SSI

An infection of the surgical wound that was acquired during the course of the surgical procedure

Unrestricted Area

usually located near the entrance and is isolated from the main hospital corridor by doors. This area often contains dressing rooms for physicians and surgery staff, an anesthesia office, a main office, and a main desk. In this area, street clothes are allowed.

Semi Restricted

Surgical scrub suits as well as hats are required. Because there are often no doors to separate these areas, many hospitals designate the semirestricted area from the unrestricted area with the use of signage and/or a red line painted on the floor. Anyone passing this line is expected to be in proper OR attire and to observe the rules of the semirestricted area.

Restricted

includes the ORs as well as the sterile storage areas. In addition to proper OR attire, masks are required in this area. Some hospital policies require masks to be worn in the OR only when a sterile procedure is in progress, meaning sterile supplies are being opened and/or have been opened or the patient is in the room.

Instrument Room

A separate room for storage of nonsterile equipment and instrumentation is necessary

Utility/ Decontamination room

with sinks for gross decontamination of instrumentation. This room often contains an ultrasonic washer for cavitation of instruments prior to sending them to central sterile for processing. In some cases this area is divided by a wall into a cleaning area and a separate preparation area.

Electrical Outlets

majority of ORs contain both 110-volt and 220-volt outlets. are mounted well above the floor and must be on a monitored electrical system. must have ground-fault interrupters and be explosion proof. Emergency outlets are designated in red and are connected to the hospital’s backup generator system in case of power outage. These outlets should be used for such equipment as anesthesia equipment and other equipment vital to the procedure and to the safety of the patient.

Suction Outlets

Must have two

ome cases more are present or required. At least one outlet is used by the surgical team for suctioning in the sterile field and one is used by anesthesia.

Gas Outlets

These outlets are placed on walls or ceilings within the OR. Emergency manual shut-off valves must be located in the outside corridor. The outlets are designated by color: compressed air—yellow; oxygen—green; and nitrous oxide—blue.

Lights

should be designed to provide a range of intensity and focus with a minimum of heat and should be freely moveable. Track lights are no longer recommended because of the danger of fallout contamination. Surgical lights should be freely adjustable in both the horizontal and vertical planes and should provide a light color approximating normal sunlight.

Viewing box

for diagnostic images is positioned at eye level so it can be seen by the surgeon without leaving the operating table. Radiographs, isotope, and computed tomography (CT) and magnetic resonance imaging (MRI) scans are routinely displayed

Operating Table

narrow, padded, and flexible. The traditional operating table was operated manually, but the modern operating table is maneuvered by an electrical control system by either the circulator or anesthesia provider. The table has breakpoints, or bendable points, at the knee, waist, and head. In addition, the operating table has removable sections at the head point and at the footboard for use in procedures where the legs are placed in stirrups

Breakpoints

Points in the operating table that indicate where a section can be moved up or down

Time

Each OR should have a wall-mounted clock with an easily readable face and a sweep second hand for the timing of certain procedures and for the timing of cardiac or respiratory arrests. Many are equipped with an additional start/stop timer.

Intercom

allows for communication by the surgical team with areas outside the OR and within the surgical department without going out of the room. This can also be used for discussions with the pathology department or for calling for diagnostic imaging. Some rooms are equipped with foot-activated intercom switches so that a scrubbed member of the surgical team may operate the device.

Back Table

Large movable table that is covered with a sterile drape for placement of sterile instruments, supplies, and equipment for surgical procedures

Mayo Stand

is the stand that is moved up to the operative field and extends across the patient’s body. The surgical technologist works from this stand to supply immediately necessary instrumentation to the surgeon. Prior to the procedure, a separate small table or Mayo stand is used to set up gowns and gloves for the surgical technologist

Ring Stands

are four-wheeled stands with one or two metal rings at the top . They are used to hold sterile basins and are covered with a sterile drape prior to the procedure. hese basins hold the various fluids to be used during the procedure, including saline and/or sterile water for rinsing instruments and for irrigation. In some cases, such as cardiac cases, these basins may be used to hold a sterile ice/slush solution for hypothermia in the absence of a slush machine.

Kick buckets

also four-wheeled stands, but they are very low to the floor and can be maneuvered with the foot (kicked) . These are buckets lined with biohazard trash bags. The sterile team member tosses soiled counted sponges into these buckets. The kick bucket is not for paper waste but for counted sponges only.

Linen Hamper/ Trash Containers

are typically four-wheeled stands but are large enough that soiled linens and trash from the sterile field may be placed into them by the surgical technologist. They too may be lined with biohazardous designator bags.

Suction Sets

are low-wheel-based stands on which the suction canisters rest. Sterile suction tubing from the field may be attached to the canister by the circulator . The canisters are connected to the suction outlet by another plastic tube. They may be lined with plastic liners and have measurements marked on the side to help estimate fluid use and/or blood loss.

Anesthesia Cart

This will include patient monitoring equipment to keep the surgical team aware of the patient’s physiological status and it is primarily used by the anesthesia provider.

Walls

• Nonglare
• Fireproof
• Nonporous
• Waterproof
• Nonreflective
• Pleasant in color
• Easy to clean with antimicrobial solution

Floors

be nonporous and waterproof, which makes them easier to clean by wet vacuuming. Tile floors are undesirable (though often seen in older ORs) because the grout tends to harbor bacteria and is difficult to clean. Many new ORs are using cushioned flooring systems to decrease personnel fatigue. If cushioned rubber standing mats are used around the table, they should be of the solid and smooth type with no grooves to allow for easy and thorough cleaning.

Cabinets and Doors

should be recessed into the wall when possible to avoid dust accumulation on their top surfaces. Storage cabinets should be provided with doors to lower dust accumulation on supplies and for ease of terminal cleaning of the room. Doors on cabinets should be of the surface-mounted sliding type when possible, because swinging doors move air within the room and disturb microorganisms that have settled on floors and surfaces within the room into the operative field. Cabinets and doors, like walls and floor, should be nonporous and waterproof for easy cleaning.

Doors

surface-mounted sliding doors that can swing open in an emergency situation should be used. Sliding doors lower the incidence of swinging-door air disturbance in the room, which can redistribute contaminant microbes onto the operative field. Traffic into and out of the OR should be limited during any procedure for this purpose, and particularly during open-joint orthopedic procedures; many ORs place signage to this effect on the doors.

Ventilation System

should provide a supply of clean air; remove airborne contamination that is produced within the room; remove waste anesthetic gases, toxic fumes, and vapors; and provide a comfortable working environment for surgical personnel.

Laminar air flow

the unidirectional positive pressure flow of air that captures microbes to be filtered

Airborne Bacteria

Transported or spread by air

Surgical Techs are primarily concerned with airborne bacteria

Air Changes in the OR

A minimum of 15 air exchanges per hour are required for the OR, with a recommended range of 20 to 25 air exchanges per hour. Studies have shown that 20 to 25 air exchanges per hour helps keep the amount of airborne contamination in the OR to a minimum. The Centers for Disease Control and Prevention (CDC) guidelines recommend that the air is filtered. High-efficiency particulate air (HEPA) filters are usually the filter of choice. These filters are capable of removing bacteria as small as 0.5–5 μm. The CDC guidelines also recommend that at least 20% of the air change per hour be from fresh outside air.

High-efficiency particulate air (HEPA) filters

usually the filter of choice. These filters are capable of removing bacteria as small as 0.5–5 μm.

Temperature

is kept between 68° and 73°F.

Humidity

The recommended range for relative humidity is 20% to 60%

Preoperative or “Same-Day” Check-in Unit

This is the area the patient is directed and admitted to on arrival at the hospital. The patient is provided with a private dressing room to change clothes. Lockers are provided for the patient to safeguard personal items, although any jewelry or money should either be left with a family member or turned over to hospital security for safekeeping

Preoperative Holding Area

is a designated room where patients wait within the surgery department before entering the OR. this may be a large area where all patients are held until transport to the specific OR or a small room just outside each OR.

postanesthesia care unit (PACU),

area where immediate postoperative care of the patient takes place before transfer to the hospital room or ICU.... where he or she is “recovered” just after surgery, until transport to a nursing unit (or discharge, in the case of same-day surgery patients) is possible.

Laboratory Department

procedures may be performed within the surgery department, such as blood gas monitoring, which is often performed by perfusionists during cardiovascular procedures.

Perfusionists

The individual responsible for running and maintaining the cardiopulmonary bypass machine during open heart procedures

Radiology Department

provides the OR with radiologic patient studies, including plain x-ray films, CT scans, and MRI, and intraoperative techniques such as fluoroscopy, which provides real-time radiographic monitoring for orthopedic and other cases. It is also important for surgical technologists in cases utilizing x-ray or fluoroscopy to wear protective lead shields such as leaded aprons and/or thyroid shields to prevent exposure to ionizing radiation.

Ionizing radiation

Process by which energy either directly or indirectly induces ionization of radiation-absorbing material or tissues; X-rays

Pathology Department

Specimens are sent for testing, processing, and diagnosis. The surgical technologist should always double check with the surgeon and circulator to ensure proper labeling and handling of the specimen.

Environmental Services

this includes cleaning the OR for turnover between cases, but increasingly, the surgical team is being used for this purpose for speed and efficiency. In many cases, the environmental services department is charged primarily with terminal cleaning of the ORs at night.

Hazards and Regulatory Agencies

(Physical Hazards)

Noise, ionizing radiation, electricity, injury to the body, fire, explosion, and injuries from sharps

Hazards and Regulatory Agencies

Biological Hazards

Laser and electrosurgical plume, pathogens found in body fluids, latex sensitivity

Hazards and Regulatory Agencies

Chemical Hazards

Disinfecting agents, waste anesthetic gases, and vapors and fumes from chemical agents

PLUME

Smoke produced by laser or electrocautery that has been shown to contain biological material

National Fire Protection Agency (NFPA)

Organization whose mission is to reduce the frequency of fires through the establishment of fire prevention standards, research, and public fire safety education.

Occupational Safety and Health Administration (OSHA)

Federal organization that is dedicated to protecting the health of workers by establishing standards that address issues related to safety in the workplace.

National Institute for Occupational Safety and Health (NIOSH)

organization whose responsibilities are similar to OSHA but tends to be more research oriented in establishing permissible exposure limits (PELs) for chemical vapors and gases.

American National Standards Institute (ANSI)

Organization of industry experts who promote and facilitate voluntary consensus standards in technical fields. An example is the laser safety standard

American Society for Testing and Materials (ASTM)

Similar to ANSI, it is also an organization of industry experts who develop and provide voluntary consensus standards for medical equipment by testing the equipment.

Association for the Advancement of Medical Instrumentation (AAMI)

Organization that establishes standards that reach across the spectrum of the health care field, including sterilization, electrical safety, levels of device safety, and use of medical devices.

Surgical Lights

have placed emphasis on trying to produce lights that emit a blue-white beam that still adequately illuminates the surgical site yet produces little glare and approximates the color intensities of normal sunlight.

Noise in the Operating Room

Noise can be irritating to patients and the surgical team. Sources of noise include music, suction, power instruments, clattering of surgical instruments, and conversation. Conversation should be kept to a minimum and, if necessary, carried on in a low to normal tone of voice.

Ergonomics and Safety Considerations

1. Stand with legs approximately shoulder width apart. This allows the ligaments of the hips and knees to naturally support the body and the wider stance is less fatiguing for the surgical technologist.
2. Avoid weight bearing on one foot for a prolonged period of time. The wide stance will prevent this from happening. If weight bearing on one foot is necessary, shift the weight as often as possible.
3. The surgical technologist should stand next to the OR table in an erect manner with arms relaxed from the shoulder down. The use of a standing stool(s) may be necessary.
4. For surgical procedures that require sitting, the surgical technologist should sit in an erect fashion with the spinal column straight. Do not lean forward from the shoulders, but from the hips.
5. Push, do not pull, heavy equipment such as microscopes, OR tables, gurneys, and laser equipment.

Fire Hazards and Safety

(three components referred to as the fire triangle can result in a fire and/or explosion)

1. Source of ignition, for example, electrosurgery, electrocautery, lasers, fiber-optic light sources, defibrillators, sparks from dental or orthopedic burs, or sparks from metal hitting metal (e.g., two metal retractors coming into contact)
2. Oxygen-rich environment
3. Fuel—flammable chemical gas, vapor, or liquid such as ethyl alcohol and skin prep solutions containing isopropyl alcohol; surgical drapes; disposable surgical supplies

Lasers

is an acronym for “light amplification by the stimulated emission of radiation.” This refers to

• (1) the process in which light energy is produced and
• (2) the device that generates the laser energy or beam.

Sterile water

must be available for the surgical team to use in the event of a small fire. is also used to keep the sponges and towels wet during the procedure to prevent them from igniting.

Portable fire extinguishers

must be immediately available. The halon fire extinguisher is recommended for laser fires due to its low toxicity and because residue is not produced.

When should Special caution be used during laser surgery

When surgery is being performed in the head or neck area

Nitrous oxide and oxygen can build up beneath the surgical drapes, presenting an environment conducive to fire or explosion.

What should be done during anorectal area surgery

Nitrous oxide and oxygen can build up beneath the surgical drapes, presenting an environment conducive to fire or explosion.

What type of instrumentation finish should be used during laser procedures

Nonreflective instrumentation

What is used for additional safety when using lasers

signs warning that a laser is in use are posted on all entrances to the OR to limit traffic in and out of the room . The surgical team should wear the appropriate eye protection and high-filtration masks when the laser is in use

Optical Density

is the ability of the protective lens of the eyewear to absorb a specific wavelength. Each type of laser has a unique wavelength; therefore the optical density will vary. The color of the lenses does not provide the eye protection; the color simply provides an indication of the optical density of the lenses.

Electrosurgical Unit

generates considerable heat. If inadvertently activated, the electrosurgical pencil may burn or smolder the surgical drapes. When not in use, the handpiece should be placed in a holder attached to the drapes or positioned so that the handpiece will not be inadvertently activated.

Fiberoptic Beam

at the end of endoscopes must not be focused on the drapes. The heat from the beam can burn or smolder the drapes.

Static Electricity

can ignite a flame under the right conditions. The humidity of the OR should be no higher than 60%. Humidity lower than 20% may be conducive to spark transmission.

three classes of extinguishers:

1. Class A: Pressurized water; suitable for fires involving solid materials, e.g., wood, paper, or textiles
2. Class B: Carbon dioxide or dry chemical for fires involving flammable liquids, oils, and gas
3. Class C: Halon for electrical or laser fires

PASS mnemonic

• P—Pull the pin at the top of the fire extinguisher
• A—Aim the nozzle toward the base of the fire
• S—Squeeze the handle to discharge the extinguisher while standing approximately 8 feet away from the fire
• S—Sweep the nozzle in a back-and-forth motion at the base of the fire until the fire is extinguished

The three main concerns if a fire should occur in the OR are to

• protect the patient,
• (2) contain the fire if possible, and
• (3) move the anesthesia equipment as far away as possible from the fire source.

RACE

• R—Remove/rescue anyone from fire or smoke danger to a safe area
• A—Alert/sound the alarm
• C—Contain the fire
• E—Extinguish/evacuate

Electrical Current

Grounding prevents the passage of the electrical current through the patient by directing the current to the ground, therefore bypassing the patient. A common example of a grounding system is the three-prong plug. Electricity is supplied through the two upper prongs and the third prong is the grounding prong.

Preventing Electrical Burns

also called the cautery or Bovie machine, produces an electrical current that is converted into thermal heat for cutting or coagulating tissue. the active electrode (formerly called Bovie pencil or electrosurgical pencil) is connected to the ESU; the electrical current travels through the active electrode and patient to the patient return electrode (formerly called grounding pad) and the current returns to the ESU.

Static Electricity

an be a source of ignition leading to explosion, especially in the presence of oxygen and anesthetic gases. There are two processes by which static charge buildup can occur. The first is by friction between two surfaces; the second is by proximity to an electrostatic field. Friction is the concern of the OR and is described as follows

Protection of the Surgical Patient

• When possible, shield the patient’s body with a lead apron. The lead shield should always be used for pregnant patients to protect the fetus. Low levels of ionizing radiation can also be harmful to the fetus.
• When fluoroscopy is not being used, it should be turned off. When fluoroscopy is turned on, the patient is continuously being exposed to the radiation.
• Cover the patient’s thyroid and/or reproductive areas with lead shields made specifically for those areas.

Protection of the Surgical Technologist

Time

<ul> <li>When not in use, make sure the fluoroscope is turned off.</li> <li>Avoid overexposure to ionizing radiation.</li> <li>Surgical technologists exposed to ionizing radiation on a frequent basis or during a long surgical procedure should wear an x-ray–monitoring device. The most popular type is the film badge.</li> </ul> <br>

Protection of the Surgical Technologist

Shielding

<ul> <li>Pregnant surgical technologists should avoid exposure. If exposure must occur, the surgical technologist should either leave the room or wear a lead shield that adequately covers the body and fetus.</li> <li>The lead apron is worn under the sterile gown and must be donned prior to scrubbing.</li> <li>Sterile and nonsterile lead gloves are available to protect the long bones of the hand.</li> <li>Lead thyroid shields should be worn during fluoroscopy.</li> <li>Lead aprons should be laid flat or preferably hung on the apron rack when not in use. Allowing the apron to fold or bend can cause cracks in the lead, rendering the lead apron inefficient.</li> </ul> <br>

Protection of the Surgical Technologist

Distance

• If possible, whether sterile or nonsterile, leave the room during exposure of x-rays.
• Surgical technologists who are a part of the sterile team and cannot leave the room should stand as far away as possible (6 ft or more) from the patient, avoiding the direct beam of ionizing radiation. Stand behind the x-ray machine if possible, behind a portable lead screen, or behind someone wearing a lead shield.

Biological Hazards and Safety Considerations

OSHA and the CDC have established policies to govern the disposal of infectious wastes and prevention of bloodborne diseases.

Standard Precautions

were defined by the CDC in 1996 apply to blood and all body fluids, secretions, and excretions (except sweat).

Causes of Injury Leading to Exposure in the Operative Environment

The strategies of Standard Precautions, including the proper use of personal protective equipment (PPE), will help to minimize risk.

Strategies for Exposure Prevention

an increasing number of safety devices have been and are being developed, including blunt suture needles, a suturing device to avoid manual handling of needles, double-gloving, and “no-touch” techniques during wound closure.`

Neutral Zone

in which sharps may be safely placed by one person and retrieved by another. This may be any of a number of devices, such as magnetic mats, trays, an instrument stand, or a designated area on the sterile field. Small basins are not recommended because items are deep within the basin and hard to pick up and the basin may tip over.

Other Sharps Safety Techniques

Hypodermic needles should never be recapped. In the rare occasion where recapping is unavoidable, a safety device or one-handed technique should be used.

Hazardous Waste Disposal

Two basic microbiological concepts govern the transmission of disease:

1. A sufficient number of microorganisms must be present in order to cause infection.
2. The microorganisms must have a path for entry into the host.

must be disposed of separately from routine surgery department waste material.The bags should also be of a color, usually red, that distinguishes the waste material as separate from routine waste

Management of Exposure

Health care professionals should know how to respond to exposure incidents immediately. Appropriate postexposure measures, including HIV postex-posure prophylaxis (PEP), are important for the prevention of occupationally acquired HIV and other diseases.

prophylaxis

Prevention of Disease or condition

For HIV: Further testing should be performed at 6 weeks, 12 weeks, and 6 months postexposure.

Laser and Electrosurgical Plume

When a laser beam strikes tissue, the tissue is coagulated, or a powered surgical instrument such as a saw cuts bone, a plume of smoke is produced depending on the power, duration of exposure, and tissue type. Research has been conducted over the years on the plume emitted during surgical procedures. Experiments have documented the content of the plume, particulate matter size, and toxicity of such plumes when inhaled by surgical personnel. Electrosurgical plume causes an offensive odor and may produce watery eyes and respiratory irritation in surgical personnel.

Why are special evacuator units required?

for laser surgery and may soon be required for electrosurgical plume. Units available on the market filter laser plume from 0.1 to 0.5 μm.

Who handles the positioning of the evacuation wand

the duty of the surgical technologist during a laser procedure. When the tip is held within 1 cm of the impact site, approximately 98% of the plume is removed.

Latex Allergy

made from the natural rubber harvested from trees found in warm tropical climates.

Two types of Latex Allergy

Type IV is the less serious, more localized reaction characterized by skin irritation and discomfort. The common benign reactions associated with Type IV are allergic contact dermatitis and irritant dermatitis.

Type I is immu-noglobulin E (IgE) mediated and is the most serious reaction, possibly leading to respiratory arrest.

How do you diagnose latex allergy?

consists of detailed patient history, skin-prick tests, and the RAST (radioallergosorbent testing) immunoassay. There are drawbacks to both the RAST and the skin-prick test. The RAST blood test, while safe, can render false negatives, and skin-prick tests can be dangerous to the latex-allergic person if the latex extract’s dilution is not carefully controlled.

Chemical Hazards and Safety Considerations

Surgical technologists should be familiar with the chemicals used in the OR and general information concerning the chemicals. Information can be gained from the Material Safety Data Sheets (MSDS) that the surgery department must have available to workers.

Waste Anesthetic Gases

are vapors that escape from the anesthesia machine and tubing. gas-scavenging system, which should be connected to every anesthesia machine used in the surgery department, removes waste anesthetic gases to be filtered and then dispersed to the outside atmosphere.

Polymethyl Methacrylate

a chemical compound composed of a mixture of liquid and powder. The common name of PMMA used in surgery is bone cement. It is used for cementing metal prostheses in place during total joint arthro-plasties. The liquid and powder components are combined by the surgical technologist at the sterile back table.

How does PMMA pose a risk to the patient

in the form of a pathology known as bone cement implantation syndrome. PMMA infiltrates the interstices of cancellous bone and binds the prosthetic device to the patient’s bone. can also cause vasodilatation and a decrease in systemic vascular resistance, which is thought to be the cause of hypotension frequently associated with the use of PMMA.

Formalin

is a commonly used preservative for tissue specimens to be sent to the pathology department. The vapors from the liquid are an irritant to the mucous membranes of the respiratory tract.

Ethylene Oxide

is a liquid chemical converted to a gas for sterilization purposes.

1. Exposure to the gas can cause nausea, vomiting, and vertigo.
2. is known to be highly mutagenic and carcinogenic.
3. If combines with water, the toxic byproducts ethylene glycol and ethylene chlorohydrin will form. (Ethylene glycol is easily absorbed through the skin, causing systemic difficulties.)

Glutaraldehyde

is a liquid disinfectant and sterilizing agent. Commercially known as Cidex^®, the fumes can be irritating to the eyes and mucous membranes. . It must be used in a well-ventilated area, and many health facilities have installed commercial ventilation systems for the removal of the fumes.