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CONTINUING EDUCATION Clinical Issues 1.2 www.aorn.org/CE AMBER WOOD, MSN, RN, CNOR, CIC; SHARON A. VAN WICKLIN, MSN, RN, CNOR, CRNFA, CPSN-R, PLNC Continuing Education Contact Hours indicates that continuing education (CE) contact hours are available for this activity. Earn the CE contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Learner Evaluation at http://www .aorn.org/CE. Each applicant who successfully completes this program can immediately print a certificate of completion. Event: #15520 Session: #0001 Fee: Members $9.60, Nonmembers $19.20 The CE contact hours for this article expire June 30, 2018. Pricing is subject to change. Purpose/Goal To provide the learner with knowledge of AORN’s guidelines related to the use of ultraviolet (UV)-cured nail polish in the OR and handling Ebola-contaminated instruments and laryngoscope blades. Objectives 1. Discuss practices that could jeopardize safety in the perioperative area. 2. Discuss common areas of concern that relate to perioperative best practices. 3. Describe implementation of evidence-based practice in relation to perioperative nursing care. Accreditation AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. Approvals This program meets criteria for CNOR and CRNFA recertification, as well as other CE requirements. AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure. Conflict-of-Interest Disclosures Ms Wood and Ms Van Wicklin have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article. The behavioral objectives for this program were created by Helen Starbuck Pashley, MA, BSN, CNOR, clinical editor, with consultation from Susan Bakewell, MS, RN-BC, director, Perioperative Education. Ms Starbuck Pashley and Ms Bakewell have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article. Sponsorship or Commercial Support No sponsorship or commercial support was received for this article. Disclaimer AORN recognizes these activities as CE for RNs. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity. http://dx.doi.org/10.1016/j.aorn.2015.03.004 ª AORN, Inc, 2015 www.aornjournal.org AORN Journal j 701 CLINICAL ISSUES 1.2 www.aorn.org/CE THIS MONTH Ultraviolet (UV)-cured nail polish Key words: nail polish, UV-cured, ultraviolet, gel nails, gel polish, shellac, hand hygiene. Handling Ebola-contaminated instruments and laryngoscope blades and handles Key words: Ebola, hemorrhagic fever, decontamination, instruments, laryngoscope blades and handles. Ultraviolet (UV)-cured nail polish QUESTION: Can health care personnel wear ultraviolet (UV)-cured nail polish (eg, gel, Shellac) in the perioperative setting? ANSWER: Ultraviolet (UV)-cured nail polish (eg, gel, Shellac) should not be worn in the perioperative setting. There have been no published research studies on the risks and benefits of health care personnel wearing these types of nail polish. Because of the lack of evidence on the potential patient harm that could result from health care workers wearing these types of nail polish, and because of their chemical similarities to artificial nail compounds, an abundance of caution should be taken 702 j AORN Journal until research is conducted that demonstrates whether these products are safe to use in health care settings. Artificial nails, including extensions or tips, gels and acrylic overlays, resin wraps, or acrylic fingernails, should not be worn by perioperative personnel.1 There are various descriptions of nail coverings used in the field of cosmetology, including UV gels (eg, premixed acrylic, ultraviolet cured, ultraviolet gel artificial nails),2 artificial nails (eg, liquid and powder, acrylic, porcelain, solar, sculptured),2 nail wraps (eg, fiberglass, resin, no-light gels, silk, paper),2 UV-cured nail lacquers,3 and nail lacquers3 (eg, nail polish). Shellac is considered a UV-cured nail lacquer. www.aornjournal.org www.aornjournal.org References 1. Bryson PH, Sirdesal SJ. Chapter 27: Colored nail cosmetics and hardeners. In: Cosmetic Dermatology: Products and Procedures. Hoboken, NJ: Wiley-Blackwell Publications; 2010: 206-214. 2. Schoon D, Baran R. Chapter 10: Cosmetics: the care and adornment of the nail. In: Baran & Dawber’s Diseases of the Nails and Their Management. Hoboken, NJ: John Wiley & Sons, Ltd; 2012:471-483. Acetone soak for 10 minutes, then removal with wooden stick Soak off gel: acetone soak for 30 minutes Traditional removal: filing Acetone soak for 30 minutes, then peel off nail Acetone Removal No Yes No Used to Extend the Nail Plate? Yes Polymerization with exposure to UVA light Polymerization with exposure to UVA light Solvent evaporation Coating Created by Polymerization Methacrylate or acrylate Urethane acrylate or urethane methacrylate Resin/solvent Chemical Formulation Methacrylate UV-Cured Nail Lacquer Nail Lacquer 1,2 Table 1. Description of Nail Polishes Clinical Issues Polish Types Artificial Liquid and Powder Ultraviolet (UV) Gels June 2015, Volume 101, No. 6 Nail lacquer contains various combinations of resins, solvents, plasticizers, colorants, thixotropic agents that provide flow control and maintain dispersal of the colorants, color stabilizers, and other minor ingredients (eg, vitamins, minerals).3 A newer type of polish, which some classify as UV-cured nail lacquers, is described by the manufacturers as chip resistant and they claim that the lacquers can be worn up to two weeks.2 Ultraviolet-cured nail lacquers contain many of the same elements of regular nail lacquer. However, rather than relying on solvent evaporation to harden, which occurs with typical nail lacquers, UV-cured lacquers create the nail coating by polymerization of a methacrylate or acrylate that hardens when exposed to UVA light.3 It is not clear what the ingredients of UV-cured nail polishes are because they are often patented formulas, and not all products have the same formulation. Table 1 contains a description of various nail polishes, including common chemical formulations, how the polish creates the nail coating, if they are used for extension of the nail plate, and removal methods. Removal of UV-cured nail polish is not performed in the same manner as regular polish and can vary by the type and manufacturer. Some UV gels, also known as soak-off gels, are removed after a 30-minute soak in acetone.2 Traditional UV gel polish is removed by filing with an abrasive file.2 Ultraviolet-cured nail lacquer (eg, Shellac) is removed with a wooden stick after a 10-minute acetone soak.2 According to the Centers for Disease Control and Prevention (CDC), pathogens harbored in subungual spaces and artificial nails may render hand hygiene ineffective.4 The CDC explains that health care personnel with artificial nails have been implicated as an outbreak source in epidemiological studies.4 Thus, the CDC recommends that artificial nails or nail extenders should not be worn when health care personnel have direct contact with high-risk patients, such as patients undergoing surgical or invasive procedures.4 Extending the nail plate or sculpting the nail is the primary function of “liquid and powder” artificial nails.2,3 Some UV gels can be used to extend the nail plate, although UV-cured nail lacquers cannot. Regardless of whether the nail plate is extended, there is insufficient evidence that artificial nails are safe for use in health care settings. The World Health Organization also recommends that health care personnel do not wear artificial nails or extenders and further advises that nail polish should not be worn when performing surgical hand preparation.5 The concern with wearing UV-cured nail polishes is that the gaps that develop between the polish and the cuticle at the base AORN Journal j 703 WooddVan Wicklin June 2015, Volume 101, No. 6 Health care organizations should establish policies and procedures on the types of nail polish, if any, workers in patient care areas are allowed to wear,5 and communicate the policies to health care personnel. If certain types of nail polish are allowed and others are not, oversight of policy compliance may be difficult to manage because there is no visibly distinguishable difference between nail lacquer and UVcured nail polishes. If nail polish is allowed, the AORN “Guideline for hand hygiene” recommends that chipped nail polish be removed before entering the restricted area.1 Chipped nail polish increases the number of microorganisms on fingernails.1,4 The recommendation to remove chipped nail polish may be difficult to achieve if UV-cured nail polishes are allowed, as the removal process is complicated and takes longer than removal of nail lacquer. When developing policies and procedures, a guiding principle should be the risk of infection transmission to patients and health care personnel rather than cultural preference.5 References 1. Guideline for hand hygiene. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2015:31-42. 2. Schoon D, Baran R. Cosmetics: the care and adornment of the nail. In: Baran & Dawber’s Diseases of the Nails and Their Management. Hoboken, NJ: John Wiley & Sons, Ltd; 2012: 471-483. 3. Bryson PH, Sirdesal SJ. Colored nail cosmetics and hardeners. In: Cosmetic Dermatology: Products and Procedures. Hoboken, NJ: Wiley-Blackwell Publications; 2010:206-214. 4. Boyce JM, Pittet D; Healthcare Infection Control Practices Advisory Committee; HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Guideline for Hand Hygiene in Health-Care Settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Society for Healthcare Epidemiology of America/Association for Professionals in Infection Control/Infectious Diseases Society of America. MMWR Recomm Rep. 2002;51(RR-16):1-45. quiz CE 1-4. 5. WHO guidelines on hand hygiene in health care: first global patient safety challenge clean care is safer care. Updated 2009. World Health Organization. http://whqlibdoc.who.int/publications/2009/ 9789241597906_eng.pdf. Accessed February 6, 2015. Amber Wood, MSN, RN, CNOR, CIC Perioperative Nursing Specialist AORN Nursing Department Editor’s note: Shellac is a registered trademark of Creative Nail Design, Inc, San Diego, CA. Handling Ebola-contaminated instruments and laryngoscope blades and handles QUESTION: How should perioperative and sterile processing team members handle Ebola-contaminated instruments and laryngoscope blades and handles? ANSWER: In the event that a patient with confirmed or suspected Ebola virus disease undergoes a surgical procedure, perioperative and sterile processing team members should handle contaminated instruments using standard, contact, droplet, and airborne 704 j AORN Journal precautions.1,2 Table 2 provides precautions to take when handling Ebola-contaminated instruments and the sequence for care of instruments from the point of use through transport to the decontamination area. Laryngoscope blades and handles used during the care of a patient with suspected or confirmed Ebola should be handled similarly (ie, using standard, contact, droplet, and airborne precautions.)1,2 Table 3 outlines necessary precautions when handling Ebolacontaminated laryngoscope blades and handles and the sequence for care of these items from the point of use through transport to the decontamination area. The www.aornjournal.org print & web 4C/FPO of the nail could harbor microorganisms, in much the same way bacteria collect in artificial nails that are worn for an extended period, although this has not been investigated in the literature.5 Ultraviolet-cured nail polish has the potential for lifting, which can occur when polish is applied over the cuticle, which continues to grow. Cuticle growth lifts up the polish and creates gaps that may harbor microorganisms, which cannot be effectively removed with hand hygiene. Microfractures in long-lasting nail polish are also a concern because of the potential for the cracks to become a reservoir for pathogens. June 2015, Volume 101, No. 6 Table 2. Precautions for Handling of Ebola-Contaminated Instruments Clinical Issues 1-3 Care of Instruments From Point of Use and Transport to Decontamination Area Have closed cart or secondary container in the ORa Remove all filters and trash from the instrument sets and rigid containers, including labels. This reduces the amount of Ebolacontaminated waste in the decontamination area Coat instruments with enzymatic cleaner Put instruments inside their rigid containers and secure the lids Place the instruments inside the cart or secondary container and close the door or lid Push the closed cart or secondary container out of the OR to the personal protective equipment (PPE) doffing (removal) area Remove PPE per facility-specific sequence with trained observer present and perform hand hygiene Don a clean gown and double gloves Disinfect the entire closed cart or secondary container, including the wheels Remove PPE per facility-specific sequence with trained observer present and perform hand hygiene Don a clean gown and double gloves Transport the closed cart or secondary container to the decontamination area with a team member who is not wearing PPE who can open doors. The person transporting the cart/container should not touch any objects except for the cart/container during transport. Do not leave the cart/container unattended On arrival at decontamination area, deliver the cart/container to sterile processing team member who is wearing Ebola-specific PPE Remove PPE per facility-specific sequence with trained observer present in the sterile processing doffing area and perform hand hygiene Care of Instruments in Decontamination Don PPE per facility-specific sequence with trained observer present Receive cart/container with Ebola-contaminated instruments from perioperative team member Process Ebola-contaminated instruments separately from other instruments and disinfect sink and ultrasonic cleaner (if used) after use Follow manufacturer’s instructions for use (IFU) to brush, flush, clean, and rinse instruments. Avoid generating aerosols by performing cleaning activities under the surface of the water. Also, avoid splashing and keep glove cuffs above the level of the water to reduce the risk of exposure If manually cleaned, disinfect instruments with 70% to 90% alcohol Place instruments in automated washer per manufacturer’s IFUs Disinfect the closed cart and secondary containers. Process in cart washer, if available Disinfect any work surfaces that touched objects, such as handles, control panels, and equipment Remove trash from the room per facility protocol Disinfect the entire floor Remove PPE per facility-specific sequence with trained observer present in the sterile processing doffing area and perform hand hygiene Care of Instruments in Clean Packaging Area If processed o in an automated washer, remove from the washer and package for sterilization o by manual cleaning and disinfection with alcohol, handle instruments with gloves. Place the instruments inside the container. Then, remove gloves, perform hand hygiene, place lid on the container without touching the contents, and continue packaging for sterilization a Bringing the cart or container into the OR before the surgery begins, if there is sufficient room in the OR to maintain a safe environment of care, may reduce the risk of exposure to additional personnel. The secondary container should be large enough to accommodate rigid containers and instrument sets. References 1. Infection prevention and control recommendations for hospitalized patients with known or suspected Ebola virus disease in U.S. hospitals. Centers for Disease Control and Prevention. http://www.cdc.gov/vhf/ebola/hcp/infection-prevention-and-control-recommendations.html. Updated January 9, 2015. Accessed January 16, 2015. 2. Guidance on personal protective equipment to be used by healthcare workers during management of patients with Ebola virus disease in U.S. hospitals, including procedures for putting on (donning) and removing (doffing). Centers for Disease Control and Prevention. http://www.cdc .gov/vhf/ebola/hcp/procedures-for-ppe.html. Updated October 20, 2014. Accessed January 16, 2015. 3. Guideline for cleaning and care of surgical instruments and powered equipment. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.; 2015:615-650. www.aornjournal.org AORN Journal j 705 WooddVan Wicklin June 2015, Volume 101, No. 6 Table 3. Precautions for Handling of Ebola-Contaminated Laryngoscope Blades and Handles 1-3 Care of Laryngoscope Blades and Handles From Point of Use and Transport to Decontamination Area Used in OR during an invasive procedure o Have secondary container or closed cart in the OR o Place the laryngoscope blades and handles inside a primary container and close the lid o Place the primary container inside closed cart or secondary container with instruments from the procedure (see Table 2) Used in area outside the OR o Have secondary container in the personal protective equipment (PPE) doffing (removal) area o Place the laryngoscope blade and handle - inside a primary container and close the lid, and then - inside a secondary container or closed cart and close it o Remove PPE per facility-specific sequence with trained observer present and perform hand hygiene o Don a clean gown and double gloves o Disinfect the exterior of the entire secondary container or cart o Remove PPE per facility-specific sequence with trained observer present and perform hand hygiene o Don a clean gown and double gloves o Transport the secondary container or closed cart to the decontamination area of the sterile processing area with a team member who is not wearing PPE and can open doors. The person transporting the container/cart should not touch any objects except the container/cart during transport. Do not leave the container/cart unattended o On arrival in the decontamination area, the secondary container or closed cart should be transferred to a sterile processing team member who is wearing Ebola-specific PPE o Remove PPE per facility-specific sequence with trained observer present in the sterile processing doffing area and perform hand hygiene Care of Laryngoscope Blades and Handles in Decontamination Area Don PPE per facility-specific sequence with trained observer present Receive cart/container with Ebola-contaminated instruments from perioperative team member Process Ebola-contaminated instruments separately from other instruments and disinfect sink and ultrasonic cleaner (if used) after use Follow manufacturer’s instructions for use (IFU) to brush, flush, clean, and rinse instruments. Avoid generating aerosols by performing cleaning activities under the surface of the water. Also, avoid splashing and keep glove cuffs above the level of the water to reduce the risk of exposure If manually cleaned, disinfect instruments with 70% to 90% alcohol after manual cleaning Place instruments in automated washer per manufacturer’s IFU Disinfect the closed cart and secondary containers. Process in cart washer if available Disinfect work surfaces and any touched object, such as handles and control panels, and equipment Remove trash from the room per facility protocol Disinfect the entire floor Remove PPE per facility-specific sequence with trained observer present in sterile processing doffing area and perform hand hygiene Care of Laryngoscope Blades and Handles in Clean Packaging Area For sterilization For high-level disinfection (HLD) o If processed in automated washer, package for sterilization o If processed in automated washer or automated washer/ as usual disinfector, handle as usual o If processed by manual cleaning and disinfection with o If processed by manual cleaning and disinfection with alcohol, handle laryngoscope blades and handles with alcohol, handle items with gloves gloves. Place the item inside the container or package for o Place the laryngoscope blades and handles in the HLD sterilization. Then, remove gloves, perform hand hygiene, solution per manufacturer’s IFU close the container without touching the contents, and o After HLD, discard the HLD solution that the laryngoscope continue packaging for sterilization blades and handles soaked in and clean and reprocess the solution containers References 1. Infection prevention and control recommendations for hospitalized patients with known or suspected Ebola virus disease in U.S. hospitals. Centers for Disease Control and Prevention. http://www.cdc.gov/vhf/ebola/hcp/infection-prevention-and-control-recommendations.html. Updated January 9, 2015. Accessed January 16, 2015. 2. Guidance on personal protective equipment to be used by healthcare workers during management of patients with Ebola virus disease in U.S. hospitals, including procedures for putting on (donning) and removing (doffing). Centers for Disease Control and Prevention. http://www .cdc.gov/vhf/ebola/hcp/procedures-for-ppe.html. Updated October 20, 2014. Accessed January 16, 2015. 3. Guideline for cleaning and care of surgical instruments and powered equipment. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.; 2015:615-650. 706 j AORN Journal www.aornjournal.org June 2015, Volume 101, No. 6 According to the CDC’s Infection Prevention and Control Recommendations for Hospitalized Patients Under Investigation (PUIs) for Ebola Virus Disease (EVD) in US Hospitals, health care personnel coming into contact with Ebola should wear personal protective equipment (PPE) that covers all exposed skin.3 Although there have been no documented transmissions of Ebola virus from environmental surfaces, contaminated instruments, or laryngoscope blades and handles, the CDC advises higher levels of precaution toward potentially contaminated objects because of Ebola’s “apparent low infectious dose, potential of high virus titers in the blood of ill patients, and disease severity.”4 As a result of these heightened precautions, perioperative and sterile processing team members should receive repeated education and training for Ebola-related infection control procedures, especially in donning and doffing of PPE, and a system that uses trained observers should be implemented to oversee PPE procedures.5 To further reduce the risk of Ebola exposure among personnel, the perioperative and sterile processing team should limit environmental surface contamination with blood, body fluids, or other potentially infectious materials4 and follow recommendations for sharps safety.6 1. Wood A. Ebola precautions in the OR; abdominal-perineal dual prep; CHG-impregnated cloths; alcohol-based antiseptics and hair removal. Clinical Issues. AORN J. 2015;101(1): 149-157. 2. Van Wicklin S, Wood A. Update on perioperative Ebola precautions. Clinical Issues. AORN J. 2015;101(5):574-585. 3. Infection prevention and control recommendations for hospitalized patients under investigation (PUIs) for Ebola virus disease (EVD) in U.S. hospitals. Centers for Disease Control and Prevention. http:// www.cdc.gov/vhf/ebola/hcp/infection-prevention-and-control-recom mendations.html. Updated January 9, 2015. Accessed January 16, 2015. 4. Interim guidance for environmental infection control in hospitals for Ebola virus. Centers for Disease Control and Prevention. http://www .cdc.gov/vhf/ebola/hcp/environmental-infection-control-in-hospitals .html. Updated January 9, 2015. Accessed January 16, 2015. 5. Guidance on personal protective equipment to be used by health care workers during management of patients with Ebola virus disease in U.S. hospitals, including procedures for putting on (donning) and removing (doffing). Centers for Disease Control and Prevention. http://www.cdc.gov/vhf/ebola/hcp/procedures-for -ppe.html. Updated October 20, 2014. Accessed January 16, 2015. 6. Guideline for sharps safety. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2015:365-388. Amber Wood, MSN, RN, CNOR, CIC Perioperative Nursing Specialist AORN Nursing Department Sharon A. Van Wicklin, MSN, RN, CNOR, CRNFA, CPSN-R, PLNC Perioperative Nursing Specialist AORN Nursing Department The CDC’s Ebola guidelines are changing and clinicians are advised to consult the most recent CDC update for infection prevention and control recommendations (http://www.cdc .gov/vhf/ebola/hcp/infection-prevention-and-control-recommendations .html). www.aornjournal.org AORN Journal j 707 print & web 4C/FPO This suggested handling sequence for instrument and laryngoscope blades and handles is based on expert opinion and is intended to support clinical practice in the development of Ebola protocols by health care organizations and individual facilities. Variations in practice settings and clinical situations may limit the degree to which this guidance can be implemented. References print & web 4C/FPO handling of laryngoscope blades and handles may vary from instrument handling depending on the location of use and type of reprocessing procedures (ie, sterilization, high-level disinfection). Using disposable laryngoscope blades, when available, may eliminate the need to follow these precautions for reprocessing, in which case the Centers for Disease Control and Prevention (CDC) guidance for managing Ebolacontaminated waste should be followed in accordance with local, state, and federal regulations.3 The US Department of Transportation’s Hazardous Materials Regulations classifies Ebola as a Category A infectious substance, and the handling of this type of waste (eg, used health care products) must comply with regulations for Category A infectious substances.4 Clinical Issues LEARNER EVALUATION Continuing Education: Clinical Issues 1.2 www.aorn.org/CE T his evaluation is used to determine the extent to which this continuing education program met your learning needs. The evaluation is printed here for your convenience. To receive continuing education credit, you must complete the online Learner Evaluation at http://www.aorn.org/CE. Rate the items as described below. PURPOSE/GOAL To provide the learner with knowledge of AORN’s guidelines related to the use of ultraviolet (UV)-cured nail polish in the OR and handling Ebola-contaminated instruments and laryngoscope blades. 6. Will you be able to use the information from this article in your work setting? 1. Yes 2. No 7. Will you change your practice as a result of reading this article? (If yes, answer question #7A. If no, answer question #7B.) 7A. How will you change your practice? (Select all that apply) 1. I will provide education to my team regarding why change is needed. 2. I will work with management to change/implement a policy and procedure. 3. I will plan an informational meeting with physicians to seek their input and acceptance of the need for change. 4. I will implement change and evaluate the effect of the change at regular intervals until the change is incorporated as best practice. 5. Other: __________________________________ 7B. If you will not change your practice as a result of reading this article, why? (Select all that apply) 1. The content of the article is not relevant to my practice. 2. I do not have enough time to teach others about the purpose of the needed change. 3. I do not have management support to make a change. 4. Other: __________________________________ 8. Our accrediting body requires that we verify the time you needed to complete the 1.2 continuing education contact hour (72-minute) program: ________________________________ OBJECTIVES To what extent were the following objectives of this continuing education program achieved? 1. Discuss practices that could jeopardize safety in the perioperative area. Low 1. 2. 3. 4. 5. High 2. 3. Discuss common areas of concern that relate to perioperative best practices. Low 1. 2. 3. 4. 5. High Describe implementation of evidence-based practice in relation to perioperative nursing care. Low 1. 2. 3. 4. 5. High CONTENT 4. To what extent did this article increase your knowledge of the subject matter? Low 1. 2. 3. 4. 5. High 5. To what extent were your individual objectives met? Low 1. 2. 3. 4. 5. High 708 j AORN Journal www.aornjournal.org