Question: As a teaching institution, our hospital has a large number of students rotating through the OR. These students often request a copy of the next day’s surgery schedule so they can prepare for their learning experiences. I remember reading about a situation In which a medical student took a copy of a surgery schedule to the cafeteria and inadvertently left it there. A patient’s family member found the schedule listing the patient’s name end surgical procedure and immediately reported the incident. In light of this, should we remain firm in not allowing students to have a copy of the schedule?

Answer: You are correct to be concerned about protecting patient privacy. Although it is important to provide learning experiences for students, surgery schedules contain confidential patient information that must be carefully protected. The surgery schedule should be shared only with authorized individuals after all patient identifiers have been removed. As it may be possible to identify patients without having their actual names, schedules that contain any information that could be used to identify specific patients should not be distributed randomly or given to individuals who do not understand the importance of securing the information. In addition, schedules should not be placed in areas where unauthorized individuals can view the information (eg, unattended volunteer desks, nonstaff member areas, admitting desks).

Protecting patient confidentiality remains a basic ethical responsibility of perioperative nurses. AORN’s “Standards of perioperative professional performance” state that perioperative nurses are patient advocates and as such have a responsibility to maintain and protect patient confidentiality.(1) As health care facilities continue to develop privacy policies and procedures to comply with the Health Insurance Portability and Accountability Act, more attention is being focused on protecting confidential medical information.(2) Security of surgical schedules should be included in policy discussions, and a common-sense strategy should be developed to protect patient confidentiality while providing health care workers and students the information needed to care for patients safely and efficiently.

Question: There is a big debate at our hospital about whether student nurses observing in the OR for one day should wear scrubs or jumpsuits. Some believe the students should wear scrubs because they come close to the sterile field, and some believe that because students are not involved in the procedure, jumpsuits will suffice.

Answer: From a practice standpoint, either type of attire is acceptable; however, why give potential future perioperative nurses such a poor welcome? Singling them out with jumpsuits is no way to create a positive reception. Why not make their first experience in the OR pleasant and welcoming? Give students the accurate OR experience of donning surgical attire and make them feel as comfortable as possible. Be nice and give them scrubs.

Question: Some people ore starting to wear homemade cloth masks in the OR. The same masks are worn all day. Is this acceptable? What argument can be made against this practice?

Answer: Homemade cloth masks are unacceptable. Although early masks were made of muslin or linen, they only redirected exhaled air away from the surgical wound. Cloth surgical masks were replaced in the early 1960s with synthetic materials that also provide bacterial filtration.(3)

Wearing masks is recommended for two reasons. First, they contain and filter microorganism droplets that are expelled from the mouth and nasopharynx during talking, sneezing, and coughing. Second, they protect the wearer from exposure to infectious materials and other respiratory hazards, such as electrosurgical and laser smoke.(4) Fluid-resistant surgical masks are considered personal protective equipment (PPE), and the Occupational Safety and Health Administration requires health care workers exposed to blood and other body fluids to wear them. To be considered appropriate, PPE must

not permit blood or other potentially infectious materials to pass through
to or reach the employee's work clothes, street clothes, undergarments,
skin, eyes, mouth, or other mucous membranes under normal conditions of use
and for the duration of time which the protective equipment will be
used.(5)

Surgical masks should filter at least 0.3 [Mu] of bacteria for regular use and 0.1 [Mu] for laser use, or they should provide 90% to 95% bacterial filtration efficiency.(6) Masks must be changed between uses and whenever they become moist. Masks should not be reused throughout the day or saved by hanging them around the neck or tucking them into a pocket for future use.(7) The filter portion of the mask harbors bacteria collected from the nasopharyngeal airway, and care must be taken when removing the mask to avoid contamination of the hands.

It is extremely unlikely that an individual would have an adequate supply of freshly laundered–not home laundered–reusable masks to be able to change as frequently as recommended. Although there may be reusable materials that could meet fluid resistance and filtration criteria, it is extremely unlikely that a suitable reusable cloth material could be found, tested by an individual according to US Food and Drug Administration (FDA) guidelines, and manufactured on a home sewing machine according to industry specifications. Surgical masks are an FDA class II medical device that require special controls and are subject to premarket notification procedures (ie, 510k guidelines).(8)

Homemade cloth masks are inadequate to protect patients and OR personnel from exposure to infectious agents and other hazardous materials. Only masks approved by the FDA for use in the surgical setting should be used.

Question: How should a surgical mask be worn? I have started working at a new facility and have noticed that several staff members do not conform the top of the mask across the nose and cheeks, nor do they lower the mask completely under the chin. Many tie the bottom of the mask so loose that you can see their chin, mouth, and nose when looking at their profile. In 28 years as an OR nurse and 15 years as a manager, I have never seen this problem before. Is this a “sacred cow”?

Answer: This is not a “sacred cow.” The masks at your facility are not being worn appropriately. Masks should be worn according to the manufacturer’s written directions, based on the mask design. When not worn appropriately, masks will not perform as designed. Masks with strings should be tied tightly to prevent the strings from coming loose during the procedure. The upper strings are tied at the back of the head, and the lower strings are tied at the neck. The strings should not be crossed as this will cause a gap around the cheeks. The metallic strip at the nose should be contoured to fit the bridge of the nose.(9)

NOTES

(1.) “Standards of perioperative professional performance,” in Standards, Recommended Practices, and Guidelines (Denver: AORN, 2001) 145.

(2.) C Peterson, “Stained surgical linen; gowning at the back table; cloth hats; removing medication stoppers; patient privacy,” (Clinical Issues) AORN Journal 73 (June 2001) 1169-1171.

(3.) J Prust, “Surgical mask selection and application: Evaluation of performance criteria,” Infection Control Rounds 18 (February 1995) 4.

(4.) Ibid.

(5.) “OSHA Preambles, Bloodborne Pathogens (29 CFR 1910.1030) Section IX. Summary and explanation of the standard,” Occupational Safety and Health Administration, http://www.osha-slc.gov/Preamble /Blood_data/BLOOD9.html (accessed 16 May 2001).

(6.) Infection Control Devices Branch, Guidance on the Content and Format of Premarket Notification [510(k)] Submissions for Surgical Mask (Washington, DC: US Department of Health and Human Services, Public Health Service, Food and Drug Administration, Center for Devices and Radiological Health, Jan 16, 1998).

(7.) “Recommended practices for surgical attire,” in Standards, Recommended Practices, and Guidelines (Denver: AORN, 2001) 176.

(8.) Federal Register (2000) (codified at 21 CFR [sections] 878.4040).

(9.) N H Fortunato, Berry & Kohn’s Operating Room Techniques, ninth ed (St Louis: Mosby, 2000) 240-241.

RAMONA CONNER RN, MSN PERIOPERATIVE NURSING SPECIALIST AORN CENTER FOR NURSING PRACTICE