Unit 1 - Operating Department Care Skills - 5N3767

Operating Department Care Skills - 5N3767

2013

Operating Department Care Skills 5N3767

UNIT ONE

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By The Open College Written by Siobhan Lynch

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MODULE UNITS: 1. Safety and Health 2. Infection Control 3. Client Care and Clinical Activity 4. Communication.

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UNIT 1 Safety and Health By the end of this unit you should gain understanding of:        



The role of the HCA in providing a healthy, safe and secure environment for clients.

The hazards and precautions of client positioning in the operating department.

The transfer and position of clients safely in the operating department.

The safe functioning of the operating table and its attachments to include achieving the various positions.

The safe positioning of lights and electrical equipment.

The safe storage of equipment.

The local policies and procedures in place for reporting incidents, accidents and emergencies in the workplace.

The procedures in the operating department for: • fire evacuation.

• major disaster.

• cardiac arrest.

Safe practice in relation to: • • • • • • • • •

electrical equipment laser treatment ionizing radiation management of hazardous chemicals classification of waste and methods of disposal management and dispatch of used/contaminated linen. handling and storage of medical gas cylinders. handling of instruments and equipment handling of clinical specimens.

 Procedures for the reprocessing of instruments, checking of surgical instruments prior to repackaging and record keeping for traceability.  Stock control within the operating theatre. .

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INTRODUCTION

An operating theatre is where certain invasive surgical procedures are performed: which means operations that involve cutting into and working inside a patient’s body. This might involve either minimally invasive procedures like keyhole surgery – where cameras and a laparoscope are inserted through small incisions – or open surgery where surgeons make larger incisions to reach the internal organs.

Surgical procedures can be broadly categorised as either elective (those which are planned) or emergency (those which are unplanned). Elective surgery aims to be performed when the patient is in optimal health, but before the surgery affects the quality of, or threatens their life. Emergency surgery may be as a result of trauma or an accident, gastrointestinal obstruction, or from perforated viscera. The injury may be immediately life threatening, and therefore the procedure is essential for life.

TYPES OF SURGERY • • • •

Diagnostic - Allows confirmation of, or establishes diagnosis.

Corrective - Excision or removal of diseased body part.

Reconstructive - Restores function or appearance to traumatised or malfunctioning tissues.

Ablative – Removes diseased body parts.

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Palliative – Relieves or reduces pain or symptoms of a disease; it does not cure.

Transplant – Replaces malfunctioning structures.

Cosmetic - Performed to improve personal appearance.

The term perioperative refers to the total surgical experience and includes pre-, intra- and postoperative phases of the patient’s surgical journey (Phillips, 2004). Perioperative care is divided into three phrases: •

PREOPERATIVE PHASE. This stage refers to the period before surgery. During this stage the patient is escorted to the operating theatre suite either with a porter or ward nurse, or both. Ward staff must check the patient’s identity, operating consent form, patient notes, and that all documentation is completed before the patient is transferred to theatres (NATN, AODP, RCN et al, 1998; Taylor and Campbell, 2000a).

The patient may be transported by wheelchair or on their bed, or in some hospitals, particularly within a day surgery unit, they are given the choice of walking (Phillips, 2004). Depending on the facilities within each unit, the patient is either admitted to the holding area (this may be part of recovery) or waits in reception. In the reception area safety checks are performed. An accurate assessment at this time by the perioperative nurse/assistant will form the basis for delivering high standards of patient care tailored to meet their needs (O’Reilly, 2001). This safety check ensures that the correct operation is carried out on the correct patient, who has been prepared to enable the safe administration of anaesthesia and continuation of the surgical procedure. At all times the patient must be treated with privacy, dignity and respect.

•

INTRAOPERATIVE PHASE. The term "intraoperative" refers to the time during surgery.

Intraoperative care is patient care during an operation and ancillary to that operation.

Activities such as monitoring the patient's vital signs, oxygenation levels, fluid therapy, medication transfusion, anaesthesia, radiography, and retrieving samples for laboratory tests, are examples of intraoperative care. Intraoperative care is provided by nurses, anaesthesiologists, nurse anaesthetists, surgical technicians, surgeons and residents, all working as a team.

•

POSTOPERATIVE PHASE. Refers to the period following surgery, commonly referred to as the recovery stage. The main objectives of recovery room care are to critically evaluate and stabilise the patient postoperatively, to anticipate and prevent potential complications and to safeguard the patient’s well-being until they are able to do so themselves (Starritt, 2000). The postoperative phase of a patient’s journey starts when the patient is transferred from the theatre to the recovery room. However, preparation for each individual patient commences well before the patient arrives. All equipment such as resuscitation, oxygen and monitoring is checked and additional resources acquired if the surgery or anaethesiologist indicates that this may be so: e.g. patient warming apparatus if the surgery has been long, provision of analgesic pumps.

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ROLE OF HEALTHCARE ASSISTANT

The HCA requires a broad knowledge and skill base including, communication, numeracy and literacy skills, in order to contribute to the smooth running of the operating department. The HCA is normally involved in the pre and intraoperative phases.

The Preoperative Phase.

During this phase the HCA will: Admit patients into the operating department as required, confirming their identity and completing the necessary documentation.

Assist the patient prior to surgery, maintaining patient confidentiality and dignity at all times.

Assist in the safe transferring and movement of patients throughout the unit.

Assist in the positioning of patients for surgical procedures.

Clean the theatre and other designated areas, in line with hospital policy.

Prepare, supply and maintain all necessary instrumentation and equipment for the specified operative procedure / theatre list. This may involve complex machinery including microscopes, lasers and endoscopes.

Position and connect equipment as required by the scrub team, disconnect and safely remove equipment as required.

Ensure proficiency with equipment before use in accordance with local policy and manufacturers' instructions.

Prepare sterile trolleys and ensure all instrumentation is correct and accounted for, pre- intra- and post-operatively, as per hospital policy.

Report appropriately any deficits, breakages, faulty equipment or sterility problems to the team leader or, practitioner in charge.

Participate as part of the perioperative team carrying out safety checks of swabs, instruments and needles in conjunction with a registered practitioner in accordance with national guidance / hospital policy.

Support and observe the patient. Report to nurse in charge.

Maintain a clean, safe environment, communicating and working effectively with the perioperative team.

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The Intraoperative Phase.

The HCA will participate as part of the perioperative team in a number of roles, including the circulating role, application of aseptic technique and infection control.

Under direct supervision of a registered nurse or, operating department practitioner, the HCA will provide skilled assistance to the scrub nurse and surgeon in the operating theatre.

The HCA will assist in the care of the surgical patient during the Perioperative period by supporting the multidisciplinary team in providing a safe, high quality environment for the carrying out of surgical procedures by: Assisting in skin preparation and draping of the surgical field.

Supporting and observing the patient throughout the operation.

Assisting in the measurement and recording of fluid input / output.

Working as part of the multidisciplinary team for the benefit of the patient, appreciating each member of the team’s needs and role.

Anticipating the needs of the surgical team and responding effectively.

Safely handling, recording and dispatching specimens and used instruments in line with hospital policy.

Disposing of clinical waste safely and appropriately in line with hospital policy.

Recording information accurately.

Undertaking the circulating role utilising communication skills, preparing the environment and equipment and acting as a link between the surgical team and other parts of the theatre and hospital.

Assisting the registered practitioner in the handover of the patient to the recovery staff, providing appropriate information and documentation.

Appropriately cleaning and clearing away all theatre furniture and equipment.

Checking, returning and preparing the theatre floor after cleaning.

The Recovery Phase: Receive, assess and deliver patient care on their arrival into the recovery unit.

Monitor the patient's physiological parameters and support them, providing appropriate interventions and treatment until the patient has recovered from the effects of the anaesthesia and/or surgery and is stable.

Assess the patient in order to ensure they can be discharged back to a surgical ward area.

Evaluate the care given during the perioperative phases (anaesthetics, surgery, recovery).

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Scrub Nurse: remains in the sterile field of the operating room and follows the designated scrub procedure, wears gloves, a mask and gown (Lewis et al., 2006). Scrub nurses aid surgeons by handing them equipment, sponges and other necessary instruments needed during the operation (AORN, 2009). They also help the surgeon by monitoring the patient’s condition during the procedure {AORN, 2009}.

Circulating Nurse: represents the coordinating link between the scrub team and all other departments and personnel associated with the surgical patient and the procedure.

The circulating nurse is responsible for managing patient care activities in the operating suite, so his/her duties begin long before the patient arrives in the operating room and continues until the final dispensation of the patient, operating room records, and specimens are completed.

The following list depicts some of the activities performed by the circulating nurse prior to induction of anaesthesia, during the procedure, and upon conclusion of the procedure: Assisting and preparing the procedure room.

Supervising the transporting, moving, and lifting of the patient.

Assisting anaesthesia as requested during induction and reversal of anaesthesia.

Positioning the patient for surgery.

Performing the surgical skin prep.

Conducting and maintaining accurate records of counts.

Maintaining accurate documentation of nursing activities during the procedure.

Dispensing supplies and medications to the surgical field.

Maintaining an aseptic and safe environment.

Estimating fluid and blood loss.

Handling special equipment, specimens, etc.

Communicating special postoperative needs to appropriate persons at the conclusion of the case.

REVCOVERY NURSE: The recovery nurse is a skilled and knowledgeable practitioner, able to deal quickly and efficiently with any changes in the patient’s condition. Within the perioperative environment, recovery nurses have the greatest autonomy, as they manage a patient’s care in the recovery area from arrival through to discharge, only requesting medical assistance when needed.

CLIENT SAFETY Each member of the surgical team has a responsibility for patient safety --surgeons, anaesthetists, technicians, porters, nurses, theatre assistants, ancillary staff, etc. Clarity of roles and relationships of team members is crucial for patient safety. As a HCA you have a responsibility to be aware of OD procedures and to follow them.

Each team member has a duty of care to the patient, who is vulnerable at this time.

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Risk areas within the operating department, include: Reception – never leave alone.

Identification – ask open questions, cross check, op site.

Possessions – prostheses, crowns.

Transfer – conscious/drowsy/unconscious. Injury risk.

Hygiene – environment /personal, aseptic technique, infection control.

Electrical equipment - maintenance and safe use.

Surgical accidents – adherence to procedures.

Positioning - pre/post anaesthetic.

Turner et al (2000) identified that the perioperative environment is potentially one of the most hazardous of all clinical environments.

Greeting the patient and providing holistic care is paramount to good patient care.

Communication is vital as the patient is handed over to theatre staff from the ward. Policies and procedures are paramount for patient safety. SAFETY checks include: •

Name.

•

Hospital ID.

•

Previous medical history.

•

Current medical issues.

•

Understanding of what is happening.

•

Consent form.

Only when everything has been checked can a procedure start, which usually means connecting the patient to monitoring, such as blood pressure, ECG, and pulse oximetry.

Different procedures may require more invasive techniques such as an arterial line for constant pressure monitoring.

Patient safety comes first. With this in mind, the HCA assists the anaesthetist in connecting the patient to all the relevant monitors and anaesthetic equipment to ensure that they are comfortable and in a state of readiness for the surgical procedure.

The team will then employ correct manual handling principles to transfer the patient to the operating table and then into position for the surgery. There are many different positions which range from the simple supine position to the complexity of other positions, prone being a good example (patient is face down).

Once positioned correctly, other equipment required for the procedure is introduced dependant on the needs and requirements of the surgical procedure to be performed.

Equipment may include diathermy laparoscopic equipment suction.

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At this point, prior to surgery, a final check is made to ensure the correct patient, who is having the correct planned procedure. The WHO CHECKLIST has been adopted by many organisations as the gold standard for prevention of surgical wrong site/procedure mistakes.

Within the intraoperative phase, the patient is vulnerable and totally reliant on perioperative staff to ensure that they come to no harm.

Some of these risks may include patient identification, informed consent and patient monitoring in the anaesthetic room.

Intraoperatively, such clinical risks are associated with patient positioning, the risk of infection, risk of deep vein thrombosis, risk of hypothermia and the risk to both staff and patients from the use of equipment. This list is not exhaustive but identifies those potential risks to each patient undergoing surgery.

For each risk, strategies are discussed to minimise the risk to patients and staff.

OBJECTIVES OF THE WORLD HEALTH ORGANISATION ‘SAFE SURGERY SAVE LIVES’ DOCUMENT: Objective 1. The team will operate on the correct patient at the correct site.

Objective 2. The team will use methods known to prevent harm from anaesthetic administration, while protecting the patient from pain.

Objective 3. The team will recognise and effectively prepare for life-threatening loss of airway or respiratory function.

Objective 4. The team will recognise and effectively prepare for risk of high blood loss.

Objective 5. The team will avoid inducing an allergic or adverse drug reaction known to be a significant risk to the patient.

Objective 6. The team will consistently use methods known to minimise risk of surgical site infection.

Objective 7. The team will prevent inadvertent retention of sponges or instruments in surgical wounds.

Objective 8. The team will secure and accurately identify all surgical specimens.

Objective 9. The team will effectively communicate and exchange critical patient information for the safe conduct of the operation.

Objective 10. Hospitals and public health systems will establish routine surveillance of surgical capacity, volume and results. {WHO 2008}

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POSITIONING CLIENTS FOR SURGERY

During surgical procedures, the surgical team is responsible for positioning the patient in a way that optimises surgical exposure while still protecting the patient from harm. The HCA has a responsibility to understand common surgical positions of patients during surgery and be able to identify and develop awareness of potential complications in patient positioning.

The HCA must practice measures to avoid injuries and others complication to patients during surgery, overall promoting safety and safeguarding patients well-being during the intraoperative period.

Poor surgical positioning of patients and misuse of positioning devices and equipment pose serious risks to patient safety. Theatre staff must understand the physiological effects of positioning and know how to use positioning devices and equipment.

The goal in selecting and adjusting a particular surgical position is to maintain the patient's safety while allowing access to the surgical site. Often a patient must be placed in an unnatural position to gain access to the surgical site.

In addition to considerations related to the location of the surgical site, the selection of a surgical position is made after considering relevant physical and physiological factors, such as body alignment, circulation, respiratory constraints, and the muscular/skeletal system to prevent stress on the patient. Physical traits of the patient must also be considered including size, age, weight, physical condition, and allergies. The type of anaesthesia used also affects the decision.

Consideration must also be given to the following patient risk factors: ADVANCED AGE. NUTRITIONAL STATUS. RESPIRATORY DISORDER. CIRCULATORY DISEASE. OBESE PATIENT. CHRONIC IMMOBILITY. PRESCRIBED MEDICATIONS. UNDERLYING MEDICAL PROBLEMS. NATURE OF SURGERY.

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Understanding Body Systems: Knowledge of the body systems is fundamental, in understanding the risks associated with surgical positioning.

•

INTEGUMENTARY SYSTEM: – Forces include pressure, shear, friction and maceration.

•

VASCULAR SYSTEM: – Dilation of peripheral vessels lead to drop in blood pressure.

– Venous compression predispose to thrombosis.

•

NERVOUS SYSTEM: – Central nervous system is depressed due to anaesthetic drugs.

– Pressure on nerves may lead to temporary or permanent damage.

•

RESPIRATORY SYSTEM: – Alteration in diaphragmatic movements and lung expansion.

– Inadequate tissue oxygenation and perfusion.

•

MUSCULOSKELETAL SYSTEM: – Loss control of normal range of movement.

– May result in joint damage, muscle stretch, strain and dislocation.

– Potential of pressure formation.

GOALS OF SURGICAL POSITIONING: According to AORN 2010, the goals of positioning include the following: Maintain patient dignity by avoiding undue exposure.

Expose the operative site adequately.

Ensure optimum ventilation by maintaining a patent airway and avoiding constriction or pressure on the chest.

Ensure adequate access to intravenous lines and monitoring equipment.

Prevent nerve damage by protecting muscles, nerves, and bony prominences from pressure and by carefully observing elbows, shoulders, toes, and fingers.

Maintain circulation by avoiding pressure on any body part.

Prevent an air embolism (i.e. a condition caused by air in the circulatory system).

Avoid poor perfusion (i.e. impaired delivery of blood to tissues) due to elevation (e.g. elevated legs during procedures conducted in the lithotomy position.

DURING THE INTRAOPERATIVE PHASE IT IS PARAMOUNT THAT THEATRE STAFF PROVIDE FOR PATIENTS' COMFORT AND SAFETY, MAINTAIN PATIENTS' DIGNITY AND ENSURE STABILITY AND SECURITY IN POSITION.

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HAZARDS ASSOCIATED WITH POSITIONING: Position may hinder breathing.

Position may hinder circulation.

May interfere with easy monitoring.

Injury to joints.

Injury to nerves.

Injury to blood vessels.

Injury to skin.

Injury to eyes.

ROLE OF HCA IN POSITIONING: Be knowledgeable on table mechanism.

Prepare table attachments and accessories.

Be familiar with various patient positions for optimum surgery access.

Ensure placement of patient in comfortable position.

Ensure correct position placement when a table break is needed intraoperatively.

Prevent interference with respiration whilst moving.

Ensure patient is fully anaesthetised before positioning.

Never reposition without anaesthetist supervision.

Ensure table fitting is placed without obstruction to incision site.

Ensure all fittings and attachments are completely secure.

Ensure ergonomic care whilst positioning.

Once the patient is positioned on the operating table, theatre staff are responsible for evaluating the patient to ensure the following (AORN; Denholm; Snyder): The patient’s head and upper body are in alignment with his or her hips.

The patient’s extremities are positioned in a way that prevents nerve damage or skin breakdown (e.g. legs are parallel, ankles and legs are not crossed).

Bony prominences and pressure points are properly padded or repositioned.

The patient is not in contact with metal parts of the OR table.

The patient is positioned securely to prevent shifting during the procedure.

Members of the surgical team are not applying excessive pressure by leaning on the patient.

No equipment or surgical instruments are resting on the patient for prolonged periods of time.

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POSITIONING INJURIES: NERVE DAMAGE Improper positioning can lead to stretching of, or prolonged pressure on, peripheral nerves.

This, in turn, can result in either transient or permanent nerve damage. Common injury sites include the brachial plexus and the ulnar, radial, peroneal, and facial nerves.

A nerve injury is per definition the material change or destruction of the complete – or part of the – anatomical structure of the nerve with following function disturbance.

Vulnerable nerves: • • • • •

Ulnar nerve: May be pressed above or by the elbow. This may cause pain and sensory disturbances in the nerve as well as paralysation of the hand muscles.

Nervus radialis: May be pressed by the outer side of the upper arm. This may cause pain and sensory disturbances in the nerve as well as paralysation of the arm and the extensor muscles of the hand or wrist (straightening muscles) – causes drop hand.

Nervus peronæus: May be pressed against the outer side of the knee. This may cause pain and sensory disturbances in the lower leg, in the nerve and possibly drop foot.

Nervus tibialis: A damage of the nerve may cause paralysation in musculus gastrocnemius (muscle of the calf) and paraesthesias under the foot and in the lateral toes.

Nervus peronæus: Damage may cause sensory disturbances in the upper side of the foot and the outer side of the calf as well as paralysation of the dorsal flexion of the feet and toes – drop foot.

PRESSURE SORES Skin breakdown is another consequence of improper positioning. The risk of skin injuries (e.g. skin breakdown, pressure ulcers) during surgery depends on a combination of factors: unrelieved pressure on areas of the patient’s body, the duration of the pressure, and the patient’s ability to tolerate the pressure (AORN).

Studies indicate that a pressures as low as 23 to 32 mm Hg can disrupt normal tissue functioning, and patients with peripheral vascular disease can suffer tissue damage at even lower pressures (AORN; Beckett). If pressure is sustained over a period of time, the patient may suffer tissue ischemia or necrosis. Skin injury may also be caused by shear forces or friction (AORN 2010).

Vulnerable areas Pressure sores can develop on every part of the body, but usually develop where a bone is close to the skin – presupposed exposure to pressure or shear between bone and mattress.

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The vulnerable areas involve: Ears – vulnerable in side position.

Head – especially the back of the head is vulnerable when children lie on their back.

Scapula (shoulder blades) – vulnerable when lying on the back.

Olecranon (elbows) - vulnerable in side position.

Os sacrum (sacrum) - vulnerable when lying on the back.

Calcaneus (heels) - vulnerable when lying on the back.

Digiti pedis (toes) - vulnerable when lying on the stomach.

Malleolus - vulnerable in side position.

Spina iliaca (hipbones) - vulnerable in side position.

Patella (knees) - vulnerable when lying on the stomach.

Tuber ischiadicum (tailbone) - vulnerable when sitting.

Buttocks - vulnerable when lying on the back.

These areas should be monitored by staff carefully by positioning.

COMPROIMISED RESPIRATORY FUNCTION Poor patient positioning can also adversely affect pulmonary function. Interference with this function can lead to hypoxia or other types of respiratory compromise. The horizontal body plane changes both airflow and the functional characteristics of the lungs; the flow of secretions can also be affected.

The combination of circulatory changes and the compromised respiratory effort then affects the oxygen saturation of the blood.

EYE INJURY Another potentially devastating risk of improper positioning is eye injury (e.g. central retinal artery occlusion, corneal abrasion) due to direct pressure on the eyes during surgery. Risk factors for eye injuries include the use of the prone position during surgery; length of procedure, particularly for procedures lasting longer than six and a half hours; and substantial blood loss during the procedure (AORN).

OTHER RISKS Wrong site: incorrect patient positioning may contribute to wrong site surgery by concealing a surgical mark or causing confusion about the operative site (Clarke et al., 1999).

Contracture: decreased mobility in the joints because of changes in the joint, shrinking of the joint capsule or shortening of the surrounding tendons and muscles.

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Thrombosis: occurs when the blood vessels are closed due to coagulation. Thrombosis can occur in all vessels of the body and may cause embolization to the lungs and post-thrombotic syndrome.

TYPES OF POSITIONS There are a number of surgical positions. The position chosen, as aforementioned, will depend on the procedure to be performed, and take into account clients' physiological condition.

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SUPINE POSITION The supine or dorsal recumbent position is the most commonly used surgical position. The patient is placed on the back with his or her head in a straight line with the rest of the body.

The most common injuries related to the supine position are backaches, respiratory compromise, and pressure ulcers on the occiput, scapulae, thoracic vertebrae, elbows, sacrum, and heels (Snyder, 1990). Such areas should be adequately padded during the procedure.

In this position the patients hands are tucked under buttocks, palm down. Neck, knees and hips are slightly flexed. Patients' knees and hips should be slightly flexed to reduce stress on the back and abdomen and the legs are flat – not crossed. The patient shouldn’t have his legs crossed because this may cause pressure on the sural nerve of the upper leg and the peroneal nerve of the lower leg.

The patient’s shoulders should remain parallel with the table and the arms should be secured to prevent them from falling off the table during the procedure.

The supine position is the most common operative position, such as in laparotomy, certain gynaecological and orthopedic cases.

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Potential Pressure Points for the Supine Position

PRONE POSITION In the prone position, the patient lies with his or her abdomen on the procedure bed. Because the patient starts in the supine position, caution must be exercised when turning the patient from back to front. Generally, four individuals are needed to safely turn the patient. The anaesthesiologist should support the patient’s head and neck and maintain the airway while the other staff members support the patient’s trunk and extremities.

In this position the patients arms are placed above the head, or the arms can be placed either at the patient’s sides or supported alongside the head. If the arms are tucked at the sides, they should be pronated and have adequate padding at the elbows. When not at the sides, the arms should be placed slightly lower than the shoulders. Keeping the arms abducted less than 90 degrees at the shoulders will help protect the brachial plexus.

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The elbows are bent so that the hands lie at the side of the head. Pillows are placed under the shoulders, hips and feet. Pillows or towels under shoulders and hips facilitate chest expansion, reduce abdominal pressure and venous oozing at operation site.

This position allows for access for all surgeries involving posterior back (cervical spine, back, rectal area and dorsal extremities).

Injuries in the prone position include respiratory compromise due to compression of the abdomen, corneal abrasions and pressure ulcers on the abdomen, breasts, ears, elbows, genitalia, hips, knees, and toes.

In this position it is essential that pressure point are well protected with padding (cheek, ear, acromion process, breast, genitalia, patella, dorsum of feet, toes). Potential pressure risk areas include the following as per diagram:

TRENDELENBURG POSITION This position is frequently used during surgery of the lower abdomen, when it is desirable to shift the abdominal viscera away from the pelvis for better exposure and visualisation.

Patients should be placed in the Trendelenburg position for only as long as is necessary for the procedure. The most serious danger in this position is a decrease in respiratory exchange due to displaced viscera pressing against the diaphragm and pooling of blood in the upper torso.

This can lead to serious pulmonary difficulties.

In this position the patient is lying in supine position with knees over lower break of the table.

The patient's head is tilted down to 15° or according to the surgeon's preferences, arms may be placed on the chest or armboard. The use of shoulder or knee braces may prevent the patient from sliding.

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Potential pressure areas in this position are the head, the scapula, sacrum, and the heels (calcaneous).

REVERSE TRENDELEBURG POSITION In the reverse Trendelenburg position, the feet are lower than the head, with arms by sides or on armboard. The table is tilted to 5-10° in order to raise the head, the head stabilised by a head ring. The position is often used for head and neck surgery to reduce venous congestion.

A well-padded foot board will help maintain alignment and prevent foot drop. A second safety strap may be necessary for stability. Lumbar and popliteal pads not only help prevent the body from slipping, but also lessen the strain on the back and legs.

Potential Pressure Points in this Position:

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LITHOTOMY POSITION In the lithotomy position, the patient is placed on the procedure table in the supine position and then moved into position after intubation. The lithotomy position requires the use of some type of leg holder, and the patient’s legs may be placed in low, standard, high, and exaggerated positions depending on how high the legs and pelvis must be elevated for the procedure.

The patient lies in supine position with buttocks at the lower break of the table, lithotomy stirrups are placed in position level with patient ischial spine. Arms are placed over the chest or on an armboard , legs are lifted together upwards and outwards and feet placed in knee crutches or candy canes. This position is a common position for urology, gynaecology, perineal or rectal operations.

Hip dislocation and back strain may occur if the legs are not placed in the leg holders at the same time. To prevent this, the circulating nurse and an assistant should each hold a foot and support the leg under the calf. The feet should then be raised and each leg flexed slowly at the knee. The feet should then be placed in the leg holders.

Common injuries in the lithotomy position include pressure ulcers on the patient’s heels and peroneal nerve damage on the lateral aspect of the knee from the leg holder. Peroneal nerve damage can result in foot drop or lower-extremity paresthesia. In addition, patients in this position are at risk of poor venous return from the lower extremities, pooling of blood in the patient’s pelvis, deep vein thrombosis caused by blood pooling in the patient’s calf muscles, and respiratory compromise.

Patients in the lithotomy position for prolonged periods of time are also at risk for compartment syndrome, an uncommon but potentially severe complication of surgical positioning that is caused by compression of the arteries and reduced blood supply to the lower limbs (AORN, 2011).

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POTENTIAL NERVE DAMAGE IN THIS POSITION

TYPES OF STIRRUPS USED FOR THE LITHOMY POSITION AND ASSOCIATED HAZARDS

•

KNEE CRUTCH {FIGURE A} – Pressure on peroneal nerve resulting in footdrop and neuropathies.

•

CANDY CANE {FIGURE B} – Pressure on distalsural and plantar nerves which can cause neuropathies of the foot.

– Hyper-abduction may exaggerate flexion and stretch sciatic nerve.

•

BOOTH TYPE {FIGURE C} – May produce support more evenly and reduce localised pressure.

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LATERAL POSITION In the lateral position, the patient is placed on the non-operative side for procedures involving the upper chest, kidney, or hip. This position increases the risk of spinal misalignment, as well as pressure ulcers on vulnerable areas on the patient’s dependent side (e.g., acromion process, ear, greater trochanter, iliac crest, lateral knee, malleolus).

In addition, patients may experience damage to the common peroneal nerve if the dependent leg becomes compressed between the fibula and the procedure bed. Vulnerable areas should be adequately padded during the procedure (AORN 2011).

In the lateral position, the patient’s lower leg should be kept flexed, and the upper leg should be kept straight. A pillow should be placed between them to prevent undue pressure, and padding should be used under the knee, ankle, and foot of the dependent leg. The patient’s upper arm should be secured on a padded armboard in front of the patient, and the lower arm should be flexed and placed on a separate padded armboard (AORN 2011).

Roll bags may be used below the hip/kidney to increase exposure of iliac region. The position is maintained by use of sandbags or braces attached to the side of the bed and the head is supported on a pillow.

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Potential complications with this position include the following:  If the kidney rest is raised too much, the lungs will not expand adequately which will result in cyanosis and hypotension.  Injuries to brachial plexus, median, radial and ulnar nerves can occur if upper arm is not supported.  If the head is not supported adequately, brachial plexus can get stretched.  Perineal nerve damage may result from compression of the knee against the operating table.

POTENTIAL PRESSURE POINTS FOR THIS POSITION

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FRACTURE TABLE POSITION The patient is positioned supine with the pelvis stabilised against a well-padded vertical perineal post. Traction of operative leg is achieved either by boot-shaped cuff or devices with restraining straps. The unaffected leg may be rested on a well-padded, elevated leg holder.

This position is a common position for open reduction and internal fixation {ORIF} of hip or closed femoral nailing.

Potential complications may include:  Injury to the genital structures, caused by pressure.  Peroneal or femoral obturator nerve damage resulting in foot drop.

KNEE-CHEST POSITION In this position the patient is lying in prone position, both legs are abducted and flexed together at right angles. The knees are flexed and hips elevated. The head, shoulders and chest rest directly on the table and arms are placed above the head. This procedure is the primary position for sigmoidoscopies and laminectomy procedures.

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Potential Complications may involve:  Lower neck and upper back pain due to hyper-extended head.  Ulnar or radial nerve palsies.  Hypotension due to pressure on inferior vena cava and pooling of blood at lower extremities.  Shoulder dislocation or brachial plexus injury when placing the arms.

Potential pressure points for this position:

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POSITIONING EQUIPMENT Patient positioning devices can be divided into two categories. Ones which are primarily geared toward pressure-relief and ones which are designed to provide better access to the surgical site.

The types of positioning equipment used in the surgical setting include pressure-relieving mattresses, foam mattress overlays, padding, axillary rolls, stirrups or leg holders, and straps to hold patients in place. Positioning equipment should help redistribute pressure, especially at bony prominences or other high-risk areas, during the surgical procedure and prevent patient injury (AORN 2011).

Positioning devices and equipment should be inspected on a regular basis and maintained in proper working condition. In addition, any devices or equipment scheduled for use during a procedure should be checked for working condition prior to the procedure.

All surfaces should be checked to ensure that they are smooth and intact; wrinkles or moisture on procedure beds or other surfaces can contribute to skin breakdown.

Theatre staff should be educated and trained on how to use the devices or equipment effectively. For example, straps or other positioning devices may cause compression on the nerves if they are secured too tightly on the patient (Fritzlen et al.).

TABLE FEATURES AND ATTACHMENTS ELEVATED ARM REST

LATERAL SUPPORT

BREAKABLE HEAD REST

STIRRUPS

DETACHABLE FOOT REST SLIDING BARS

ARM BOARD

MANUAL LEVER

METAL SOCKET

HYDRAULIC WHEELED BASE STAND

OTHERS – PILLOWS, HEAD RING, SANDBAGS, ROLL SUPPORT, SOFT PADS, MATTRESS

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MANUAL HANDLING & TRANSFER Manually handling of unconscious patients and positioning them to facilitate surgical access, brings with it the likelihood of inadvertent physical harm to the patient. Anaesthetised patients lack muscle tone. Theatre staff need to anticipate the risk of harm and introduce strategies to protect the health and safety of the surgical patient. All staff must apply the principles of manual handling and adhere to Manual Handling Policy.

Manual handling regulations recommend that the team involved undertake a risk assessment for the moving and positioning of each individual patient, and that relevant aids and methods are used to reduce patient movement and potential injury to both staff and patients (Turner et al, 2000). An assessment will include the physical condition of the patient, nature of the intervention and individual patient needs (NATN, 1998).

Manual transfer and positioning of anaesthetised patients must be smooth and gentle, coordinated by the person {usually the anaesthetist} who has control of the patient's head and airway. It requires at least three or four people lifting. Prior to and after positioning, it is vital that IV lines/drains are checked and protected. Participants must ensure the patient's dignity during transfers.

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THE OPERATING TABLE & LIGHT The Operating Table

The operating table is a centre piece of the room, a very versatile piece of equipment. It has to be in order to accommodate the great variety of different operating positions. The table can be raised, lowered, and tilted in any direction. The operating table on which the patient is positioned for surgery is fully adjustable for height, degree of tilt in all directions, orientation in the room.

This allows manipulation of the patient in any position while maintaining proper body alignment. The surface is covered with a firm pad that can be removed for cleaning. The table and its attachments must be cleaned daily, between cases and checked to ensure they are in good working order, the pad is intact, and all attachments are present.

A variety of attachments for the operating table are available, their usage depends on patient position and type of surgery. Knowledge of their application and ensuring they are in good working order is paramount to ensuring patient safety. Removable arm boards allow extension of the patient's arms and hands for intravenous lines. The surgical arm-board is wider and provides a broader surface on which to place the hand and arm for surgery in these areas.

Stirrups, used in gynaecologic and some general surgical procedures, connect to the midbreak of the table, which is flexed downward and away or removed altogether. Leg holders may be attached to the sides of the table.

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TABLE ACCESSORIES AND ATTACHMENTS

The Operating Lights There are usually two operating lights in a theatre, attached to the ceiling. The lights are easily manoeuvred and necessary to accommodate the needs of surgery.

The operating room environment requires a combination of satisfactory ambient lighting. The ability to adjust these lighting levels and change their characteristics enables staff to be more effective. Incorrect or poor lighting can impact on the patient, through poor performance and impaired effectiveness.

It is paramount that prior to commencement of the theatre list, the operating light is checked to ensure correct working order, it is clean and functioning correctly {ie moveable} . Between cases, and at the beginning and end of the theatre list, the light must be cleaned as per hospital policy.

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SAFE STORAGE OF EQUIPMENT

All staff should be aware of the potential dangers of using machinery and learn to use machinery correctly.

Attention must be paid to: The use of risk assessment sheets.

The importance of protective clothing.

Carrying out safety checks on all machinery prior to use.

The positioning of warning signs/barrier tape.

The use of circuit breakers and extension leads.

Training in the safe use and selection of tools & attachments.

Correct positioning of cables.

Appropriate use of wall sockets.

Positioning & storage of machinery when not in use.

Storing machines in the upright position.

Removal of the base plate on rotary floor machines.

Storing wires neatly.

Ensuring sufficient air circulating on tanks.

Checking machines at the end of each shift and reporting defects immediately.

Cleaning machinery after every use.

Store Rooms The equipment room is used to store large apparatus such as the operating microscope, image intensifier and laser machine. Some hospitals also store their gas anaesthesia machines in this area. The equipment stored here should be kept free of dust and cleaned routinely just as in any other area of the operating room.

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The equipment room is a valuable area because it prevents the storage of such equipment in hallways where it could be a hazard or become damaged.

The store room: Should be of adequate size.

Should have adequate lighting.

Should have adequate ventilation.

Should have shelving and cupboard space for all spare equipment and materials.

Should have shelving no more than 2 meters from the floor.

Should have hooks, fixings for hoses, etc.

Should have a fully functioning sink with hot and cold water supply.

Should contain /display risk assessment / manual handling information and company policies.

Should be secure.

Never block the entrance to store rooms. Store items dependent upon how often they are used.

STORGAE OF MACHINES: Store machines in the upright position.

Remove base plate on rotary floor machines.

Store wires neatly.

Ensure sufficient air circulating on tanks.

Check at the end of each shift and report any issues immediately.

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RECORDING & REPORTING OF INCIDENTS & ACCIDENTS

The collection of data on near-misses and errors is essential if a hospital is to improve patient safety and the quality of care it provides. The importance of incident reporting in reducing the volume of adverse clinical events that occur throughout healthcare, is internationally accepted. Reporting and recording is a health and safety requirement.

When an incident occurs the HCA /staff involved must fill out an incident/accident report. An incident report (also called an event report or occurrence report) is a formal report written by practitioners, nurses, or other staff members. It serves two purposes: to inform facility administrators of incidents that allow the risk management team to consider changes that might prevent similar incidents. to alert administration and the facility insurance company of potential claims or need for further investigation.

The forms used for incident reports are consistently being revised and updated, and some may be electronic. Most healthcare facilities provide guidelines for when incident reports must be completed.

An incident is any event that affects patient or employee safety. In most healthcare facilities, injuries, patient complaints, medication errors, equipment failure, adverse reactions to drugs or treatments, or errors in patient care must be reported. Data from incident reports is tracked for quality assurance and to allow the detection of emerging trends or problems.

Incident reports bring problems to light in a non-blaming way and can provide a catalyst for changing the practice or procedure that contributed to the error.

An incident report should be initiated only by someone who directly observes the incident or by the first person to arrive at the site of the incident.

COMPLETING THE DOCUMENT When filling out an incident report, include the following information: the exact time and date. the names of persons involved and any witnesses. factual information about what happened. other relevant facts, including your actions (such as notifying the healthcare provider) and any corrective actions taken.

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After completing the incident report, you must sign and date it. If the incident reports are filed electronically, the form will require you to type in this information.

Follow the hospitals policy regarding the policies and procedures for how the incident report is to be followed up; this will determine whether the matter needs further investigation.

In addition to filling out the incident report, you must document the facts of the event in the patient's medical record. The medical record documentation, completed close to the time of the incident report, should contain only factual, objective, descriptive documentation relative to the patient's condition and response to the incident.

Guidelines for completing an incident report: Write objectively.

If relevant, document patient and witness accounts of the event into the report.

Don't assign blame.

Avoid hearsay and assumptions.

Forward the report to department line manager.

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SAFE PROCEDURES

In relation to the below, it is important to note and be aware that all hospitals will have their own individual policy, which is based on best international practices, conforms to legislation and HSE policy and health and safety practices and legislation.

FIRE Equipment used on a routine basis during a surgical procedure can be a source of possible combustion, given the oxygen-enriched atmosphere. Electrosurgical devices, fibre optic light sources or lasers, all have the potential for combustion. Linen or nonwoven surgical drapes can serve as sources of fuel. Oxygen serves as the supporter of combustion.

All are essential for fire to exist. All of these items are present during any surgical procedure in any operating room. Although fire in the operating room is a rare occurrence, it is always a possibility. Thus attending in-servicing training in fire drills and emergency plans is paramount.

Possible causes: • • • •

Use of lasers, electrosurgical or electrocautery equipment.

Use of fibre optic light sources and cables.

Spark production from high speed drills, lasers and electrosurgical units.

Presence of oxygen enriched environment - oxygen, nitrous oxide, trapping of oxygen under surgical drapes.

• Presence of flammable materials and alcohol based prepping agents.

• Failure to put laser into standby mode when not in use.

• Unmaintained equipment. {Health and Safety Authority}

If a fire should start in the surgical suite, the first concern is always for the safety of human life, the patient's, visitors, and OR personnel. You may or may not be directly involved in the rescue of patients or personnel.

However, preparation for emergency situations is necessary. If the patient is under anaesthesia, the entire OR table should be moved in the interest of time and to prevent injury to the patient and staff.

Know the locations of all fire alarms within the department and where the nearest alarm is to your location. Should a fire break out within your surgical suite, you can be of great assistance by simply initiating the fire alarm. Fire alarms go directly to the fire department for the service area. This enables the fire personnel to know the exact location of the fire within the hospital.

It is preferable, but not always possible, to extinguish the fire in the room.

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Know where the fire extinguishers are within the department you are servicing. Always know where the closest fire extinguisher is to your location. There is a fire extinguisher in every surgical suite. Proper application of the device is imperative to the personal safety of the operator and other personnel within the vicinity. Know the exit route.

Turn off oxygen and other gas supply. Disconnect electrical equipment in immediate area if safe to do so. In the event of a fire, each nursing unit within the hospital has duties that are specific to its nursing function and location. These responsibilities are in addition to those outlined in the hospital's fire plan. These guidelines are an effective means to provide and maintain a safe environment for patients, visitors, and staff.

Major Disaster The purpose of a major disaster policy is to provide a plan for the mobilization of the resources of the hospital to respond to a major community disaster. This Disaster Plan will be activated when the number of ill or injured exceeds the capacity of the Emergency Department or the normal operations of multiple departments to provide the quality of care required.

Hospital disaster plans should include policies for personnel notification, staffing, and recall. A determination of who'll be responsible for continually assessing hospital resources and capabilities should be made. A plan for how information will be communicated to staff and the public should also be included. A central command or operating centre should be identified. It's essential that staff review all plans and participate in drills periodically.

Cardiac Arrest The term sudden cardiac death refers to the sudden loss of function of the heart. This is often referred to as a cardiac arrest. It can occur in a person with or without heart disease. The problem occurs due to an abrupt disturbance in the heart’s rhythm which results in the heart not beating or beating too little to keep the person alive. The rhythm disturbances are of different types. "Asystole " is where there is no electrical activity and thus, no heartbeat.

A flat-line is seen on the monitor. Ventricular fibrillation (VF) is where there is very erratic electrical activity, but the heart does not pump. Complete heart block is where the heart rate is too slow to keep the patient alive for long. In each case, it occurs suddenly or shortly after the onset of symptoms. Without treatment, the outcome is usually fatal {Irish Heart Foundation, 2012}.

Cardiopulmonary Resuscitation (CPR) is a series of assessments and interventions which consist of 4 main parts: Airway, Breathing, Circulation and Defibrillation. Good quality CPR improves a victim's chances of survival.

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Procedure for Adult Basic Life Support: On discovering a collapsed victim, the rescuer should establish that the scene is safe to approach the victim.

Determine unresponsiveness, the rescuer will gently shake the victim's shoulders and shout loudly into the victim's ear to gain a response.

If unresponsive, shout for help and request activation of the emergency response team { local policy phone number} and retrieve nearest emergency trolley and defibrillator .

Commence CPR. {30 chest compressions ---- 2 rescue breaths --- 30 compressions.} Continue until cardiac team arrive.

When team arrive advanced life support will commence, intubation, attached to defribillator.

ADVANCED LIFE SUPPORT

Arrhythmias associated with cardiac arrest are divided into two groups: shockable rhythms (VF/VT) and non-shockable rhythms (asystole and PEA). The principle difference in management is the need for attempted defibrillation in patients with VF/VT. Subsequent actions, including chest compression, airway management and ventilation, vascular access, administration of adrenaline, and the identification and correction of reversible factors, are common to both groups. The ALS algorithm provides a standardised approach to the management of adult patients in cardiac arrest. {Resuscitation Council Uk , 2012}.

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SAFE PRACTICES Electrical Equipment

Almost every device used in modern theatres is electrical. With so much equipment in operation at one time, the source and type of system becomes important. The length of the electrical cords also is an important safety feature. Electrical cords draped across the floor and equipment have the potential for great injury to personnel and visitors. Electrical cords should be contained and should not be attached to extensions.

General Rules • Inspect all equipment before use.

• Follow manufacturers' instructions.

• Do not use with wet hands.

• Turn off equipment before unplugging.

• Adhere to maintenance schedules.

• Report any damage/wear.

Diathermy Diathermy is one of the most commonly used tools in the operating theatre. Diathermy is the generation of heat in body tissues by means of radiofrequency energy (passage of an electric current through the tissues). The energy is used to cut tissues, seal blood vessels and destroy unwanted cells by the deliberate application of intense heat. Two basic patient circuits are used: 1. Monopolar: During monopolar diathermy the patient forms part of the electrical circuit.

Only one side of the generator output is connected to the active electrode, the other side is connected to a large patient return plate. The plate provides a safe path for the current to pass back to the diathermy.

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2.BIPOLAR: During bipolar diathermy the current flows between the tips of the forceps, one tip acting as an active electrode and the other as a return. The patient’s tissue acts as the conducting medium, through which the current will flow. One advantage with this type is that production of the cutting current is virtually impossible. The field of coagulation is limited to the contact area; the surrounding tissues are not damaged. There is no patient plate attached.

EFFECTS OF SURGICAL DIATHERMY • • •

CUTTING. COAGULATION/DESICCATION. FULGURATION.

PATIENT PLATE/RETURN ELECTRODE A minimum conductive area of 10sq inches is recommended. Plate must be kept in secure contact with the patient’s body surface.

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Patient plates are disposable, and are generally thin, lightweight and flexible, they have a conductive adhesive which works like gel and a continuous adhesive border. The plate can be positioned on the: • • • • • •

CALF .

UPPER ARM. ABDOMEN. MID BACK. BUTTOCKS. ANTERIOR & POSTERIOR THIGH.

Diathermy can pose the following hazards: surgical smoke and accidental burns.

Safety Checks with the Diathermy Machine: - All cables and electrodes insulation are intact.

- Adequate supply of patient plates.

- Functioning alarm systems.

- Connections are all fitting securely.

- Foot pedals are all present and working.

Safety with Patient Plate: Any faulty equipment must be removed immediately.

Plates are single use.

Avoid placement near scars, implant sites or ECG electrodes.

A muscular well vascularised area is most suitable.

Site must be clean, dry and shaved.

Protect skin integrity by ensuring patient is not resting on dispersive plate clamp.

The diathermy setting is determined by the surgeon.

Be familiar with normal power settings.

Do not allow fluid to pool at plate site.

Check patient contact and connection before commencing.

Ensure patient is not in contact with any metal.

Place active electrode in a quiver when not in use.

Only aqueous fluids should be used for irrigation.

On completion of procedure, remove the plate carefully and inspect the skin.

Document use of diathermy in patient’s record.

SURGICAL PLUME: Surgical smoke is called by a variety of names, including cautery smoke, diathermy plume, plume, smoke-plume, aerosols, bio-aerosols, vapour and air contaminants. It can be seen and smelled (Ott 1997).

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The long-term effects for healthcare staff exposed to surgical smoke remains unknown, staff must be proactive and prevent any potential harm. Engineering controls and personal protective equipment should be used to protect all staff and patients from exposure to surgical smoke.

Tools to achieve haemostasis and dissection include electrosurgery units, lasers, ultrasonic devices, high-speed drills, burrs and saws. All of these devices produce heat, which allows the surgeon to achieve the desired tissue effect. The most common device used is the electrosurgery unit.

Electrosurgery uses high-frequency current to cut and coagulate tissue. The disruption releases the cellular fluid as steam and spews the cell contents into the air forming surgical smoke plume [www.afpp.org.uk}.

Guidelines to reduce the risks of smoke plume: Face mask.

Smoke evacuators.

Smoke Evacuator: • • • •

Smoke evacuation systems should be specifically designed for electro surgery and laser smoke plume, with ULPA filters.

Filters and other accessories should be changed/maintained in accordance with the manufacturer's guidance.

Filters, tubing, and all consumable accessories used with a smoke evacuator should be disposed of according to infection control procedures for blood borne pathogen contamination.

The collection device of the smoke evacuator, should be in close proximity to the operative site.

LASER TREATMENT: {Light Amplification by Stimulated Emission of Radiation} Lasers are used in a wide range of surgical procedures and various types of laser exist. Lasers are usually distinguished by the colour of the light they produce and the medium in which they are transported, such as carbon dioxide, argon and potassium titanyl phosphate (KTP).

Potential risks to the staff and patients are: • • • •

Fire due to the use of high temperatures.

Eye injury due to laser light inadvertently striking the cornea and destroying it or the retina behind.

Skin injury due to burns by the laser beam.

The biological hazards of smoke plume.

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Several legislative safety standards exist in all hospital departments where lasers are used and include the requirement for a Laser Safety Officer in each area. The utilisation of lasers is rigorously controlled, monitored and recorded, and each perioperative practitioner must have appropriate knowledge and skills so as to be able to participate during a surgical procedure where lasers are used (Taylor and Campbell, 1998; NATN, 1998).

During all laser procedures, staff must wear appropriate eye protection, safety signs must be put in place and all staff must be trained in usage.

IONISING RADIATION Is a form of radiation which destabilises the atom (the smallest part of an element), forming an ion, which is electrically charged. X-Ray is an example of Ionising radiation used for diagnostics and nuclear medicine for pharmaceutical treatment. Ionising radiation is harmful to cells, can cause tissue damage, tumours or genetic defects.

Safe practices: Limit exposure time.

Check pregnancy status.

Work behind perspex shields.

Wear lead aprons.

PPE. Safety signs.

Monitor doses received - photographic film badge if constantly exposed.

Radiation control officer in each hospital.

WASTE MANAGEMENT All clinical waste should be placed in YELLOW clinical waste bags, no more than three quarters full and swan necked to ensure an effective seal. Heavily contaminated waste should be placed in a UN approved rigid plastic container with an orange cable tie. Human body parts should be placed in a UN approved rigid container.

All staff should refer to local hospital policy. All suction equipment including liners must be changed in-between patients to prevent cross infection and fluid loss volume management in the container. Non healthcare waste should be placed in black domestic bag.

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Categorise HEALTHCARE RISK WASTE Infectious waste - {General infectious items, incontinence wear, blood/body fluids, specimens from labs, sharps.} Radioactive waste - {Some waste from, eg. X-ray dept, nuclear medicine department.} Toxic waste - {Discarded chemicals.} NON-HEALTHCARE WASTE Domestic – {Normal kitchen, household, nontoxic, non-radioactive, non-chemical, non-infectious.} Confidential material – {Shredded – documents.} Medical equipment – {Clean, eg plastic bottles, packaging.} Potentially offensive – {Not contaminated with hazardous body fluids, e.g nappies, stoma bags.} SHARPS MANAGEMENT: Every day within the healthcare setting, staff of all grades are exposed to life threatening diseases as a result of needle-stick and sharp injuries. A needle stick injury is a penetrating wound with an instrument that is potentially contaminated with blood or body fluid from another person.

Puncturing the skin with a contaminated sharp carries a risk of possible contamination from as many as 20 blood borne pathogens.

HOW NEEDLESTICK INJURIES OCCUR --- risk factors: Performing IV canulation, IM injections, blood collection, suturing.

Sharps disposal.

Re-capping of needles.

Careless behaviour.

Taking short cuts.

Sharp containers too full.

Lack of education / training.

Inexperienced staff.

Staff shortages.

Emergency situations.

The Operating Department is an at risk area for sharps injuries.

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PREVENTION OF INJURY: Sharp containers --- should be correctly located, of correct size, assembled correctly, not over filled {to identified mark} and secured properly.

Never place sharp containers at floor level.

The temporary closer mechanism on the sharps box should be in place when not in use.

Store sharp boxes away from public.

Never re-sheath needles.

Dispose of all used needles / sharps immediately following use.

Always wear protective clothing {gloves, goggles}.

Never try to retrieve sharp from container.

Be extra cautious during emergency situations.

Know hospital policy and procedures.

Be aware of procedure if accident occurs.

Receive education and training.

Receive the necessary immunisations.

Be aware of the location of first aid materials.

SHARPS CONTAINERS: Must be UN approved, colour coded, closed when ¾ full, and positioned in a secure location, transported to designated disposal site when full, signed and dated.

SHARP BINS – RED OR BLUE LID  Used for items such as needles, syringes, scalpels, stitch cutters.

SHARP BIN – PURPLE LID  Used for sharps that have been used for the administration of cytotoxic drugs, such as intravenous administrative sets, needles, syringes.

SHARP -- YELLOW RIGID BOX WITH YELLOW LID  Used to dispose of contained body fluids and blood. Such as vacuum dressings, suction liners, dialysis equipment.

LINEN MANAGEMENT Linen and contaminated theatre clothes must be changed at the end of the case and bagged according to local policy. Dirty used theatre linen placed in water soluble bag and secured.

Transported to laundry in green laundry bag. Fouled and infected linen must be placed in an alginate bag prior to being placed in a green linen bag.

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Segregation of linen objective:  Protect patients and staff from cross infection from used linen.  Reduce number of microorganisms on linen.  Meet health and safety requirements.

HANDLING OF CLINICAL SPECIMENS During operative procedures blood, urine, tissue specimens may be required for investigation, diagnosis, autologous donation or transplant purposes. Healthcare staff must adhere to local policy with regards to the collection and transport of samples to laboratory.

All staff must apply standard precautions for infection prevention and control and other appropriate health and safety measures.

On collection of a specimen from the scrub nurse the HCA and the circulating nurse must adhere to the following: 1. Wear PPE. 2. Protect self from splashes, wear, apron/goggles.

3. Confirm the clinician’s requirements for the type of clinical specimen to be collected and that relevant consent has been obtained.

4. Ensure the correct transport medium and containers are available for the type of specimen being collected by the clinician/surgeon.

5. Receive the specimen correctly and safely in line with organisational policies and procedures, place it in the appropriate container/transport medium.

6. Confirm with the scrub nurse that the specimen labels on containers are correct and clear with all relevant information and that necessary documentation has been completed.

7. Store upright during transit.

8. Confirm dispatch of the specimen to the correct destination for investigation / or holding area if not urgent.

9. Clearly and accurately record information regarding specimen retrieval in the patient care plan/theatre records.

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HANDLING & STORAGE OF MEDICAL GAS CYLINDERS Medical gas cylinders are used to store compressed gases.

Types of gases: Oxygen.

Nitrous oxide.

Entono .

Carbon dioxide.

Medical air.

Helium/oxygen.

Identify different gas cylinders: All gas cylinders are colour coded. The colour of the cylinder indicates the gas.

• • • • • •

Oxygen = black body with white shoulders.

Nitrous oxide = all blue cylinder.

Entonox = blue cylinder, white segments on shoulders.

Carbon dioxide = grey cylinder.

Air = grey cylinder, black and white shoulder quarters.

Helium/oxygen = black cylinder, white and brown shoulder quarters.

SAFE STORAGE • • • • • • • • • • •

Store under cover.

Good ventilation.

Well away from naked flames or combustible materials.

Warning notices posted nearby.

Emergency services should be notified of location of cylinder store.

Segregate different types of gas cylinders inside store.

Store empty and full cylinders separately.

Use full cylinders in strict rotation.

Do not re-paint cylinders or remove labels.

F size and larger cylinders stored vertically.

E size and smaller stored horizontally.

Note on Entonox gas Before use, cylinders stored horizontally (lying down) for 24hrs above 5degrees C. If required urgently, stored above 10 degrees C for 2 hours and then inverted 3 times.

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Safe handling of medical gas cylinders: • • • • • • • • •

Handle with care.

Do not let fall or knock violently.

Move using appropriate size and type of trolley.

Secure to a suitable cylinder support when in use.

All liquid gas cylinders must be used vertically, with valve uppermost.

No smoking or naked lights within vicinity.

After use, close valves using moderate force only.

When cylinder empty, valve must be kept closed.

Ensure plastic cap is fitted to bullnose type valves/outlets.

CHEMICAL SAFETY: The use of chemicals is widespread in healthcare and includes chemicals such as: • • • • • •

Cleaning agents.

Disinfecting and sterilising agents.

Laboratory chemicals.

Medical gases.

Anaesthetic agents.

Cytotoxic drugs and pharmaceutical substances.

Risk of: • • • •

Health hazards such as respiratory problems, allergies and dermatitis.

Fire.

Explosion.

Burns.

Possible causes: •

Improper handling of compressed gases.

Exposure to: • • •

• • • •

Latex consumables.

Smoke plumes from laser or electrosurgical units.

Waste anaesthetic gases (enflurane, isoflurane, sevoflurane, desfulrane, halothane) due to patient exhalation, poor gas connections or poor maintenance of scavenging system.

Methyl methacrylamide during bone surgery.

Disinfectants.

Cryogenic agents during cryosurgical procedures.

Hazardous drugs via inhalation or during injection or administration.

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SAFETY MEASURES INVOLVE: Know hospital policy.

Hand hygiene.

Report incidents immediately.

Handle with care.

Wear appropriate PPE – gloves, goggles, mask.

Read instructions.

Use correct dilutions, avoid confined spaces.

Wash hands before and after use.

Clean up spillages immediately and dispose of correctly.

Follow safe storage procedures.

Be label aware!

Colour coding used by some companies: – Red = Acid.

– Blue = Alkaline.

Green = Neutral.

Hazardous chemicals - Be Symbol aware: Xn = May have harmful health risks.

Xi = Irritant. Eyes, throat, nose, skin.

T/T+ = Toxic/very toxic. Serious health risk.

C = Corrosive. Severe burns. = Oxidising. May start fire or make it worse when in contact with flammable substances.  F/F+ = Highly/extremely flammable. The vapours from these catch fire at room (F) or even lower (F+) temperatures.     

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CARE OF SURGICAL INSTRUMENTS

Surgical instruments represent a significant threat of cross-contamination between the patient and surgical personnel. Used instruments in all cases must be sent to a Central Sterile Service Department (CSSD) for reprocessing. Instruments must never be washed locally.

Disposable/ single use equipment must never be reused.

Traceability with sets of instrument trays within the operating theatre must be maintained. To ensure that any decontaminated instrument can be traced back to a particular sterilisation cycle and a record on the patient’s chart of each instrument’s decontaminating batch number.

Ideally, the tracing system should make it possible to trace sets of instruments utilised on individual patients. All stages of the sterilisation/decontamination process should be documented.

STERILISATION Means to render a product free of all micro-organisms including spores.

There are many methods available ==HEAT==RADIATION==OR CHEMICAL. Instruments and materials used for medical interventions are expensive and thus are designed such that they can be re-used.

HEAT STERILISATION Autoclaving {moist heat}.

Common form.

Items are cleaned and wrapped in various methods.

Items are autoclaved at 121 degrees C or 134 degrees C. Stringent recording.

THE STERILE SUPPLY CYCLE: Carried out in the CSSD, the cycle involves: Use. Transport.

Cleaning/disinfections.

Inspection and tray assembly.

Packaging.

Sterilisation.

Storage.

Transport.

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THE CYCLE •

Transport to CSSD === soiled equipment is collected and transported in suitable containers / trolleys. Cleaning === equipment is brought to the ‘dirty area’ where the instruments are cleaned in order to remove visible tissue and blood, reduce and remove micro-organisms, protect against corrosion and to ensure safe movement of equipment. Cleaning is done manually, with a hand shower spray gun initially.

Secondly, the instruments are placed in an automatic washer/disinfector.

•

Inspection of tray === following the cleaning process the instruments are checked ensuring they are in working order, and that the correct amount are present. They are then assembled correctly on a tray. Packaging === at the end of the cleaning process the instruments are packed. There are various methods available {linen, containers, non-woven sheets, paper sheets, laminated film pouches}. Instruments are double packed {ie, inner and outer layer}. An indicator is placed clearly to indicate whether the product is sterilised.

•

Sterilisation [autoclaved] === after packaging, the load is placed into the autoclave.

Moist heat using pressurised high-temperature steam is the most common method.

When the cycle is complete, the goods are removed, the indicator is checked and logged and the sterile goods are then stored in a designated area until it is ready or required to be transported to the user.

Each step in the sterile supply cycle is crucial for client /patient and staff safety. A mistake at any stage is costly both in time and money. Therefore, close monitoring and recording at each stage is carried out.

CENTRAL STERILE SERVICES DEPARTMENT [CSSD] It provides the hospital departments, theatres and wards with both decontaminated and sterile equipment. The high standards maintained in the CSSD can only be brought about by ensuring the staff are properly trained and informed of the correct procedure in handling the equipment and sterilisation.

Cleaning surgical medical devices is done in Central Sterile Services Department. This is the removal of soil. Cleaning is physically removing organic material and micro-organisms from equipment and medical devices.

Disinfection is a process which kills or inactivates micro-organisms, but not spores. It does not eliminate all micro-organisms, but reduces them to a safe level for handling.

Sterilisation is a process which destroys all living micro-organisms including bacteria spores. It renders medical devices free from viable organisms. The most rapid and effective way of killing micro-organisms is with moist heat. This is achieved by exposing micro-organisms to steam generated to a temperature of 134˚C for 3 minutes under pressure of 2.1 bar in a sealed chamber commonly referred to as an Autoclave.

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There are also a number of other methods of sterilisation, including dry heat sterilisation, gas sterilisation, chemical sterilisation and radiation sterilisation.

Sterile Services Departments are key players in the technical support structures in modern hospitals and operating theatres. The field is technically very challenging. Sterilisation processes are underpinned by fundamentals in physics, microbiology, chemistry and material science. Over the past number of years dedicated Sterile Services Departments in hospitals have evolved where the need has arisen for specialised training, management and quality control systems, including traceability.

Since the European Directives and Standards have become law, and in particular the Medical Devices Directives in 1996, pressure has been brought to bear on all areas performing cleaning/decontamination and sterilisation processes. It is also very important that specialised trained staff are employed in this area. Courses and in-service training have become a very important part of the CSSD. Range of Services to be Provided by CSSD: Decontamination, sorting and disassembly of RIMD sets and equipment.

Cleaning of RIMD/ equipment.

Assembly and checking/ replacement.

Sterilisation.

Sterile storage.

Dispatch of sterile items.

Key Objectives of CSSD: To provide high quality sterile services to support the clinical work of the hospital by providing a safe and effective service consistent with sterile service customer needs.

To provide a reliable, flexible service that meets the needs of the sterile service customers and allows fast and reliable turnaround of sterile RIMDs. To ensure the effective and timely collection, cleaning and decontamination of all RIMDs and return of them, once sterile, to their designated location e.g., theatre or designated collection containers in CSSD.

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The CSSD is committed to providing a quality decontamination service in line with best practice outlined in the HSE Code of Practice for Decontamination of Reusable Invasive Medical Device (RIMD) 2007.

Ensuring that there is a system in place that ensures, as far as reasonably practicable, that all RIMDs are properly decontaminated prior to use, and that the risks associated with decontamination facilities and processes are adequately managed.

The decontamination of RIMDs is a combination of processes, which if not correctly undertaken, individually or collectively, may increase the likelihood of infectious agents being transferred to individuals or the environment.

The sterile services department is responsible for preparing, processing, storing and distributing sterile and non-sterile medical and surgical supplies and equipment required for patient diagnosis, treatment and on-going care.

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SINGLE USE ITEMS A single use invasive device is defined as a device intended by the manufacturer to be used on one patient / client for one procedure only. These devices are sterile and pre-packed. They should be stored in a clean designated area, where there is no risk of contamination.

The term ‘Single Use’ means that the manufacturer intends the device to be used once and then discarded and considers that the device is not suitable for use on more than one occasion.

It is not intended to be reprocessed and used again or used on another client. In circumstances where a medical device intended by the manufacturer for single-use is reprocessed, the person/s responsible for putting the reprocessed device into service assumes the legal responsibility of a device manufacturer and must have supporting technical and clinical documentation to demonstrate that the reprocessed device conforms to all the essential requirements of the Medical Devices Directives.

Medical devices designated as ‘Single Use Only’ should not be reprocessed or reused under any circumstances. GUIDELINES FOR USAGE: o The device is not to be reprocessed. o To avoid cross-contamination, they should be used where practical. o Should be disposed of after use.

Single client use: A medical device that is intended for single-client use means that the device may be used for more than one episode of use on one client only. The device may be reprocessed between each use as per manufacturer’s instructions.

Examples include: nebuliser tubing / masks and some infusion equipment. Medical devices designated as ‘Single client use’ should be used for one client only and not reused on a different client under any circumstances. These devices should be cleaned and used in accordance with manufacturer's instructions.

Reusable devices: Reusable equipment should be decontaminated after every client use and before use on another client in accordance with the manufacturer’s instructions.

EXAMPLES OF SINGLE USE DEVICES: NEEDLES. SYRINGES. TROCARS. LAPARSCOPY SURGICAL INSTRUMENTS SUCTION CATHETERS. INDWELLING CATHETERS. WOUND DRESSING PACKS. STUTURES.

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STOCK CONTROL PRACTICES

Stock control is about how much stock you have at any one time, and how you keep track of it.

Efficient stock control will mean you have the right amount of stock in the right place at the right time.

Possible hazards • • • • • • • • • • •

Goods falling from shelving or racking.

Someone falling when climbing on shelving.

Stock or materials blocking fire exit routes.

Accumulations of used packaging.

Poor storage causing increased manual-handling risks, eg putting bulky items above head height.

Spillages of goods causing environmental damage or increasing the risk of slips and trips occurring.

Exposure to badly stored hazardous substances.

Contamination or danger caused by storing inappropriate materials together.

The use of mechanical-handling equipment, eg loads falling from forklift trucks.

Vandalism, theft and arson causing pollution.

Flammable substances.

Storage of dangerous or hazardous materials • Under the Control of Substances Hazardous to Health (COSHH) Regulations 2002, you must ensure chemicals and dangerous substances are stored and handled so that people's exposure to them is minimised.

• You need to assess the risks of storing and handling dangerous substances - including the possibility of environmental damage caused by leaks and spillages.

• You should then implement any precautions needed to control risks, including: – – – – – – – –

storing chemicals according to the manufacturer's instructions on the safety data sheet. keeping the minimum quantity of hazardous substances necessary. storing incompatible substances separately. taking steps to prevent release or leakage of dangerous substances. cleaning up any leaks or spills that occur. using appropriate precautions when handling substances - wearing protective clothing or ensuring adequate ventilation, for example. ensuring employees who store and handle dangerous substances are properly trained. checking containers used for short-term storage are properly labelled.

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If you store chemicals or dangerous substances that could create a fire or explosion, you must also comply with the Dangerous Substances and Explosive Atmospheres Regulations 2002. Download a leaflet on fire and explosion safety regulations from the Health & Safety Executive (HSE) website (PDF).

Ensure that flammable substances are correctly stored in suitable containers and are not stored near to a source of ignition such as a heater.

It's also best practice to: – – – – – – –

place stores of liquid above ground where they're unlikely to be damaged, eg away from traffic routes. avoid overfilling containers. supervise deliveries. maintain gauges, valves and pipework . monitor oil use - unexpectedly high use may indicate a leak. have procedures for dealing with emergency leakages. use a secondary containment system such as a drip tray or bund (a storage area designed to prevent liquids escaping).

Shelf life of sterile stock Shelf life refers to the period during which an article is considered safe to use. All items for sterilisation require a batch number which refers to the sterilisation and production of the item.

Given the correct cleaning, packaging materials and methods, sterilising, handling and storage conditions, shelf life of sterile stock is considered event and not time related.

Remember that some materials may age and deteriorate over time and as a result lose strength. In some cases materials with chemical indicators may have a time related use-bydate. For this reason, the shelf life of packaging materials is obtained to maintain a standard of practice which ensures that stock is handled correctly and rotated.

This means that materials are kept for a minimum time period, reducing the risk of challenges occurring to the packages. Challenges or adverse events to packaging materials can occur from the time an item comes out of the steriliser, with the type and number of events determining whether the item will become contaminated.

Stock rotation Even though event related sterility principles are used, it is still necessary to ensure stock is arranged on shelves so that the oldest stock is used first. As stated previously, all items processed are required to have a date of sterilisation and this allows for the identification of stock that should be used first. Stock rotation principles should apply to all areas where sterile stock is stored including operating theatres and ward areas. Stock rotation also applies to commercially produced products.

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This is the End of Unit 1:

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NOTES:

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