Updates to AORN

Guidelines for
Perioperative
Practice
Objectives
Define the numbering process for the AORN
Guidelines

Describe how must, an action verb, and may are

used in the guidelines

State three recommendations in the new guidelines

that will impact your practice.

State three changes in the revised guidelines that

will impact your practice
 Guidelines Updates
FORMAT
Guideline for Sterilization
Guideline for Safe Environment of Care
Guideline for Sterile Technique
Guideline for Transmission Based Precautions
Guideline for Safe Patient Handling And Movement
Guideline for the Design & Maintenance of the Surgical Suite
Guideline for Surgical Attire
Guideline for Prevention of Hypothermia
In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.
Format

No
Regulatory Recommendation Conditional recommendation

Standardized terminology
Rationales
Guideline Structure

Current Revised
Introduction Introduction
Purpose Purpose
Evidence Review Evidence Review
I. Recommendation 1. Topic Header
I.a. Intervention [Rating] 1.1. Recommendation [Rating]
I.a.1. Activity [Rating] 1.1.1. Activity [Rating]
Glossary Glossary
References References
Guideline Update:
Sterilization
Reusable semicritical items that are manufacturer-validated for
sterilization should be sterilized if possible.

Spaulding
classification
 Sterilization should be performed in an area
intended, designed, and equipped for sterilization
processes

Equipment and supplies

Physical space
Personnel with
documented
competency
Traffic patterns and Quality assurance
functional workflow measures
Organizations should have standardized process and
oversight for off-site sterilization

Standardized Oversight
process

Multisite
Consistent
coordination
standard of care
 Phacoemulsification hand pieces should be steam
sterilized in an upright orientation

Vertical position Free drainage

Steam sterilization Narrow channel

 The organization should monitor and control the
steam supply to all steam sterilizers

Monitor steam utility supply

for large sterilizers; water Upon installation
quality supply to table-top and repairs
sterilizers

Any changes of steam

Wet load investigations routing or to equipment
connected to steam supply
 Failed loads: Investigation and Correction

Communicate and inform –

Recall and quarantine chain of command

Corrective action
depends on
investigative
Determine patient risk, findings
Reporting and patient
exposed patients follow-up needed?
 The health care organization should assess the
environmental impact of sterilization processes and
equipment
Shutting down idle
sterilizers

Energy consumption,
emissions, toxicity
 Chemical steriliants: discussion of environmental toxicity,
exposure limits, and potential health effects

Peracetic Acid Ethylene Oxide

Ozone Hydrogen Peroxide

 Leadership in sterilization

Qualifications Responsibilities

Knowledgeable about Quality programs, safe

sterilization science, working conditions,
issues, regulatory staffing, regulatory
compliance, processes, compliance,
equipment procurement of
equipment and
materials, facility design
Guideline Update: A Safe
Environment of Care
 Fire Prevention & Management Plan
• Perioperative team members’ roles
• Communication procedures
• Methods of prevention
• Processes for safely managing different fire scenarios
• Alarm activation procedures
• Methods to extinguish a fire
• Preferred routes and levels of evacuation
• A description of the facility’s fire prevention protocol
• The required content for and frequency of fire safety education
• The frequency of and procedures for fire drills
Assessment
OLD NEW

Fire Risk Fire Prevention

Fire Prevention Assessment Tool
A. Is an alcohol-based skin antiseptic or other flammable solution being used preoperatively?
Yes No

B. Is the operative or other invasive procedure being performed above the xiphoid process or in the
oropharynx?
Yes No

C. Is open oxygen or nitrous oxide being administered?

Yes No

D. Is an electrosurgical unit, laser, or fiber-optic light being used?

Yes No

E. Are there other possible contributors (eg, defibrillators, drills, saws, burrs)?
Yes No
Blanket warmer temperature
• No longer 130° F (54.4° C) maximum
• Interdisciplinary team to decide proper temperature.
 Guideline Update:
Sterile Technique:

.
Table Covering
Tables should be covered during unanticipated
delays or during periods of increased activity
If the sterile field is in use, the portion of the
field that will not be used immediately may be
covered
Monitoring Covered Sterile Tables
Measures for preventing contamination to covered sterile
fields include:
– A communication process for notifying personnel where a covered
sterile table is located
– Limiting traffic in locations with covered sterile tables
– Direct observation

Two-“Cuffed”-Drape Method of Table Covering

Unidirectional Ultraclean Air
Delivery
When using a unidirectional ultraclean air
delivery system, position the surgical site and
instrument tables within the air curtain of the
system.
Portable Unidirectional Ultraclean Air Delivery Systems

• HEPA filtered air directed over the instrument table or the surgical
incision site
• When a fixed unidirectional
ultraclean air delivery system is
not available or is not large enough
to cover the entire sterile field
 PAPRs: Powered Air-Purifying Respirators
• Interdisciplinary team evaluation of perioperative PAPR use when
sterile fields are present
• If PAPR use is allowed, a standard plan for
• protecting the sterile field from contamination should be in place

https://www.ncbi.nlm.nih.gov/books/NBK294223/
https://www.osha.gov/Publications/3352-APF-respirators.pdf
Gloving Name Update
Assisted gloving with
gown cuffs at the Assisted gloving with
fingertips gown cuffs at the wrists

Closed assisted gloving Open assisted gloving

 VII.d

Door Opening
VII.d.1

• “Doors to the operative or invasive procedure room should be kept closed

as much as possible except during entry and
exit of patients, required personnel,
and necessary equipment.”
 Wound Protectors
• Use when entering the gastrointestinal (GI) or biliary tract
• Recommended by:
– World Health Organization
– Society for Healthcare Epidemiology of America
– Infectious Diseases Society of America
Open Items Close to Time of Use
Wound Classification Decision Tree
2019 Guideline - Figure 7
Welc

Guideline Update:
Transmission-Based
Precautions
Standard Precautions

1. Hand hygiene
2. Clean environment
3. Personal protective equipment (PPE)
4. Respiratory hygiene
5. Safe injection practices
6. Clean reusable equipment
Contact Precautions

Protection for Unscrubbed

Type of Organism/Disease Transport Personnel* Preoperative Area Environmental Measures
• Draining abscess
• Infectious wounds
• Clostridium difficile • Use standard precautions
• Acute viral infection • Wear gloves whenever
• Methicillin- touching the patient’s skin or
resistant Staphylococcus • Cover or contain the infected items that are in close
aureus (MRSA) or colonized areas of the proximity to the patient.
• Vancomycin- patient’s body. • Wear a gown when it can be
resistant Enterococci (VRE) • Remove and dispose of anticipated that clothing will
• Vancomycin- contaminated personal come into contact with the
intermediate/resistant S protective equipment (PPE) patient or contaminated
aureus (VISA/VRSA) and perform hand hygiene environmental surfaces.
• Extended-spectrum beta- before transporting the patient. • Don a gown upon entry into • Hold the patient in a single-
lactamase (ESBL) • Don clean PPE to handle the the room. Remove the gown patient room if possible; • Clean the room immediately
• Multidrug-resistant patient at the transport and perform hand hygiene otherwise keep ≥ 3 ft after patient use. Focus on
organism destination. before exiting. separation between patients. frequently touched surfaces.
Droplet Precautions

Protection for Unscrubbed

Type of Organism/Disease Transport Personnel* Preoperative Area Environmental Measures
• Diphtheria
• Haemophilus influenzae type b
• Seasonal influenza
• Pandemic influenza
• Meningococcal disease • Hold the patient in a single-
• Mumps patient room if possible;
• Mycoplasma pneumonia • Instruct the patient to wear a otherwise keep ≥ 3 ft separation
• Group A streptococcus mask and follow respiratory between patients.
• Pertussis hygiene and cough etiquette. • Use standard precautions • Draw a privacy curtain
• Adenovirus • The transporter is not • Wear a mask upon entry into between beds to minimize the
• Rubella required to wear a mask. the room. opportunity for close contact. • Routine
Airborne

Protection for Unscrubbed

Type of Organism/Disease Transport Personnel* Preoperative Area Environmental Measures
• Consult an infection
preventions before patient
placement to determine the
safety of an alternative room
that does not meet AIIR
• Instruct the patient to wear a • Place the patient in an requirements.
• Mycobacterium tuberculosis mask and follow respiratory • Use standard precautions airborne infection isolation • If an AIIR is not available,
• Disseminated herpes zoster hygiene and cough etiquette. • Wear a fit-tested N95 or room (AIIR), if possible. the OR should remain vacant
• Rubeola Monkeypox • Cover and contain affected higher level respirator that is • Provide at least 6 (existing postoperatively for sufficient
• Smallpox skin lesions. approved by the National facility) or 12 (new time to allow for a full
• Varicella zoster • The transporter is not Institute for Occupational construction/renovation) air exchange of air, generally 1
• Chicken pox required to wear a mask. Safety and Health. changes per hour. hour.
Transmission Risk: Personnel

• See occupational health:

– Infections
– Exudative lesions
– Nonintact skin
• Report exposures ASAP
• TB screening

CDC Guidelines: Infection Control in Personnel (1998) & TB (2005)

Guideline Update :
Safe Patient Handling
and Movement
Recommendation I

• The health care organization and the perioperative team

should collaborate to establish and sustain a culture of safety
that incorporates the principles of SPHM.
 Recommendation II

• The health care organization and the perioperative team

should establish a formal, systemized SPHM program.
 Recommendation III
• The health care organization and the perioperative SPHM
program team should incorporate ergonomic design principles
in the planning and design of the surgical suite.
 Recommendation IV

• The health care organization and the perioperative team

should collaborate in the selection, installation, and
maintenance of safe patient handling technology into the
perioperative setting.
 Recommendation V

• The health care organization and the perioperative team

should collaborate to establish education, training, and
competency verification in safe patient handling techniques and
equipment.
 Recommendation VI

• The perioperative team should assess the patient and the

perioperative environment and develop a plan for SPHM.
 Recommendation VII
• The health care organization and the perioperative SPHM
team should provide an injured employee with reasonable
accommodations for post-injury return to work.
 Recommendation VIII
• The perioperative SPHM program team should establish a
quality assurance and performance improvement program.
New Guideline:
Design and
Maintenance of
the Surgical Suite
 Document Layout
• I. Interdisciplinary team • VIII. Sterile processing
• II. Perioperative suite • IX. Procedure rooms
• III. Preoperative area • X. Preventing contamination
• IV. Intraoperative area during construction
• V. Hybrid OR • XI. Utility failure
• VI. Postoperative area • XII. Monitoring and
• VII. Support areas maintaining surfaces and HVAC
system performance
 Zones
Sterile
Admissions Processing
Waiting room PACU Supply

PACU Phase I Storage Decon Clean

Phase 2 SSPD

NS OR 1
Soiled Locker rooms

OR2 1 floor below

Clean
Pre-op OR 3

Pharmacy OR 4
Zones of Protection
• General areas accessible to the public at all times
• General areas restricted to the public during non-
visiting hours, periods of lesser activity, or other
periods of increased vulnerability
• Screened public areas
• Staff and accompanied public areas
• General staff-only areas
• Areas for designated staff with appropriate
clearance
Zones within
the OR
Postoperative areas
Patient care
stations Medication safety
zone
Other support
areas Hand washing Nourishment area
stations
Ice-making
Bathrooms for
equipment
patients and
Storage for personnel
belongings
Support Areas
Include May include

Locker rooms Information systems control room

Medical records storage areas
The nurse station
Multipurpose rooms
Clean equipment storage areas Patient waiting rooms
Soiled workroom Specimen holding areas
Environmental services room Medical gas storage
Supply breakout area/room Satellite laboratory
Sterile processing department Satellite pharmacy
Satellite sterile processing area
Administrative areas
Sterile Processing

Part of the surgical suite

YES or NO ?
Satellite sterile processing
YES or NO ?
Two-Room Satellite Sterile Processing
Construction safety and infection control
measures

• Perform construction site and infection control barrier monitoring and

periodically
• Barriers (eg, solid fiberboard or sheetrock walls, sealed plastic walls)
Utility Failure
Electrical HVAC Sewage Vacuum Plumbing

Medical Boiler . Generator

Water Communication
Gases Steam And Fuel
Immediate actions

Reschedule Delay Emergency

Close
or redirect elective only

NOTHING
 HYPOTHERMIA

Coming to the Facility Reference Center: July 1

Coming to the book: 1-1- 2020
Temperature Measurement

• Who
• How
• When
Hypothermia prevention
• Who
• How
• When
• Prewarming
 SURGICAL
ATTIRE

Coming to the Facility Reference Center: July 1

Coming to the print book: 1-1- 2020
Laundering
Launder scrub attire after
each daily use at
• a health care-accredited laundry facility,
• the health care organization according to
state regulatory requirements, or
• the health care organization according to
Centers for Disease Control and Prevention
recommendations for laundering in the
absence of state requirements.
 Remove scrub attire

Before leaving
the facility
 Personal Clothing
Establish a process:
• the type of fabrics (eg, nonlinting) that may be
No worn under scrub attire,
• the amount of fabric that may extend beyond
Recommendation the scrub attire (eg, a crew neck collar under V-
neck scrub attire),
• laundering frequency (eg, daily), and
• laundering method (eg, facility laundering,
home laundering).
 Antimicrobial Scrubs

No
Recommendation
Long Sleeves

Arms MAY be covered during

performance of preoperative
patient skin antisepsis.
No recommendation can be
made for wearing long sleeves
in the semi-restricted and
restricted areas.
Head Coverings
Beards
Shoes
 Guidelines Being Updated for
Publication in 2021 book
Guideline for Surgical Attire
Guideline for Prevention of Hypothermia
Guideline for Tourniquets
Guideline for Environmental Cleaning
Guideline for Packaging
Guideline for Sharps Safety Currently up for Public Comment
Guideline for Autologous Tissue
Guideline for Energy Generating Devices (Laser and ESU)
AORN Links
Evidence Model
https://aorn.org/guidelines/about-aorn-guidelines/evidence-rating
Evidence Tables
https://www.aorn.org/guidelines/about-aorn-guidelines/evidence-tables
Public Commenting
https://www.aorn.org/Aorn-org/Events/Public-Comments
Guidelines
https://aorn.org/guidelines/about-aorn-guidelines
Toolkits
https://aorn.org/guidelines/about-aorn-guidelines