AORN Talks Guideline Development for Perioperative Nurses

By Kelly Teal

Every year, the Association of periOperative Registered Nurses (AORN) releases the latest version of its Guidelines for Perioperative Practice to its 41,000 members. Each edition of the book features updated instruction on practices that help perioperative nurses and, in turn, infection preventionists, ensure patient health and safety. For example, the 2017 publication contains detailed new insight into hand hygiene in the surgical suite. The information discusses how fingernails, and even polish, can harbor germs, and offers best practices for preventing contamination that could hurt the patient. Through the teaching efforts of AORN members, and the acceptance of the U.S. Agency for Healthcare Research and Quality National Guideline Clearinghouse, these directions will reach more than 2,500 hospitals and more than 160,000 RNs.

But just how does such widely embraced instruction come to life? The process is onerous and time-consuming. Indeed, the entire experience of crafting a new AORN guideline “is like giving birth to a child,” says Amber Wood, MSN, RN, CNOR, CIC, FAPIC, senior perioperative practice specialist for AORN. “The guidelines each take nine months to a year from concept to publication,” she said. “At the end, we are very proud to show the world what we’ve created, in hopes of improving patient outcomes and the safety of perioperative team members.”

The Making of a Guideline
For more than 40 years, AORN has equipped perioperative nurses and other healthcare professionals with the knowledge needed to pro-mote what it calls “optimal outcomes” for patients in the OR. Thus, the organization has its guideline-developing methodology down pat.

A guideline starts out as an idea that is subjected to a thorough investigation before becoming official.

Anyone may bring a specific piece of evidence to the attention of the Guideline writing team but only AORN members may submit a proposal, says Ramona Conner, MSN, RN, CNOR, editor-in-chief of AORN’s Guidelines for Perioperative Practice.

That inquiry goes to Conner. She reviews it and asks any necessary follow-up questions before forwarding it to AORN’s Guidelines Advisory Board (GAB). Board members “play a vital role in guiding the profession of perioperative nursing by facilitating review and approval of the Guidelines,” Conner said. As such, they must set themselves apart as top-notch experts.

The GAB is comprised of a chairperson, at least eight perioperative nurse members and liaisons from other professional associations such as the American Association of Nurse Anesthetists, the American College of Surgeons, the Association for Professionals in Infection Control and Epidemiology, and more. All GAB members must hold a degree in nursing or a related field and AORN prefers that they have a master’s. AORN’s president-elect appoints the members; they serve for one year and can be re-appointed. The GAB liaisons are determined by the organizations they represent.

Proposed guideline in hand, the board then evaluates it to see if it:
• Supports the mission of the organization;
• Has a significant impact on perioperative nursing practice;
• Applies to all areas where operative and other invasive surgical procedures may be performed;
• Is not addressed in another AORN document;
• Addresses conflict in or confusion regarding optimal level of practice;
• Includes published research or non-research evidence related to the topic; and
• Addresses new/emerging technology or a gap in perioperative nursing practice guidance.

Upon finishing that evaluation, the GAB takes one of the following steps: It accepts the proposal and tells Conner to schedule a new work item, and initiate the development process; it forwards the item to a different committee or department for consideration; it incorporates the proposal into an existing guideline; or it rejects the proposal.

If AORN decides to move forward with a new guideline, the deep dive into its merit begins.
First up, a medical librarian conducts an extensive literature search. This investigation of multiple databases will unveil the extent to which the topic has undergone examination or received attention.

Then, the lead author, a nurse in AORN’s nursing department, analyzes the strength and quality of gathered data using the appropriate AORN Evidence Appraisal Tool. The author determines what evidence to include or not, Conner said. The result is a set of recommendations that undergoes assessment in areas including regulatory requirements and whether the benefits of implementation outweigh any harms.

Next, that document goes out for a 30-day public comment period. Anyone may chime in on the matter, Conner says.

After the public comment period closes, the guideline’s final draft is sent to the GAB for review and approval. This step provides yet one more check for accuracy and relevance.

Finally, with the board’s sign-off, a guideline is published, and distributed digitally and in print.

Each AORN guideline receives a review and update every five years. That stringent attention is why AORN’s guidelines are accepted by the U.S. Agency for Healthcare Research and Quality National Guideline Clearinghouse, and are nationally recognized principles for perioperative practice.

The New Hand Hygiene Directives
Hand hygiene is one of the most pressing matters AORN is dealing with for 2017. Despite typical precautions such as the use of soap and hot water, and the wearing of gloves, this subject remains critical within the OR. “Good hand hygiene practice is a key component of effective infection prevention practices everywhere in the healthcare facility, but is especially critical in the surgical suite,” Conner says. As a result, AORN created the new guideline, which it released to electronic subscribers in September and will publish in the 2017 Guidelines for Perioperative Practice.

The guideline is extensive, covering issues from healthy fingernail condition and healthy hand skin condition to the wearing of jewelry and how to perform hand hygiene.

Regarding fingernail condition, tips should measure no longer than .08 inches, to reduce the risk of harboring potential pathogens, puncturing gloves or injuring patients. Artificial nails or extenders should not be allowed in the perioperative setting. The former have been known to cause hand contamination and have been “epidemiologically implicated in outbreaks caused by gram-negative bacteria and yeasts,” according to “Key Takeaways: Guidelines for Hand Hygiene.”

Whether nail polish, even ultraviolet-cured polish, may be worn in the perioperative setting remains undetermined. AORN recommends that a multidisciplinary team within each healthcare organization make its own decision because evidence “is inconclusive and of low quality regarding the effect of fingernail polish on hand hygiene.” However, the association notes that wearing UV-cured polish could pose problems because it could damage the natural nail, thus allowing harmful germs to flourish in the gaps created as the nail and cuticle grow.

In terms of skin condition, AORN says lotions should be approved by the individual healthcare organization because some lotions affect the integrity of latex gloves and hand antiseptics, and can contain bacteria. Hands must be completely dry before gloves are donned, as wearing gloves on wet hands increases the risk of skin irritation, according to AORN. Moreover, the organization advocates using alcohol-based hand rubs, instead of soap and water, when hands are not visibly soiled, as the rubs cause less irritant contact dermatitis.

Wearing jewelry in the OR is off limits. Rings and bracelets could impede microorganism removal from the hands and wrists, and could transmit bacteria to the patient, AORN says.

The new guideline further tackles, in-depth, how perioperative team members should perform hand hygiene; much of the advice seems like common sense. For example, the guideline discusses washing hands before and after patient contact, before and after eating, after using the restroom, after exposure to bodily fluids and blood, and so on.

Likewise, AORN reminds perioperative team members that glove use does not replace the need for hand hygiene. Of interest is the section that reads, “In the event that performing hand hygiene would put the patient’s safety at risk, the perioperative team member should weigh the risks and benefits of delaying hand hygiene.” Citing one possible scenario, the guideline points out that the anesthesiologist may wear two pairs of gloves. That way, he or she can remove the contaminated outer layer after airway manipulation to continue treating the patient until the inner gloves can be removed and hand hygiene performed.

Finally, the guideline talks about surgical hand antisepsis as the primary defense against pathogens that could contaminate the patient during surgery. Sterile surgical gloves serve as the second defense measure but gloves can fail, according to the guideline. Therefore, AORN advises OR personnel use a surgical hand scrub or rub before donning sterile gowns and gloves.

For this topic, AORN relied heavily on its liaisons from the Association for Professionals in Infection Control and Epidemiology and the Society for Healthcare Epidemiology of America, Conner says. Over the past year, those two organizations “have been very much involved” in reviewing and revising this guideline, she said.

But Wait, There’s More
Of course, AORN isn’t only attentive to hand hygiene. Other recent guidelines include how to enact multi-modal programs such as enhanced recovery after surgery (ERAS) protocols, which aim to improve outcomes, including infection prevention, for surgical patients, Wood said. The National Institutes of Health describes ERAS as a way to achieve early recovery by maintaining preoperative organ function and reducing the “profound stress response” following surgery.

Wood and Conner also both said processing of flexible endoscopes remains a major challenge for many perioperative nurses. Thus, AORN continues to formulate ideal procedures for high-level disinfection and sterilization.

Lastly, the organization is working to put in place surgical attire policies and best practices.

To be sure, the need for these and other guidelines won’t diminish. “Perioperative nursing practice has become increasingly complex over the past 40-plus years,” Conner says. Changing technologies, emerging and evolving viruses, and other shifts all contribute to the “ever-growing need for credible practice guidance to meet the challenges of modern healthcare,” she added.

From Concept to Reality: Where Infection Preventionists Fit In
So what happens when a guideline moves from publication toward real-world implementation? Besides making sure the right resources are in place, there’s the tricky matter of altering basic human behavior. And that is tough. “You need to know what you’re up against,” Wood says.

“We know that we can have the best practices, and the latest and greatest gadgets, but they won’t work if health care providers won’t use them,” said Wood.

That’s where infection preventionists really can help. These folks often are most able to assist in easing the pain of adaptation, since they understand human behavior and the concepts of change management – two factors critical to implementing a new AORN guideline. In addition, infection preventionists can aid in engaging the leaders who approve buying equipment, and hiring or assigning people. That aspect is crucial, Wood says. Regular communication is, too, said Conner, and “team collaboration is key.”

Overall, infection preventionists must remain “present and involved,” says Wood, working alongside perioperative nurses as informed advisers, providing accurate, knowledgeable insight.

Kelly Teal is a freelance writer.