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Perioperative Etiquette

MedWrench Guru Tony Cody, Technology Management Director at Banner Health, shares advice on how to build trust with a challenging customer using perioperative etiquette.

Sat Oct 03 2020By Tony Cody

As I continue my standard operating procedure writing journey, I wanted to share one that may help build trust with a challenging customer. There is an opportunity for HTM technicians to understand what is expected in the operating room environment that can minimize risk to the patients. Below is an SOP for perioperative etiquette.

Purpose: 

Perioperative etiquette is critical for patient safety and building trust in perioperative and designated invasive procedural areas. This standard operating procedure will establish and standardize perioperative etiquette and expected attire for all HTM employees. All HTM employees are responsible for following this Standard Operating Procedure (SOP) anytime the employee is at a restricted area or semi-restricted area. HTM leadership is responsible for the implementation and management of this procedure.

Outcomes:

All HTM employees dress appropriately for restricted areas and semi-restricted areas and follow appropriate aseptic practices. This is essential for patient safety and building trust with perioperative and designated invasive procedure department customers.

Definitions:

  • Aseptic Technique: methods by which contamination with microorganisms is prevented
  • Clean: the absence of visible dust, soil, debris or blood
  • Designated invasive procedure departments: departments designated for medical procedures that invade the body, usually by cutting or puncturing the skin or by inserting instruments into the body
  • Independent Service Organization Field Service Representative (ISO FSR): contracted personnel providing service in leu of an OEM representative
  • Infection Control Risk Assessment (ICRA): provides the strategic, proactive design to mitigate environmental sources of microbes and for prevention of infection through architectural design, as well as specific needs of the population served by the facility; recognizing the renovation requires more compromise of air and water quality than new construction the following guidelines are adopted and implemented when appropriate
  • Leader: an HTM employee with responsibilities for supervision of employees
  • Personal Protective Equipment: specialized clothing or equipment worn by an employee for protection against infectious materials
  • Restricted area: includes the surgical suites, operating rooms and adjacent sterile areas and is accessible only from a semi-restricted area; C-section rooms are also part of the restricted area
  • Scrub attire: non-sterile apparel designed for the perioperative practice setting that includes two-piece pantsuits and scrub dresses
  • Semi-restricted area: includes the peripheral support areas of the surgical suite and has storage areas for sterile and clean supplies, work areas for storage and processing of instruments, and corridors leading to the restricted areas of the surgical suite
  • Surgical attire: non-sterile apparel designated for the perioperative practice setting that includes scrub attire (e.g., two-piece pantsuits, scrub dresses), scrub jackets and head coverings
  • Un-scrubbed person: person that has not practiced proper preparatory procedures to work in the sterile field (including but not limited to surgical hand antisepsis)

Procedure:

Dress code for restricted areas, semi-restricted areas, and invasive procedure areas: all HTM employees are expected to dress appropriately for the work environment in restricted, semi-restricted, invasive procedure areas while adhering to System Dress Code policy.

The following guidelines apply to all restricted, semi-restricted, and designated invasive procedure departments. Depending on the facility and procedure requirements, exceptions may be made after review and approval from clinical leadership.

  1. Scrub Attire:
    1. Scrub attire/head coverings must be changed daily or whenever it becomes visibly soiled, contaminated or wet.
    2. Scrub attire shall not be worn off hospital campus.
  2. Warm-up jackets:
    1. Warm-up jackets prevent shedding from bare arms and are included in the OSHA regulation for use of PPE.
    2. Warm-up jackets are not worn with the arms tied at the waist and should be worn snapped at the front.
  3. Lab covers or cover gowns, if worn outside of the department, should be removed prior to entering the semi-restricted and restricted areas.
  4. Head and facial hair is covered and contained by a bouffant or hood - whichever is appropriate and completely covers facial hair. Facial hair is defined as approximately ¼ inch in length.
  5. Shoes:
    1. HTM employees should wear closed-toed shoes. 
    2. Tennis shoes are not permitted. 
    3. Exceptions will be made only if a medical order is in play regarding footwear.
    4. Shoe covers or dedicated new indoor shoes should be worn in restricted areas, semi-restricted areas and designated invasive procedural departments as appropriate and should be disposed when leaving the department. 
    5. Practice appropriate hand hygiene after removal.
  6. Masks:
    1. Surgical masks are worn at all times in the presence of open sterile surgical supplies by all individuals in the OR suite.
    2. Exclusion: The necessity of wearing a mask by any member of the team during cystoscopy cases is up to the discretion of the surgeon.
    3. The mask covers the nose and mouth completely and is secured in such a manner as to prevent side venting.
    4. The mask is changed between cases and immediately upon becoming wet or soiled. The mask should never be worn around the neck (front or in the back) or worn while eating or drinking.
    5. Masks are not to be saved by hanging around the neck/wrist or tucking into a pocket for future use and should be disposed when leaving the department.
    6. When removing the mask, only the ties are handled to avoid contamination. Hand-washing should follow.
    7. In the event of a pandemic, organizational mandates should be followed.
      1. e.g. - During the COVID-19 pandemic, once a surgical or procedural mask is removed, the social comfort mask must be put on.
  7. Disposable coveralls:
    1. Clean disposable coverall provided by the department is permissible providing it completely covers the street clothing and only if the persons are not going to be in the area for an entire case.
    2. Disposable hats, masks, face covers and shoe covers are worn with the coverall and removed before exiting the department.
  8. Jewelry, artificial nails and false eyelashes:
    1. All jewelry is kept at a minimum. Non-dangling earrings are allowed. Bracelets are not allowed.
    2. Fingernails kept in accordance to the Hand Hygiene, Antisepsis, and Artificial Nails policy.
    3. False eyelashes/extension are not permitted.
  9. ID badging: 
    1. All HTM employees will be provided and wear the appropriate badge as appropriate for the customer.
    2. ID badges must be worn at all work times:
      1. Above the waist
      2. Attached to the outermost garment, lanyards are discouraged for safety reasons
      3. Photo side facing outward, unobstructed and clearly visible to customers

Dress code accountabilities:

  • HTM employees who are deemed not complying with the dress code guidelines, including not having a badge, must be able to remedy the deficiencies on-site (example - securing temporary badging) or they will be sent home to remedy the deficiencies. Leaders will document violations in the employee’s record and apply the corrective action process at their discretion.
  • Time away to address the above issues is not considered work time.
  • All ISO FSRs, manufacturer representatives and employees whose services are required in the restricted and semi- restricted areas will adhere to the policy.

Reducing infection risk while performing service:

In order to reduce patient and staff exposure to airborne particulates or moisture from construction, installation, or routine maintenance, follow Infection Control Risk Assessment policy when appropriate.

  • Avoid bringing in unnecessary boxes or packing when possible. When unavoidable, clean as appropriately and set up a terminal clean.
  • When bringing in tools, carts and test equipment:
    • Clean wheels/casters of the cart before crossing posted red lines and remove unnecessary items and trash from your tool cart.
    • Clean tools and test equipment appropriately.
    • If you deem a terminal clean is necessary, communicate appropriately and make the arrangements.
  • Aseptic Techniques:
    • Un-scrubbed persons face the sterile field on approach and move from unsterile to unsterile area.
    • Un-scrubbed persons do not walk between sterile fields (anything covered in blue sterile drapes, e.g., draped patient, back table, mayo stand) or between scrubbed persons; maintain a distance of at least 12 inches from the sterile areas or scrubbed persons at all times.
    • Un-scrubbed persons should not reach over an uncovered sterile field or scrubbed person.
    • Un-scrubbed persons, enter through the clean core side if a total case (e.g. total hip or knee arthroplasty) is being performed only after permission from staff.
    • Un-scrubbed persons may be required to don additional PPE in cases requiring additional precautions (e.g. MRSA).
    • It is the discretion of the customer to allow entry into a Restricted area or Designated Invasive procedure department.


References:

  1. Association of Operating Room Nurses (2014), Standards and Recommended Practices. Denver: AORN.
  2. Appendix A: Proper doffing of Personal Protective Equipment
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