1,400 nm) ranges are absorbed by the retina and choroid of the eye.3,4,8 Argon and http://dx.doi.org/10.1016/j.aorn.2013.01.006 Ó AORN, Inc, 2013 April 2013 Vol 97 No 4  AORN Journal j 481 CLINICAL ISSUES April 2013 Vol 97 No 4 potassium titanyl phosphate (KTP) lasers are examples of lasers in the visible region of the spectrum.6 An individual’s color vision and night vision could be impaired or lost if the laser beam were to focus on his or her retina.7 Protective glasses for use with lasers are manufactured to specifications that will prevent damage to the eye by preventing laser energy from penetrating the eyewear and reaching the lens of the eye.4 Laser eyewear must be labeled with the appropriate optical density (ie, the ability of the eyewear to absorb a specific laser wavelength1) and wavelength for the laser in use.2,4 If a facility requires employees to undergo a baseline eye examination, it should be performed before an employee begins working with lasers, as directed by the health care organization’s policies and procedures.2,3,9 A baseline eye examination provides historical information about the condition of an employee’s eyes in the event of a laser injury.2-4 The American National Standards Institute recommends that medical surveillance be limited to individuals who are at risk from particular types of laser radiation such as that from a carbon dioxide or KTP laser.10,11 A medical eye examination should be performed any time there is a suspected or known abnormal exposure of an employee’s eyes to laser radiation.1,2,5,9,11 The examination should be performed as soon as possible and within 48 hours of the injury. The examination should focus on acute symptoms, the wavelength of the laser involved in the exposure and its emission characteristics, and the length of the exposure. If the laser is one that is capable of causing retinal damage, an eye evaluation should be performed by an ophthalmologist.10,11 MARY J. OGG MSN, RN, CNOR PERIOPERATIVE NURSING SPECIALIST AORN CENTER FOR NURSING PRACTICE References 1. Recommended practices for laser safety in perioperative practice settings. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2012: 125-142. 2. Z136.3-2005: Safe Use of Lasers in Health Care Facilities. Washington, DC: American National Standards Institute; 2005. 3. Houck PM. Comparison of operating room lasers: uses, hazards, guidelines. Nurs Clin North Am. 2006;41(2): 193-218, vi. 4. Andersen K. Safe use of lasers in the operating roomdwhat perioperative nurses should know. AORN J. 2004;79(1):171-188. 5. Medical surveillance (rationale). In: Environmental Health Criteria 23: Lasers and Optical Radiation. Geneva, Switzerland: World Health Organization; 1982:132. 6. Hospital eTool. Use of medical lasers. Occupational Safety and Health Administration. http://www.osha.gov/ SLTC/etools/hospital/surgical/lasers.html. Accessed December 3, 2012. 7. Baxter DA. Laser safety in the operating room. Insight. 2006;31(4):13-14. 8. Laser effects on the human eye fact sheet. Laser Institute of America. http://d12d0wzn4zozj6.cloudfront.net/pdf/ OSHAEyeFactSheet.pdf. Accessed December 10, 2012. 9. Suess MJ, Benwell-Morrison DA. Nonionizing Radiation Protection. 2nd ed. Albany, NY: World Health Organization Publications Centre; 1989. 10. Z136.1-2007: Safe Use of Lasers. Washington, DC: American National Standards Institute; 2007. 11. Z136.3-2011: Safe Use of Lasers in Health Care Facilities. Washington, DC: American National Standards Institute; 2011. The difference between a laser safety specialist and a laser safety site contact QUESTION: What is the difference between the position AORN designates as a laser safety specialist and what the American National Standards Institute (ANSI) calls a laser safety site contact? 482 j AORN Journal ANSWER: The primary difference between AORN’s laser safety specialist (LSS) and the ANSI laser safety site contact (LSSC) is the name. The responsibilities and duties are the same except that the LSSC has responsibility for equipment and inventory. CLINICAL ISSUES AORN’s “Recommended practices for laser safety in perioperative practice settings”1 defines an LSS as the designated person responsible for oversight of safe laser use in each area when lasers are being used. In a health care organization that has lasers in use in multiple sites, such as the OR, specialty operating suites, or clinics, an LSS would be assigned to be the resource person in each area.1 The responsibilities of the LSS should include n n n n n n n supervising laser use in a specific area (eg, ambulatory surgery unit, eye clinic), acting as a liaison between the clinical laser users and the laser safety officer (LSO), troubleshooting equipment problems, monitoring compliance with the health care organization’s laser policies and procedures, reviewing laser-related documentation (eg, logs, laser manufacturer’s directions), acting as a resource to staff members and laser users, and assessing needs for continuing education and training.1 An LSSC, as defined by ANSI, is someone appointed by the LSO or managers to oversee operational aspects when there are multiple laser sites and laser types.2 The operational aspect duties of the LSSC may include overseeing laser activities in an identified use area (eg, ophthalmology clinic, day surgery unit, neonatal intensive care unit); n working as a liaison between clinical staff members and the LSO regarding concerns or questions related to clinical practice; n troubleshooting equipment; n monitoring compliance with operational policies and procedures; n www.aornjournal.org n n n n n n maintaining unit inventory and processing requests for new or additional equipment through to the LSO; reviewing documentation pertinent to the use site; assisting users and staff members as needed during laser use; assisting the LSO with audits, assessments of continuing education and training needs, and monitoring of the licensure, credentialing, and certification status of all staff members involved with laser use; reporting of issues or problems to the LSO; and other activities as assigned.2 An LSO is responsible for evaluating laser hazards and is authorized by the health care organization’s administrators to monitor and supervise laser safety and control of laser hazards as part of a laser safety program. The LSO helps to ensure the safety of patients and personnel and may function in multiple roles (eg, LSS) within the health care organization, depending on the scope of services provided. An LSS may not be needed when the laser is used in only one location and an LSO is available. The LSS should be designated and approved by the LSO.1 The LSSC is appointed by the LSO or by department managers.2 MARY J. OGG MSN, RN, CNOR PERIOPERATIVE NURSING SPECIALIST AORN CENTER FOR NURSING PRACTICE References 1. Recommended practices for laser safety in perioperative practice settings. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2012:125-142. 2. ANSI Z136.3-2011: Safe Use of Lasers in Health Care Facilities. Washington, DC: American National Standards Institute; 2011. AORN Journal j 483 CLINICAL ISSUES April 2013 Vol 97 No 4 Isolation precautions during care of a patient with a herpes simplex virus infection of the eye QUESTION: A patient with a chronic herpes simplex virus (HSV) infection of the eye is having surgery at our facility. Should we take any special precautions in caring for this patient? ANSWER: Health care providers should implement contact isolation precautions throughout all phases of perioperative care when a patient has an HSV infection that can be transmitted by direct or indirect contact with the patient or his or her environment.1 When caring for a patient in contact isolation, nonscrubbed perioperative personnel should don a clean isolation gown and gloves in addition to adhering to standard precautions before patient contact occurs. Standard precautions (eg, gloves, eyewear, hand hygiene) should always be taken in tandem with implementation of contact isolation precautions. The basis of standard precautions is that infections are transmitted via blood, body fluids, secretions, nonintact skin, and mucous membranes.2 As part of standard precautions, health care providers should anticipate their potential exposure by assessing the nature of the interaction with the patient and should implement measures to prevent transmission, including using proper hand hygiene and wearing gloves, gowns, masks, and eye protection.2 Understanding the pathophysiology of HSV infections will assist perioperative team members in determining appropriate isolation precautions. There are two strains of HSV: HSV-1 and HSV-2. After an initial infection with either strain at the skin, the virus ascends through the nervous system, typically following the trigeminal ganglion, in a retrograde manner (ie from the skin to the nervous system) where it replicates and survives in a dormant state for the life of the infected person.3,4 484 j AORN Journal Latency refers to this dormant state, which predisposes the patient (ie, host) to a recurrence of HSV activation and increases the potential for viral transmission.4 Reactivation of HSV can lead to asymptomatic viral shedding without clinical evidence of disease.4 Most ocular HSV infections, including HSV keratitis (ie, inflammation of the cornea), are caused by HSV-1.3,5 Initial ocular HSV infections can occur after acquisition of HSV at a non-ocular site that is spread to the eye directly or that is spread indirectly to the eye from latency in the trigeminal ganglia.3 Herpes simplex virus presents in a variety of ocular diseases, including keratitis, which is the most common type of infectious blindness seen in developed nations.5 In the United States, ocular HSV infection is a leading cause of corneal blindness.4 Clinical symptoms of an active ocular HSV infection can include n n n n n n n n n conjunctivitis, inflammation of the eyelids, marked inflammatory vesicles and ulcers, corneal lesions, pain, photophobia, blurred vision, tearing, and redness.6 Herpes stromal keratitis also can present the following clinical symptoms in an active infection: stromal opacity, n edema, and 6 n neovascularization. n Health care providers should use contact isolation precautions when caring for patients with active clinical symptoms of ocular HSV infections. Latency CLINICAL ISSUES of HSV in the cornea is unknown, although studies indicate possible long-term HSV activity in corneal tissue.5 Thus, health care providers should also use contact isolation precautions for patients with chronic HSV infections involving the cornea.5 When an HSV lesion is oozing fluid, the patient is highly contagious. If the patient has an active mucocutaneous HSV infection that is oozing fluid in the tissues surrounding the eye, health care providers should follow contact precautions until lesions are dry and crusted.2 Standard precautions are sufficient for preventing transmission of an inactive recurrent mucocutaneous HSV infection in a patient who presents with a dry and crusted HSV lesion of the tissues surrounding the eye or in a patient without apparent lesions who has had previous HSV eye infection.2 For surgical procedures that involve HSV-infected eye tissue, the safest means of protection is for health care providers to use contact isolation precautions (ie, gown, gloves, eyewear, hand hygiene). If the procedure involves use of a laser or electrosurgery on HSV-infected tissue, there may be a concern about aerosolization of the HSV in surgical smoke and the potential for transmission because viruses have been found in surgical smoke; however, their potential for transmission is unknown.7,8 Personnel should use a smoke evacuation system and wear fit-tested www.aornjournal.org surgical N95 filtering respirators to avoid contracting HSV via airborne transmission.7,8 AMBER WOOD MSN, RN, CNOR, CIC, CPN PERIOPERATIVE NURSING SPECIALIST AORN CENTER FOR NURSING PRACTICE References 1. Recommended practices for prevention of transmissible infections in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2012:341-352. 2. 2007 Guideline for isolation precautions: Preventing transmission of infectious agents in health care settings. Centers for Disease Control and Prevention. http:// www.cdc.gov/hicpac/2007IP/2007isolationPrecautions .html. Accessed December 7, 2012. 3. Kaye S, Choudhary A. Herpes simplex keratitis. Prog Retin Eye Res. 2006;25(4):355-380. 4. Fatahzadeh M, Schwartz RA. Human herpes simplex infections: epidemiology, pathogenesis, symptomatology, diagnosis, and management. J Am Acad Dermatol. 2007; 57(5):737-763. 5. Farooq AV, Shukla D. Herpes simplex epithelial and stromal keratitis: an epidemiologic update. Surv Ophthalmol. 2012;57(5):448-462. 6. Rowe AM, St Leger AJ, Jeon S, Dhaliwal DK, Knickelbein JE, Hendricks RL. Herpes keratitis. Prog Retin Eye Res. August 27, 2012. pii: S1350-9462(12) 00057-2. doi:10.1016/j.preteyeres.2012.08.002. [Epub ahead of print]. 7. Recommended practices for laser safety in perioperative practice settings. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2012: 125-142. 8. Recommended practices for electrosurgery. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2012:99-118. Environmental cleaning of blood spills on the floor of the OR QUESTION: How should we clean blood spills on the floor of the OR? ANSWER: Perioperative personnel should clean spills of blood or blood-containing body fluids as soon as possible to remove the organic material from the floor surface before it dries and makes disinfection more difficult.1,2 Cleaning the spill as soon as possible also limits the exposure of personnel to bloodborne pathogens (ie, HIV, hepatitis B, hepatitis C) and pathogenic microorganisms (ie, multi-drug resistant organisms) by decreasing the time for potential exposures.1,2 As soon as possible after the blood or blood-containing body fluid spill, perioperative personnel should take the following steps in this order: don appropriate personal protective equipment (PPE), n clean all of the visible matter with a disposable absorbent material, n AORN Journal j 485 CLINICAL ISSUES April 2013 Vol 97 No 4 dispose of used cleaning materials in a biohazard waste bin, n disinfect the spill area on the floor, n remove PPE, and 1,2 n perform hand hygiene. n Appropriate PPE includes an impervious gown; gloves made of natural rubber latex, nitrile, chloroprene blends, or butyl rubber; a mask; and eye protection.1 All visible blood must be absorbed from the site so that adequate disinfection can occur.1,2 When visible organic matter is present, an Environmental Protection Agency (EPA)-registered disinfectant cannot perform proper disinfection. Because discarding blood-soaked cleaning materials in a biohazard waste bin is necessary, health care personnel should ensure that the absorbent material used is disposable before cleaning a spill. A common rule for determining whether an item belongs in a biohazard waste bin is to see whether it leaks blood when compressed.1 Material used for absorbing a spill also should be lint-free to prevent contamination of the OR with microbial-laden lint particles.1 The Healthcare Infection Control Practices Advisory Committee “Guidelines for environmental infection control in health-care facilities”2 recommends using an EPA-registered germicidal disinfectant that is effective against hepatitis B and HIV in accordance with the manufacturer’s instructions to decontaminate spills of blood and other body fluids. To minimize aerosolization during disinfectant application, personnel can pour disinfectant onto a disposable cloth or paper towel, swab the spill area, and allow the surface to dry, rather than spraying the disinfectant on the area.1 Alcohol should not be used as a disinfectant to clean blood spills or to clean large environmental surfaces because it is not an EPA-registered 486 j AORN Journal disinfectant and because of its flammable nature.1 When using sodium hypochlorite (ie, bleach) solutions, an EPA-registered product is preferred.2 If an EPA-registered sodium hypochlorite product is not available, personnel should use a 1:100 dilution of sodium hypochlorite to decontaminate the OR floor after cleaning the spill. For the first application of germicide before cleaning a large blood spill, personnel should cover the spill with an absorbent material and pour a 1:10 dilution of sodium hypochlorite onto the area while minimizing splashing.2 If blood contamination of surgical attire occurs while an individual is cleaning the spill, he or she should remove the attire as soon as possible.3 This blood-contaminated attire should be left at the health care facility for appropriate laundering to reduce the transmission of pathogenic microorganisms from the facility to the home or general public.3 If contamination of the individual’s body occurs, he or she should shower and then don freshly laundered, clean surgical attire before reentering the semirestricted area or street clothes if leaving the facility.3 AMBER WOOD MSN, RN, CNOR, CIC, CPN PERIOPERATIVE NURSING SPECIALIST AORN CENTER FOR NURSING PRACTICE References 1. Recommended practices for environmental cleaning in the perioperative setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2012: 237-250. 2. Guidelines for environmental infection control in healthcare facilities. 2003. Centers for Disease Control and Prevention. http://www.cdc.gov/hicpac/pdf/guidelines/ eic_in_HCF_03.pdf. Accessed November 14, 2012. 3. Recommended practices for surgical attire. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2012:57-72. LEARNER EVALUATION CONTINUING EDUCATION PROGRAM 1.2 Clinical Issues T his evaluation is used to determine the extent to which this continuing education program met your learning needs. The evaluation is printed here for your convenience. To receive continuing education credit, you must complete the Learner Evaluation online at http://www.aorn.org/CE. Rate the items as described below. PURPOSE/GOAL To provide perioperative nurses with knowledge related to AORN’s recommendation practices for safe laser use and prevention of transmissible infections. OBJECTIVES To what extent were the following objectives of this continuing education program achieved? 1. Discuss practices that could jeopardize safety in the perioperative area. Low 1. 2. 3. 4. 5. High 2. Discuss common areas of concern that relate to perioperative best practices. Low 1. 2. 3. 4. 5. High 3. Describe implementation of evidence-based practice in relation to perioperative nursing care. Low 1. 2. 3. 4. 5. High CONTENT 4. To what extent did this article increase your knowledge of the subject matter? Low 1. 2. 3. 4. 5. High 5. To what extent were your individual objectives met? Low 1. 2. 3. 4. 5. High Ó AORN, Inc, 2013 www.aorn.org/CE 6. Will you be able to use the information from this article in your work setting? 1. Yes 2. No 7. Will you change your practice as a result of reading this article? (If yes, answer question #7A. If no, answer question #7B.) 7A. How will you change your practice? (Select all that apply) 1. I will provide education to my team regarding why change is needed. 2. I will work with management to change/ implement a policy and procedure. 3. I will plan an informational meeting with physicians to seek their input and acceptance of the need for change. 4. I will implement change and evaluate the effect of the change at regular intervals until the change is incorporated as best practice. 5. Other: ________________________________ 7B. If you will not change your practice as a result of reading this article, why? (Select all that apply) 1. The content of the article is not relevant to my practice. 2. I do not have enough time to teach others about the purpose of the needed change. 3. I do not have management support to make a change. 4. Other: ________________________________ 8. Our accrediting body requires that we verify the time you needed to complete the 1.2 continuing education contact hour (72-minute) program: _________________________________ April 2013 Vol 97 No 4  AORN Journal j 487