Periop Standards

Promoting Excellence
OPERATING ROOM NURSES ASSOCIATION OF CANADA (ORNAC)

10TH Edition
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1084471
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Standards, Guidelines and

Position Statements for Perioperative
Registered Nursing Practice
Page
Foreword ............................................................................................................................................................7
A Message From the President ...........................................................................................................................9
Section 1 ORNAC Beliefs, Professional Standards and Competencies
Part A
ORNAC's Fundamental Principles and Position Statements ...........................................................................12
ORNAC Philosophy .........................................................................................................................................13
ORNAC Mission, Values, Vision.....................................................................................................................14
National Standards for Perioperative Registered Nursing Practice ..................................................................15
Conceptual Model for Perioperative Registered Nursing Practice ...................................................................16
ORNAC Scope of Perioperative Registered Nursing Practice .........................................................................17
Scope of Practice for Expanded Perioperative Nursing Practice ......................................................................17
Scope of Practice for Advanced Perioperative Registered Nursing Practice ....................................................18
ORNAC Position Statements
a) Staffing the Surgical Suite.............................................................................................................19
b) Perioperative Certification ............................................................................................................21
c) Perioperative Nursing Experience in Basic Nursing Education Programs ....................................22
d) Environmental Responsibility .......................................................................................................24
e) Perioperative Registered Nurses are Essential to Quality Care in the Operating Room ...............24
f) The Perioperative Registered Nurses Role in Primary Healthcare ..............................................25
Safe Surgery Saves Lives .................................................................................................................................26
Part B
Standards for Perioperative Registered Nursing Practice .................................................................................28
Professional Standards .......................................................................................................................29
Professional Standards for Perioperative Registered Nurses..............................................................30
Professional Standards for Perioperative Registered Nurse Managers ..............................................39
Professional Standards for Perioperative Registered Nurse Educators ..............................................41
Professional Standards for Expanded Practice Perioperative Registered Nurses ...............................43
Professional Standards for Perioperative Registered Nurse Researchers ...........................................45
Professional Standards for Advanced Practice Perioperative Registered Nurses ...............................48
Part C
Competencies for Perioperative Registered Nursing Practice ..........................................................................50
Purpose ...............................................................................................................................................51
Knowledge and Skills Expected of the Perioperative Registered Nurse Prior to Entering the
Specialty of Perioperative Nursing .....................................................................................................52
Characteristics of Each Competency ..................................................................................................53
Competencies of the Perioperative Registered Nurse ........................................................................54
Competencies of the Perioperative Registered Nurse Manager .........................................................59
Competencies of the Perioperative Registered Nurse Educator .........................................................67
Competencies of the Advanced Practice Perioperative Registered Nurse ..........................................73
Competencies for Expanded Practice Perioperative Registered Nurses
Registered Nurse First Assist (Appendix A) .....................................................................75
Standards, Guidelines, and Position Statements For Perioperative Registered Nursing Practice
ORNAC Beliefs, Professional Standards and Competencies
Revision Date: March 2011
Introduction
Page 2 of 334

Table of Contents
Routine Practices and Additional Precautions ..................................................................................................89

Routine Practices ..............................................................................................................................................89
Airborne Precautions ..........................................................................................................................91
Droplet Precautions ............................................................................................................................94
Contact Precautions ............................................................................................................................95
Classic Creutzfeldt-Jakob disease (CJD) ..........................................................................................................97
Implementing CJD Precautions ..........................................................................................................97
CJD Perioperative Precautions ...........................................................................................................98
Reference Guide Assessment Tool (Appendix A) ..........................................................................102
Environmental Cleaning/Sanitation ................................................................................................................104
General Practices ..............................................................................................................................104
Preliminary Cleaning........................................................................................................................106
Intraoperative Cleaning ....................................................................................................................106
End of Procedure Cleaning (Between Cases) ...................................................................................107
Terminal Cleaning ............................................................................................................................108
Weekly and /or Monthly Cleaning ...................................................................................................108
Traffic Control ................................................................................................................................................109
People ...............................................................................................................................................110
Supplies and Equipment ...................................................................................................................111
Dress Code .....................................................................................................................................................112
Patients .............................................................................................................................................112
Visitors .............................................................................................................................................112
Staff ..................................................................................................................................................113
Scrubbing, Gowning, Gloving ........................................................................................................................116
Scrubbing .........................................................................................................................................116
Gowning ...........................................................................................................................................117
Gloving.............................................................................................................................................118
Aseptic Technique ..........................................................................................................................................121
Establishing an Aseptic Environment ..............................................................................................121
Establishing the Sterile Field............................................................................................................121
Dispensing Sterile Supplies ..............................................................................................................122
Maintaining the Sterile Field ............................................................................................................123
Storage of Sterile Supplies ...............................................................................................................124
Instrument Management and Reprocessing ....................................................................................................126
Intraoperative Instrument Care .........................................................................................................126
Reprocessing Surgical Instruments ..................................................................................................127
Loaned and Leased Surgical/Medical Equipment ............................................................................129
Packaging for Sterilization ...............................................................................................................129
Rigid Sterilization Containers ..........................................................................................................131
Sterilization ......................................................................................................................................132
Emergency (Flash) Sterilization .......................................................................................................134
High Level Disinfection ...................................................................................................................135
Introduction
Page 3 of 334

Section 2 Infection Prevention and Control
Single Use Medical Devices (SUMeDs) ........................................................................................................142

Selection, care and handling of materials .......................................................................................................143
Wrappers, Surgical Gowns, and Drapes ...........................................................................................143
Bundles.............................................................................................................................................145
Skin Preparation (Prep) ..................................................................................................................................146
Draping ..........................................................................................................................................................149
Dressing(s), Drain(s), Irrigation .....................................................................................................................150
Dressings ..........................................................................................................................................150
Drains ...............................................................................................................................................151
Irrigation...........................................................................................................................................152
Section 3 Safety/Risk Prevention and Management
Introduction to Risk Management ..................................................................................................................155

Risk Avoidance/Minimization ........................................................................................................................156
Patient Safety ..................................................................................................................................................160
Ambulatory Patient Care Recommendations ...................................................................................160
Patient Admission and Identification ...............................................................................................163
Consent for Surgical Intervention ....................................................................................................164
Surgical Site Verification .................................................................................................................165
Surgical Pause/Time Out .............................................................................................................166
Surgical Counts ................................................................................................................................167
Surgical Positions .............................................................................................................................178
Visitors to the Surgical Suite ............................................................................................................184
Gathering Medicolegal Evidence in the Surgical Suite ....................................................................185
Guidelines for Collection of Evidence: (Appendix E) ....................................................................189
Specimen Management ....................................................................................................................190
Medication Management ..................................................................................................................193
Nursing Documentation ...................................................................................................................196
Electronic Health Records ................................................................................................................201
Organ and Tissue Procurement Protocol ..........................................................................................203
Team Safety ....................................................................................................................................................206
Credentialing ....................................................................................................................................206
Occupational Health & Safety ..........................................................................................................207
Students/Preceptors ..........................................................................................................................209
Orientation/In-service/Continuing Education ..................................................................................211
Environmental/Equipment Safety ...................................................................................................................212
Construction/Renovation ..................................................................................................................212
Introduction
Page 4 of 334

Specialized Instruments and Equipment .........................................................................................................140

Prosthesis Care and Handling...........................................................................................................140
Power Equipment Management .......................................................................................................141
Specialized Surgical Equipment ......................................................................................................226

Electrosurgery (ESU) ..........................................................................................................226
Laser Safety and Administration ..........................................................................................234
Minimally Invasive Surgical Equipment ..............................................................................242
Section 4 Environmental Hazards and Responsibilities

Physical Hazards ............................................................................................................................................250
Environmental Factors .....................................................................................................................250
Light ......................................................................................................................................250
Noise......................................................................................................................................251
Ventilation .............................................................................................................................252
Electricity .........................................................................................................................................254
Radiation ..........................................................................................................................................256
Fire/Explosion ..................................................................................................................................260
Chemical Hazards...........................................................................................................................................263
Anesthetic Agents ............................................................................................................................263
Sterilizing Agents - Ethylene Oxide .................................................................................................264
Other Sterilizing Agents/Disinfectants .............................................................................................264
Formaldehyde ........................................................................................................................265
Glutaraldehyde ......................................................................................................................265
Methyl Methacrylate ........................................................................................................................265
Drugs: Cytotoxic, Dyes, Pharmaceuticals .......................................................................................266
Waste Management ........................................................................................................................................266
Infectious Waste ...............................................................................................................................266
Latex Sensitivity/Allergy: Staff ......................................................................................................................268
Section 5 Nursing Care of the Anesthetised Patient

Preoperative Considerations ...........................................................................................................................273
Intraoperative Considerations .........................................................................................................................275
Postoperative Considerations .........................................................................................................................279
Local Anesthesia ............................................................................................................................................281
Procedural Sedation/Analgesia .......................................................................................................................283
Introduction
Page 5 of 334

Equipment Selection/Trialing...........................................................................................................221
Preventative Maintenance Programs ................................................................................................225
Risk Alerts/Recalls ...........................................................................................................................225
Intra-operative Equipment Malfunction ...........................................................................................226
Regional Anesthesia-Spinal, Epidural, Peripheral Nerve Blocks ...................................................................290

Herbal Remedies ............................................................................................................................................292
Blood and Blood Products ..............................................................................................................................294
Emergency Situations .....................................................................................................................................296
Malignant Hyperthermia ..................................................................................................................296
Latex Allergy ...................................................................................................................................298
Cardiac Arrest ..................................................................................................................................300
Disseminated Intravascular Coagulation ..........................................................................................302
Death ................................................................................................................................................304
Glossary ..........................................................................................................................................................307
Evaluation Form .............................................................................................................................................332
CSA Standards ...............................................................................................................................................333
Introduction
Page 6 of 334

Intravenous Regional Anesthesia (Bier Block) .............................................................................................288
ORNAC was inaugurated in 1983, and by June 1986, the Standards Committee had developed Standards for
Operating Room Nursing Practice. Two years later, in 1988 Recommended Technical Standards were
published. This was a significant milestone for a young organization. The body of knowledge required in the
specialty was defined as required by the Canadian Nurses Association to meet the requirements of a certification
process.
The two documents were combined in a single issue in 1993 and also included a chapter on competencies. That
issue was used as a primary resource for the development of the Canadian Nurses Association (CNA) Certification
exam in Perioperative Nursing Practice.
The document continued to evolve with the 1998 edition, which reflected the movement towards ambulatory
surgery.
The 2003 revision incorporated a major format change. This edition was re-designed into modules. The constant
rapid change in healthcare requires a design that enables more consistent review/revision. ORNAC is a volunteer
organization of committed perioperative Registered Nurses. Revision/review of modules is more easily facilitated
on a continuous basis by these volunteers. According to the Canadian Nurses Association (CNA), a standard is a
desired and achievable level of performance against which we can measure actual performance. Self regulating
professions are characterized by standards of practice, based on the values of the profession. This document is meant
to complement not replicate other standards in existence.
The 9th edition, 2009 revision was published in a bound format as a result of feedback and requests from
perioperative nurses across the country. A bound publication provides assurance that each and every copy contains
all of the most current revisions. Committee energy was focused on the fourth and fifth sections of the publication.
Minor revisions were made to the remaining sections based on questions the committee received through the
ORNAC website.
For the current (10th edition) revision, the committee focused on Section 2, with minor revisions to the remaining
sections.
It is the mandate of the Standards Committee to develop and review standards on an ongoing basis. Content
expertise has been provided by perioperative Registered Nurses across Canada and reflects current practice, research,
and review of medical/surgical literature.
The Standards Committee has endeavoured to develop a user-friendly document that will serve as a guide and
reference for perioperative Registered Nurses, health care facilities that care for surgical patients, and other
professional associations. It is the responsibility of individual perioperative Registered Nurses and health care
facilities to ensure that the most recent recommendations are being used.
Those who served as reviewers and validators are to be commended for a job well done. Thank-you to the ORNAC
Board and Executive, and perioperative Registered Nurses from across the country for their assistance and to
colleagues from other specialty areas who assisted us.
Introduction
Page 7 of 334

FOREWORD

Kathy Radcliffe RN, BSN, CPN(C) Chair, Standards Committee, Ontario

Loraine Best, RN, BSN, CPN(C) British Columbia
Chris Downey RN, BScN, CPN(C), MSc, RNFA, CMLSO, Ontario
Cathy Ferguson RN, BScN, RNFA, CNOR, CPN(C) Nova Scotia
Carol Knudson RN, BN Manitoba
Rupinder Khotar RN, BScN, CPN(C) British Columbia
Kelly Kuz RN, BScN, MN, CPN(C) Alberta
Corenia Price RN, CPN(C), CMDRT Newfoundland & Labrador
Leah Restall RN - Manitoba
Anne Smith RN, Prince Edward Island
Cathy Timmons, RN Nova Scotia
Margot Walsh RN Newfoundland & Labrador
1
10th edition committee members
Notes:
1.
The intended application of these standards, guidelines, and position statements, is for the perioperative
environment. It is the responsibility of the users of this document to apply it in the context of their
individual setting respecting provincial/national and professional regulations and laws within each province
and jurisdiction.
2.
This document was developed from broad input of perioperative Registered Nurses and the final document
represents consensus of the content. Consensus is defined as agreement in collective opinion and belief.
Consensus is more than a simple majority, but not necessarily unanimity.
3.
ORNAC standards, guidelines, and position statements are subject to periodic review.
4.
Shall is used to express a requirement, i.e., a provision that the user is obliged to satisfy in order to
comply with the standard, should is used to express a recommendation or that which is advised but not
required, and may is used to express an option or that which is permissible within the limits of the
standard.
Introduction
Page 8 of 334

A MESSAGE FROM THE PRESIDENT. . .

Promouvoir lExcellence
A MESSAGE FROM THE PRESIDENT

On behalf of the Operating Room Nurses Association of Canadas Board and Executive, it is my pleasure to preface
the tenth edition of the ORNAC Standards, Guidelines, and Position Statements for Perioperative Registered
Nursing Practice. During the fall ORNAC strategic planning process, the executive, provincial and affiliate
representatives confirmed that the production and continuous review of the Standards is a strategic priority to support
best practices in perioperative patient care. This edition represents the ongoing validation and revision of the
Standards, necessary to keep pace with the health care environment and maintain safe patient care.
As demonstrated by the ORNAC conceptual model, this document is the foundation of registered nursing practice in
the perioperative setting and represents our professional practice to our colleagues. While the Standards have
evolved since the first publication, ORNAC Recommended Standards for Operating Room Nursing Practice, June
1986, the intent remains the same to guide the delivery of safe patient care and perioperative registered nursing
practice in Canada. The review and compilation of the Standards document is an enormous task coordinated by the
volunteers of the ORNAC Standards committee. Their generous donation of time, knowledge and expertise to
develop and inform this document is commendable.
The Operating Room Nurses Association of Canada is a professional organization dedicated to the promotion and
advancement of excellence in perioperative practice. The
ORNAC Standards, Guidelines, and Position Statements for Perioperative Registered Nursing Practice
provides the vital reference to demonstrate to the public, government and other stakeholders that as a profession,
perioperative registered nurses are dedicated to maintaining the public trust and to upholding standards for
excellence in professional practice.
Bonnie McLeod, RN, BScN, MN, CPN(C)

ORNAC President, 2009 - 2011
Introduction
Page 9 of 334

Section 1
ORNAC Beliefs, Professional Standards and
Competencies
Part A
ORNAC's Fundamental Principles and Position Statements ...........................................................................12
ORNAC Philosophy .........................................................................................................................................13
ORNAC Mission, Values, Vision.....................................................................................................................14
National Standards for Perioperative Registered Nursing Practice ..................................................................15
Conceptual Model for Perioperative Registered Nursing Practice ...................................................................16
ORNAC Scope of Perioperative Registered Nursing Practice .........................................................................17
Scope of Practice for Expanded Perioperative Nursing Practice ......................................................................17
Scope of Practice for Advanced Perioperative Registered Nursing Practice ....................................................18
ORNAC Position Statements
a) Staffing the Surgical Suite.............................................................................................................19
b) Perioperative Certification ............................................................................................................21
c) Perioperative Nursing Experience in Basic Nursing Education Programs ....................................22
d) Environmental Responsibility .......................................................................................................24
e) Perioperative Registered Nurses are Essential to Quality Care in the Operating Room ...............24
f) The Perioperative Registered Nurses Role in Primary Healthcare ..............................................25
Safe Surgery Saves Lives .................................................................................................................................26
Part B
Standards for Perioperative Registered Nursing Practice .................................................................................28
Professional Standards .......................................................................................................................29
Professional Standards for Perioperative Registered Nurses..............................................................30
Professional Standards for Perioperative Registered Nurse Managers ..............................................39
Professional Standards for Perioperative Registered Nurse Educators ..............................................41
Professional Standards for Expanded Practice Perioperative Registered Nurses ...............................43
Professional Standards for Perioperative Registered Nurse Researchers ...........................................45
Professional Standards for Advanced Practice Perioperative Registered Nurses ...............................48
Part C
Competencies for Perioperative Registered Nursing Practice ..........................................................................50
Purpose ...............................................................................................................................................51
Knowledge and Skills Expected of the Perioperative Registered Nurse Prior to Entering the
Specialty of Perioperative Nursing .....................................................................................................52
Characteristics of Each Competency ..................................................................................................53
Competencies of the Perioperative Registered Nurse ........................................................................53
Competencies of the Perioperative Registered Nurse Manager .........................................................59
Competencies of the Perioperative Registered Nurse Educator .........................................................67
Competencies of the Advanced Practice Perioperative Registered Nurse ..........................................73
Competencies for Expanded Practice Perioperative Registered Nurses
Registered Nurse First Assist (Appendix A) ......................................................................................75
Section 1
Page 11 of 334

Section 1 ORNAC Beliefs, Professional Standards and Competencies

Part A
ORNAC'S FUNDAMENTAL PRINCIPLES

AND POSITION STATEMENTS
Section 1
Page 12 of 334
The Operating Room Nurses Association of Canada (ORNAC) is an organization of professional perioperative
Registered Nurses dedicated to the promotion of excellence in perioperative nursing.
ORNAC serves as a spokesperson for perioperative Registered Nurses on issues affecting Registered Nurses, nursing
practice, patient care, and societal needs/ expectations.
We believe:
Perioperative nursing is a dynamic process guided by theoretical knowledge, ethical principles,

research, specialized clinical skills, and caring practice.
Perioperative Registered Nurses respond to complex and changing clinical needs during a crucial
period of a persons surgical experience.
The scope of perioperative nursing practice is continually evolving as Registered Nurses respond
to societal and technological changes.
Standards of nursing practice, as well as collegial and interdisciplinary collaboration, enhance

perioperative nursing practice.
People are unique individuals whose needs change and may be compromised during the
perioperative experience. They have a right to high-quality health care that promotes informed and
responsible decision making.
Health encompasses the whole being and is influenced by one's environment. Using a wellness
approach, individuals and communities shall be proactive and responsible for achieving optimal
health.
Education is an ongoing life-long process and perioperative Registered Nurses are responsible for
their learning. ORNAC is committed to enabling perioperative Registered Nurses to meet this
responsibility.
The introduction to perioperative nursing should be a component of the basic nursing curriculum.
To fully practice the scope of perioperative nursing, the Registered Nurse needs to acquire
additional knowledge and clinical skills.
ORNACs Motto Promoting Excellence demonstrates commitment to meeting the needs of its
members and society.
Approved by Board and Executive: April 1994

Revised: May 2003, June 2007, February 2009, March 2011
Section 1
Page 13 of 334

ORNAC Philosophy
The Operating Room Nurses Association of Canada (ORNAC) is a professional organization of perioperative
Registered Nurses dedicated to:
The promotion and advancement of excellence in the provision of perioperative care to our patients.
The professional growth, competence and personal enhancement of perioperative Registered Nurses.
The ongoing development of Standards, Guidelines and Position Statements for Perioperative Registered
Nursing Practice
The promotion and advancement of perioperative nursing practice at a regional, provincial and national
level through political activity.
Vision Statement

Mission Statement
The Operating Room Nurses Association of Canada (ORNAC) is a strong, unified national association that enhances and
advances the practice of perioperative Registered Nurses.
Values Statement
Values reflect the basic beliefs that are most important to the Operating Room Nurses Association of Canada
(ORNAC):
KNOWLEDGE
We recognize and are committed to education and research which are essential
components guiding our practice.
We promote and demonstrate critical thinking skills in the delivery of
perioperative nursing care.
RESPECT
We recognize the worth, quality, diversity, and importance of the patients we care for,
and of each other.
PROFESSIONALISM
We promote and continually develop our unique specialized body of knowledge.

We encourage all perioperative Registered Nurses to become certified through the
Canadian Nurses Association (CNA).
We collaborate with nurses, organizations /agencies, other disciplines and
medical industries that impact our practice.
We are responsible and accountable for our actions and decision-making.
We comply with the Canadian Nurses Association (CNA) Code of Ethics.
CONTINUOUS QUALITY
We strive to achieve excellence in perioperative practice, and the activities

influencing our Association.
Section 1
Page 14 of 334
We are role models who communicate a vision and who empower

others to achieve perioperative nursing excellence.
PATIENT ADVOCACY
We promote the perioperative patients right to be informed and to

make autonomous decisions regarding their care.
We strive to protect the rights, health and safety of the patient
throughout the perioperative experience.
STEWARDSHIP
We strive to be fiscally and environmentally responsible while optimizing patient

outcomes.
National Standards for Perioperative Registered Nursing Practice

ORNAC holds the following beliefs regarding standards:
The implementation of standards contributes to the continued improvement of safe patient care and
perioperative registered nursing practice in Canada.
Standards assist the perioperative Registered Nurse in attaining and maintaining competence in the
performance of quality patient care.
Standards define safety measures for patients and the health care team.
Standards provide a baseline and tool for measurement when evaluating perioperative registered nursing
practice.
Standards are an integral part of a facility's quality assurance and improvement program.
Standards provide a consistent reference base for programs such as orientation, in-service, continuing
education, research, and formal perioperative post basic education programs.
Standards are the benchmark from which the perioperative Registered Nurse Manager and Educator
provide the structure, resources, and environment for the health care team.
Section 1
Page 15 of 334

LEADERSHIP

CONCEPTUAL MODEL FOR

PERIOPERATIVE REGISTERED NURSING PRACTICE
The conceptual model provides direction for perioperative registered nursing practice. The surgical patient is the
focus of perioperative registered nursing practice, which has as its foundation professional and clinical standards,
and competencies.
The professional standards provide guidelines for the perioperative Registered Nurse on which to base decisions in
such areas as ethics, legal aspects, and professional conduct.
The competency statements reaffirm that perioperative Registered Nurses are responsible and accountable for the
nursing care of the surgical patient during the perioperative phase.
In order to implement the standards and develop competence, the perioperative Registered Nurse shall be cognizant
of the qualities necessary to become a Registered Nurse. Competence integrates the characteristics of knowledge,
clinical and ethical decision-making, communication skills, psychomotor skills, safety, accountability, responsibility,
team organization, continuing education, and leadership skills. The perioperative Registered Nurse is guided in the
clinical area by these characteristics in order to function both independently and in collaboration with other members
of the health care team.
The clinical standards provide a basis for consistent, uniform, and acceptable outcomes of nursing practice. The
perioperative Registered Nurse is systematically guided through the perioperative phase. The clinical standards are
the benchmarks for quality improvement.
The standards are implemented during the immediate preoperative, intraoperative, and immediate postoperative
phases of the surgical patient's experience. Administration and management provide support, direction, leadership,
resources, and commitment to the practice of these standards.
Section 1
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The Scope of Perioperative Registered Nursing Practice is a continuum of nursing activities that focuses on
identifying and meeting the individual needs of the surgical patient throughout the perioperative experience.
This nursing practice occurs in, but is not limited to operating rooms, ambulatory care settings, clinics, and
physicians offices.
The perioperative Registered Nurse provides excellent care to the surgical population using critical thinking
skills guided by the ORNAC Standards, Guidelines and Position Statements for Perioperative Registered
Nursing Practice and provincial legislation. Basic and expanded nursing knowledge is used to address the
physiological, psychological, socio-cultural, and spiritual responses of the patient to the surgical event.
The perioperative Registered Nurse possesses the knowledge, skills and abilities to provide quality care for
all perioperative patients.
Working in collaboration with the health care team, the perioperative Registered Nurse performs skills
supported by perioperative nursing education and evidence-based research within the boundaries of the
health care facilitys policies and procedures.
The perioperative Registered Nurse precepts and mentors colleagues.
BIBLIOGRAPHY
Canadian Nurses Association (2007). CNA joint position statement Promoting Continuing Competence for
the Registered Nurse. Ottawa: Author.
International Council of Nurses (R2007). The ICN position statement on Ethical Nurse Recruitment.
Geneva: Author.
Watson D. S. (2008). Patient Safety, an Issue of Perioperative Nursing Clinics. Toronto: Elsevier.
Scope of Practice for Expanded Perioperative Nursing Practice

Registered Nurse Anesthesia Assistant- RNAA
The experienced perioperative Registered Nurse, with additional education, knowledge and skills in anesthesia
assists the anesthesiologist to facilitate quality care of patients undergoing anesthetic procedures. The increasing
complexity of patient condition and anesthetic procedures provides the perioperative Registered Nurse who has
expanded perioperative nursing education with the opportunity to practice in collaboration with and under the
direction of the anesthesiologist. The scope of practice of the Registered Nurse Anesthesia Assistant is part of
perioperative nursing practice and encompasses the preoperative, intraoperative, and postoperative phases of the
anesthetic experience.
Section 1
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ORNAC Scope of Practice for Perioperative Registered Nurses
Nagelhout, J. J. & Plaus, K. (2010). Nurse Anesthesia (4th ed.). Toronto: Elsevier/Mosby.
Registered Nurse First Assistant - RNFA

The experienced perioperative Registered Nurse, with additional education, knowledge and skills in surgery assists
the surgeon to facilitate quality care of patients undergoing surgical procedures. The increasing complexity of patient
conditions, diagnoses, and surgical procedures provides the perioperative Registered Nurse who has expanded
perioperative nursing education with the opportunity to practice in collaboration with and under the direction of the
surgeon. The scope of practice of the RNFA is part of perioperative nursing practice and encompasses the
preoperative, intraoperative, and postoperative phases of the surgical experience.
BIBLIOGRAPHY
Schroeder, J. L. (2008). Acute Care Practitioner: An Advanced Practice Role for RN First Assistants.
AORN, 87(6), 1205-1215.
Scope of Practice for Advanced Perioperative Nursing Practice

The scope of Advanced Nursing Practice focuses on a specialty clinical service (i.e. Perioperative), providing
support to clients and the healthcare team, as a consultant, researcher, administrator, educator, and clinical
practitioner. Advanced Practice Nurses include Nurses Practitioners (NP) and
Clinical Nurse Specialists (CNS).
BIBLIOGRAPHY
Canadian Nurses Association. (2008). Advanced Nursing Practice: A National Framework. Ottawa: Author.
Canadian Nurses Association. (2008). Nursing Leadership: Do We Have a Global Social Responsibility. Ottawa:
Author.
Canadian Nurses Association (2008). Advanced Nursing Practice A National Framework. Ottawa: Author.
Girard, N. J. (2009). Leadership an Issue of Perioperative Nursing Clinics. Toronto: Elsevier/Mosby.
MacDonald, M., Schreiber, R. & Davis, L. (2005). Exploring New Roles for Advanced Nursing Practice, A
Discussion Paper. Ottawa: CNA.
Section 1
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BIBLIOGRAPHY
STAFFING THE SURGICAL SUITE

For the patient undergoing surgical intervention, one of the most critical periods of care occurs in the operating room
theatre.
Every patient has a right to an optimal level of nursing care, and each facility has the responsibility to provide
appropriate staffing in order to:
Meet individual patient's needs and surgical complexity.
Maintain acceptable levels of safety for patients, personnel and physicians.
Function within legal limitations of the provincial scope of practice.
Facilitate appropriate initial and specialty orientation, and continuing education.
Attain and maintain perioperative Registered Nurse competency.
Each surgical patient care encounter occurs in an environment where each individual theatre is a specific unit of care
that shall be staffed independently with the staffing levels as defined.
To promote excellence in perioperative nursing care, the position of the Operating Room Nurses Association of
Canada (ORNAC) is:
The surgical patient in each theatre shall be under the direct supervision of an appropriately experienced
perioperative Registered Nurse who is physically present in each theatre, and who is immediately available,
i.e. Circulating Role to respond to unstable, unpredictable and emergency situations.
That in order to maintain competency in the circulating role, the perioperative Registered Nurse shall be
competent in the scrub role.
Each case or surgical procedure shall be staffed by a minimum of two perioperative professional nurses
competent within their scope of practice. The circulating role shall be assigned only to a perioperative
Registered Nurse. The scrub role may be filled by another healthcare professional. A second perioperative
Registered Nurse shall be immediately available within the surgical suite. It may be necessary for additional
circulating perioperative Registered Nurses and competent healthcare personnel to be present in the theatre
to provide care within their scope of practice or job description. Only a perioperative Registered Nurse may
relieve the circulating Registered Nurse for coffee, lunch, or other duties.
Each procedure or case shall be staffed with a minimum of one perioperative Registered Nurse and a second
perioperative Registered Nurse immediately available.
Documentation shall include all personnel in attendance and clearly identify who provided direct patient
care.
The surgical theatre shall be managed by an experienced perioperative Registered Nurse.
Section 1
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ORNAC POSITION STATEMENTS
Bull, R. & FitzGerald, M. (2006). Research Paper, Nursing in a technological environment: Nursing care in the
operating room, International Journal of Nursing Practice, 12, 3-7.
Canadian Health Services Research Foundation (CHSRF), (2006). Staffing for Safety: A Synthesis of the
on Nurse Staffing and Patient Safety, CHSRF, Ottawa, ON retrieved March 29, 2009 from www.chsrf.ca
Evidence
Canadian Health Services Research Foundation (CHSRF), (2006). Evidence Boost Implement nurse staffing
plans for better quality of care, The Problem: Current nurse staffing strategies are not adequate to
improve patient safety, CHRSF, Ottawa: Author.
Canadian Nurses Association. (2007). C NA Policy Brief # 2, Meeting Future Health-Care Needs Through
Innovations to Nursing Education. Ottawa: Author.
Canadian Nurses Association. (2006). CNA joint Position Statement, Practice Environments: Maximizing
Client, Nurse and patient Outcomes. Ottawa: Author.
Canadian Nurses Association. (2005). CNA Position Statement Interprofessional Collaboration. Ottawa: Author.
Canadian Nurses Association (CNA), (2005). Evaluation Framework to Determine the Impact of Nursing Staff Mix
Decisions. Ottawa: Author.
Canadian Nurses Association. (2003). Patient Safety: Developing the Right Staff Mix, Report of the Think Tank.
Ottawa: Author.
Craddick, S. (2009). Quality Indicators, An Issue of Perioperative Clinics. Toronto: Elsevier/Mosby
Garrett, C. (2008). Effective Nurse Staffing Patterns on Medical Errors and Nurse Burnout. AORN,
87(6), 1191-1204.
International Council of Nurses, (ICN). (2008). Nurse Retention & Migration. Geneva: Author
Springer, P. J., Corbett, C. & Davis, N. (2006). Enhancing Evidence-based Practice through Collaboration,
The Journal of Nursing Administration, 36(11), 534-537.
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BIBLIOGRAPHY
The certification program for perioperative Registered Nurses was established in 1995 by Canadian Nurses
Association (CNA) in collaboration with Operating Room Nurses Association of Canada (ORNAC), whose motto is
Promoting Excellence.
The certification exam measures the knowledge, skills, abilities, attitudes, and judgments in specific competency
areas required of perioperative Registered Nurses in Canada.
The mission of ORNAC includes the promotion and advancement of excellence in perioperative patient care, and the
professional and personal enhancement of perioperative Registered Nurses. One of the objectives of the Canadian
Nurses Association is to promote high standards of registered nursing practice in specialty areas in order to promote
quality nursing care in Canada. Certification confirms this pursuit for quality and excellence.
ORNAC supports the CNA certification/ recertification program and recommends that perioperative Registered
Nurses in perioperative nursing practice write the certification exam and earn the national credential of Certified
Perioperative Nurse (Canada) CPN(C), in order to:
promote high standards of perioperative nursing practice for optimal patient care;
validate competency in perioperative nursing;
meet national standards in perioperative nursing;
confirm commitment to nursing excellence and personal achievement;
confirm professional accountability for continuing education;
promote risk management principles; (CNA, 2006, p. 108)
enhance qualifications;
maintain accountability to the public; and
provide a nationally recognizable level of competency to the employer.
REFERENCES
Canadian Nurses Association. (2006). Perioperative nursing certification exam prep guide. Ottawa: Author
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PERIOPERATIVE CERTIFICATION
The Operating Room Nurses Association of Canada (ORNAC) believes that perioperative clinical experience is the
primary means by which student nurses attain knowledge and skills in the management of care for the surgical
patient.
Whereas the Canadian Nurses Association (CNA) has an ideal opportunity to influence future changes in basic
nursing education, and whereas consistency in the basic preparation of nurses is desirable, ORNAC recommends
CNA endorse the perioperative experience as an integral component of basic nursing education.
Perioperative registered nursing practice encompasses professional and clinical nursing activities, which focus on
identifying and meeting the needs of the surgical patient while applying the nursing process. The perioperative
Registered Nurse performs in a collaborative role with other members of the health care team.
Learning Assumptions
The student nurse gains experience in the perioperative setting as a member of the multidisciplinary team
through the use of a conceptual model, the nursing process, and standards of perioperative nursing practice.
The surgical suite provides the best environment for learning perioperative registered nursing practice.
The theory and clinical experiences are best retained when the student can immediately apply what has been
taught. Active participation is the most effective method of teaching and learning.
Advantages of Perioperative Experience

1.
For the Student
Students gain knowledge and skills through their perioperative experience. Advantages include, but are not limited
to:
1.1
Participating in the active management of surgical patients during the preoperative, intraoperative and
immediate postoperative phases;
1.2
Developing confidence and assertiveness in the ability to make decisions regarding the care of
the surgical patient;
1.3
Improving observational and organizational skills by practicing in an environment where

activities shall be performed quickly and accurately;
1.4
Developing critical-thinking skills through the identification of priorities and the organization
of patient care;
1.5
Developing collaborative working relationships within the perioperative environment;
1.6
Communicating effectively with patients and members of the health care team;
1.7
Developing and enhancing leadership skills;
1.8
Developing specialized clinical skills;
1.9
Developing proficiency in the application of aseptic technique;
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PERIOPERATIVE NURSING EXPERIENCE IN BASIC REGISTERED

NURSING EDUCATION PROGRAMS
Increasing knowledge of anatomy and pathophysiology by observing the surgical

intervention;
1.11
Recognizing how the surgical intervention impacts postoperative care and recovery;
1.12
Recognizing the legal and ethical responsibilities and accountability of the perioperative
Registered Nurse and other health care team members; and
1.13
Developing the role of patient advocate.
For the Patient
Patients benefit from the knowledge and skills that the student nurse gains from experience in the surgical suite.
Advantages include but are not limited to:
3.
2.1
Higher quality of care;
2.2
Decreased preoperative and postoperative apprehension, discomfort, and stress due to the
Registered Nurse's understanding, empathetic approach, and confidence;
2.3
Improved education for the surgical patient and family due to the Registered Nurses
increased knowledge base; and
2.4
Reduced risk of infection through improved aseptic technique.
For the Employing Agency
The employing agency will benefit from the students perioperative nursing experience due to their increased
understanding of effects of surgical intervention. Advantages include but are not limited to:
3.1
Increased interest in perioperative nursing after graduation, thereby enhancing

recruitment and retention strategies;
3.2
Increased knowledge and ability to provide comprehensive care to a wider range of patients;
3.3
Increased understanding of legal issues related to surgical interventions e.g., informed

consent, surgical counts;
3.4
Experience functioning as members of the surgical multidisciplinary team;
3.5
Improved communication between departments, health care facilities and schools of

nursing; and
3.6
Potential for increased patient satisfaction.
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2.
1.10
The Operating Room Nurses Association of Canada (ORNAC) supports the environmental responsibility principles
of Reduce, Reuse, Recycle, Recover, and Re-educate.
Perioperative Registered Nurses should participate in and support waste management programs and waste reduction
initiatives. We must be influential in setting standards and effecting change through environmental awareness within
surgical suites, health care facilities, with medical suppliers, and on a professional level. In addition, ORNAC
supports compliance with applicable federal, provincial, and municipal government regulations regarding
environmental protection issues.
BIBLIOGRAPHY
Canadian Council of Ministers of the Environment (CCME). (1992). Guidelines for the Management of
Biomedical Waste in Canada. www.ccme.ca
Canadian Nurses Association. (2008). Role of Nurse in Addressing Climate Changes. Ottawa: Author.
Canadian Standards Association (CSA) Standard, CAN/CSA-Z317.10-01 (R2006). Handling of Waste
Materials in Health Care Facilities & Veterinary Health Care Facilities. Toronto: Author.
www.csa.ca
Joint Canadian Nurses Association (CNA)/Canadian Medical Association (CMA) (2000). Position
Statement Environmentally Responsible Activity in the Health Sector.
PERIOPERATIVE REGISTERED NURSES ARE ESSENTIAL TO

QUALITY PATIENT CARE IN THE OPERATING ROOM
The scope of Perioperative Registered Nursing practice is a continuum ranging from a novice to an expert level of
professional nursing that focuses on identifying and meeting the individual needs of the surgical patient,
preoperatively, intraoperatively, and immediately postoperatively.
Perioperative Registered Nurses are:
professionally responsible and accountable for their practice

coordinators of patient care
leaders and educators in the health care field
cost effective (multi-skilled and cross trained)
patient and family advocates
risk managers (protect the patient, personnel, and the environment)
health promoters
Perioperative Registered Nurses have:

critical-thinking skills
a broad knowledge of human and natural sciences
specialized surgical nursing knowledge including anatomy, physiology/ pathophysiology, pharmacology,
aseptic technique and assessment skills
a functional knowledge of medical legal aspects
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ENVIRONMENTAL RESPONSIBILITY
a certification process (examination established by the Canadian Nurses Association)

a Code of Ethics through the Canadian Nurses Association which guides nursing practice
Perioperative Registered Nurses:

establish respectful, trusting, therapeutic relationships with patients and their families
use the nursing process to direct care
use evidence based practice in the provision of nursing care
assume new responsibilities in response to the changing needs of patients
work independently and collaboratively to provide focused care
recognize that all surgery is a major life event for each patient
define and direct their practice (Scope of Practice)
articulate their roles and expectations as defined by the standards for perioperative Registered Nursing
practice
develop and implement policies and protocols to provide safe patient care
establish professional working relationships with members of the multidisciplinary team
coordinate multidisciplinary team activities
care for patients with both predictable and unpredictable outcomes.
Perioperative Registered Nurses will:
develop professionally in response to the changing needs of patients, the health care systems and society.
BIBLIOGRAPHY
Canadian Nurses Association. (2006). Nursing Information and Knowledge Management. Ottawa: Author.
Canadian Nurses Association. (2004). Nurses and Patient Safety: A Discussion Paper CNA & Univ. of Toronto Nrsg.
Ottawa: Author.
Keegan-Doody, M. (2007, June). Walk or be driven? Canadian Operating Room Nursing Journal, 25 (2), 30, 31,
33-35.
THE PERIOPERATIVE REGISTERED NURSES ROLE IN PRIMARY

HEALTH CARE
The Operating Room Nurses Association of Canada (ORNAC) supports the Canadian Nurses Associations beliefs
that Registered Nurses have a key role in making primary health care a reality in our country.
While perioperative Registered Nurses have traditionally not been involved in the provision of initial health care
services, a clinical aspect of perioperative nursing practice is broadening in scope within the preoperative,
intraoperative and immediate postoperative patient care. This provides the opportunity for more patient and family
contact. Within this scope, perioperative Registered Nurses are able to perform direct patient care, teach and educate
patients, family, health care personnel and as well the community. Perioperative Registered Nurses support and/or
perform research and supervise/manage health care services.
Examples of the perioperative Registered Nurse as a primary health care provider are evident in the promotion of:
Healthy lifestyle choices that may prevent possible surgical intervention

Participation in health and wellness-related organizations so that activities can be proactive instead of
reactive.

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Surveillance of disease conditions, recurrent operative procedures and patients requiring infection control
follow-up.
Health education to patients, students and the public:
- Perioperative assessment clinics and/or admission to the operating room suite
- Nurse educators and staff to teach students and/other health care team members
- Promotion of events such as National Perioperative Nurses Day
Collaboration with other primary health care personnel in providing patient care.
Effectiveness of services through Quality Improvement Programs with particular emphasis on the effect of
such services on primary health care.
BIBLIOGRAPHY
Canadian Nurses Association. (2005). Unregulated Health Workers A Canadian and Global Perspective, A
Discussion Paper. Ottawa: Author.
Canadian Nurses Association. (2005). National Planning for Human Health Resources in the Health Sector. Ottawa:
Author.
Canadian Nurses Association. (2005). Nursing Now Issues and Trends in Canadian Nursing, Nursing Staff Mix: A
Key Link to Patient Safety. CNA, 19, Ottawa: Author.
SAFE SURGERY SAVES LIVES:

SURGICAL SAFETY CHECKLIST
The Operating Room Nurses Association of Canada (ORNAC) endorses the global efforts to enhance the
safety of surgical procedures, to protect patients from harm and ultimately, to save lives. ORNAC is committed to
assisting perioperative Registered Nurses in providing the safest care for each surgical patient.
ORNAC is aware of the World Health Organizations (WHO) work to assist in the provision of safe surgery
for all patients. The second Global Patient Safety Challenge: Safe Surgery Saves Lives is a campaign established
by the WHO World Alliance for Patient Safety to improve the safety of all surgeries. The goal established was to
define global safety standards, which could be applied in all perioperative settings. An International team met in
Geneva, January 2008 and created the WHO Surgical Safety Checklist. The WHO Surgical Safety Checklist was
launched in North America in June 2008, with prior endorsement of many organizations including the Canadian
Anesthesiology Society, Canadian Medical Association, Canadian Nurses Association, International Federation of
Perioperative Nurses, Royal College of Physicians and Surgeons of Canada, and the Operating Room Nurses
Association of Canada.
Toronto General Hospital, University Health Network, was one of the eight global pilot sites for the
implementation of the Checklist. There was a significant reduction in deaths and complications for lower income
sites using the checklist, and also a reduction in deaths and complications in higher income sites. When surgeons
were asked if they would want the checklist used if they were having surgery, nearly 100% of them reported that
they would. The research results can be reviewed in the issue of the New England Journal of Medicine identified
below.
The WHO Surgical Safety Checklist was designed as a template for facility adaption. The Canadian Patient
Safety Institute facilitated a working group that adapted the WHO Surgical Safety Checklist to meet the Canadian
healthcare context. The Canadian adaption was formally launched at a national meeting in Toronto on March 4,
2009. ORNAC has been represented at each of these activities.
ORNAC strongly encourages all perioperative Registered Nurses to use a Surgical Safety Checklist for
every patient with every surgical procedure.
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Haynes AB, Weiser TG, Berry, WR, et al (2009). A Surgical Safety Checklist to Reduce Morbidity and Mortality in
a Global Population. New England Journal of Medicine, 360 (5), 491-497.
http://content.nejm.org/cgi/content/full/NEJMsa0810119
RESOURCES
www.patientsafetyinstitute.ca
www.ornac.ca
www.safesurgerysaveslives.ca
www.who.int/safesurgery
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BIBLIOGRAPHY

Part B
STANDARDS
FOR
Section 1
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STANDARD 1: Perioperative Registered Nursing Practice Requires Knowledge From Nursing, The
Sciences, And The Humanities.
STANDARD 2: Perioperative Registered Nursing Practice Requires The Effective Use Of The Nursing
Process For Clinical Decision-Making.
STANDARD 3: Perioperative Registered Nursing Practice Requires Perioperative Registered Nurses To Be
Professionally Responsible And Accountable.
STANDARD 4: Perioperative Registered Nursing Practice Requires That A Specific Perioperative
Registered Nurses(s) (Specialty Service Team Leader) Shall Be Assigned and Accountable
For A Specific Service Or Service Areas, Theatre(s), And/or Coordination Of
Multidisciplinary Team Members In The Provision Of Patient Care.
STANDARD 5: Perioperative Registered Nursing Practice Requires That The Perioperative Registered
Nurse Manager Coordinates The Direction And Availability Of Resources At A
Departmental Level.
STANDARD 6: Perioperative Registered Nursing Practice Requires That The Perioperative Registered
Nurse Educator Facilitates And Supports The Role Of The Perioperative Team.
STANDARD 7: Perioperative Registered Nursing Practice Requires That The Expanded Practice
Perioperative Registered Nurse Facilitates And Supports The Role Of The Perioperative
Team and the Perioperative Client.
STANDARD 8: Perioperative Registered Nursing Practice Requires That Perioperative Registered Nurses
Facilitate, Conduct and Support Research.
STANDARD 9: Perioperative Registered Nursing Practice Requires that the Advanced Practice Nurse
(Perioperative) Facilitates and Supports the Perioperative Health Needs of Client and the
STAND
Healthcare Team.
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PROFESSIONAL STANDARDS
STANDARD 1: Perioperative Registered Nursing Practice Requires Knowledge From

Nursing, The Sciences, And The Humanities.
KNOWLEDGE
1.1
Perioperative registered nursing practice requires the use of a conceptual model to

give direction for nursing practice.
The perioperative Registered Nurse shall practice in a manner that:

1.1.1
demonstrates knowledge, adheres to and promotes the mission, vision, values, philosophy,
objectives, goals, policies and procedures of the organization, while providing patient care;
1.1.2
accomplishes goals consistent with professional perioperative registered nursing standards. These goals
shall contribute to the overall goals of the health care team;
1.1.3
demonstrates knowledge of the health care facilities and surgical suite's organizational charts;
1.1.4
demonstrates knowledge of position description, scope of practice and limitations for surgical suite
personnel;
1.1.5
participates in the formulation and revision of surgical suite goals, objectives, policies and procedures;
1.1.6
ensures a caring, compassionate, and respectful approach is used in meeting the needs and concerns of the
patient and family/significant others;
1.1.7
provides specific care relating to the probable origin of the patient's actual or potential health problem;
1.1.8
improves or maintains the well-being of the patient applying consistency throughout the surgical
intervention;
1.1.9
promotes and supports the role of the perioperative Registered Nurse;
1.1.10
helps create a respectful environment that minimizes stress and anxiety;
1.1.11 identifies priority nursing diagnoses through a complete perioperative nursing assessment of the
patient;
1.1.12
identifies appropriate nursing interventions specific to individual patients requiring

surgical intervention;
1.1.13
evaluates and supports the expected outcomes for the perioperative patient;
1.1.14 promotes the concept of self-care for the perioperative patient;

1.1.15
is based on knowledge of perioperative policies and procedures;


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PROFESSIONAL STANDARDS FOR PERIOPERATIVE

REGISTERED NURSES
1.1.17
promotes and facilitates communication among all members of the health care team;
1.1.18
communicates and collaborates with management to promote and facilitate a progressive surgical suite
consistent with professional nursing standards, ORNAC standards and delivery of quality patient services;
and
1.1.19
exhibits clinical, operational, organizational and leadership skills to facilitate achievement of the surgical
suites mission, vision, values, philosophy, objectives, and goals in the delivery of safe patient care.
1.2
Perioperative registered nursing practice requires a base of knowledge, skills, and

competencies that are current and practical for meeting the needs of the surgical
patient.

1.2.1
uses current and accepted rationale when implementing nursing actions designed to meet the individual
needs of the surgical patient;
1.2.2
consistently applies the principles of Standard Precautions and additional precautions in reducing the risk of
infection to patients and the health care team;
1.2.3
consistently applies the principles of aseptic technique to reduce the potential risk of infection to the patient
and health care team;
1.2.4
consistently applies safety measures and risk management strategies for all patients and the health care
team;
1.2.5
implements, promotes, and facilitates the scrub, circulating, education, research, leadership roles, as well as
Registered Nurse First Assist (RNFA) and other expanded roles of the perioperative Registered Nurse;
1.2.6
complies with legal and professional requirements to participate in, implement, and maintain a safety and
risk management program that protects the patient and health care team from adverse consequences;
1.2.7
uses and manages human, material, and financial resources effectively;
1.2.8
values, initiates, promotes and participates in ethically approved research projects that are designed to
improve and/or evaluate patient care;
1.2.9
promotes change in nursing practice to strive for the best patient outcome based on the results of such
research;
1.2.10
consistently demonstrates competency in perioperative Registered Nursing practice progressing toward

expert levels;
1.2.11
exemplifies the perioperative Registered Nurse as a role model, preceptor and mentor;
1.2.12
shares knowledge and skills, and supports a positive learning environment for the healthcare team;

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1.1.16 promotes and participates in orientation of staff, continuing education and maintenance of
competence;
actively pursues, contributes to, plans, and organizes educational activities that maintain current
perioperative nursing practice levels consistent with professional nursing standards and ORNAC Standards,
Guidelines, and Position Statements For Perioperative Registered Nursing Practice;
1.2.14
incorporates reflective practice;
1.2.15
strives to advance the image of the perioperative Registered Nurse with competent and progressive clinical,
educational, research, leadership and administrative skills;
1.2.16
uses appropriate and professional communication skills (i.e., written, electronic, verbal, and non-verbal) for
the benefit of the patient, health care team, and health care facility; and
1.2.17
actively participates in collaborative practice utilizing positive reinforcement and constructive feedback
among the health care team and self-evaluation.
STANDARD 2:
Perioperative Registered Nursing Practice Requires The Effective Use Of The

Nursing Process For Clinical Decision-Making
CLINICAL DECISION-MAKING
2.1
Perioperative Registered Nurses are required to collect data during the

perioperative period.

2.1.1
includes a preoperative assessment prior to surgery through a systematic collection of data using appropriate
sources, including patient, family, significant others, physicians, unit nurses, and other health care team
members;
2.1.2
uses appropriate techniques for data collection including interview, consultation, observation,
and relevant health record review;
2.1.3
encourages the patient to confirm the assessment, allowing time to identify and discuss concerns and
expectations relative to the impending surgery and care;
2.1.4
provides information, resources, and/or other personnel to assist the patient/ legal designate in making
informed decisions and addressing concerns;
2.1.5
uses detailed assessment, intuitive, and observation skills to obtain information when the patient is unable to
participate and family/legal designate are not available;
2.1.6
encourages the expression of individual diversity regarding culture, race, age, sexual orientation, gender,
beliefs and values; and
2.1.7
respects patients and/or family's/significant others, or legal designates wishes i.e., a living will, power of
attorney, and personal care directives.
2.2
Perioperative Registered Nurses are required to analyze data collected in

accordance with the goals of perioperative registered nursing practice and
knowledge from related fields.

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1.2.13
2.2.1
effectively integrates and utilizes all data collected by the health care team to reduce redundant and
repetitive practices of questioning and review;
2.2.2
validates the assessment with the patient, and/or others as required to facilitate interpretation of the data
collected;
2.2.3
reassures the patient that the surgical team will analyze data and determine/identify actual and potential
problems;
2.2.4
communicates relevant data to the patient and appropriate others regarding identified actual and/or potential
problems; and
2.2.5
identifies and records specific nursing diagnoses and observations that define individual needs of
the patient.
2.3
Perioperative Registered Nurses are required to plan their nursing actions based
upon the identified actual and/or potential problems.

2.3.1
identifies and establishes priorities of patient care based on the preoperative assessment and nursing
diagnosis related to actual and/or potential health problems recognizing the patients individual diversities;
2.3.2
selects appropriate nursing actions based on the identified needs of the patient;
2.3.3
assists in identifying and reducing risk factors, actual or potential, that may compromise the patient, the
health care team, and the health care facility;
2.3.4
affirms the patient's readiness and willingness for the surgical intervention;
2.3.5
strives to provide environmental conditions that are conducive to positive patient outcomes;
2.3.6
strives to provide the required staffing and material resources for the specific patient needs;
2.3.7
communicates the plan of care to the patient, specified family members/designate, and the health care team;
and
2.3.8
provides a mechanism for, and actively participates in communication and problem solving with the patient,
family/legal designate, and the health care team.
2.4
Perioperative Registered Nurses are required to perform nursing actions, which

implement the nursing care plan.

2.4.1
encourages patient and family/significant others participation in implementation of nursing actions,

recognizing their individual diversities;

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presents a competent, professional and caring approach, which includes identifying themselves, their role
and responsibilities throughout the perioperative experience;
2.4.3
assists the patient to anticipate and understand steps in the care provided;
2.4.4
demonstrates responsibility, and accountability in implementing the nursing plan of care;
2.4.5
appropriately communicates nursing assessments, care activities, and interventions to the health care team;
2.4.6
appropriately delegates patient care activities to the health care team within their scope of practice and job
description;
2.4.7
effectively uses the appropriate human and material resources for patient care;
2.4.8
provides optimal care by adjusting the surgical theatre environment to meet the specific patient needs;
2.4.9
effectively communicates nursing interventions to the patient and/or family/legal designate;
2.4.10
consistently applies knowledge, and uses skills, competencies, and safety measures;
2.4.11
assists the anesthesiologist in providing patient care consistent with the knowledge, competencies, and skills
of the perioperative Registered Nurse;
2.4.12
provides psychological and physical support to the patient during local anesthesia and conscious sedation;
2.4.13
monitors and accurately documents patient parameters during local anesthesia and in procedures when an
anesthesiologist is not present;
2.4.14
assists, facilitates, and supports the surgical team's activities throughout the perioperative experience;
2.4.15
provides appropriate response to emergency situations;
2.4.16
maintains accurate, legible, timely and complete documentation, using only accepted abbreviations of the
health care facility; and
2.4.17
contributes to and maintains a communication network that facilitates a progressive, integrated, successful,
positive, and safe work environment.
2.5
Perioperative Registered Nurses are required to evaluate all steps of the nursing
process.

2.5.1
evaluates and communicates the outcomes of patient care; and
2.5.2
respects the individual diversity of the patient while recommending, supporting and implementing
modifications to the nursing care plan.
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2.4.2
Perioperative Registered Nursing Practice Requires Perioperative Registered Nurses

To Be Professionally Responsible And Accountable.
PROFESSIONAL RESPONSIBILITY AND ACCOUNTABILITY
3.1
Perioperative Registered Nurses are required to comply with legislation and policies
relevant to the profession and the Surgical Suite.

3.1.1
adheres to the professional and legally recognized scope of practice for the protection of the patient, self,
employer, and the health care team;
3.1.2
complies with organizational and regulatory body policies and legalities pertaining to perioperative
registered nursing practice;
3.1.3
reports and documents errors, near misses, unsafe practice, incapacity, incompetence, or professional
misconduct to the appropriate person(s);
3.1.4
is based on knowledge, and practice requirements related to registration, competence, credibility and
licensure of the perioperative Registered Nurse; and
3.1.5
demonstrates the responsibility to notify their employer that they are unable to give appropriate care if they
do not have the necessary physical, mental or emotional health.
3.2
Perioperative Registered Nurses are required to be professionally responsible and

accountable.

3.2.1
values, and meets the needs of, patients and the health care team;
3.2.2
provides appropriate documentation and effective reporting of sentinel events, crisis situations and near
misses;
3.2.3
provides appropriate and safe patient care regardless of personal limitations or prejudices;
3.2.4
exercises prudent and reasonable judgment in completing perioperative nursing activities in a timely
fashion;
3.2.5
delivers clinical practice that reflects current evidence-based knowledge;
3.2.6
consistently demonstrates responsibility and accountability for own actions;
3.2.7
monitors actions of the health care team that constitute non-compliance and reports/documents
appropriately;
3.2.8
promotes patient advocacy and practices patient safety;
3.2.9
promotes professional perioperative registered nursing activities;
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STANDARD 3
encourages, participates in, and supports programs that provide professional development;
3.2.11
encourages, participates in, and supports preceptorship and mentoring of students, novices, and newly hired
perioperative Registered Nurses, colleagues and auxiliary personnel;
3.2.12
uses knowledge, skills, and competencies consistent with the standards for perioperative registered nursing
care and other related standards;
3.2.13
confirms that emergency equipment and supplies are available at all times and has knowledge of their use;
3.2.14
exhibits knowledge of, and participation in, safety programs that protect the patient, self, and the health care
team; and
3.2.15
demonstrates awareness of the evacuation routes out of the surgical suite and is familiar with disaster plans.
3.3
Perioperative Registered Nurses are required to comply with the Code of Ethics for
Registered Nurses.

3.3.1
complies with the Canadian Nurses Association Code of Ethics for Registered Nurses.
3.4
Perioperative Registered Nurses are required to function as an integral member of

the health care team.

3.4.1
maintains a collaborative and professional working relationship with the health care team, including but not
limited to, surgeons, anesthesiologists, nursing units, administration, interdisciplinary teams, auxiliary staff
and colleagues, to achieve and maintain an efficient, effective safe working environment;
3.4.2
actively promotes and collaborates with administration to facilitate empowerment and job satisfaction;
3.4.3
promotes and exhibits skills in conflict resolution, interpersonal relationships, and leadership;
3.4.4
demonstrates respect, a caring attitude, and professional conduct;
3.4.5
encourages and provides collaboration with the health care team to complete the nursing process;
3.4.6
facilitates coordination of patient care within a multidisciplinary team;
3.4.7
demonstrates efficient management of human, material, and financial resources;
3.4.8
assigns and evaluates the use of resources in collaboration with the surgical suite team to determine staffing,
equipment and resources necessary to comply with safety standards and guidelines; and
3.4.9
demonstrates zero tolerance for violence, bullying, harassment and discrimination in the workplace.
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3.2.10
4.1
Perioperative Registered Nursing Practice Requires That A Specific Perioperative

Registered Nurse(s) (Specialty Service Team Leader) Shall Be Assigned And
Accountable For A Specific Service Or Service Areas, Theatre(s), And/or
Coordination Of Multidisciplinary Team Members In The Provision Of Patient
Care.
Perioperative registered nursing practice requires a complex level of coordination of

multidisciplinary team members to provide surgical intervention, which
encompasses a significant number of risk potentials. A theatre, surgical suite or
service area(s) require an assigned perioperative Registered Nurse to coordinate
activities.
The perioperative Registered Nurse assigned a service, theatre, or group of theatres shall practice in a manner that:
4.1.1
confirms that an identified, qualified, perioperative Registered Nurse is assigned to and accountable for the
care of patients in that service;
4.1.2
maintains and expands specialty knowledge, implements and communicates changes in the specialty
service;
4.1.3
demonstrates leadership skills to support and advance the practice of the health care team;
4.1.4
coordinates preoperative communication with the health care team i.e., changes in the scheduled surgery
time;
4.1.5
builds and promotes a collegial relationship between other units and the surgical suite for continuing
education, service delivery, and continuous quality improvement that will benefit and enhance patient care;
4.1.6
collaborates with administration to maintain and acquire appropriate instrumentation, equipment and new
technology; and
4.1.7
maintains a relationship with vendor representation in accordance with corporate policies and that assists in
the provision of education for the health care team.
4.2
Perioperative Registered Nurses assigned a service, theatre, or group of theatres

shall establish a collaborative relationship and environment that facilitates the role
of the surgeon.

4.2.1
verifies accurate scheduling information for each patient and resolves discrepancies;
4.2.2
identifies and monitors staff identification of problems related to resource limitations or equipment
deficiencies in order to facilitate alternate plans;
4.2.3
organizes surgery times in consultation with staff and physicians, to meet the needs of the patient and the
health care team;
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STANDARD 4:
monitors requirements for surgical assistance and/or equipment in consultation with the surgeon for specific
types of surgery, ensuring availability of equipment; and
4.2.5
confirms the environment and personnel are prepared in sufficient time to facilitate surgical procedures.
4.3 Perioperative Registered Nurses assigned a service, theatre, or group of theatres shall
establish a collaborative relationship and environment that facilitates the role of the
anesthesiologists.
4.3.1
confirms that theatre and anesthetic equipment, supplies, and required drugs are available prior to the
admission of the patient to the theatre;
4.3.2
acknowledges the importance and critical nature of anesthesia by being present to assist with pre-induction,
induction, positioning, and emergence;
4.3.3
assists with, and effectively communicates complications or difficult situations/crisis to the appropriate
personnel; and
4.3.4
serves as a resource and mentor to other perioperative Registered Nurses regarding effectively and
efficiently assisting the anesthesiologist.
4.4

shall establish a collaborative relationship and environment with auxiliary personnel
and interdisciplinary members of the health care team.

4.4.1
maximizes resources and experience in assigning scrub, circulating, charge and preceptor duties for patient
care, teaching and staff development;
4.4.2
promotes a work environment that minimizes stress, anxiety, and respects individual health care team
members;
4.4.3
supports an environment that integrates and maximizes collaboration with the health care team by taking
appropriate action when non-supportive or unacceptable behaviors occur;
4.4.4
assists in the orientation of perioperative personnel and provides positive and constructive feedback related
to performance;
4.4.5
identifies and monitors areas for improvement with specific recommendations;
4.4.6
apprises administration of activities, problems, solutions, recommendations, and performance of the health
care team;
4.4.7
assigns auxiliary personnel to maximize patient care, efficiency, and resources;
4.4.8
acts as a resource to staff in the management of equipment and instrumentation with respect to safety,
aseptic technique, preventative maintenance, care, and handling according to health care facility protocols
and manufacturer's recommendations; and
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4.2.4
monitors compliance with policies, procedures, and promotes ORNAC Standards, Guidelines and Position
Statements For Perioperative Registered Nursing Practice.
4.5

shall establish a supportive environment for the patient.

4.5.1
supports the patient throughout the perioperative phases by acting as a patient advocate;
4.5.2
reduces waiting time to a minimum for the patient waiting in the preoperative phase in the surgical
suite;
4.5.3
reduces the stresses of the pre-induction phase by coordinating and organizing activities, providing physical
comfort, controlling temperature, and reducing noise levels;
4.5.4
strives to reduce patient risk;
4.5.5
facilitates positive patient outcomes in an expedient and effective manner; and
4.5.6
communicates with family/designate/significant other.
PROFESSIONAL STANDARDS FOR PERIOPERATIVE REGISTERED

NURSE MANAGERS
STANDARD 5
Perioperative Registered Nursing Practice Requires That The Perioperative

Registered Nurse Manager Coordinates The Direction And Available Resources At
A Departmental Level.
MANAGEMENT
5.1
The perioperative Registered Nurse manager works collaboratively with all

members of the health care team to ensure appropriate resource allocation and to
provide direction.
The perioperative Registered Nurse manager shall practice in a manner that:

5.1.1
ensures the facility mission; vision, values, philosophy, objectives and goals are communicated and
available to the health care team;
5.1.2
ensures surgical suite objectives and goals are compatible with those of the facility, and are communicated
and available to the health care team;
5.1.3
assures current policies, procedures, and protocols, ORNAC Standards, Guidelines and Position statements
for Perioperative Registered Nursing Practice, perioperative nursing resource material and relevant CSA
standards are available for the health care team;
5.1.4
ensures the health care team is compliant with facility policies, procedures, and protocols, local, provincial

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4.4.9
5.1.5
provides the health care team with a current organizational chart outlining department structure, lines of
reporting, communication, authority and accountability;
5.1.6
maintains current position descriptions;
5.1.7
ensures the health care team is knowledgeable about expectations, roles, responsibilities and
accountabilities;
5.1.8
completes a review of department policies, procedures and protocols based on standards of practice, job
descriptions, and health care team input according to the frequency required by the health care facility;
5.1.9
promotes patient advocacy and supports the patients right to self-determination;
5.1.10 facilitates, promotes and encourages interdisciplinary perioperative activities, projects, audit reviews and
research;
5.1.11
facilitates, promotes, and encourages perioperative Registered Nurses to participate in the development,
review, and revision of policies and procedures, related to perioperative Registered Nurses documentation;
5.1.12 ensures compliance with documentation requirements and incorporation of current standards;
5.1. 13 provides the health care team with appropriate educational opportunities for improvement of
identified learning needs;
5.1.14
facilitates and encourages staff development, continuing education and membership in

perioperative professional organizations;
5.1.15
ensures an appropriate orientation program is provided by the perioperative educator or a qualified

designate;
5.1.16
employs health care team members with knowledge, experience, attitude, skills, competencies, and
attributes to support excellence in patient care within a positive high-performance team;
5.1.17 facilitates, promotes and encourages active participation of the health care team in responsible and efficient
management of human, material and financial resources;
5.1.18
provides health and wellness information, and promotes regular attendance at work;
5.1.19
completes performance appraisals in a timely manner, including review of accomplishments and

competencies, assisting the team members to perform self-assessment, establishment of goals for
performance improvement, competency enhancement and professional development;
5.1.20 maintains effective risk management strategies including prevention, reporting, investigation, and resolution
of unusual occurrences and sentinel events;
5.1.21
ensures implementation of a safety program with a focus on prevention of adverse events for patients and
the health care team; and
5.1.22
promotes a practice environment that supports effective interdisciplinary communication,

professional responsibility and accountability, critical-thinking and problem-solving.
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and federal legislation, and professional standards of practice;

5.2.1
encourages and promotes health care team members to participate and collaborate in research;
5.2.2
encourages evidence-based decision-making in the formulation of policies and procedures affecting surgical
suite practices;
5.2.3
facilitates and promotes respect, caring, and professional conduct among all health care team members;
5.2.4
establishes and promotes an open and positive interpersonal communication network; and
5.2.5
models, promotes and encourages the acquisition and maintenance of Certification in Perioperative Nursing
for perioperative Registered Nurses.
5.3
The Perioperative Registered Nurse manager implements a continuous quality

improvement program.

5.3.1
collaborates with quality improvement personnel to promote enhancement of perioperative care;
5.3.2
ensures professional nursing standards, ORNAC Standards, Guidelines, and

Position Statements for Perioperative Registered Nursing Practice, and appropriate CSA
Standards are easily accessible;
5.3.3
provides human and material resources within the existing budget of the health care facility while
maintaining standards of patient care;
5.3.4
encourages staff to participate in the quality improvement cycle; and
5.3. 5
reviews quality improvement reports, evaluates recommendations, shares information with the health care
team in a timely manner, and ensures appropriate changes are implemented and sustained.
PROFESSIONAL STANDARDS FOR PERIOPERATIVE REGISTERED

NURSE EDUCATORS
STANDARD 6
6.1
Perioperative Registered Nursing Practice Requires That The Perioperative

Registered Nurse Educator Facilitate And Supports The Role Of The Perioperative
Team.
The perioperative team requires a variety of specific skills and knowledge for a high
level of performance, which is best achieved when the perioperative Registered
Nurse educator facilitates and supports the learning needs of the team.
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5.2 The Perioperative Registered Nurse manager encourages continued professional

development of health care team members.
6.1.1
demonstrates leadership as it relates to health trends and issues for perioperative nursing;
6.1.2
encourages staff and students to identify their learning needs;
6.1.3
facilitates staff and student learning to acquire the requisite skills and knowledge in the appropriate job
classification;
6.1.4
co-ordinates resources for appropriate orientation for students and new staff members;
6.1.5
supports staff and students in establishing expectations of performance, competency, goals, and
opportunities at time of hire;
6.1.6
facilitates staff and students learning opportunities;
6.1.7
provides professional and educational resources as required;
6.1.8
facilitates, supports, and/or contributes to resources required for ongoing post basic education, certification,
and expanded/advanced perioperative registered nursing roles;
6.1.9
provides assistance to staff and students who are developing educational materials and presentations;
6.1.10
facilitates opportunities for continuing education, such as specialty development, and emerging
technologies;
6.1.11
facilitates staff and students in problem-solving and goal attainment;
6.1.12
demonstrates a team approach in coordinating educational activities;
6.1.13
assists perioperative team members to apply theory to perioperative practice;
6.1.14
monitors and adjusts efficacy of educational activities for continuous quality improvement of learner and
patient outcomes;
6.1.15
supports and contributes to a learning environment that is appropriate for the patient care and services that
are provided;
6.1.16
facilitates and supports an environment that demonstrates zero tolerance for violence, bullying,
harassment and discrimination in the workplace;
6.1.17
facilitates an environment that is conducive to change and encourages collaborative practice;
6.1.18
collaborates with a multidisciplinary team to solve problems and change processes to improve function,
quality of patient care, and support systems;
6.1.19
develops and supports specialty service team leaders, preceptors and mentors;
6.1.20
facilitates a structured means to improve performance of team members not meeting expected standards in a
timely and progressive manner ;
6.1.21
demonstrates knowledge of the strategic plan of the organization and anticipates the related educational
needs;

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The perioperative Registered Nurse educator shall practice in a manner that:
contributes to the development and revision of standards of nursing practice;
6.1.23
monitors compliance with policies, procedures, and promotes ORNAC Standards, Guidelines and Position
Statements for Perioperative Registered Nursing Practice;
6.1.24
promotes and encourages research;
6.1.25
shares relevant research findings with staff, students and colleagues formally and informally;
6.1.26 demonstrates excellent organizational skills and facilitates processes for staff to achieve excellence in
perioperative patient care;
6.1.27
co-ordinates the monitoring of probationary performance through consultation processes for the
completion of appraisals;
6.1.28
supports the health care teams understanding of the importance of compliance with departmental
policies, procedures and protocols; and
6.1.29 supports and encourages staff and students to actively participate in their professional groups or
organizations.
BIBLIOGRAPHY
Association of PeriOperative Registered Nurses. (2008). Perioperative standards and recommended
practices. Denver: Author.
Canadian Nurses Association. (2008). Code of ethics for Registered Nurses. Ottawa: CNA.
Philips, N. (2007). Berry & Kohns operating room technique. (11th ed.). Toronto: Mosby.
PROFESSIONAL STANDARDS FOR EXPANDED PRACTICE

PERIOPERATIVE REGISTERED NURSES
STANDARD 7:
Perioperative Registered Nursing Practice Requires That The Expanded Practice

Perioperative Registered Nurse Facilitates And Supports The Role Of The
Perioperative Team and the Perioperative Client.
Perioperative nursing is a specialized area of practice.

Perioperative registered nursing practice encompasses a wide range of specialties. Currently in Canada, there are two
recognized roles for expanded practice, the Registered Nurse First Assistant (RNFA) and the Registered Nurse
Anesthetic Assistant (RNAA). These roles require the perioperative Registered Nurse to obtain, through formal
education, preparation that includes supervised clinical practice, development of cognitive, psychomotor and
affective behaviors that are necessary to function in a collaborative relationship with the operating surgeon and/or
anesthesiologist and other members of the health care team. (Vaiden, 2005, p.1).
Registered Nurse First Assistants and Registered Nurse Anesthetic Assistants progress from novice to expert, as
nurses generally function at a variety of levels depending on knowledge, skills, work environment, and experience.
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6.1.22
The expanded practice perioperative Registered Nurse is accountable and

responsible for their actions within accepted legal, professional and ethical
standards established by their regulatory body.
The expanded practice perioperative Registered Nurse shall practice in a manner that:
7.1.1
is responsible for continuing education and maintaining competence; and
7.1.2
is accountable for their own level of competence while acting in this role and seeks consultation as
required.
7.2
The expanded practice perioperative Registered Nurse demonstrates competencies

relevant to their own perioperative practice environment.
7.2.1
delivers expert care drawn from integrated knowledge and experience, and integrates knowledge from other
disciplines into their practice;
7.2.2
demonstrates knowledge grounded in nursing and medical theory, professional standards, competencies,
and ethical reasoning;
7.2.3
facilitates the integration of research-based knowledge into their practice;
7.2.4
demonstrates the ability to influence health policy by using critical thinking skills; and
7.2.5
promotes a practice environment that supports continuous professional development of standards, which are
evidence based.
7.3
The expanded practice perioperative Registered Nurse advocates for patients.
7.3.1
promotes a practice environment that advocates for the patients; and
7.3.2
promotes a safe environment facilitating optimal patient outcomes.
REFERENCES
Association of PeriOperative Registered Nurses. (2005). Core Curriculum for the RN First Assistant. (4th
Ed.). Denver: Author.
Vaiden, R. E. (ed) (2005). Core Curriculum for the RN First Assistant. (4th Ed.). Denver: AORN.
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7.1

BIBLIOGRAPHY
Arpin, J. (2005). Nurse First Assistant, (NFSA) Canadian Operating Room Nursing Journal, 23(4), 3236.
Australian College of Operating Room Nurses. (2006). ACORN Standards for Perioperative Nursing
Practice including Nursing Roles, Guidelines, Position Statements and Competency Standards,
Anesthetic Nurses, NR1. Adelaide: ACORN.
Perioperative Nurse Surgeons Assistant, (PNSA). Adelaide: ACORN.
Advanced Practice Nursing Role, (NR5). Adelaide: ACORN.
College of Registered Nurses of Nova Scotia. (2005). Position statement on Registered Nurse First
Assistant Role, Halifax: CRNNS.
Giannidis, R. (2005). RNFAs: one innovative solution as hospitals cope with doctor shortage, Hospital
News, 18(1), 17.
Groezsch, G. (2004). Why An RN First Assistant? A Look at the Benefits. Canadian Operating Room
Nursing Journal, 21(2), 21-23.
Ilton, S. (2002). The Benefits of Registered Nurse First Assistant Practice, Canadian Nurse, 98(6), 22-27.
National Health System. (2006). National Practitioner Program Physician Assistant Factfile, UK, NHS.
Nurses Association of New Brunswick, (2003). Position Statement Registered Nurse First Assistant,
(RNFA), Saint John, NANB.
Phillips, N. (2007). Berry & Kohns Operating Room Techniques. (11th ed.). St Louis: Mosby.
Rothrock, J. (2007). Alexanders Care of the Patient in Surgery. (13th ed.). St. Louis: Mosby.
Spry, Cynthia. (2005). Essentials of Perioperative Nursing, 3rd (ed.). Sudbury Mass: Jones & Bartlett.
Weeks, M. (2002). Determining the cost-effectiveness of the Registered Nurse First Assistant: the Research
Link. Canadian Operating Room Nursing Journal, 20(4), 16-21.
PROFESSIONAL STANDARDS FOR PERIOPERATIVE

REGISTERED NURSES CONDUCTING RESEARCH
STANDARD 8:
Perioperative Registered Nursing Practice Requires That Perioperative Registered

Nurses Facilitate, Conduct and Support Research.
As nursing practice is evidence-based, nursing research related to clinical practice, education, and
management within the perioperative setting is essential to the achievement and maintenance of optimal
patient outcomes. Research is a professional obligation and assists in providing and ensuring evidencebased practice that is safe and effective. Registered Perioperative Nurses assume different roles in the
research process as appropriate to their education, competence, roles and responsibilities. (CRNBC, 2005)
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The perioperative Registered Nurse shall conduct research according to the nursing
research process. This process will be ethical, open, honest and transparent.
The perioperative Registered Nurse conducting research shall practice in a manner that includes:
8.1.1
writing the research proposal;
8.1.2
identifying and focusing on the issue;
8.1.3
defining the aims of the study;
8.1.4
establishing and ensuring its ethical status;
8.1.5
measuring, collating and analyzing the data;
8.1.6
making conclusions and recommendations; and
8.1.7
reporting and disseminating the findings.
8.2
Perioperative Registered Nursing research shall be conducted within the parameters

of competent, professional, safe, and ethical registered nursing research practice.
The perioperative Registered Nurse conducting research shall practice in a manner that:
8.2.1
performs research within the accepted legal, professional, and ethical standards;
8.2.2
functions within the policies and guidelines of specific organizations, federal and provincial/ territorial
legislation;
8.2.3
respects the rights of patients, their families, and individuals involved in a research project;
8.2.4
promotes a research environment that supports patient advocacy, participation and safety; and
8.2.5
is professionally accountable and responsible while practicing within a research environment.
8.3
Research-based knowledge shall be integrated into practice to improve the quality of

perioperative patient care.

8.3.1
uses research to demonstrate the relationship between nursing interventions and patient outcomes;
8.3.2
promotes a practice environment, which supports the conduct of research;
8.3.3
facilitates closing the gap between theory and practice in order that the results of research may be safely
implemented; and
8.3.4
demonstrates cognizance of topics requiring research.
8.4
Perioperative Registered Nurses shall participate in nursing research.


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8.1
8.4.1
participates in research activities such as data collection, dissemination of research results, implementation
of recommendations, and identifying areas for further research;
8.4.2
recognizes areas of patient care, which may be improved through research;
8.4.3
informs colleagues of research activities;
8.4.4
advocates for ongoing research designed to identify best nursing practices and for collection and
interpretation of nursing case data at a national level (CNA Code of Ethics, 2002); and
8.4.5
promotes a work environment, which supports and enhances research.
REFERENCES
Canadian Nurses Association. (2008). Code of ethics for Registered Nurses. Ottawa: CNA.
College of Registered Nurses of British Columbia, (2005). Position statement Nursing and Research.
Vancouver: CRNBC.
BIBLIOGRAPHY
Anesthetic Nurses, NR1. Adelaide: ACORN.
Beyea, Suzanne C. (2004). Evidence-based practice in perioperative nursing. American journal of Infection
Control, 32(2), 97-100.
Canadian Nurses Association. (2002). Position statement on expanded nursing practice. Ottawa: Author.
Canadian Nurses Association (2002). Everyday Ethics- Putting the code into practice (2nd ed.). Ottawa:
Author.
College of Registered Nurses of British Columbia, (2005). Position statement Nursing and Research.
Vancouver: CRNBC.
Wilkes, Lesley, (2005). Role Conflict: appropriateness of a nurse researchers actions in the clinical field.
Nursing Research, 14(5), 57-70.
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STANDARD 9:
Perioperative Registered Nursing Practice Requires that the Advanced Practice Nurse
(Perioperative) Facilitates and Supports Meeting the Perioperative Health Needs of
Individuals, Families, Groups, Communities, and Populations.
Definition:
Advanced nursing practice is an umbrella term describing an advanced level of clinical nursing practice that
maximizes the use of graduate educational preparation, in-depth nursing knowledge and expertise in meeting the
health needs of individuals, families, groups, communities, and populations (CNA, 2008, p. 9). Advance Practice
Nurses (APN) include both Nurse Practioners (NP) and Clinical Nurse Specialists (CNS). APNs are change agents
who function as consultants, researchers, educators, administrators and practicing caregivers.
Accountability and Responsibility
9.1
The APN (Perioperative) is accountable and responsible to the public for safe,
competent, effective, evidence-based, and ethical nursing practice whether providing
direct perioperative healthcare or through a supportive/consultative role .
APNs (Perioperative) have greater autonomy with a high level of accountability and shall practice in a manner that:
9.1.1
is appropriate for nurses who have acquired education at the graduate level to meet the needs of the
perioperative population (Masters or Doctorate with an advanced practice concentration);
9.1.2
contributes to the evolution of the role;
9.1.3
requires continued competence to meet the evolving challenges of health care delivery.
9.1.4
promotes perioperative nursing research and generates new knowledge (CNA, 2008); and
9.1.5
uses academic preparation, synthesis and knowledge-transfer skills to interpret and incorporate
new knowledge into clinical practice (CNA, 2008, p. 13)
9.2
The APN (Perioperative) continuously evaluates their practice based on defined core
competencies.
Advocate
9. 3
The APN (Perioperative) is an active client advocate.
The APN (Perioperative) will advocate for clients in a manner that:

9.3.1
consistently demonstrates autonomy of practice in collaboration with other

disciplines;
9.3.2
promotes an environment where advocacy is the norm; and
9.3.3
acts to influence organizational and health care policy.


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PROFESSIONAL STANDARDS FOR ADVANCED

PRACTICE NURSES (PERIOPERATIVE)
Canadian Nurses Association. (2008). Advanced Nursing Practice a National Framework. Ottawa: Author.
Hamric, A.B., Spross, J.A., and Hanson, C.M., (2005). Advanced nursing practice: An integrative approach.
Philadelphia: W.B.Saunders Company.
BIBLIOGRAPHY
Canadian Nurses Association. (2008). Position Statement - Workplace Violence. Ottawa: Author.
Canadian Nurses Association. (2004). Position Statement - Promoting Culturally competent Care. Ottawa: Author.
Canadian Nurses Association. (2004). Joint Position Statement - Promoting Continuing Competence. Ottawa:
Author.
Newland, C. E. M. (2007, June). The joys of perioperative nursing. Canadian Operating Room Nursing
Journal,25 (2), 20, 22, 23, 25-28, 36.
Reseoul, S. L. (2008). Making a Difference Through Research. AORN Journal, 88 (5).
Rothrock, J. C. (2009). Education an Issue of Perioperative Nursing Clinics. Philadelphia:
Elsevier/Mosby.
Saskatchewan Registered Nurses Association (SRNA), (2007). Standards and Foundation Competencies for the
Practice of Registered Nurses. Regina: Author.
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REFERENCES

Part C
COMPETENCIES
FOR
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The novice states and/or demonstrates knowledge and skills but is still learning to anticipate and incorporate
perioperative skills into efficient planning, actions, and clinical decision-making. Performance requires
supervision, coaching, and preceptoring.
The intermediate practitioner confidently and accurately applies knowledge and skills in the clinical setting,
is capable of anticipating, and is prepared to function independently and be supportive to others, in usual or
unusual circumstances. Performance may require occasional supervision and coaching. The intermediate
practitioner is able to assist, guide, teach, and supervise the beginner and take charge of limited situations.
The expert's scope of knowledge and skills is such that all actions are directed toward anticipated outcomes.
The expert intuitively adapts to changing situations and implements the appropriate action(s) prior to the
event(s) or demand(s) of patient care. The expert perioperative Registered Nurse will independently
supervise, teach and coach/precept health care team members, manage direct patient care, and the specific
theatre or the entire surgical suite. The expert practices as a role model and mentor and is able to take
charge and effectively manage complex situations.
PURPOSE OF COMPETENCY STATEMENTS
Competency statements for perioperative Registered Nurses shall:
affirm that perioperative Registered Nurses are responsible for the nursing care they provide to the surgical
patient during the perioperative period;
state the knowledge, skills, professional practice, and leadership required for accountable clinical decisionmaking;
assist in the development and maintenance of the perioperative Registered Nurses position descriptions;
provide the basis for orientation and continuing/formal educational programs;
provide perioperative Registered Nurses with a tool for performance appraisal and self-evaluation;
enhance the professional image of perioperative Registered Nurses;
assist in the development of a standard guideline for working with CNA and all schools of nursing in
promoting perioperative experience in basic nursing education;
assist in the development, revision, and integration of the Canadian Standards Association (CSA) Standards;
and
provide a basis for clinical advancement, career development, leadership opportunities, and expanded
perioperative practice.
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Competencies range in progression from those expected of the beginner/novice to those essential in the expert. These
stages may be defined as follows:
A Registered Nurse shall bring:
a holistic approach to patient care that incorporates knowledge of the biological, physiological,
psychological, social, cultural, environmental, and spiritual needs of the patient;
the ability to relate disease processes, trauma, and illness to health and wellness, recognizing the impact of
the environment and support systems on overall patient outcomes;
knowledge of the natural and social sciences (anatomy, physiology, microbiology, psychology, sociology,
and pharmacology);
the ability to apply the nursing process in problem-solving and clinical decision-making using evidencebased knowledge;
a caring attitude that includes acting as a patient advocate;
the ability to assist and support patients or their designates to make informed choices;
effective and positive communication and interpersonal skills;
the ability to provide quality education to patients and their families/significant others;
personal commitment to the nursing profession, which is demonstrated by accountability and responsibility
for continuing education, maintenance of competencies, quality improvement in nursing practice, and
involvement in professional associations;
a positive attitude, willingness and ability to mentor/preceptor members of the health care team;
psychomotor dexterity that indicates the ability to accurately perform complex skills in limited time periods;
and
the ability to recognize and manage personal stress and stressful situations in a constructive and positive
manner.
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Knowledge, Skills and Attributes Expected of the Registered Nurse Entering

The Specialty of Perioperative Nursing

CHARACTERISTICS OF EACH COMPETENCY

The specialty of perioperative nursing requires that specific competencies be identified, progressing from
the beginner to expert practitioner. All of the following characteristics are integrated components for
each competency statement:
knowledge;
respect;
clinical decision-making;
communication skills;
team-work skills;
accountability and responsibility;
organizational skills; and
teaching and leadership ability.
COMPETENCIES OF PERIOPERATIVE REGISTERED NURSES

COMPETENCY 1: Practices Professionally
COMPETENCY 2: Provides Physical Care
Circulating Role
Scrub Role
COMPETENCY 3:
Provides Supportive Care

Client/Designate
Health Care Team Members
COMPETENCY 4:
Promotes A Safe Environment
COMPETENCY 5:
Responds To Urgent/Emergency Situations
COMPETENCY 6:
Manages Resources
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COMPETENCY 1: Practices Professionally

LEGAL PRACTICE
1.1
is congruent with the CNA Code of Ethics and healthcare facility ethical guidelines;
1.2
demonstrates commitment to continually improve the knowledge and skills required to respond with
compassion to the patients health care needs;
1.3
is congruent with ORNAC, CNA, and provincial professional association standards of practice/regulatory
body, as well as the policies and procedures of the health care facility; and
1.4
incorporates promotion of, and compliance with, the health care facility mission, vision, values, philosophy,
objectives, goals, policies, and procedures for perioperative registered nursing.
PROFESSIONAL PRACTICE
1.5
complies with the legal requirements of the professional association/regulatory bodies, current legislation,
policies of the healthcare facility, and standards of care;
1.6
maintains and continually improves competence by identifying learning needs and seeking opportunities for
improvement;
1.7
establishes and maintains respectful, collaborative and therapeutic professional relationships;
1.8
exemplifies characteristics of a mentor/role model by sharing expertise, experience, and skills;
1.9
involves participation in, contribution to, and support of, professional perioperative registered nursing
activities;
1.10
takes responsibility for developing leadership skills;
1.11
is accountable and responsible for their actions and decisions at all times;
1.12
adapts to changes within the health care system that impact their practice;
1.13
understands, participates in, identifies and recommends quality management activities in relation
to perioperative patient care; and
1.14
identifies, documents and reports unprofessional conduct.
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COMPETENCIES OF THE PERIOPERATIVE REGISTERED NURSE
CIRCULATING ROLE
2.1
assesses the physical status of the patient;
2.2
develops, modifies and documents the individualized plan of care, or a clinical pathway to meet the specific
needs of the patient;
2.3
provides resources for the health care team to function efficiently;
2.4
provides physical comfort measures specific to each surgical patient;
2.5
provides appropriate care during the admission, pre-induction, induction, intraoperative, and emergence
phases;
2.6
performs the surgical count procedure concurrently with the scrub nurse and documents accurately;
2.7
uses a surgical conscience to maintain and monitor the integrity of the sterile field;
2.8
reduces risk by providing continuous, astute, and vigilant observation of the surgical team throughout the
surgical phase meeting the health care team and patient's needs;
2.9
acts as the patient's advocate throughout the perioperative period;
2.10
responds appropriately to complications and unexpected events during the perioperative period;
2.11
organizes and coordinates appropriate resources in a timely manner in preparation for the subsequent
patient;
2.12
provides and assists with procedures/devices required to complete patient care following the
surgical procedure;
2.13
assists in the patient transfer and postoperative positioning;
2.14
accurately and appropriately documents nursing, surgical, and other health care team activities during the
perioperative period;
2.15
promotes appropriate communication techniques to keep noise levels at a minimum;
2.16
assists with patient transport to a receiving unit and communicates pertinent patient information;
and
2.17
organizes and coordinates appropriate resources to ensure an efficient theatre turnover.
SCRUB ROLE
2.18
sets priorities and expedites an efficient aseptic set-up for each surgical procedure;

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COMPETENCY 2: Provides Physical Patient Care
applies knowledge and skills while anticipating and adapting to changes in the surgical procedure;
2.20
is vigilant and attentive throughout the surgical procedure, and responds appropriately to complications and
unexpected events;
2.21
uses a surgical conscience to monitor aseptic technique throughout the procedure;
2.22
performs the surgical count concurrently with the circulating perioperative Registered Nurse and accounts
for all items;
2.23
demonstrates knowledge and function of instruments and equipment;
2.24
identifies malfunction or breakage of surgical instruments and equipment, and responds appropriately to
ensure patient and health care team safety;
2.25
acts as the patient's advocate during the surgical procedure;
2.26
appropriately teaches and coaches learners throughout the surgical procedure;
2.27
promotes appropriate communication techniques to keep noise at a minimum; and
2.28
dismantles the surgical set-up in a timely manner to contribute to an efficient turnover.
COMPETENCY 3: Provides Supportive Care
TO THE PATIENT AND FAMILY/DESIGNATE

3.1
establishes a supportive relationship that fosters trust and respect;
3.2
remains attentive to the needs of the patient throughout the perioperative period;
3.3
provides explanations and demonstrates a caring attitude;
3.4
provides an environment in which the patient feels safe;
3.5
conveys a collaborative team concept for the patient;
3.6
effectively advocates and supports the right to make informed decisions; and
3.7
responds appropriately to complications, unusual occurrences and sentinel events.
TO THE HEALTH CARE TEAM

3.8
confirms the presence of appropriate staff with the required skills are available for the intended surgical
procedure;

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2.19
contributes to and encourages collaborative and positive working relationships promoting team problemsolving and decision-making;
3.10
supports and assists in sharing knowledge, expertise, and skills;
3.11
manages stressful situations in a positive manner; and
3.12
advocates for time and support to be available as needed to debrief team members following crisis
situations.
COMPETENCY 4: Promotes A Safe Environment

4.1
uses a surgical conscience to practice, teach, and monitor aseptic technique, environmental control, and
other infection control practices;
4.2
provides immediate and appropriate action when safety is compromised;
4.3
prevents and/or effectively responds to fires, disasters, and other crisis events;
4.4
practices and facilitates compliance with Workplace Hazard Materials Information System
(WHMIS) regulations, safety policies and procedures;
4.5
follows regulations related to the care, handling, use, and documentation of narcotics and controlled drugs;
4.6
follows regulations and guidelines regarding registration and tracking of implanted devices,
transplanted organs, cells and tissue;
4.7
practices, teaches, and supervises the protocol for the principles of Routine Practices and additional
precautions in reducing the risk of infection to patients and the health care team;
4.8
confirms equipment and instruments are in proper working condition and that required resources are
available;
4.9
manages surgical specimens according to facility policy;
4.10
assists law enforcement with medico-legal evidence gathering when appropriate;
4.11
practices within the scope established by current legislation, and facility policy;
4.12
conducts the surgical count in an accurate and efficient manner following the facilitys policies
and procedures;
4.13
documents unusual occurrences, near-misses and sentinel events and follows up appropriately;
4.14
participates in quality improvement activities; and
4.15
participates in ongoing educational activities.
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3.9

5.1
recognizes and responds effectively and appropriately to urgent and emergency situations in the surgical
suite;
5.2
anticipates, prioritizes, and prepares for the management of urgent and emergency situations;
5.3
directs, assists, and supervises other members of the health care team to effectively respond to urgent and
emergency situations;
5.4
advocates for debriefing opportunities following urgent and emergency situations, identifies
opportunities for improvement, and makes recommendations; and
5.5
follows facility emergency preparedness processes, policies, procedures, and guidelines.
COMPETENCY 6: Manages Resources

6.1
plans, organizes, and prioritizes care and resources to meet patient needs;
6.2
delegates and coordinates team members to provide effective patient care;
6.3
identifies and reports to administration any issues that compromise patient care;
6.4
participates with administration in problem-solving, decision-making and quality improvement;
6.5
assembles, prepares for use, and disassembles equipment and supplies for each surgical procedure;
6.6
uses materials in a manner that provides safe patient care, reduces waste, is cost effective, respects
environmental concerns, and maintains safe working conditions for the health care team;
6.7
organizes and coordinates patient care with the health care team maximizing efficient use of resources and
time;
6.8
monitors and evaluates progress of activities, delegated duties, and patient outcomes;
6.9
participates in the clinical evaluation of products and equipment;
6.10
participates in research activities;
6.11
monitors expenditures, usage and waste contributing information for budget process; and
6.12
encourages appropriate time management.
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COMPETENCY 5: Responds To Urgent/Emergency Situations

BIBLIOGRAPHY
Australian College of Operating Room Nurses. (2006). Standards for Perioperative Nursing including
Nursing Roles, Guidelines, Position Statements, Competency Standards. Adelaide: ACORN
College and Association of Registered Nurses of Alberta. (2005). Nursing Practice Standards. Edmonton:
Author.
Canadian Nurses Association. (2008). Code of ethics for Registered Nurses. Ottawa: Author.
Canadian Nurses Association. (2004). Everyday Ethics Putting the Code into Practice. Ottawa: Author.
National Association of Theatre Nurses. (2005). Standards and Recommendations for Safe Perioperative
Practice. Harrogate, UK: NATN
Phillips, N. (2007). Berry & Kohns operating room technique. (11th ed.) Toronto: Mosby.
Nurses Association of New Brunswick (2005). Standards of Practice for Registered Nurses.
Spry, C. (2008). Essentials of Perioperative Nursing. (4th ed.). Sudbury: Jones & Bartlett.
COMPETENCIES OF THE PERIOPERATIVE REGISTERED NURSE MANAGER

COMPETENCY 1:
Professional and Clinical Practice
COMPETENCY 2:
Managerial Skills and Expertise
COMPETENCY 3:
Human Resource Management
COMPETENCY 4:
Financial Management: Budget; Human, Material and Capital

Resources
COMPETENCY 5:
Communication and Interpersonal Skills
COMPETENCY 6:
Team Building
COMPETENCY 7:
Legal and Ethical Responsibilities
COMPETENCY 8:
Technology: Understanding and Use
COMPETENCY 9:
Quality Management
COMPETENCY 10:
Systems Thinking, Strategic Planning and Project Management
COMPETENCY 11:
Collaboration with Surgeons
COMPETENCY 12:
Collaboration with Anesthesiologists
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COMPETENCY 1:

1.1
is a role model who exemplifies ORNAC, CNA and other related associations' standards of practice;
1.2
contributes to the development and upgrading of standards of practice as knowledge increases and practices
change;
1.3
confirms that staff members follow standards of practice in the delivery of patient care;
1.4
expects and facilitates a high level of performance among staff members;
1.5
exemplifies and expects a professional work environment from all health care team members;
1.6
promotes an environment that respects confidentiality, privacy of patients, team members, and health
information in a professional manner and as defined by various regulatory bodies;
1.7
facilitates an environment that is conducive to change and encourages collaborative practice;
1.8
demonstrates zero tolerance for violence, bullying, harassment and discrimination in the workplace;
1.9
are provided; and
1.10
promotes an environment that encourages research.
COMPETENCY 2: Managerial Skills and Expertise

2.1
provides appropriate resources for the health care team to support surgical patient care;
2.2
organizes the human and material resources in the right quality, quantity, skill set, place, and time;
2.3
hires appropriate numbers of staff members with the required skills and knowledge, in the appropriate job
classification for duties intended;
2.4
provides resources for appropriate orientation for new staff members;
2.5
provides resources for continuing education, specialty development, and new technology training;
2.6
facilitates, supports, and contributes to resources required for ongoing post basic education, certification,
expanded perioperative nursing roles, and advanced degrees;

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COMPETENCIES OF THE PERIOPERATIVE REGISTERED NURSE

MANAGER
establishes an expectation for, contributes to, and promotes a learning environment;
2.8
maintains a current organizational chart which is readily available to staff;
2.9
collaborates with staff in designing a framework for clinical practice that encompasses roles,
responsibilities, and accountabilities by staff categories, staff mix, scope of practice, and limitations,
avoiding a "quick-fix" approach;
2.10
demonstrates exceptional organizational skills and facilitates processes for staff to achieve excellence in
patient care;
2.11
develops, in collaboration with the health care team/organization, and executes appropriate priority setting
based on current needs, activity, resources, and safety;
2.12
demonstrates decision making that is efficient, effective, inclusive, ethical, legal, fair, and transparent when
possible; and
2.13
promotes an environment that meets biological, chemical, mechanical, environmental, and physical safety
standards.
COMPETENCY 3: Human Resource Management

3.1
manages the human resource component of the surgical suite;
3.2
promotes a practice environment that is accepting and respectful of all job classifications and employees of
varied backgrounds and experience;
3.3
interviews, checks references, and hires appropriate skilled professional staff to meet patient care needs and
specialty expertise;
3.4
interviews, checks references, and hires appropriate support staff with skill sets for specific positions, tasks
and duties;
3.5
establishes expectations of performance, competency standards, attitude, goals, and opportunities at time of
hire;
3.6
provides current position descriptions to new employees;
3.7
maintains current position descriptions;
3.8
confirms the probationary performance is closely monitored, peers are consulted, and appraisals are
completed which accurately reflect the expectation of continued employment;
3.9
provides regular performance appraisals for staff members, based on current position descriptions,
performance expectations, and written protocols, that are reflective of practice, constructive, and promote
personal development;
3.10
provides a structured means to manage performance of health care team members not meeting standards of
expectation in a timely and progressive manner;

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2.7
terminates staff that are determined, through due process, to be lacking in competency and overall
performance;
3.12
removes staff who present a risk to patients or health care team members from the area, in a timely and
respectful manner, pending appropriate outcomes;
3.13
replaces vacant positions in a timely manner, with the most qualified staff available, which assists in
reducing training costs, stress, and the impact on the patient and surgical suite;
3.14
is conversant with and follows union contracts and labor laws;
3.15
is accountable for staff schedules, rotations, daily assignments, and vacation planning that is coordinated
with contract requirements and with departmental, organizational, and staff needs; and
3.16
encourages a positive environment that promotes wellness.
COMPETENCY 4: Financial Management-Budget, Human, Material and Capital

Resources
4.1
plans and monitors the approved operational budget;
4.2
integrates the strategic, fiscal, and change requirements of the facility;
4.3
facilitates a team approach to obtain a balanced budget;
4.4
participates collaboratively within the system to acquire appropriate materials in a timely, and efficient
manner;
4.5
participates collaboratively in the decisions regarding the tendering, evaluation, approval, and acquisition of
materials;
4.6
collaboratively plans, prioritizes, and requests capital equipment replacement;
4.7
maintains existing equipment in good repair, facilitates necessary preventative maintenance processes, and
maintains a record of historical data for equipment problems, repairs, and down-times due to
malfunctioning equipment; and
4.8
participates collaboratively to develop contingency plans for inadequate or unavailable resource

components.
COMPETENCY 5: Communication and Interpersonal Skills

5.1
demonstrates effective communication with the health care team and external partners and representatives;
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3.11
utilizes effective listening skills to maximize understanding of the issues;
5.3
provides a comfortable, respectful, and confidential environment that encourages health care team members
to discuss issues;
5.4
promotes an environment that encourages health care team members to resolve issues in a respectful, nonconfrontational manner;
5.5
ensures compliance with policies related to zero tolerance of abuse in the workplace;
5.6
facilitates negotiation, collaboration, and conflict resolution;
5.7
incorporates knowledge and expertise in coaching, facilitating, and promoting group dynamics; and
5.8
is cognizant of, and provides direction and resources to enable staff to deal with personal stress and health
problems.
COMPETENCY 6: Team Building

6.1
facilitates, supports, and encourages a multidisciplinary department that promotes team building;
6.2
collaborates with the health care team supporting decision making at the point of care/service;
6.3
facilitates and encourages empowerment of teams with associated accountability and responsibility;
6.4
collaborates with a multidisciplinary team to solve problems, change processes, and improve the function
and quality of patient care and support systems;
6.5
demonstrates respect and the value of each health care team member; and
6.6
provides support to improve dysfunctional processes and strengthen the health care team.
COMPETENCY 7: Legal and Ethical Responsibilities

7.1
confirms proof of required licensure prior to hiring;
7.2
confirms security clearance, if applicable, prior to hiring;
7.3
assures confirmation of annual professional licensure of regulated staff;
7.4
facilitates the development and maintenance of applicable department policies

that are current and available to staff;
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5.2
provides policies that reflect current legal expectations and meet various regulatory requirements;
7.6
supports health care team members in understanding the implication and importance of policies and
compliance with current departmental policies;
7.7
confirms that all practicing surgeons have the required surgical privileges granted by the designated medical
authority;
7.8
confirms that the health care team members work within their mandated scope of practice;
7.9
monitors any restrictions or limitations of practice;
7.10
monitors compliance with policies and procedures related to patient care;
7.11
confirms investigation of all incidents in a timely manner according to the health care facility
protocol;
7.12
removes impaired, fraudulent or negligent staff from the environment until the appropriate investigation is
completed and the individual is approved to practice;
7.13
notifies the specific medical designate immediately in the event of negligent or impaired activities
involving a physician; and
7.14 declares when there is a personal conflict of interest.
COMPETENCY 8: Technology: Understanding and Use

8.1
facilitates and supports the advancement of technology that improves patient care;
8.2
lobbies and promotes the need for computer technology that facilitates data analysis;
8.3
understands, uses, and facilitates the provision for ongoing staff development to support technology;
8.4
integrates department statistics with benchmarking, economic, and financial information for decision
making;
8.5
prepares a business plan which forecasts the impact of new technology leading to changes in practice; and
8.6
informs the appropriate departments and healthcare team members regarding the introduction of new
technology and practices.
COMPETENCY 9: Quality Management

9.1
is committed to a process/program of quality improvement;
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7.5
facilitates and confirms that a quality management process is in place; in which health care team members
are integral and outcomes are managed;
9.3
decides in collaboration with the health care team, the performance indicators to be measured;
9.4
facilitates a consistent, accurate means of data collection;
9.5
confirms that processes are in place for data validation;
9.6
reports the data results, outcome measures, and recommendations as determined by the health care facility
policy;
9.7
analyzes data to determine if improvement measures are successful; and
9.8
implements measures that reduce risk for the patient and surgical team.
COMPETENCY 10: Systems Thinking, Strategic Planning and Project Management

10.1
integrates the facilitys mission, vision, values, philosophy, objectives and goals into department activities,
direction, and decisions;
10.2
maintains goals and objectives that are current and congruent with strategic direction of the facility;
10.3
incorporates visionary approach into strategic decision making;
10.4
manages an environment that facilitates partnerships, teams, and relationships that incorporate and support
the overall mission, goals, and focus of the health care facility;
10.5
collaborates closely with Departments of Surgery, Anesthesiology and other services that utilize and
support patient care in the surgical suite;
10.6
communicates effectively with senior administration;
10.7
participates in disaster services planning on an organizational level;
10.8
participates in collective bargaining and labor action planning/impact on an organizational level;
10.9
follows the health care facility policy for media requests;
10.10
collaborates and assists in the coordination of reduced activity/downsizing of activity;
10.11
participates in organizational meetings and activities;
10.12
understands the organization is a system and uses systems thinking in planning and decision making;
10.13
uses change management theories and practices;
10.14
incorporates clinical, technological, and research concepts into decision making;


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9.2
incorporates evidence-based research into policy, procedure, and practice changes;
10.16
coordinates inter and intra departmental and external resources to maintain efficient surgical suite functions;
and
10.17
facilitates communication and respects limitations and resources of supporting departments.
COMPETENCY 11: Collaboration with Surgeons

The Perioperative Manager shall practice in a manner that:
11.1
develops open communication and positive relationships with surgeons and their
offices;
11.2
facilitates systems which support the delivery of appropriate and timely care of patients based on
the surgeons information;
11.3
monitors and manages systems that will promote efficient use of time while in the
operating room;
11.4
manages the allocation of operating room time/resources for surgeons;
11.5
promotes respect and professional interactions between staff and surgeons;
11.6
prepares for and participates in interviews for prospective and new surgeons;
11.7
prepares appropriate additional funding requests for new surgeon requirements;
11.8
ensures adequate operating time, supplies and other resources will be available for
additional surgeons;
11.9
receives, processes, and reviews information on new products, requests, procedures

and information, and participates in processes that will ensure due process to
either approve or disapprove new technology, products or procedures; and
11.10
appropriately addresses behavior issues that affect the department and the staff.
COMPETENCY 12: Collaboration with Anesthesiologists

The Perioperative Manager shall practice in a manner that:
12.1
collaborates with the Department of Anesthesiology to maximize safety and effective use of resources to
meet the patient needs;
12.2
ensures a tripartite process of handling patient priorities which includes anesthesia, surgeons and nursing;
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10.15
facilitates the education and practice process of nursing skills to effectively and consistently assist the
anesthesiologist throughout the perioperative period;
12.4
uses and promotes effective problem solving techniques to resolve issues surrounding anesthesia concerns;
12.5
promotes respect and professional interactions between staff and anesthesiologists; and
12.6
appropriately addresses behavior issues that affect the department and the staff.
COMPETENCIES OF THE PERIOPERATIVE REGISTERED NURSE EDUCATOR
COMPETENCY 1:
COMPETENCY 2:
Educator Skills and Expertise
COMPETENCY 3:
Human Resource Support
COMPETENCY 4:
Communication and Interpersonal Skills
COMPETENCY 5:
Team Building
COMPETENCY 6:
Legal and Ethical Responsibilities
COMPETENCY 7:
Technology: Understanding and Use
COMPETENCY 8:
Quality Management
COMPETENCY 9:
Systems Thinking, Strategic Planning and Project Management
COMPETENCIES OF THE PERIOPERATIVE REGISTERED

NURSE EDUCATOR
COMPETENCY 1: Professional and Clinical Practice

1.1
is a role model who exemplifies CNA, ORNAC, CSA, and other related associations' standards of practice;
1.2
demonstrates accomplishment within perioperative nursing (e.g. publishes work, conference speaker);
1.3
actively participates in committees or professional interest group activities;
1.4
demonstrates leadership as it relates to health trends and issues for perioperative Registered Nurses;
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12.3
contributes to the development and improvement of standards of practice as knowledge increases and
practices change;
1.6
facilitates and supports the health care team to comply with Standards of practice in the delivery of patient
care;
1.7
exemplifies a role model of professional behavior for the health care team;
1.8
promotes an environment that respects confidentiality, privacy of patients, health care team members, and
health information in a professional manner and as defined by various regulatory bodies;
1.9
facilitates an environment that is conducive to change and encourages collaborative interdisciplinary

practice;
1.10
facilitates and supports an environment that does not tolerate violence, bullying, harassment and
discrimination in the workplace;
1.11
are provided;
1.12
promotes, encourages and participates in research; and
1.13
functions as a change agent and perioperative leader.
COMPETENCY 2: Educator Skills and Expertise

2.1
encourages staff to identify their learning needs;
2.2
uses the principles of adult learning to support/provide education that assists staff to meet their learning
needs;
2.3
demonstrates knowledge of the strategic plan of the organization and anticipates the related educational
needs;
2.4
liaises with other perioperative Registered Nurses, educators and managers;
2.5
facilitates staff learning to acquire the requisite skills and knowledge, in the appropriate job classification;
2.6
co-ordinates resources for appropriate orientation for new staff members and students;
2.7
facilitates opportunities for continuing education, specialty development, and new technology training;
2.8
facilitates, supports and/or contributes to resources required for ongoing post basic education, certification,
expanded and advanced perioperative nursing roles, and advanced degrees;
2.9
establishes an expectation for, contributes to and promotes a learning environment;
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1.5
collaborates with staff and management in designing a framework for perioperative clinical practice that
encompasses roles, responsibilities, competencies and accountabilities by staff categories, skill mix, and
scope of practice;
2.11
demonstrates optimal organizational skills and facilitates processes for staff to achieve excellence
in perioperative patient care;
2.12
demonstrates economical use of resources to develop and implement educational programs;
2.13
provides professional and educational resources as requested;
2.14
demonstrates decision making that is efficient, effective, inclusive, ethical, and transparent when possible;
2.15
promotes an environment that meets biological, chemical, mechanical, environmental, and physical safety
standards;
2.16
assists the health care team to bridge perioperative theory to evidence-based practice;
2.17
demonstrates consistent improvement in educational activities based on learner and patient outcomes;
2.18
demonstrates decision making based on current research and standards of practice;
2.19
demonstrates accountability for the outcomes of their educational activities; and
2.20
creates opportunities for the healthcare team to build critical and reflective
thinking skills promoting problem-solving strategies.
COMPETENCY 3: Human Resource Support

3.1
promotes a practice environment that is accepting and respectful of all job classifications and employees of
varied backgrounds and experience;
3.2
supports new staff in establishing expectations of performance, competencies, goals, and opportunities at
time of hire;
3.3
supports the health care team to maintain practice competencies;
3.4
supports the perioperative Registered Nurse manager in maintaining current job descriptions;
3.5
co-ordinates the monitoring of probationary performance through consultation processes and

facilitates the completion of appraisals;
3.6
collaborates in the completion of regularly scheduled performance appraisals for staff members;
3.7
facilitates a learning plan to improve performance of health care team members not meeting required
standards;
3.8
demonstrates sensitivity to workplace constraints which interfere with learning, and works

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2.10
3.9
encourages staff to enhance their knowledge base by collaborating with mentors, colleagues, and other
health care team members;
3.10
encourages a positive environment that promotes health and wellness;
3.11
effectively redirects issues, which require non-educational strategies;
3.12
counsels and supports nursing staff in advancement opportunities; and
3.13
develops preceptors or experts as resources for clinical skills.
COMPETENCY 4: Communication and Interpersonal Skills

4.1
demonstrates effective interpersonal communication strategies;
4.2
uses effective listening skills to maximize understanding of the issues;
4.3
demonstrates a willingness to be accessible to staff;
4.4
provides a comfortable, respectful, and confidential environment for health care team members to discuss
issues;
4.5
promotes an environment that encourages health care team members to resolve issues in a respectful, nonconfrontational manner;
4.6
facilitates negotiation, collaboration, and conflict resolution;
4.7
incorporates knowledge and expertise in coaching, facilitation, and group dynamics; and
4.8
is cognizant of, and provides direction and resources for nursing staff to deal with personal stress and health
issues.
COMPETENCY 5: Team Building

5.1
facilitates, supports, and encourages a multidisciplinary department that promotes team building;
5.2
demonstrates a team approach in coordinating educational activities;
5.3
collaborates with the health care team supporting decision-making at the point of care/service;
5.4
facilitates and encourages accountability and responsibility within the health care team;
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proactively towards the reduction or elimination of these constraints whenever possible;
facilitates health care team members to develop problem-solving and coping techniques for use during
stressful or emotional situations;
5.6
promotes an open and supportive learning environment;
5.7
functions as a resource to assist nursing staff to develop educational materials and presentations;
5.8
demonstrates a willingness to modify educational program content based on evaluation feedback and/or
outcomes;
5.9
supports and encourages nursing staff to actively participate in their professional groups;
5.10
distributes relevant research findings to nursing staff and colleagues formally and informally;
5.11
collaborates with a multidisciplinary team to solve problems, change processes to improve function, quality
of patient care, and support systems; and
5.12
demonstrates respect and values each health care team member.
COMPETENCY 6: Legal and Ethical Responsibilities

6.1
facilitates the development and management of policies that reflect current legal expectations, standards of
practice, and meet various regulatory requirements;
6.2
promotes resolution of ethical dilemmas in a nonjudgmental environment;
6.3
supports health care team members to understand the importance of compliance with policies; and
6.4
monitors compliance with policies and procedures.
COMPETENCY 7: Technology: Understanding and Use

7.1
facilitates and supports the learning needs of perioperative staff as it relates to current, advanced and
emerging technologies.
COMPETENCY 8: Quality Management

8.1
is aware of, and committed to, a process/program of quality improvement;
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5.5
ensures the health team has the knowledge to actively and appropriately participate in quality processes;
8.3
views challenging situations as opportunities for improvement;
8.4
confirms that the learners needs and objectives are met; and
8.5
collaborates with the health care team in the development of the performance indicators to be measured.
COMPETENCY 9: Systems Thinking, Strategic Planning and Project Management

9.1
encourages an environment that facilitates partnerships, teams, and relationships that incorporate and
support the organizations mission, vision, values, objectives and goals;
9.2
instills the knowledge and understanding of systems thinking within the health care team;
9.3
collaborates closely with surgeons, anesthesiologists and other professionals that support or provide patient
care in the surgical suite;
9.4
communicates effectively with management and administration;
9.5
participates in disaster services planning on a unit/organizational level;
9.6
participates in facility meetings and activities;
9.7
applies change management theories and practices;
9.8
supports and facilitates clinical, technological, and research concepts into decision making; and
9.9
supports and facilitates evidence-based research into policy, procedure, and practice changes.
BIBLIOGRAPHY
Council on Collegiate Education for Nursing. (2002). Nurse Educator Competencies.
Retrieved January 5, 2007, from
http://www.sreb.org/programs/nursing/publications/Nurse_Competencies.pdf
National League for Nursing. (2005). Core competencies of nurse educators with task
statements. Retrieved January 5, 2007, from
http://www.nln.org/profdev/corecompetencies.pdf
Vigeant, D., Lefebure, H., & Reidy, M. (2008). The Use of video as a pedagogic tool for the training
of perioperative nurses: a literature review. Canadian Operating Room Nursing Journal, 26(1), 8, 9, 14, 15, 17-20.
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8.2
COMPETENCY 1: Advanced Practice Nurses-(Perioperative) Possess Required Core

Competencies that Incorporate Advanced Perioperative Nursing Knowledge, Theory and
Research Augmented by Clinical Experience.
Competencies for advanced nursing practice are based on an appropriate depth, breadth and range of nursing
knowledge, theory and research, enhanced by extensive clinical experience (CNA, 2008)
Advanced Practice Nurses (Perioperative) shall practice in a manner that incorporates:
1.1
clinical expertise;
1.2
advanced assessment and intervention strategies for clients;
1.3
the use of qualitative and quantitative data from a multitude of sources when making clinical decisions and
managing/facilitating change;
1.4
the analysis of the sociological, psychological, and physiological processes; the determinants of health, and
the clients lived experience;
1.5
the wide range of client responses to actual or potential health problems and recommended actions;
1.6
decision making skills in complex clinical situations;
1.7
engaging clients and members of the healthcare team in resolving issues at the individual, organizational
and healthcare system levels;
1.8
the ability to identify and assess trends or patterns that have health implications for clients;
1.9
the generation and incorporation of new nursing knowledge and development of new standards of care,
programs and policies;
1.10
planning and implementation of educational programs as determined by needs, priorities and resources;
1.11
research;
1.12
identifying and implementing research-based innovations for improving client care, organizations or
healthcare systems;
1.13
collaboration with members of the healthcare team or the community to identify, conduct and support
research that enhances and /or benefits nursing practice;
1.14
research findings in practice at the individual and systems levels;
1.15
data collection, outcomes evaluations and advanced nursing practice for clients, the nursing profession and
the healthcare system;
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PROFESSIONAL COMPETENCIES FOR ADVANCED PRACTICE

NURSES (PERIOPERATIVE)
research interpretation, application and dissemination;

a contribution to nursing and the healthcare system by disseminating new knowledge through formal and
informal channels including presentations and publications;
1.18
leadership and change;
1.19
advocating for clients in relation to treatment, the healthcare system and policy decisions that affect health
and quality of life;
1.20
the learning needs of nurses and other members of the healthcare team and finding or developing programs
or resources to meet those needs;
1.21
mentoring and coaching nursing colleagues, members of the healthcare team, and students;
1.22
advocating for and promoting the importance of healthcare access to healthcare professionals, legislators,
and policy makers;
1.23
contributing to and advocating for an organization culture that supports professional growth, continuous
learning and collaborative practice;
1.24
evaluating programs in the organization and community and developing innovative approaches to complex
issues;
1.25
understanding and integrating the principles of resource allocation and cost-effectiveness in organizational
and system level decision making;
1.26
the development of partnerships to manage identified gaps in the healthcare system;
1.27
development and articulation of the vision for nursing practice;
1.28
guiding and advising clients, members of the healthcare team, the community, healthcare institutions and
organizations, and policy makers on issue related to nursing, health, and healthcare;
1.29
identification of problems and initiating change to meet challenges at the individual, organizational or
systems level;
1.30
developing strategies to improve health, healthcare access and policies by understanding socio-political
issues that influence health policy;
1.31
consultation and collaboration;
1.32
the development of quality improvement and risk management strategies in consultation with members of
the healthcare team;
1.33
working with others to gather information on determinants of health;
1.34
collaborative practice and building coalitions;
1.35
the application of theories related to group dynamics and roles;
1.36
the demonstration of skill and knowledge in communication, negotiation and conflict resolution;
1.37
articulating the role of the Advanced practice Nurse within the healthcare team;

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1.16
1.17
collaborative practice with academic institutions; and
1.39
advocating for change in health policy by participating on regional, provincial/territorial and federal
committees that influence decision making.

1.38
REFERENCES
Canadian Nurses Association. (2008). Advanced Nursing Practice A National Framework. Ottawa: CNA.
BIBLIOGRAPHY
Hamric, A.B., Spross, J.A., and Hanson, C.M., (2005). Advanced nursing practice: An integrative approach.
Philadelphia: W.B.Saunders Company.
ADDITIONAL RESOURCES
Canadian Nurses Association. Position Statements, Discussion papers, Briefs, Nurse One Portal
www.cna-nurses.ca
Canadian Nurses Protective Society. www.cnps.ca
Canadian Patient Safety Institute. Surgical Safety Checklist & Scorecard: Canada, Version 1. Edmonton,
AB: Canadian Patient Safety Institute; 2009 Jan 9. www.safesurgerysaveslives.ca
Canadian Standards Association. www.csa.ca
Health Canada. www.hc-sc.gc.ca
Provincial/Territorial professional nursing associations.
Provincial/Territorial government health ministries
Michael Villeneuve & Jane MacDonald, (2006). Toward 2020 visions for Nursing, CNA, Ottawa, ON
Appendix A:
REGISTERED NURSE FIRST ASSIST
Competency 1
The registered nurse first assist (RNFA) is competent to apply the nursing process in all facets of the
nurse first assist role.
Measurable Criteria:
Applies the nursing process in the RNFA role as the theoretical framework for patient care.
Examples:
Possesses and applies expert knowledge of the principles of biological, physical, and
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surgical patients optimal outcome.
Evaluates each patient individually and determines appropriate application of knowledge and
skills according to patients needs.
Conducts systematic, ongoing assessment of the patients health status throughout the perioperative
experience.
Examples:
Collects data from the appropriate multiple sources (e.g., physicians office, clinic, admissions
system, operating room, post-anesthesia care unit [PACU]), continuing throughout the
patients postoperative course. Recognizes the importance of chronic or concomitant diseases;
malignancies; routine or preoperative prescribed, herbal, and over-the-counter medications;
previous surgery or injuries; and/or preexisting infections that may affect the patients health
status and the outcome of the planned surgical interventions and takes appropriate action.
Performs an appropriate and focused nursing assessment based on the planned surgical
intervention(s). Assesses for possible risk factors that may be present (e.g., age, weight,
nutritional status, developmental stage, medical history, diagnosis[es], laboratory values,
immunological/hydration/perfusion status, comorbidity).
Assesses patients intraoperatively for prevention or early detection of perioperative

complications (e.g., recognizes early symptoms of cardiac complications secondary to acidbased imbalance, cardiac dysfunction, cervical spine injury, electrolyte imbalance, anesthetic
agents, medications, vagal stimulation, surgical manipulation).
Monitors and assesses patients immediate postoperative status to determine progress toward
expected outcomes or signs and symptoms of potential postoperative complications.
Formulates and modifies nursing diagnoses based on patient assessment throughout the perioperative
continuum.
Examples:
Synthesizes and interprets health assessment data to identify and prioritize patient health
problems amenable to collaboratively prescribed intervention(s).
Demonstrates ability to support nursing diagnoses with current scientific knowledge and/or
research.
Documents and communicates identified nursing diagnoses based on patients condition and
clinical situation.
Communicates changes in patients situation to appropriate members of the health care team
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behavioral sciences; clinical observation; and communication theory to contribute to the
Identifies and communicates desired patient outcomes.
Examples:
Establishes individualized, realistic outcomes with patient based on the identified nursing
diagnoses. Communicates patients goals to appropriate members of the health care team.
Outcome statements specify measurable criteria for determining the relationship between
nursing intervention and outcome achievement.
Develops an individualized plan of care that directs the intervention(s) of the RNFA.
Examples:
Selects, analyzes, and interprets relevant assessment data to develop a plan of care that meets
individual patient needs, is age specific, and reflects professionally recognized standards of
care based on the nursing process.
Addresses collaborative problems* and potential complications with

physicians to achieve consensus regarding delegated medical functions and prescribed nursing
interventions.
Communicates RNFA plan of care with other members of the surgical team to achieve
consistency of purpose and action during the intraoperative phase of care.
Implements and manages the perioperative plan of care consistent with RNFA practice.
Examples:
Reviews and uses history, physical assessment, and preoperative test results to establish a
physiologic baseline.
In collaboration with the surgeon, anesthesia care provider, and other perioperative team
members, initiates interventions efficiently, safely, and skillfully using sound clinical
judgment.
Provides knowledge-based technical assistance to the surgeon during the operative procedure
according to licensure, provincial/territorial regulation, and facility/practice protocols. (See
competency 4 for intraoperative assisting knowledge and skills)
Works closely with RN circulator, and scrub nurse (RN/LPN/RPN), collaborating with and
participating in perioperative nursing interventions as appropriate.
Serves as an information resource for RN circulator and scrub nurse (RN/LPN), and other
member of the surgical team throughout the perioperative course by applying/sharing expert
surgical knowledge of aseptic practice, hemostasis, tissue handling, wound healing, and
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as intervention progresses
Applies principles of problem solving in response to changes in the patients condition during
any/all phase(s) of the surgical encounter. Modifies, communicates, and implements plan of
care accordingly.
Maintains flexibility and adaptability when emergencies or unanticipated events occur.
Documents patient/family preoperative care and teaching, operative notes following surgical
procedure, postoperative care/assessment, and discharge planning, as determined by guidelines
of practice and institutional policy.
Evaluates the effect of RNFA/nursing interventions as part of the ongoing assessment process.
Examples:
In collaboration with the patient, evaluates patient outcomes by comparing patient responses
to nursing interventions, current practice standards, and anticipated outcomes.
In collaboration with surgeon and other members of the perioperative team, evaluates personal
surgical performance and patient outcomes.
Attends postoperative visits in clinic to assess patient surgical outcomes (i.e.: wound healing).
Competency 2:
The RNFA is competent to exercise critical thinking skills in all aspects of the RNFA role.
Uses critical thinking theory in the application of nursing knowledge and perioperative patient care.
Examples:
Analyzes and synthesizes as a means of approaching a situation, issue, or decision.
Exercises analytical problem-solving techniques and sound principles of proficient decision

making when encountering new situations.
Bases critical thinking on previous experience and theoretical knowledge. Continuously

builds acquired knowledge as a result of critical thinking.
Competency 3:
The RNFA is competent to establish and maintain a safe perioperative environment.
As a primary patient advocate is continually vigilant, using acquired and intuitive knowledge to anticipate,
prevent, and/or respond to circumstances that could compromise the patients well-being.
Examples:
Recognizes potential hazards and initiates preventive and/or corrective actions at any time
throughout the perioperative continuum.
Ensure safe, aseptic environment consistent with infection control principles and safe
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surgeons preferences. Intervenes as appropriate to specific circumstance(s).
Transfers patient safely (e.g., locks transport vehicle wheels; secures IV lines, catheters,
feeding tubes; protects patients extremities during transfer; uses transfer devices as
appropriate).
In partnering with the surgeon, the RNFA directs, manages, and/or participates in positioning
the anesthetized patient.
In collaboration with the surgeon and anesthesia care provider, assumes accountability for
positioning patient safely. Demonstrates expert knowledge of anatomy and physiology, safe
positioning principles, and the function and correct use of positioning equipment to avoid
circulatory and neurological compromise.
Protects patient from thermal, electrical, chemical, and/or mechanical injury.
Is cognizant of and can recognize possible adverse reactions patient may experience during the surgical
encounter.
Examples:
Anticipates and assesses the effects of routine and preoperative pharmacological agents and
herbal remedies. Intervenes as appropriate to the situation.
Verifies patient allergies. Reviews, analyzes, and interprets information from the patients
history and physical examination noting any intolerance that might signify an unsafe surgical
encounter.
Accountable for verification of the correct surgical site.
Examples:
Verifies site with patient, surgeon, and other members of surgical team.
Demonstrates knowledge of patient safety standards published by regulatory bodies.
Examples:
Volunteers to participate in facility-wide safety programs. Seeks opportunities to promote

patient safety as work ethic. Teaches colleagues. Models desired behaviors.
Competency 4:
The RNFA is competent to provide technical first assistance to the primary surgeon in the
operating room and throughout the perioperative period.
Demonstrates clinical expertise.
Examples:
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operating procedures.
Is familiar with proposed surgical procedures, surgeon approach, and clinical anatomy.
Recognizes anatomical abnormalities that may impact the surgical intervention.
Applies cognitive and technical skills obtained throughout the continuum of basic nursing
education, perioperative nursing education, and formal RNFA educational programs.
Possesses the essential mental discipline and fine motor skills to provide technical assistance to the surgeon.
Examples:
Continually demonstrates attention to detail, thoroughness, stamina, continued competence of

surgical assisting skills, and concentration during the surgical procedure.
Strictly adheres to principles of aseptic technique to prevent infection and promote optimal wound healing.
Examples:
Demonstrates knowledge and command of principles of surgical asepsis.
Creates and monitors sterile field. Identifies and corrects breaks in aseptic technique.
Identifies and addresses factors that place the patient at risk for infections.
Accepts appropriate delegated restricted activities as defined within the RNFA scope of practice.
Examples:
Performs preoperative activities as ordered by surgeon (e.g., venipuncture for preoperative

blood test).
Initiates and performs intraoperative activities as directed by the surgeon.
Monitors wound healing.
Uses surgical instruments to assist the surgeon and facilitate the surgical intervention.
Examples:
Demonstrates thorough understanding of the underlying principles for using surgical

instruments. Understands the design and use principles/action of surgical instruments used
and the resultant effect on tissue.
Demonstrates skill and manual dexterity in instrument use.
Handles tissue safely.
Examples:
Employs principles of safe tissue handling. Handles tissues with a gentle touch to preserve
neurovascular structures and promote wound healing.
Applies knowledge regarding tissue response to injury, wound healing, and wound
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encourage wound complications).
Exercises independent clinical judgment when identifying specific types of tissue and
selecting appropriate instrument(s) for handling that tissue (e.g., muscle, fat, and most organ
tissues are easily lacerated when clamped or pulled; skin, fascia, cartilage, ligament, and bone
tissues are generally tough and may be handled with toothed tissue forceps or Kocker clamps).
Provides exposure of operative site to promote a safe and effective surgical procedure.
Examples:
Exercises independent judgment in selecting and employing various methods to provide

exposure of the surgical site, including patient positioning, use of retractors and other
instruments, retraction sutures, and/or packing materials as dictated by procedural need.
Selects, places, and moves proper retractor(s) to provide surgical site exposure and reduce
tissue injury.
Packs wound as appropriate.
Suctions surgical site as necessary to remove smoke, blood, and fluids from the site to
improve visualization and decrease biohazard exposure.
According to individual provincial/territorial regulation and facility policy, dissects tissue as delegated and
supervised by the primary surgeon.
Examples:
Under the direction of the operating surgeon, uses appropriate tissue dissection techniques to
facilitate an optimum surgical outcome. For example, privileges may
be granted to qualified RNFAs to perform specialized tissue handling, such as trocar
placement, preparation of allografts, and saphenous vein harvesting.
According to individual provincial/territorial regulation and facility, policy assists with and/or performs
wound closure.
Examples:
Uses suture and suturing techniques in a manner consistent with principles that promote
wound healing.
Differentiates one type of suture from another, having knowledge of the physical
characteristics and biological responses to various suture materials
Selects appropriate suture material for the type of closure to be performed.
Demonstrates proficiency in knot-tying techniques with consideration to knot security, suture
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classification (i.e., identifies and assesses risk factors that impair wound healing and/or
Demonstrates proficiency in wound closure using a skin stapler.
Competency 5:
The RNFA is competent to work as a professional colleague with the physician and to enhance the
effectiveness of patient care.
Partners with the physician to collaboratively direct the patients perioperative course.
Examples:
Prepares the patient preoperatively for surgical intervention, performs intraoperative surgical
assisting, and collaboratively manages the patients postoperative regimen.
Understands and applies current theories and concepts of antimicrobial prophylaxis, ensuring
that the appropriate medication is administered at the correct time to maximize effectiveness.
Participates with physician in determining product use and/or therapies to be used.
In collaboration with surgical team, directs and/or manages patient care activities during the
intraoperative phase of care.
Implements and directs (as appropriate) use of environmental control measures and
standard/transmission-based precautions to prevent undue patient and provider exposure to
and infection from bloodborne pathogens.
Accepts appropriate responsibility if surgeon becomes incapacitated; protects the surgical

wound, maintains hemostasis, and maintains sterility of the operative field until the
replacement surgeon accepts responsibility for procedure completion.
Makes postoperative rounds in conjunction with or at the direction of physician.
Plans and/or collaborates, with other members of the health care team, for patient discharge,
accessing community resources as appropriate.
Serves as educator, mentor, consultant, and resource to patients, colleagues, other health care professionals,
and the community.
Examples:
Provides individualized patient and family education by applying principles of learning,

actively involving the learner, and providing and environment conducive to teaching/learning.
Consults effectively with the surgeon and other member of the health care team to promote
efficient use of time, supplies, equipment, and personnel.
Monitors emerging technology. Analyzes new products to determine risk/benefit for patients
and the facility.
Participates in and consults on facility and nursing committees, nursing associations, and
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selection, and tissue characteristics.
Serves as a source of information, including procedural instruction and/or policies and

procedures to both nursing colleagues and multidisciplinary students (i.e.: surgical procedure,
urinary catheterization, wound closure, and use of various surgical equipment).
Serves as a community resource to educate the public and promote quality patient care.
Educates the public and other health care professionals about the role of the RNFA.
Competency 6:
The RNFA is competent to promote professionalism and to model professional behaviors to
other health care providers.
Bases professional and practice behaviors on the knowledge and application of the scope of practice for the
specific job category as defined by the provincial/territorial licensing bodies, professional practice
standards, and facility guidelines to practice.
Examples:
Possesses knowledge of and works within appropriate regulatory guidelines and legal
constraints, exercising caution to not extend into the practice of medicine.
Completes credentialing process as defined by facility(ies) in which the RNFA practices.
Obtains and maintains clinical privileges for activities to be performed.
Practices according to recognized standards of nursing practice, such as the ORNAC

Recommended Standards, Guidelines, and Position Statements for Perioperative Registered
Nursing Practice {and the AORN Standards of perioperative professional performance.}
Maintains professional credentials.
Examples:
Meets the necessary requirements to obtain and maintain certification-CPN(C), advanced

cardiac life support ACLS, pediatric advanced life support - PALS.
Actively participates in self, peer, and colleague review processes.
Demonstrates knowledge of risk management, professional liability, and malpractice issues.
Examples:
Is encouraged to secure and maintain individual liability insurance, either independently or as

a member of a Professional Regulatory body or physician practice group (if so employed).
Collaborates with facility risk manager to identify potential risk-inducing behaviors in the
practice arena. Initiates appropriate teaching and/or practice change to reduce risk.
Is vigilant in staying abreast of patient safety issues and published standards to promote
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medical/industry focus groups.
Practices in an ethical manner.
Examples:
Respects patients dignity and autonomy. Maintains patient confidentiality.
Actively participants in and accesses expert resources to resolve ethical dilemmas.
Seeks out and participates in lifelong learning opportunities.
Examples:
Builds upon the knowledge base and skill level of an assistant-at-surgery through experiential
learning and ongoing education.
Pursues formal advanced education to further his/her nursing career (i.e.,

baccalaureate/graduate degrees).
Networks with other health care professionals to promote the practice of RNFAs and to
discuss practice issues.
Participates in professional nursing activities at the local, provincial, and federal levels.
Attends local and national conferences and specialty forums to expand knowledge base and
stay abreast of emerging technology.
Participates in professional activities and defined processes directed towards improving patient care.
Examples:
Actively participates in multidisciplinary activities in the workplace (e.g., institutional grand

rounds, committees, quality improvement activities).
Identifies and analyzes situations in which collaborative consensus for patient care
interventions cannot be attained. Takes actions appropriate to the specific situation.
Initiates process review mechanisms.
Influences interdisciplinary relationships by enhancing collaborative processes, corporate

culture, institutional values, and professionalism.
Identifies situations in which additional education and/or disciplinary action is indicated and
takes appropriate action.
Considers factors such as developmental age or cultural background when planning effective
education for patients and families.
Participates in the research process to build and promote RNFA clinical practice thereby contributing to the
body of nursing knowledge, with particular interest in perioperative nursing and the RNFA role.
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patient safety.
Searches the literature to identify pertinent existing research data.
Evaluates and interprets published research for its relationship to clinical practice.
Conducts and/or participates in research studies to advance not only RNFA practice, but all
nursing practice.
Uses evidenced-based practices relevant to perioperative patient care management and RNFA
practice.
Seeks publication of articles and/or research studies pertinent to RNFA practice.
Participates in public policy development.
Examples:
Maintains awareness of proposed/pending legislation affecting nursing and the RNFA role.
Makes contact with provincial/territorial and federal legislators and administrators, as

appropriate, to provide information and insight regarding health care issues and regulations.
Actively supports public policy promoting quality care and RNFA practice.
Campaigns and contributes to success of candidate(s) of choice who promote(s) RNFA

practice and quality patient care. (Reproduced with permission)
*Collaborative problem: Patient problems requiring intervention using both a medical and nursing model.
Oucharek Mattheis, A. (2004) Registered Nurse First Assist Competencies: A Project in partial fulfillment
of a Master of Nursing. Unpublished Masters project, University of Saskatchewan, Saskatoon,
Saskatchewan, Canada.
Adapted with permission from AORN, RN First Assistant Guide to Practice, 2nd edition.
Copyright 2005 AORN, Inc, 2170 S Parker Road, Suite 300, Denver, CO 80231
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Examples:

Section 2
Infection Prevention and Control
Routine Practices and Additional Precautions ..................................................................................................89

Routine Practices ..............................................................................................................................................89
Airborne Precautions ..........................................................................................................................91
Droplet Precautions ............................................................................................................................94
Contact Precautions ............................................................................................................................95
Classic Creutzfeldt-Jakob disease (CJD ...........................................................................................................97
Implementing CJD Precautions ..........................................................................................................97
CJD Perioperative Precautions ...........................................................................................................98
Preoperative Risk Assessment Tool (Appendix A) ..........................................................................102
Environmental Cleaning/Sanitation ................................................................................................................104

General Practices ..............................................................................................................................104
Preliminary Cleaning........................................................................................................................106
Intraoperative Cleaning ....................................................................................................................106
End of Procedure Cleaning (Between Cases) ...................................................................................107
Terminal Cleaning ............................................................................................................................108
Weekly and /or Monthly Cleaning ...................................................................................................108
Traffic Control ................................................................................................................................................109
People ...............................................................................................................................................110
Supplies and Equipment ...................................................................................................................111
Dress Code .....................................................................................................................................................112
Patients .............................................................................................................................................112
Visitors .............................................................................................................................................112
Staff ..................................................................................................................................................113
Scrubbing, Gowning, Gloving ........................................................................................................................116
Scrubbing .........................................................................................................................................116
Gowning ...........................................................................................................................................117
Gloving.............................................................................................................................................118
Aseptic Technique ..........................................................................................................................................121
Establishing an Aseptic Environment ..............................................................................................121
Establishing the Sterile Field............................................................................................................121
Dispensing Sterile Supplies ..............................................................................................................122
Maintaining the Sterile Field ............................................................................................................123
Storage of Sterile Supplies ...............................................................................................................124
Instrument Management and Reprocessing ....................................................................................................126
Intraoperative Instrument Care .........................................................................................................126
Reprocessing Surgical Instruments ..................................................................................................127
Loaned and Leased Surgical / Medical Equipment ..........................................................................129
Packaging for Sterilization ...............................................................................................................129
Rigid Sterilization Containers ..........................................................................................................131
Sterilization ......................................................................................................................................132
Emergency (Flash) Sterilization .......................................................................................................134
High Level Disinfection ...................................................................................................................135
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Section 2 Infection Prevention and Control
Single Use Medical Devices (SUMeDs) ........................................................................................................142

Selection, care and handling of materials .......................................................................................................143
Wrappers, Surgical Gowns, and Drapes ...........................................................................................143
Bundles.............................................................................................................................................145
Skin Preparation (Prep) ..................................................................................................................................146
Draping ..........................................................................................................................................................149
Dressing(s), Drain(s), Irrigation .....................................................................................................................150
Dressings ..........................................................................................................................................150
Drains ...............................................................................................................................................151
Irrigation...........................................................................................................................................152
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Specialized Instruments and Equipment .........................................................................................................140

Prosthesis Care and Handling...........................................................................................................140
Power Equipment Management .......................................................................................................141
1.1 Routine Practices

Routine Practices (RP), formerly known as Standard Precautions or Universal Precautions shall be used when
caring for all patients. Additional precautions (Airborne, Droplet and/or Contact) shall be used to manage
infections spread by those specific methods of transmission.
1.1.1
PRACTICE
RATIONALE
All members of the health care team shall

use Routine Practices, which include but are
not limited to, the following requirements:
The principles of Routine Practices are based on the

premise that all clients/patients/residents, their secretions,
excretions and body fluids and their environment might be
potentially contaminated with harmful microorganisms. By
following simple preventative practice at all times
regardless of whether or not an illness is known staff will
be protecting client/patients/ residents and themselves from
an unknown, undiagnosed infectious risk. (Best Practices
for Environment Cleaning for Infection Prevention and
Control in Health Care Settings, December 8, 2009 p. 35).
The need for additional precautions will depend on the

routine practices used by the health care facility, and the
microorganisms encountered.
Hand washing shall be done with an

approved antimicrobial agent or an
approved alcohol gel prior to and
immediately after each patient contact;
after contact with contaminated items;
immediately upon removing gloves and;
at the end of each procedure, with
specific attention to areas between
thumb and first digit to reduce
microbes;
Gloves are not required for routine

patient care activities in which contact
is limited to patient's intact skin.
Gloves should be used as an additional

measure, not as a substitute for hand
washing
Gloves do not provide complete protection against hand

contamination. The use of gloves does not replace the need
for hand hygiene (Best Practices for Environment Cleaning
for Infection Prevention and Control in Health Care
Settings, December 8, 2009 p. 35).
Gloves shall be changed between care

activities and procedures with the same
patient after contact with materials that
contain high concentrations of
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Routine Practices and Additional Precautions

PRACTICE
RATIONALE
microorganisms (e.g. urinary catheter,

endotracheal tubes, etc).
appropriate personal protective

equipment (PPE) such as gloves, fluidresistant gowns, head and foot
coverings, face shields, masks, and eye
protection when there is a potential for
exposure to blood, body fluid
substances, or other potentially
infectious material(s);
impervious gowns shall be worn during
procedures that are likely to result in
splashes or where excessive irrigation
will be used;
masks, protective eyewear, or eye/face
shields shall be worn by the scrub team
during surgery;
all PPE should be removed immediately
following use and placed in an
appropriately designated area or
container;
reusable PPE must be decontaminated
between uses as per the manufacturers
instructions;
all procedures involving blood or
potentially infectious materials should
be performed in a manner that
minimizes splashing and/or spraying;
and
body fluids and any infectious
material(s) shall be confined and
contained.
1.1.2
Clean mouthpieces, resuscitation bags, or

other ventilation devices shall be provided
for use where the need to resuscitate is likely
to occur.
Care of the patient may be provided without crosscontamination to the health care team.
1.1.3
Health care team members with exudative

lesions or weeping dermatitis shall refrain
from providing direct patient care or
invasive procedures.
Cuts, abrasions, and hangnails tend to ooze serum and are

a potential risk for infection between health care team and
the patient. Microorganisms grow readily in exudate and
open skin lesions.
1.1.4
Blood/body fluid splashes in the eyes, or

mucous membrane and/or skin punctures
shall be reported to the Occupational Health
Department and the health care facility's
protocol followed.
Hepatitis and HIV are examples of diseases, which may

enter through the mucous membranes or via skin puncture.
Section 2
Page 90 of 334
RATIONALE
1.1.5
Used/contaminated needles shall not be

recapped, bent, sheared, broken, or
resheathed by hand. Safety engineered
needles (SENs) are the recognized best
practice.
1.1.6
All disposable sharps shall be placed in a

designated puncture-resistant container
located in the area where the items were
used.
The move to needleless systems or needle-protection

systems prevents percutaneous injuries. Risk of injuries
escalates when recapping needles, and/or handling sharps.
Occupational Health and Safety Regulations have been
passed in several provinces regarding the use of safety
engineered devices in an effort to reduce exposure to blood
borne pathogens. Health care facilities should protect
workers by implementing SEN systems whenever possible,
and facilitating safe work procedures and practices related
to the use of needles.
1.1.7
Specimens shall be placed in leak proof

containers clearly labeled "Biohazard" for
handling and transport. Any specimen
container received from the sterile field shall
be placed into a fluid resistant bag and
similarly labeled.
All specimens are potentially infectious.
1.1.8
Hepatitis B Virus (HBV) immunization shall

be made available to all perioperative staff
as per facility policy and procedure.
Immunization against HBV is effective in preventing the

disease and should be given before occupational exposure
occurs.
Additional Transmission Based Precautions

1.2 Airborne Precautions (used in addition to Routine Practices)
1.2.1
PRACTICE
RATIONALE
Airborne Precautions shall be used for

patients who are suspected or known to
have certain infections as outlined by the
health care facility, including but not limited
to:
- Tuberculosis;
- Varicella;
- Rubeolla;
-Sudden Acute Respiratory Syndrome
(SARS); and
- emerging respiratory communicable
diseases.
Airborne microorganisms are widely dispersed by air

currents and can be inhaled. These can deposit on
surfaces or on a susceptible host. Airborne
particles range in size from 0.001 microns to several
hundred microns (AORN, 2010, p. 241).

follow the facilitys infection prevention and
control policy/procedure for Airborne
Precautions which may include, but is not
limited to:
- placing a surgical mask on a patient
during transport and ensuring the
Occlusive fitting 0.1 micron filter masks provide

personal protection in cases where airborne infection
Section 2
Page 91 of 334

PRACTICE
1.2.2
Staff susceptible to chicken pox or measles

shall be excluded from caring for patients
with active measles, chicken pox or shingles
(Health Canada 1999).
Personnel who have had unprotected contact
with active untreated pulmonary
tuberculosis shall be notified; shall report to
the Occupational Health
Department; and shall follow the health care
facility's protocol.
1.2.3
The same between case cleaning procedures

used in other theatres in the facility should
be used (Gruendemann & Mangum, 2001, p.
352). An approved hospital grade
germicide/ disinfectant that is not
tuberculocidal may be used.
1.2.4
Theatres should remain vacant in order

to allow for a complete air exchange. The
time is dependent on number of room air
exchanges per hour. The airborne
precaution sign must remain on the door

patient is transported directly into the

theatre;
health care workers caring for a patient
known or suspected to have
microorganisms transmitted by the
airborne route shall wear NIOSH
approved N95 or equivalent
respirator/mask when in the same room
with the patient;
Fit testing for N95 masks shall comply
with federal, provincial, and facility
policies;
respirators/masks should be closely
fitted to the face to prevent leakage
around edges and shall be fit tested;
Airborne Precaution signs shall be
posted on theatre doors. All doors to the
theatre shall be kept closed. Strict traffic
control shall be enforced;
Air pressure in operating room should
be changed from positive to negative;
and
for suspected SARS, or an emerging
communicable respiratory disease, refer
to federal and provincial directives.
is suspected or confirmed.
Extraordinary attempts to disinfect or sterilize

environmental surfaces are not required. Walls,
floors, and other environmental surfaces are rarely
associated with transmission of infections to patients
or health care workers.
Time is needed to allow for appropriate ventilation

air exchanges. Follow CSA Heat, Ventilation and
Air Conditioning (HVAC) guidelines (CSA Z317.201).
Section 2
Page 92 of 334
1.2.5
If the room is urgently needed before the

air has been sufficiently cleared of
tubercle bacilli, an N95
respirator must be worn during
cleaning; and removed only
after leaving the room and the door has been
closed.
1.2.6
Disposable anesthetic equipment shall be

used on all patients with suspected or known
airborne diseases.
1.2.7
When pulmonary TB is known or suspected,

a TB specific bacterial filter shall be placed
on the patient's endotracheal tube or at the
expiratory side of the anaesthesia breathing
circuit.
It is preferable to wait for sufficient air exchanges to

clear the air before cleaning the room (Best Practices
for Environment Cleaning for Infection Prevention
and Control in Health Care Settings, December 8,
2009 p. 96).
Helps reduce risk of contaminating equipment or

discharging tubercle bacilli into the ambient air
(Phillips, 2007, p. 239).
REFERENCES
Association of PeriOperative Registered Nurses. (2010). Perioperative Standard and Recommended
Practices. Denver: AORN.
Canadian Standards Association (2008). CSAZ317.2-01 (R2008) Special requirements for heating, ventilation, and
air conditioning (HVAC) systems in health care facilities. Toronto: Author.
Gruendemann, B. & Mangum, S. (2001). Infection prevention in surgical settings. Toronto: W.B.
Saunders.
Phillips N. (2007). Berry & Kohns Operating room technique. (11th ed.). Toronto: Mosby.
Provincial Infectious Diseases Advisory Committee (PIDAC), (December 8, 2009)
Best Practices for Environment Cleaning for Infection Prevention and Control in Health Care Settings. Ontario.
Siegel, J., Rhinehart, E., Jackson, M., & Chiarello, L., the Healthcare Infection Control Practices Advisory
Committee, (2007). Guidelines for Isolation Precautions: Agents in Healthcare Settings.
Section 2
Page 93 of 334

until sufficient time has elapsed (Best

Practices for Environment Cleaning for
Infection Prevention and Control in
Health Care Settings, December 8, 2009
p96).
Association of Anaesthetists of Great Britain and Ireland (AAGBI), (2008). AAGBI Safety Guideline Infection
Control in Anaesthesia, AAGBI, London. www.aagbi.org
McKay, M., & Farley, M. (2006 December). Infection control circle of safety. Canadian Operating Room Nursing
Journal, 24, (4), 20-24, 41.
Neil, J. A. (2008). The Perioperative Care of the Patient with Tuberculosis. AORN, 88 (6) 942-960.
For current information on SARS, refer to the website www.SARSReference.com
1.3 Droplet Precautions (to be used in addition to Routine Practices)

1.3.1
Droplet Precautions shall be used for

patients who are suspected or known to have
certain infections as outlined by the health
care facility or Infection Prevention and
Control department, including but not
limited to:
-parainfluenza;
-croup;
-pertussis;
-influenza;
-bacterial meningitis caused by haemophilus
influenza and neisseria meningitis;
-rubella;
-mumps; and
-parvovirus B19.
1.3.2
Follow facility's Infection Prevention and

Control procedures for Droplet Precautions
which may include, but is not limited to:
- placing a surgical mask on a patient during
transport and ensuring that they are
transported directly into the theatre;
-posting Droplet Precaution signs on theatre
doors;
-a high efficiency mask shall be worn when
working within 2 meters of patients (the
high efficiency mask approved for operating
room use provides sufficient protection
when worn according to manufacturers
instructions); and
- eye protection shall be worn when there is
Precautions may differ for pediatric and adult patients

(check with the facility infection control practitioner).
(Canada Communicable Disease Report, 1999, p. 42)
As it is not possible to predict when droplets will be
Section 2
Page 94 of 334

BIBLIOGRAPHY
encountered it is preferable to err on the side of

caution and wear eye protection at all times.
Staff susceptible to measles and/or chicken

pox shall be excluded from assignments that
pose a risk of exposure to these
microorganisms (Health Canada, 1999).
1.4
1.4.1
1.4.2
Contact Precautions (to be used in addition to Routine Practices)

Contact Precautions shall be used for
patients who are suspected or known to have
certain infections as outlined by the health
care facility and the Infection Prevention
and Control Department, including but not
limited to:
- scabies, impetigo, herpes simplex and
other skin infections;
- antibiotic resistant organisms (ARO)
e.g.: MRSA/VRE;
- gastrointestinal infections e.g. Hepatitis
A and E;
- pseudomonas
- clostridium difficile ;
- respiratory syncytial virus (RSV);
- wound infections such as necrotizing
fasciitis; and
- major burn wound infection.
Follow the facility's Infection Prevention
and Control procedures for Contact
Precautions which may include but is not
limited to:
- when possible, schedule these surgical
procedures as the last case of the day in
a specific theatre;
- removing unnecessary equipment from
the theatre;
- posting Contact Precaution signs on
theatre doors;
- ensuring that an additional circulator is
assigned outside the theatre to assist
with obtaining items throughout the
procedure, the recovery, and the
cleanup;
- wearing gloves when touching a patient,
or coming in contact with items that
may contain a high concentration of
microorganisms;
- gowning when clothing will have direct
Most microorganisms are spread by direct or indirect

contact. They are often transferred via hands but
may be spread by patient care equipment and other
objects.
Contact transmission precautions may differ between
the adult and pediatric population, therefore
adherence to the health care facility's policy is
crucial. (Canada Communicable Disease Report,
1999, p. 46)
Reduces time delays and possible cancellations due

to the cleaning time required post case.
Removal of unnecessary equipment and supplies
from the room prior to the patients arrival will assist
in controlling replacement costs as exposed items that
cannot be reprocessed must be discarded.
It is important that appropriate barriers are used to

reduce the opportunity of transmission of
microorganisms between patients, visitors and staff.
Section 2
Page 95 of 334

a chance that droplets may be expelled into

the eyes of staff.
It is important to remember that these resistant

microorganisms can survive on surfaces for an
extended period of time. (PIDAC December 8, 2009
p. 21 - 22) have a table which shows VRE up to 58
days on counter tops; MRSA 9 weeks after drying;
gram positive & cocci 25 days and gram negative 60
days on hospital fabrics and plastics; and
entercocci/staphylococci up to 90 days. Cleaning
with appropriate hospital grade disinfectants will
control the microorganisms thereby protecting other
patients, staff and the aseptic environment.
REFERENCES
Association of PeriOperative Registered Nurses. (2010). Perioperative Standard and Recommended
Practices. Denver: AORN.
Canada Communicable Disease Report. (1999) ISSN-4169, Vol. 25S4, 42.
Provincial Infectious Diseases Advisory Committee PIDAC, (December 8, 2009)
BIBLIOGRAPHY
Arpin, Jocelyne (2005). Sars and its Effect on Health Care. Canadian Operating Room Nurses Journal, 23(4).
Barrow, C. (2009). A patients journey through the operating department from an Infection Control perspective.
Journal of Perioperative Practice, 19(3), 94-98.
CDC, (2007). Guidelines for isolation precautions: preventing transmission of infectious agents in healthcare
settings, CDC, Atlanta GA.
CHICA-Canada, (2008). Position Statement, Hand Hygiene. http://www.chica.ca
Canadian Standards Association (2007). CSA Z94.3-F07 Eye and Face Protectors. Toronto: Author.
Canadian Standards Association (2009). CSA Z94.3.1-09 Selection, Use and Care of Protective Eyewear.
Toronto: Author.
Department of Health, (2008). Clean, Safe Care: Reducing Infections and Saving Lives, Dept. of Health.
www.dh.gov.uk/publications
Freeman, S. (2009). An Evidence-based Process for Evaluating Infection Control Policies. AORN Journal,
89 (3), 489-508.
Section 2
Page 96 of 334

contact with the patient, or touch

surfaces or objects in the theatre which
came into contact with the patient;
recovering patient in the theatre or a
separate isolated area of the Post
Anesthetic Care Unit (PACU);
terminal cleaning of the theatre after
case; and
ensure the patient health record does not
have contact with the bed linen during
the transport of the patient.
Ott, M. & Wirick, H. (2008). Vancomycin-Resistant Entercocci (VRE) and the role of the healthcare worker.
Canadian Operating Room Nursing Journal, 26(1), 21-24, 26-29.
Stopp-Caudell, B. (2008). Gangrene: Recognizing and Treating Cellular Necrosis, Surgical Technologist, 40(12),
547-552.
Tanner J (2008). Surgical Hand Antisepsis: The Evidence, Journal of Perioperative Practice, 18 (8), 330-339.
Tanner J & Blunsden C (2007). National Survey of Hand Antisepsis Practices, Journal of Perioperative Practice
17(1), 27-37.
Tarrac, S. E., (2008). Application of the Updated CDC Isolation Guideline for Healthcare Facilities, AORN, 87(3),
534-545.
Weaving P, Cox F, & Melton S (2008). Infection Prevention and Control in the Operating Theatre: reducing the risk
of SSI, Journal of Perioperative Practice, 18(5), 199-204.
Valentin Rodriquez, (2008). Necrotizing Fasciitis, Surgical Technologist, 40(7), 305-315.
Classic Creutzfeldt-Jakob Disease (CJD)

CJD Precautions
These recommendations summarize those outlined by Health Canada in Infection Control Guideline Classic
Creutzfeldt - Jakob disease in Canada. (CCDR, 2002; 28S5, p.1-84) and include updates from the Infection Control
Guidelines Creutzfeldt-Jakob Disease in Canada Quick Reference Guide 2007. They apply to all forms of classic
CJD (sporadic, familial and iatrogenic), and to Gerstmann-Straussler-Scheinker syndrome (GSS) and Fatal Familial
Insomnia (FFI). The Public Health Agency of Canada guidelines should be consulted for detailed information
regarding the management of CJD. www.phac-aspc.gc.ca/publicat/ccdr-rmtc/02vol28/28s5/index.html. Updates and
Quick Reference Logarithm can also be accessed from The Public Health Agency of Canada Agency Guidelines,
2007 http://www.phac-aspc.gc.ca/nois-sinp/cjd/cjd-eng.php
At this time, variant CJD is excluded from Health Canadas recommendations.
2.1 Implementing CJD Precautions

CJD precautions shall be implemented when warranted, after completing an assessment of the combination of patient
risk and tissue risk. Refer to Appendix A, p.102 for an example of a patient risk assessment tool.
Section 2
Page 97 of 334

Lee, T. C., Carrick, M.M., Scott, B.G., Hodges, J.C. (2007). Incidence and Clinical Characteristics of Methecillinresistant Staphylococcus Aureus necrotizing Fasciitis in a Large urban Hospital. Canadian Journal of
Surgery, 194, 809-813.

The following table summarizes the situations when CJD precautions are required.
Low Risk Patient

Tissue Contact
During Surgery
High Risk Patient

i.e. CJD diagnosed or
suspected
High Infectivity
Tissue
Brain, spinal cord &
spinal ganglia,
trigeminal ganglia.
cerebrospinal fluid
(CSF), dura mater,
pituitary, and posterior
eye (including retina
and optic nerve)
Low Infectivity Tissue
Kidney, liver, lung,
lymph nodes, spleen,
placenta, cornea
No Detected
Infectivity Tissue
All other tissue
including blood, body
fluids (except CSF).
i.e. Recipients of high

infectivity tissue grafts
or injections, or
members of families
with familial CJD
No Risk Patient
All other patients
YES
NO
NO
YES
NO
NO
NO
NO
NO
2.2 CJD Precautions

PRACTICE
RATIONALE
When CJD is identified prior to surgery,

the CJD protocol shall include the following:
2.2.1
Notify OR and other affected departments

(i.e. central processing and laboratory) in
advance.
2.2.2
Remove unnecessary supplies and

equipment from the theatre.
2.2.3
Use single use items (including drapes and

gowns) whenever possible.
2.2.4
Protect fixed surfaces and equipment with

water resistant drapes and covers.
Section 2
Page 98 of 334
2.2.6
RATIONALE
Do not use difficult to clean items e.g.

power equipment, flexible scopes, or
stereotactic equipment.
When possible, schedule these surgical
procedures as the last case of the day in a
specific theatre.
These items would be destroyed by CJD reprocessing

protocol.
2.2.7
Limit the number of staff in the room.
2.2.8
Wear personal protective equipment as per

Routine Practices. Refer to Section 1 page
92 for further information.
2.2.9
Once the contaminated part of procedure

has begun, no items shall leave the room
until the completion of the surgical
procedure.
2.2.10
Specimens shall be sealed and clearly

labeled Infectious, Biohazardous and CJD.
2.2.11
Ensure that instruments sent to the

reprocessing area are sealed in a
biohazardous container and clearly labeled
as CJD Protocol Required.
2.2.12
Instruments that will not be incinerated shall

be kept moist in a closed container during
transport to the reprocessing area.
2.2.13
Whenever possible, incinerate used

instruments following surgery.
2.2.14
Immediately after the completion of surgery,

all personnel shall wear appropriate personal
protective equipment to clean the theatre,
and will follow the CJD Hard Surface
Decontamination (CCDR, CJD, 2002)
protocol:
Remove visible soil.
Flood soiled area(s) with freshly prepared
sodium hydroxide 1 N solution or sodium
hypochlorite (bleach) solution (20,000 ppm)
for 1 hour of contact time.
Rinse well.
2.2.15
This will reduce delays and potential patient

cancellations that would result from the extensive
cleaning protocols required for CJD.
Contaminated refers to the part of the procedure

that begins when contact is made with infective tissue
as described in the preceding table.
Disposable brain biopsy sets are available.

Incineration of biohazardous materials is provincially
regulated.
Full strength sodium hypochlorite (bleach) is usually

~ 5% or 50,000 ppm. 20,000 ppm is about half
strength.
Sodium hydroxide remains active for only a short
period of time (approximately 20 min).
Garbage and solid wastes shall be sealed in a

leak-proof, puncture-resistant container,
labeled Infectious, Biohazardous and CJD,
and sent for incineration.
Section 2
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2.2.5
PRACTICE
2.2.16
Suctioned liquids shall be solidified, sealed

in a leak-proof, puncture-resistant container,
labeled Infectious, Biohazardous and CJD,
and sent for incineration
2.2.17
Liquids for cleaning can be flushed down

the drain.
RATIONALE
Postoperative Instrument Containment

Following surgery, the procedure for processing contaminated instruments that will not be incinerated shall include
the following:
2.2.18
Process in a specially designated area,

preferably within the Decontamination area.
Protect the separate area with disposable,
waterproof covers.
2.2.19
Reprocess instruments following the CJD

Decontamination protocol (Public health
Agency, 2007):
- Manually clean instruments using
detergent.
- Rinse well.
- Immerse in fresh sodium hydroxide
(1N) or sodium hypochlorite (bleach)
(20,000 ppm) solution for 1 hour.
Cover container during immersion.
- Rinse well.
- Sterilize:
- Position instruments in a mesh
bottomed instrument pan and steam
sterilize in a Prevac cycle @ 134C
for 1 hr
- Reprocess through a washer
decontaminator/disinfector using
standard methods.
Following washer decontaminator/
disinfector reprocessing, run one empty
cycle before further use.
2.2.20
Incinerate solid waste and cleaning supplies.
2.2.21
Cleaning liquids may go down the drain.
Processing in a separate area limits the potential for

cross-contamination.
A detailed inspection of a complex or fragile piece of

a reusable device may reveal that the item can be
dismantled more thoroughly than anticipated.
Various parts of the device may tolerate the CJD
decontamination process safely. By completing this
process, far less of the device may need to be
incinerated. If necessary, the manufacturer should be
contacted for assistance.
CAUTION: Highly alkaline detergents should not be
used when manually cleaning as they pose a safety
risk to staff.
Recent research indicates promising results regarding
prion inactivation using highly alkaline detergents in
combinations with various sterilization methods.
(Yan, et.al, 2004 and Fichet, et.al, 2004)
Because the final rinse water of one cycle is often
used as the pre-rinse water of the next cycle, running
an empty cycle removes all saved water.
Infective Tissue or Fluid Spill protocol shall include the following:

2.2.22
Flood area of spill with full strength bleach.

Let stand 10 minutes.
Section 2
Page 100 of 334

PRACTICE
2.2.23
Apply absorbent material.
2.2.24
Follow CJD Hard Surface

Decontamination protocol outlined in
2.1.14.
2.2.25
Incinerate clean-up materials.

PRACTICE
RATIONALE
Quarantine for Suspected CJD protocol shall include the following:

Some facilities may choose to quarantine used instruments until a diagnosis of CJD is confirmed. If
instruments are quarantined, the following measures shall be taken:
2.2.26
Clean instruments. Scrub nurse shall

remove gross soil.
2.2.27
Separate in reprocessing of instruments and

quarantine.
2.2.28
Store in a sealed container that is:

dated;
leak-proof;
puncture-resistant; and
labeled Infectious, Biohazardous, and
CJD Protocol.
2.2.29
Monitor in a secure area.
2.2.30
When diagnosis is confirmed:

If positiveincinerate or reprocess
following CJD Instrument
Decontamination protocol.
If negativereprocess using standard
(usual) methods.
The protocol for CJD Risk identified after procedure completion shall include the following:
2.2.31
Implement CJD precautions as required.
Refer to clause 2.2 of this section.
2.2.32
Identify all reusable instruments used on

patient prior to the risk being identified.
A method for tracking instruments used in high-risk

procedures facilitates quarantine.
2.2.33
If unable to identify specific instruments

used, follow recommendations for High
Risk patients managed Retrospectively
(Public Health Agency, 2007) and the
healthcare facility policy.
Section 2
Page 101 of 334

Appendix A
Source: (Risk Assessment tool Recommendations for managing instruments used on CJD patients. Decision
algorithm-graphic version),
Public Health Agency of Canada, (2007) Reproduced with the permission of the Minister of Public Works and
Government Services Canada, 2009.
Section 2
Page 102 of 334
Adapted from Canada Communicable Disease Report - Infection Guidelines, Classic Creutzfeldt-Jakob Disease in
Canada, Volume 28S5, November 2002, and Health Canada. Accessed April 26, 2009 at www.phacaspc.gc.ca/publicat/ccdr-rmtc/02vol28/28s5/index.html. Reproduced with the permission of the Minister of
Public Works and Government Services Canada. Health Canada assumes no responsibility for any errors or
omissions, which may have occurred in the adaptation of its material.
Fichet, G., Comoy, E., Duval, C., Antloga, K., Deher, C., Charbonnier, A., et al. (2004). Novel methods for
disinfection of prion contaminated medical devices. Lancet, 364, 521-526.
Public Health Agency of Canada (2007). Infection Control Guidelines: Classic Creutzfeldt-Jakob disease in Canada,
Quick Reference Guide. Accessed on April 26, 2009 at http://www.phac-aspc.gc.ca/nois-sinp/cjd/cjdeng.php
Yan, Z., Stitz, L., Heeg, P., Pfaff, E., & Roth, K. (2004) Infectivity of prion protein bound to stainless steel wires: A
model for testing decontamination procedures for transmissible spongiform encephalopathies. Infection
Control and Hospital Epidemiology, 25(4), 280-283.
BIBLIOGRAPHY
Advisory Committee on Dangerous Pathogens Spongiform Encephalopathy. (1998). Advisory Committee
Transmissible spongiform encephalopathy agents: safe working and the prevention of infection. London,
England: The Stationary Office.
Barnett, F., McLean, G. (2005). Care management of Creutzfeldt-Jakob disease within the United Kingdom. Journal
of Nursing Management. 13(2), 111-8.
Beesley, J. (2003). Creutzfeldt-Jakob Disease. British Journal of Perioperative Nursing, 13(1), 21-2.
Belkin, N. (2003). Creutzfeldt-Jakob disease: Identifying prions and carriers. AORN Journal, 78(2), 204-208, 210.
Farling, P. & Smith, G. (2003). Anesthesia for patients with CJD: A practical guide. Anesthesia, 58(7), 627-629.
International Association Healthcare Central Services Material Management (2007) Central Services
Technical Manual. Author. http://iahcsmm.org/
Knight, R. (2006) Creutzfeldt-Jakob Disease: A rare cause of dementia in elderly persons. Clinical Infectious
Diseases, 43(3), 340-346.
McNeil, B. (2004). Management of a CJD Case: Part 2-The patient with CJD in the operating theatre. British Journal
of Perioperative Nursing, 14(5), 223-226.
Scicchitano, L. (2004). Bovine spongiform encephalopathy and CJD: Background & implications for nursing
practice. Insight. 29(4), 17, 19-21.
World Health Organization. Variant Creutzfeldt-Jakob disease. Retrieved April 26, 2009 from
www.who.int/mediacentre/factsheets/fs180/en/
Section 2
Page 103 of 334

REFERENCES

Environmental Cleaning/Sanitation
Principles:
1.
Only essential equipment should be

maintained within the operating room.
The less equipment in the room the less cleaning is

necessary and a reduced number of areas are
available for dust to harbour organisms.
2.
Open shelving shall not be used in the

patient operating room to store sterile
supplies.
Bioburden may be increased by microbial laden

aerosols and dust may land on the sterile packages.
Sterile goods should be protected from high traffic.
Sterile packages may be at risk with routine
cleaning agents and activities.
3.
All cupboards should have doors

preferably with glass.
Bacterial growth is impeded by fluorescent lighting.
4.
Positioning equipment components should

be stored within a cupboard with door
Bioburden may be increased by microbial laden

aerosols and dust may land on the components.
5. OR doors shall remain closed at all times,

including during cleaning.
PRACTICE
Closed doors are essential to maintain the positive

room pressure and preventing air from potentially
contaminated corridors entering the room.
RATIONALE
3.1 General Practices

3.1.1
3.1.2
All surgical procedures shall be considered

potentially infectious and environmental
cleaning protocols shall be documented and
implemented for all procedures with
additional precautions required for specific
patient conditions as outlined in Routine
Practices, Section 2.
All surgical patients shall be provided with a
clean, safe environment, which is free from
dust, debris and bioburden.
The perioperative nursing team, lead by the
Registered Nurse circulator share the
responsibility and accountability for
ensuring a clean environment for each
patient.
It is essential that doors to the rooms be kept
closed, except for entry/exit, including
during cleaning procedures to ensure
positive pressure is maintained.
A clean OR environment ensures minimal microbial

growth, which is essential to the reduction of infections
and well-being of patients and personnel.
Procedures shall be available for the
Additional precautions are available in addition to
The surgical suite can become heavily contaminated with

microbes, becoming a risk for patients, unless it is
properly cleaned and disinfected.
Positive pressure is easily lost with open doors, which

allow air currents from corridors, and surrounding rooms
that may be laden with organisms and dust entering the
clean/sterile areas.
Section 2
Page 104 of 334
RATIONALE
containment and control of antibioticresistant organisms (AROs) and emerging

diseases according to the health care
facilitys infection control protocol.
Routine Practices for such contaminants as antibioticresistant organisms (AROs), drug resistant gram-negative
organisms, tuberculosis and Creutzfeldt-Jakob disease.
(See specific sections).
AROs can be found on surfaces many days to weeks after
improper/ incomplete cleaning
Studies show that microorganisms can survive after
inoculation onto items/surfaces and/or can be cultured
from the environment in healthcare settings; and/or can
proliferate in or on items/surfaces in the environment
(Best Practices for Environment Cleaning for Infection
Prevention and Control in Health Care Settings,
December 8, 2009 p. 21).
The theatre's environment shall be designed

so that it can be easily cleaned:
- floors should be smooth, seamless, and
easy to clean
- finishes on all walls and ceiling surface
materials should be hard, non-porous,
fire-resistant, waterproof, stain-proof,
seamless, non-reflective, and easy to
clean (CSA Z314.8-08; CSA Z314.309; Phillips, 2007; Rothrock, 2011);
- wall finishes should be free of fissures,
open joints, or crevices;
- room furnishings and equipment shall
be easily washable/wipeable;
- shelving and cabinets should be of a
material and design that is easily
cleaned; and
- minimal supplies and equipment should
be stored inside the theatre.
Debris could become lodged in cracks and uneven

surfaces.
Spaces or crevices may retain or permit passage of soil

particles.
Supplies and equipment stored in the operating room

make it difficult to maintain a clean environment.
Sterile supplies become laden with dust, microbes over
time.
3.1.4
Intraoperative, between - case, terminal,

daily, weekly, monthly cleaning schedules
shall be documented and available to all
involved team members.
Environmental sanitation practices shall be
performed by trained personnel according to
health care facility protocol.
Documentation of cleaning provides a means of tracking

for Quality Assurance purposes...
3.1.5
Cleaning solutions, equipment, and supplies

utilized for sanitation shall be approved by
the Infection Prevention and Control
Committee.
Selection of above items shall be supported
by current evidence.
Ensures that appropriate solutions, equipment and

supplies are utilized to reduce microbial contamination of
the environment.
Section 2
Page 105 of 334

3.1.3
PRACTICE
RATIONALE
3.2
Preliminary Cleaning
3.2.1
The perioperative Registered nurse is

responsible for ensuring all team members
take an active role in facilitating a clean
surgical environment.
A clean surgical environment will reduce the number of

microbial flora present. Staphylococcus aureus is the
most common microbe causing surgical wound infections.
The microbes are transferred by lint, dust, air currents and
hands.
3.2.2
All horizontal surfaces within the theatre

(e.g., furniture, tops of surgical lights, and
equipment) shall be damp-dusted. Damp
dusting is done with a clean, lint-free cloth
moistened with a hospital approved lowlevel disinfectant. Start dusting at higher
surfaces and work down to lower levels.
Proper cleaning of the theatre reduces the amount of

exogenous microorganisms, dust, debris and bioburden in
surgical environments. It also helps to reduce airborne
contaminants that may travel on dust and lint and settle on
surfaces.
Dust with a solution approved by the facility

IPC Committee and validated by the
manufacturer for the intended purpose.
Ensures the product being used meets the required

standards.
Electronic equipment (i.e. monitors) shall be

cleaned as per manufacturers instructions.
Inappropriate use of liquids on electronic medical

equipment may result in fires and other damage,
equipment malfunctions and health care provider burns
(Best Practices for Environment Cleaning for Infection
Prevention and Control in Health Care Settings,
December 8, 2009 p. 81).
The team shall be vigilant in checking the

reflective surface of the surgical lights for
blood splatters.
The reflective portion of the surgical lights
shall be wiped between cases and as needed.
3.2.3
Equipment from other areas such as X-ray

machines, compressed gas tanks, etc., shall
be damp-dusted before being brought into
the operating room and prior to leaving.
3.3
Intraoperative Cleaning
3.3.1
During the procedure, all contaminated

items and spills shall be contained and/or
promptly cleaned up using a facility
approved disinfectant.
Prompt cleaning prevents spreading of microorganisms.
3.3.2
Equipment leaving the theatre shall first be

wiped down with a hospital approved
disinfectant prior to being stored.
Prevent cross contamination.
Damp dusting reduces viable microbial contamination

from air and other sources.
Section 2
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PRACTICE

PRACTICE
RATIONALE
3.4
End of Procedure Cleaning (Between Cases)
3.4.1
Any surface and equipment that comes in

direct or indirect contact with the patient or
body fluids, are considered contaminated
and shall be cleaned with a hospital-grade
disinfectant approved by Infection
Prevention and Control. Clean up for
surfaces and equipment shall proceed from
the least contaminated to the most
contaminated area
3.4.2
Regulated Medical Waste (RMW) shall be

handled as little as possible and disposed of
according to municipal/provincial/federal
legislation and/or health care facility
policies and procedures.
Prevents leakage and cross-contamination.
3.4.3
After removal of trash, linen and

instruments, the floor area to within a 1 to
1.5m (3 to 4 ft) perimeter around the
operative area should be cleaned if visibly
soiled. The area cleaned shall be extended
as required to encompass visibly soiled
areas. (CSA Z314.8-08 p 23)
The extent of cleaning is case-specific depending on the

amount of contamination.
3.4.4
Mop heads shall be changed after each use.

If a bucket of hospital grade disinfectant
solution is prepared for multiple uses, used
mops shall not be reintroduced into the
bucket (AORN, 2008).
A minor cleaning with a wet mop immediately around the

OR table (without moving the OR table) is adequate after
a minor case with no spillage.
3.4.5
Suction containers/liners should be

disposable and wherever possible solidifiers
should be used.
Containers shall be disposed of as per
facility waste management policies
Use of solidifiers will prevent splashing and

aerosolization of blood, body fluids and microorganisms.
3.4.6
Reusable suction containers should not be

used (AORN, 2008).
Risk of splashing and aerosolization are a high risk to

personnel
3.4.7
Suction tubing shall be disposable.
The lumen of suction tubing cannot be cleaned

effectively.
Section 2
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3.5
Terminal Cleaning
3.5.1
After the days schedule each theatre, scrub

area, corridor, furnishings, and equipment
shall be terminally cleaned. This includes:
- lights and ceiling-mounted tracks;
- door handles and push plates;
- light switches and controls;
- telephones and computer keyboards;
- spot-checking walls for cleanliness;
- the exterior surfaces of all machines and
equipment (allow adequate drying time
as per manufacturers instructions
before storage);
- all furniture, including wheels/casters;
- all horizontal surfaces;
- scrub sinks and surrounding walls;
- floors should be mopped with a
sufficient amount of disinfectant/
detergent to ensure that the floor remains
wet for 5 minutes. Each floor shall be
thoroughly cleaned using fresh solution
and a fresh mop/mop head; and
- floors should be power scrubbed at
regular intervals according to established
protocols.
To reduce the number of infectious

agents/microorganisms present.
Refillable liquid soap dispensers should

not be used.
If refillable soap dispensers must be
used, they shall be disassembled,
cleaned and terminally disinfected before
refilling with antiseptic solutions.
Dispensers shall not be topped up (Health
Canada, 2004).
Refillable dispensers may become contaminated and

act as a reservoir for microbial growth (Health
Canada, 2004; AORN, 2010).
3.5.2
Moisture encourages microbial growth.
3.6
Weekly and/or Monthly Cleaning
3.6.1
Cleaning protocols and schedules for all

areas of the surgical suite shall be
documented and assigned to specific
personnel.
Effective sanitation techniques reduce the possibility

of cross-contamination of patients and decrease risks
to personnel.
Promotes effective collaborative practice.
A means to confirm that cleaning has been done is
essential for infection control audit purposes. i.e.
signed checklists.
3.6.2
Items/areas scheduled to be cleaned should

include, but are not limited to:
- walls;
- floors
- air-conditioning and ventilation
Effective sanitation techniques reduce the possibility

of cross-contamination of patients and decrease risks
to personnel.
Section 2
Page 108 of 334

grills/vents;
light fixtures, sprinkler heads and other
fixtures
ducts and filters;
sterilizers;
cabinets, closets, shelves;
warming cupboards;
theatre walls and ceilings;
recessed ceiling tracks;
store rooms;
offices and lounges;
pre-op holding area
refrigerators, ice machines; and
washrooms and locker rooms
REFERENCES
Canadian Standards Association. (2009). Z314.3-09. CAN/CSA. Effective sterilization in health care
facilities by the steam process. Toronto: Author.
Canadian Standards Association. (2008). Z314.08-08. CAN/CSA. Decontamination of reusable medical
devices. Toronto: Author.
Health Canada (2004). Drugs and Health Products. Retrieved April 1, 2009 from www.hc-sc.gc.ca
Phillips, N. (2007). Berry & Kohns operating room technique. (11th ed.). Toronto: Mosby.
Woodhead, K. and Wicker, P. (2005). Textbook of Perioperative Care. Toronto: Elsevier.
BIBLIOGRAPHY
Nelson , Jason., et al. (2006). Microbial Flora on operating Room Telephones, AORN Journal, 83(3), 607-626.
Walsh, Eric F., et al. (2006). Microbial Colonization of Tourniquets Used in Orthopedic Surgery,
Orthopedics, 29(8), 709-713. www.ORTHOSuperSite.com
Traffic Control
PRACTICE
4.1
RATIONALE
General Practice
The surgical suite shall have three (3) levels
of increasingly restricted access.
4.1.1
-
Microbial load is reduced with progression of area

restrictions.
Unrestricted Areas
street clothes are permitted;

Section 2
Page 109 of 334
4.1.2
-
4.1.3
-
4.2
4.2.1
includes a control point or desk to

monitor and direct further access; and
depending on facility policy, may also
include pre-op holding area, staff
lounge, booking office and/or
managers office.
RATIONALE
Identified in CDC requirements for infection control in

perioperative settings (Gruendemann,1999).
Semi-restricted Areas
personnel are required to wear
appropriate surgical attire and cover
head and facial hair; and
includes peripheral support areas, i.e.
clean and sterile supplies, work areas
for storage, scrub sink areas, corridors
leading to restricted areas.
Restricted Areas
surgical attire and facemask required;
and
includes any area where scrub personnel
are present such as the operating room
and/or any area where sterile supplies
are opened.
People
All visitors shall report to, or communicate
with, the reception desk and receive
authorization and directions as to traffic
flow and dress protocol.
Control and identification of persons entering the

surgical suite is essential for patient confidentiality,
infection control, and evacuation in the event of a fire or
other disaster.
All visitors and staff shall wear

identification while in the surgical suite and
adhere to specific hospital policy.
4.2.2
The number of personnel in the theatre

should be kept to a minimum.
The potential for microbial contamination within the

theatre increases significantly as the number of people
and movement in the theatre increases, as this increases
the shedding and air turbulence that carries microbes to
the wound (Phillips, 2007, p. 257).
4.2.3
Doors to an operating room should be kept

closed except when moving patients,
supplies and equipment in or out.
Doors to an operating room should be kept
closed during cleaning procedures.
Disrupted pressurization mixes the clean air of the OR

with the corridor air, which has a higher microbial count
(Phillips, 2007, p. 257).
Pressure in room is lost just prior to sterile set up when
left open during cleaning.
Section 2
Page 110 of 334

PRACTICE
Supplies and Equipment
4.3.1
Cupboard doors shall be kept closed.
Reduces environmental dust, which is laden with

microorganisms, from settling on shelves and
packages. The presence of this dust can increase the
risk of contamination when opening sterile packages.
Prevents inadvertent splash contamination during
procedures or cleaning.
4.3.2
All movement of clean and sterile supplies

and equipment shall be separated from the
movement of soiled equipment and waste.
Where there is a clean core items should be
moved from the clean core through the
operating room to the peripheral core.
Direct contamination from soiled to clean items is

reduced when routes are separated.
In suites where there are peripheral

corridors, clean items such as equipment
should be moved through the corridor and
not through sterile storage areas.
4.3.3
Soiled equipment/items shall be

covered/contained when being transported.
Spillage presents risk to personnel and the

environment.
Soiled supplies, instruments and equipment

should not enter the clean core area, but
should be covered/contained and transported
to a designated soiled area through a
corridor.
4.3.4
Exterior packing containers and/or

corrugated cardboard shall be removed in an
unrestricted area before goods enter a
restricted or semi-restricted area.
Corrugated cardboard shall not be used for
storage in the Surgical Suite.
Gross soil and organisms are prevented from entering

the surgical suite when exterior packing/shipping
containers are removed prior to entry. During
transport, corrugated cardboard may carry dust,
shavings, debris, insect larvae, and insects (Phillips,
2007).
Corrugated cardboard, can harbor moisture and
attract potentially pathogenic microorganisms and
spores (PLUS 1112 March 2004 p61).
4.3.5
Sterile and clean supplies shall be

transported to the theatre or the semirestricted storage area in clean containers or
covered carts selected to protect the integrity
of the sterile packages.
Covered or contained carts protect the clean and

sterile supplies from environment contamination via
aerosols, air contaminants, dust and excess handling.
REFERENCES
Canadian Standards Association (March 2004). PLUS 1112, (2nd ed.) Infection prevention control in office-based
health care and allied services.
Section 2
Page 111 of 334

4.3
PRACTICE
RATIONALE
5.1
Patients
5.1.1
The majority of patients should be required

to remove all clothing prior to surgery.
Exceptions: see Section 3: Gathering
Medico-legal Evidence in the Surgical
Suite
The amount of clothing removed will depend on the

type of surgery and the patients individual needs.
Underpants may be worn if it does not interfere with
the surgical procedure.
Consider clothing removal to reduce a potential
source of microbial contamination.
5.1.2
Patients should wear a clean gown, hair

covering and be covered with clean linen.
Clean gown, hair covering and linen minimize

contamination from shedding.
5.1.3
Patients are not required to wear a mask in

the surgical suite unless immunocompromised or under airborne precautions.
5.1.4
For outpatient surgery, the patient may wear

some of their own clothing, especially if the
clothing does not interfere with the
procedure and the procedure is of short
duration (e.g., cataract surgery). However,
the patient should still wear a clean gown,
have their hair covered and be covered with
clean linens (AORN, 2010).
Recommendations from AORN, 2010 do not

specifically state that outpatients must remove all
clothing.
If it is judged by the health care worker that more
clothing needs to be removed, that can be
accommodated on a patient-by-patient basis. The
matter of attire for outpatients is a facility decision.
5.1.5
All jewellery, including items contained

within body piercings, shall be removed.
Jewellery carries microorganisms into the theatre.

Failure to remove jewellery is an issue related to
patient safety, as there is a potential for injury from
burns, tears, infection or inability to access areas
required for interventions during the surgical
procedure.
(i.e. endotracheal intubation, catheterization etc.)
5.2
5.2.1
Visitors
Visitors requiring limited time in the OR,
such as, parents accompanying children, law
enforcement officers and/or biomedical
engineers may don one piece coverall or
cover gowns along with head and facial hair
coverings.
Visitors who will remain in the theatre for
any extended period of time will follow the
staff section of the dress code standards.
Shoe covers are not required.
Section 2
Page 112 of 334

Dress Code
RATIONALE
5.3
Staff
5.3.1
All personnel who enter the semi-restricted

and restricted areas of the surgical suite shall
wear appropriate surgical attire and adhere
to the health care facility's dress code policy.
Surgical attire minimizes patient exposure to

microorganisms from the skin, mucous membranes, or
hair of surgical team members. Surgical attire may also
be considered personal protective equipment and worn
to prevent the spread of contamination from the patient.
5.3.2
The top of a two piece scrub suit should be

tucked inside the pants.
The uniform should confine skin cell and microbe

shedding and promote infection control. Shedding is
increased by movement and friction. Pants confine
bacterial shedding.
5.3.3
Scrubs that are worn into the institution or

between institutions, where outside access is
required, must be changed before entering
the semi-restricted and restricted areas.
5.3.4
Within restricted and semi-restricted areas,

non-scrubbed personnel should wear a long
sleeved jacket. Jackets shall be buttoned or
snapped closed during wear. Jackets shall
be changed daily and laundered after each
use.
Long-sleeved attire prevents shedding from bare arms.

Loose-fitting jackets may cause accidental
contamination of the sterile field.
5.3.5
Personal clothing (i.e. long sleeve

undershirt) that cannot be completely
covered by surgical attire should not be
worn.
Potential to contaminate surgical environment with

outside organisms.
5.3.6
The use of cover-up attire (e.g. lab coats)

should be determined by the practice setting.
The value of cover gowns within the institution has not

been substantiated.
5.3.7

don freshly laundered scrub attire upon entry
to the unit. If surgical attire is worn outside
the facility, it is removed and new attire is
donned before entering any semi-restricted
or restricted area. Surgical attire should be
changed daily, and whenever it becomes
visibly soiled, contaminated, or wet.
Soiled clothing increases the risk of cross-contamination

to patients, staff, and the public.
Upon removal of surgical attire, it is placed

in a designated container for washing or
disposal. Surgical attire is not hung in a
locker to be worn later.
Reusable surgical attire shall be laundered
by the laundry facilities used by the health
care facility for other surgical textiles (Best
Practices for Environment Cleaning for
Infection Prevention and Control in Health
Approved laundering facilities use recommended

detergent and temperature settings to launder linen.
Section 2
Page 113 of 334

PRACTICE
RATIONALE
Care Settings. (December p. 16)).
5.3.8
5.3.9
Footwear for the surgical suite should meet

provincial labour codes. Shoes that can be
easily cleaned and have enclosed toes and
heels are recommended. Shoe covers should
be worn when splash and spills of body
fluids are anticipated. Shoe covers shall be
removed or changed when soiled, or when
leaving the department.
The literature indicates there is no significant difference

in relation to the amount of bacteria tracked regardless
of the type of footwear (street shoes, clinic shoes, or
shoe covers) worn in the surgical suite; and there is no
clinically significant airborne bacterial dispersion caused
by foot movement. There have been no controlled
clinical studies to evaluate the role of covers in
preventing or reducing surgical site infections (SSI).
Handling soiled shoes may be a hazard to team
members. Depending on the extent of soiling, gloving or
good hand washing is required.
Shoe covers provide personal protection and prevent
environmental contamination outside the theatre.
All hair (including facial hair) shall be

completely confined by a clean hood or hat.
Shedding of squamous cells and hair has been shown to

affect surgical wound infection; therefore, complete
coverage is necessary.
Fingernails shall be clean, short, natural and

appear healthy.
The subungual region harbors the majority of

microorganisms on the hand.
Damaged nails, chipped or peeling polish may provide a
harbor for microorganisms (Phillips, 2007, p. 269).
Long nails, natural and/or artificial can tear gloves.
Natural nail tips should be less than .6 cm

(1/4 in.) long (CDC, 2002, p. 33).
Artificial nails, extenders or artificial
enhancers shall not be worn.
Artificial nails and tips harbour higher numbers of

organisms, Artificial nails are known to promote the
growth of Staphylococcus aureus, gram negative bacilli
and yeast as moisture becomes trapped between the
natural and artificial nail.
Each health care facilitys infection control

policy should dictate the use of nail polish.
Surgical conscience must be foremost in the minds of

those individuals who choose to wear nail polish.
5.3.10
All jewellery should be removed.
5.3.11
Health care workers must wear protective

eyewear if splash is anticipated. Reusable
eyewear shall be cleaned after use.
Jewellery harbours microorganisms and could result in a

glove tear. Several studies have demonstrated that skin
underneath rings is more heavily colonized than skin on
fingers without rings (Thurston, 2007). Necklaces and
earrings may fall on the outside of the sterile scrub gown
into the sterile field or wound.
Protective eyewear that includes side shields and face
shields is worn to reduce the incidence of contamination
of mucous membranes of the eyes.
Contaminated eyewear that is not immediately cleaned
may result in contamination to the wearer.
Section 2
Page 114 of 334

PRACTICE
5.3.12
RATIONALE
All personnel shall wear a single surgical

mask during procedures and/or in the
presence of open sterile supplies (Thurston,
2007). The type of mask that offers the
most appropriate protection for the specific
circumstances shall be worn e.g., laser
masks.
Masks should be considered both a patient and personal

protection item. Laser masks give protection when there
is exposure to aerosolized particles such as laser or
electrosurgical plume, or from power instruments. Two
masks act as a barrier rather than a filter and create sideventing because of the increased effort to breathe.
Special N95 or equivalent respirator/masks

shall be available when airborne infection is
suspected or confirmed. These
respirator/masks shall be fit tested.
Masks shall cover the nose and mouth and
be adjusted for proper fit to prevent venting.
Masks should not hang around the neck or
be stored in pockets.
Masks should be changed between
procedures, or immediately if they become
soiled.
Occlusive fitting 0.1 micron filter masks provide

personal protection in cases where airborne infection is
suspected or confirmed.
Masks should be removed by handling ties

only and discarded. Hands should be
washed.
Used masks contain a large number of microorganisms,

which are transferred to the hands during inappropriate
handling.
Hand washing protects the health care worker and the
patient from the possible spread of infection.
REFERENCES
Center for Disease Control and Prevention. (2002). Guideline for hand hygiene in healthcare settings.
Atlanta: Author.
Phillips, N. (2007). Berry & Kohns operating room technique. (11th ed.). Toronto: Mosby.
Thurston, A. J. (2007). Sources of infection in the operating theater in Limb, D. & Hay, S. (editors). The
Evidence for Orthopaedic Surgery. Shewsbury, UK: tfm Publishing.
BIBLIOGRAPHY
Community and Hospital Infection Control Association (CHICA) Information about Hand Hygiene
retrieved April 24, 2009 from www.chica.org/links_handhygiene.html#STANDARDS
Lipp Allyson & Peggy Edwards (2005). Disposable surgical masks: A Systemic Review. Canadian Operating Room
Nurses Journal, 23(3).
Section 2
Page 115 of 334

PRACTICE
Roxburgh M, Gall P, & Lee K (2006). A cover up? Potential risks of wearing theatre clothing outside theatre,
Journal of Perioperative Practice, 16(1), 30-41.
Thurston, A.J. (2007). Sources of infection in the operating theatre in the Evidence for Orthopaedic Surgery. Edited
by David Limb and Stuart M Hay. Shewsbury, UK: tfm Publishing Limited.
Scrubbing, Gowning, Gloving

PRACTICE
RATIONALE
6.1 Scrubbing
6.1.1
Health care workers should practice general

hand hygiene including;
- hand hygiene immediately before and after
patient contact
- after removing gloves, and
any time when there is possibility of blood
or other infectious material contact.
Gloves do not provide complete protection against

hand contamination (CSA Z314.8-08 p. 35).
6.1.2
Masks and protective eyewear shall be

adjusted for proper fit prior to beginning a
surgical hand scrub.
To be effective, a mask filters inhalations and

exhalations. Therefore, it is worn over both the nose
and the mouth. To be effective, air must pass only
through the filtering system; thus, the mask needs to
conform to facial contours to prevent leakage of
expired air (Phillips, 2007, p. 270).
6.1.3
The skin of the hands and arms shall be free

of open lesions and have no breaks in skin
integrity.
Cuts, abrasions, burns and dermatitis are sources of

infection and pose a risk to patients and personnel.
6.1.4
Members of the scrub team shall be free of

respiratory infections.
Reduces the spread of possible infections to the

patient and other members of the surgical team.
6.1.5
A surgical hand antiseptic/scrub agent

approved by infection control shall be used.
A broad spectrum surgical hand antiseptic/scrub

agent should have the ability to kill organisms
immediately upon application, provide antimicrobial
persistence to reduce regrowth of microorganisms
and have a cumulative effect over time.
Each surgical hand antisepsis/scrub

procedure (water or waterless) should follow
a standardized protocol established and
approved by the health care facility and the
manufacturers written instructions for use.
6.1.6
The manufacturer's written instructions should

prevail because scrub procedures may differ.
Scrub personnel who have an identified

allergy or sensitivity to antimicrobial agents

Section 2
Page 116 of 334

Nathan L Belkin, (2006). Opinion Masks, Barriers, Laundering, Gloving Where the Evidence is? AORN Journal,
84(4), 655-664.
RATIONALE
should be directed by Occupational Health

and Infection Control staff regarding
appropriate hand scrub antiseptic agents.
6.1.7
Special attention should be given to nails,

subungual areas, between fingers and
between thumb and index finger. Cleaning
under each fingernail shall be done before
performing the first scrub of the day. Nail
cleaners shall be used to remove soil from
nails.
The majority of flora on the hands is found under and

around the fingernails
When using water facilitated scrub methods,

hands shall be held above the elbows and
away from surgical attire at all times during
the surgical hand scrub and while drying the
hands and arms with a sterile towel. The
direction of the scrubbing procedure is from
the hands to the elbows, without returning to
the cleaned hands.
To allow the flow of water to run from clean to least

clean. Applies the principle of clean to dirty.
6.1.9
Open the scrub nurse's towel, gown, and

gloves on a separate sterile field, away from
the back table and operative area.
Reduces the chance of contamination of the

instrument table.
6.1.10 When using water facilitated scrub methods

hands and arms shall be dried with a sterile
towel prior to gowning. When using a
waterless facilitated scrub method, hands
and arms shall be dry. Sterile glove liners, if
used, are put on prior to gowning. Once
donned, glove liners are not considered
sterile.
Residual moisture increases the risk of strikethrough, which contaminates the gown and surgical
field.
6.2 Gowning
6.2.1
Sterile gowns shall be made of materials that

are resistant to penetration by blood and
other body fluids as necessitated by their
intended use and compliant with
CSAZ314.10.
Protective barriers reduce the risk of exposure to

blood, body fluids, or other liquids that may contain
potentially infectious agents.
Barrier selection may be determined by the
complexity and length of the planned procedure,
increased potential for exposure to blood borne
pathogens may require selection of a gown with
greater barrier capability.
6.2.2
Gowns should be resistant to tears,

punctures and abrasions.
The inability to withstand tears, punctures and

abrasions may allow for passage of microorganisms,
particulates and fluids between sterile and nonsterile
areas and expose patients to exogenous organisms
(AORN, 2010 p. 392).
Section 2
Page 117 of 334

PRACTICE
6.2.3
Surgical gowns should be large enough to

adequately cover the scrubbed person.
Wrap-around gowns shall be turned by
another sterile person or use of a sterile item
by the circulating perioperative Registered
Nurse.
6.2.4
Sterile gowns shall be considered sterile

only in front, from the chest to the level of
the sterile field, and sleeves from 5 cm
(2 in.) above the elbow to cuff.
The neckline, shoulders, under the arms,
sleeve cuffs, and the back are considered
unsterile.
Stockinette cuffs of the sterile gown shall be
enclosed under the sterile gloves.
RATIONALE
These are friction areas and collect moisture.
Stockinette is permeable, absorbent and retains

moisture, and therefore, does not provide a microbial
barrier.
Sleeve cuffs become contaminated when the
scrubbed persons hands pass through the cuff
(AORN, 2010).
6.3 Gloving
6.3.1
The closed-gloving method shall be used

during set-up.
6.3.2
A gowned and gloved scrub person should

assist the surgical team members in donning
their sterile gowns and gloves. Once the
incision is made, anyone requiring gowning
will do so independently from a separate
table. The scrub nurse may glove them but
will use caution when gloving to avoid
contaminating the inner surface of the glove.
6.3.3
Sterile surgical gloves should be inspected

immediately upon application and prior to
contact with sterile supplies or tissue.
Gloves, both latex and nonlatex, should be
checked frequently for perforations/tears.
Glove barriers become compromised with use.
6.3.4
Scrubbed personnel should wear double

gloves during invasive procedures
Each operation should be assessed for risk.

Operations involving bone, metal work, deep
cavities, confined space and lasting more than one
hour have a higher incidence of perforation.
Double gloving for invasive procedures is supported
by the American Academy of Orthopedic Surgeons,
the American College of Surgeons, and the Centers
for Disease Control and Prevention (AORN, 2010, p.
279).
Risk of contamination is significantly reduced when

hands are covered during gloving.
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6.3.5
Sterile surgical gloves should be changed:

- after each patient contact;
- when a defect is noted;
- following suspected or actual
contamination;
- when perforation from a needle, suture,
or other event occurs;
- immediately following the use of
methyl methacrylate;
- if unintentional electric shock from the
electocautery device is received;
- when gloves swell or become loose; and
- according to hospital policy.
6.3.6
The recommended procedure for changing a

glove during a procedure is as follows:
- the non-sterile person (wearing
appropriate PPE/gloves) removes the
contaminated glove touching only the
glove, not the gown;
- the gown cuff shall remain at the wrist
level;
- the correct method for regloving is for
one member of the sterile team to glove
the other; and
- the closed-glove method shall not be
used for regloving unless both the gown
and gloves are changed.
6.3.7
Health care workers should be familiar with

the intended use and limitations of each
glove material.
RATIONALE
Users should refer to glove manufacturers written

instruction for use with certain chemicals.
Surgical glove materials have specific characteristics

that affect the performance and use of the glove.
Removal of Contaminated Gown and Gloves

6.4.1
If the gown becomes contaminated, it shall

be changed as soon as possible. The team
member steps away from the field, and the
circulator unfastens the neck and waist ties
of the soiled gown. The contaminated person
grasps the front of the gown at the shoulders
below the neckline. The gown is pulled off
inside out by the wearer and rolled off away
from the body. The gloves are removed
using a glove-to-glove and then skin-to-skin
technique. (Phillips, 2007, p. 281) and
discarded immediately.
Careful handling of used gowns and gloves prevents

contamination.
The scrub perioperative Registered Nurse
Regowning from the sterile back or instrument table
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regowns and regloves self, using closedglove technique (from another table, not the
back or instrument table).
brings unsterile scrub attire too close to the sterile

field. Reaching over the sterile set-up may also occur
and breaches aseptic technique.
6.4.2
At the completion of the case, the same

technique for removal of contaminated gown
and gloves shall be used.
6.4.3
Hands shall be washed as soon as gloves are

removed.
Hand perspiration contains high levels of

microorganisms. Hands may be contaminated from
hole(s) in the gloves. Washing hands immediately
may decrease the risk of latex allergy.
REFERENCES
Canadian Standards Association. (2010). Z314.10.1 CAN/CSA, Selection and use, of gowns, drapes, and wrappers in
health care facilities... Toronto: Author.
Canadian Standards Association. (2010). Z314.10.2 CAN/CSA, Laundry, maintenance and preparation of multi-use
gowns, drapes and wrappers in health care facilities... Toronto: Author.
Canadian Standards Association (March 2008). CSA Z314.8.08 Decontamination of reusable medical devices.
Mississauga, Ontario
Gruendemann, B. & Mangum, S. (2001). Infection prevention in surgical settings. Toronto: W.B. Saunders.
Korniewicz, D.M., Garzon, L., Seltzer, J., & Feinleib, M. (2004). Failure rates in non-latex surgical gloves.
American Journal of Infection Control, 32(5), 268-273.
BIBLIOGRAPHY
Kelsell, N.K.R. (2006). Should finger rings be removed prior to scrubbing for theatre. Journal of Hospital
Infection, 62, 450-452.
Marchand, R., Theoret, S., Dion, D. & Pellerin M. (2008). Clinical Implementation of a Scrubless
Chlorhexidin/ethanol Pre-operative surgical Hand Rub, Canadian Operating Room Nurses Journal, 26 (2).
Public Health Agency of Canada.(2009) . Stop Clean Your Hands. retrieved April 26, 2009.
http://cpsi.discoverycampus.com/courses/cps002/cps002.html
Tanner J & Parkinson H (2007). Surgical Glove practice: the evidence, Journal of Perioperative Practice, 17(5),
216-225.
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PRACTICE
RATIONALE
7.1
Establishing an Aseptic Environment
7.1.1
An aseptic environment must be established

and maintained in order to create a sterile field
All OR doors shall remain closed at all
times except to allow for the procurement of
supplies, receiving patients and admittance of
personnel.
An aseptic environment requires control of the

parameters of air exchange and air currents, dust
control, temperature and humidity in order to keep
microbial growth to a minimum.
7.1.3
Traffic shall be kept to a minimum.
Traffic into and out of the room increases the

potential of contamination from increased air
turbulence in the room.
7.1.4
The number of air exchanges must adhere to

the provincial building code. This rate is
dependent on the ratio of fresh air to
recirculated air exchanges.
7.1.5
The ambient temperature should be maintained

between 20C - 23C (68 F- 73 F).
7.1.2
An aseptic environment is enhanced by positive

pressure in the room moving the air out into the
corridor and taking any particulate matter with it.
Microbial growth and static electricity are reduced if

temperature and humidity are kept within acceptable
parameters.
The humidity should be maintained between

30% and 60 % (Rothrock, 2011 p. 67; CSA
Z314.8- 08)
7.2
Establishing the Sterile Field
7.2.1
All flat surfaces shall be dry and dust-free

prior to the placement of a sterile bundle or
drape.
Moisture may cause strike-through and contaminate

the sterile field. Dry, clean surfaces reduce the risk of
strike-through.
7.2.2
Sterile drapes used to establish a sterile field

shall be impermeable to liquids including
blood and body fluids.
Sterile impermeable drapes establish an aseptic

barrier.
7.2.3
Only the working surface of a draped area

shall be considered sterile.
The drape below the working surface is not under

direct vision of the surgical team and is not
considered sterile. The table top serves as a
demarcation line between sterile and non-sterile.
7.3
Dispensing Sterile Supplies
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RATIONALE
7.3.1
Supplies shall be opened as close as possible to

the surgical start time
The potential for contamination increases with time.

Dust and other particles, stirred up by movement of
personnel, can settle on horizontal surfaces (AORN,
2010, p. 94).
7.3.2
All items added to the sterile field shall be

assessed prior to opening for sterility by
checking for wrapper integrity, and changed
chemical indicators (external and internal).
The contents of packages with questionable
wrappers or indicators shall be considered
unsterile.
If there is any doubt about the sterility of an item it

shall be considered contaminated. Indicator tape
assures personnel that the item has been exposed to
the sterilization process, it does not guarantee
sterility.
7.3.3
Items which display a manufacturer's expiry

date shall be considered unsafe for use after
that date.
Frequently expiry dates refer to the degradation of

the product or a component of the product after the
specified date.
7.3.4
Peel-packages shall be opened carefully to

prevent tearing the package. The sterile
boundary of a peel-open package is the inner
edge.
Only the inner border of the heat seal is considered

sterile. Torn packages are considered unsterile.
7.3.5
Large bundles or packages shall be opened on

a flat surface.
Large and/or heavy items are difficult to open

aseptically while being held in the circulators hand.
7.3.6
Sterility and integrity shall be maintained when

opening, dispensing and transferring items to
the sterile field.
Methods of transfer include, but are not
limited to the following:
- place the item on the edge of the sterile
instrument table with the inside of the
wrapper everted and secured over your
hand. Never reach over the sterile field
and shake an item from its package;
- expose the contents so the scrub person
can remove the item from the wrapper or
package by using a forcep or by grasping
the item; and
- items shall not be flipped.
Protects the sterile field from potential contamination
Flipping creates air turbulence. It also creates the

potential for device contamination or damage
(Phillips, 2007).
7.3.7
Sterile supplies shall be handled as little as

possible.
Increased handling increases the potential for

contamination and prolongs set-up time.
7.3.8
Items that have been dropped on the floor or

that are compressed, torn, or wet shall be
considered to be contaminated and they shall
Dropping items wrapped in woven materials and

paper could force air and contaminants through the
wrapper; therefore such dropped items shall not be
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RATIONALE
be repackaged and reprocessed or discarded

(CSA Z314.3-09).
used. (IAHSCMM, 2007).

Paper has not been shown to have greater strikethough resistance than fabric.
7.3.9
Once a patient has entered the theatre where

sterile supplies have been opened, those
supplies shall be discarded/dismantled in the
event that surgery is cancelled.
Potential for cross-contamination will be prevented.
7.3.10
When a bottle of sterile solution is opened, the

contents of the bottle shall be dispensed and
the remainder discarded.
Re-application of sterile caps is a questionable

technique as the pour spout and cap may have been
contaminated. The edge of a container is considered
contaminated after the contents have been poured;
therefore, the sterility of the contents cannot be
ensured if the cap is replaced (AORN, 2010, p.94).
7.3.11
When pouring solutions, care shall be taken to

avoid splashing. The solution should be
poured in a slow steady stream. The scrub
nurse should hold the receptacle away from the
table or set it near the edge of the table. The
circulating Registered Nurse shall not reach
over the sterile field when pouring.
Droplets, which have splashed on unsterile areas,

may roll back on to the sterile field.
7.4
Maintaining the Sterile Field
7.4.1
Opened sterile supplies/set-up shall not be left

unattended. They shall be continuously
monitored for possible contamination.
Sterility of unattended items cannot be ensured

without direct observation. Event-related sources of
possible contamination can occur at any time. These
include personnel, airborne contaminants, liquids and
insects.
7.4.2
Unsterile persons shall not reach over the

sterile field.
Invisible shedding of skin laden with microorganisms

may contaminate the field.
7.4.3
Sterile persons shall not reach over unsterile

areas.
Sterile persons shall stay within the sterile
field. Sterile persons shall not walk around or
go outside the theatre.
Contamination of the sterile gown or gloves may

occur.
The scrub team should remain close to, and

face the sterile field. Movement shall be
between sterile areas only. If position changes
are necessary, scrubbed personnel shall pass
face to face or back to back. When changing
positions, the scrub personnel should avoid
changing levels; they either sit or stand. Hands
shall be kept above waist level.
The back of the sterile gown is considered unsterile.

To maintain sterility, scrub persons should not allow
their hands or any sterile item to fall below the level
of the sterile field (Rothrock, 2011, p. 86).
7.4.4
7.4.5
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7.4.6
Talking should be kept to a minimum.
Talking increases droplet formation and forces

moisture droplets to be dispersed into the air. Talking
also causes friction between the mask and the skin
increasing shedding.
7.4.7
Unsterile health care team members shall

remain at least 30cm (1 ft.) from the sterile
field.
Movement is from unsterile to unsterile areas.
They should not pass between sterile fields.
Protection of the sterile field is enhanced by limited

activity and direct vision.
7.4.8
The sterile set-up shall not be covered.
Removing a table cover without contaminating the

sterile area cannot be done because the drape below
the level of the tabletop is considered contaminated,
and the cover would touch the sterile tabletop during
removal (Phillips, 2007).
7.4.9
Cover unsterile equipment with sterile barriers

before placing them over or in the sterile field.
7.4.10
Breaks in aseptic technique shall be

monitored, documented and corrective action
taken as soon as safely possible.
7.5
Sterile Storage
7.5.1
Sterile supplies shall be stored in a separate

protected area.
7.5.2
Separate and protected areas for sterile

supplies shall be:
-
The documentation indicates to infection control

what may have been a potential source of a surgical
site infection, and allows them to follow the patient
postoperatively.
Dust, traffic, excess handling, and exposure to water

sources increase the risk of contamination.
on open or closed shelves (shelves being

at least 20 - 25 cm [8 - 10 in.] from the
floor and at least 45 cm [18 in.] from the
ceiling);
controlled for humidity, temperature and
ventilation ( See Establishing an Aseptic
Environment Section 2, 7.1.4 7.1.5); and
traffic restricted (CSA Z314.3-09).
7.5.3
An item shall be considered contaminated if

there is any doubt about its sterility.
7.5.4
Manufacturer's recommendations and

suggested expiration dates shall be followed.
Sterility is event related rather than time related.

Event related sterility is multifactorial including, but
not limited to:
type of wrapper used;
- the number of times a package is
handled; and
- the use of dust covers.
The manufacturers expiration date printed on the
package indicates the maximum time the
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manufacturer can guarantee product stability and
sterility on the basis of test data (Fuller, 2005, p.
133). Hospital liability/ risk management issues are
prevented by following manufacturers directives.
7.5.5
Sterile supplies shall be rotated on a first in

first out system (FIFO). For example, stock to
the right, take from the left or stock to the
back, take from the front).
Rotation of sterile goods reduces the number of

handlings and facilitates the practice that the older
product is used first. Dates shall be used as a method
to rotate materials.
7.6. Storing and Transporting Clean and Sterile Surgical/Medical Devices
7.6.1
The perioperative Registered Nurse

shall ensure the storage and transportation of clean
surgical/medical devices is in
compliance with CSA Z314.15-10
Local, provincial, and national

regulatory bodies recognize and sterile
support the use of CSA Standards.
REFERENCES
Canadian Standards Association. (2009). Z314.3-09. CAN/CSA Effective sterilization in health care
facilities by the steam process. Toronto: Author.
Canadian Standards Association (2009)
Gruendemann, B. & Mangum, S. (2001). Infection prevention in surgical settings. Toronto: W.B. Saunders.
International Association Healthcare Central Services Material Management (2007). Central Services
BIBLIOGRAPHY
Fry , Donald E., Fry, Rosemary V. (2007). SSI: the Host Factor. AORN Journal, 86(5), 801-814.
McBride, Tara., Beamer, Jennifer. (2007). Pre-operative patient preparations in the prevention of surgical site
infections. Canadian Operating Room Nurses Journal, 25(4).
Section 2
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PRACTICE
Note: users shall follow the medical device manufacturers instructions related to reprocessing (CSA Z314.8-08)
PRACTICE
RATIONALE
8.1
Intra-operative Instrument Care
8.1.1
Each health care facility shall have copies

of the current and relevant CSA Standards
readily available.
8.1.2
All reusable instruments that have been

opened for use shall be decontaminated
prior to resterilization.
8.1.3
Instruments shall be handled gently and in

small groups. Delicate instruments should
be handled individually (IAHCSMM,
2007).
Instrument tips may be damaged by rough or careless

handling.
The perioperative scrub nurse is responsible

for keeping instruments clean throughout
the procedure by using sterile water. Saline
is never used to soak or clean instruments.
Blood, body fluids and saline can cause pitting and

damage to instruments.
The scrub nurse shall prepare instruments

for reprocessing. This includes, but is not
limited to:
- separating delicate/sharp instruments
from others;
- protecting tips of fine/sharp
instruments;
- placing heavy instruments in the
bottom of the pan;
- opening/disassembling instruments to
expose jaws and box locks; and
- flushing/soaking soiled lumens with
sterile water.
Special attention is required to ensure all
single-use sharps, e.g. blades, needles, etc.
have been removed and safely disposed of
by the scrub perioperative nurse.
The cleaning process and protection of instruments is

facilitated by organized sorting and careful
placement.
Reduces the potential for injury among health care
workers. Protecting instrument tips in towels, silicone
mats or foam wrappers, or using tip protectors or
special protective boxes/pans prevent damage to the
instruments and injury to personnel.
Contaminated instruments and/or supplies

shall be transported to the decontamination
area in a closed container or covered cart.
Instruments should be promptly and
thoroughly cleaned following the
Thorough decontamination facilitates the sterilization

process. Prompt removal of proteinaceous soil
prevents drying and facilitates thorough cleaning.
8.1.4
8.1.5
For review or reference.
Irrigating cannulated or lumened instruments with

sterile water during the procedure helps to remove
residue.
Injury from contaminated sharps for unsuspecting
members of the health care team is a common and
high risk occurrence.
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Instrument Management and Reprocessing
RATIONALE
established procedure and according to the

manufacturer's recommendations.
8.2
Reprocessing Surgical Instruments
8.2.1
Staff trained in a recognized program and

certified in reprocessing techniques, shall be
assigned to instrument reprocessing.
8.2.2
Surgical instrument reprocessing practices

shall be based on current CSA Standards.
These include but are not limited to:
- Decontamination of Reusable Medical
Devices Z314.8;
- Effective Sterilization in Health Care
Facilities by the Steam Process Z314.3
- Effective Sterilization in Health Care
Facilities by the Ethylene Oxide
Process Z314.2
Following CSA Standards will minimize the risk to

patient safety. The CSA Standards are also endorsed
by Health Canada.
8.2.3
All items being reprocessed shall first be

thoroughly cleaned:
- cleaning should be done in a dedicated
"decontamination" area. Cleaning shall
not be done at a surgical suite scrub
sink;
Failure to remove soil, organic material, and

microorganisms from an object will render
disinfection or sterilization ineffective. Inadequate
pre-cleaning can be hazardous and will pose serious
risks of infection to both the patient and staff.
cleaning staff shall wear appropriate

personal protective equipment (i.e.
water resistant gown, durable gloves
and a face shield and/ or mask and
goggles);
Contaminated medical devices are a source of microorganisms that can infect personnel through nicks,
cuts, or abrasions in skin or through contact with the
mucus membranes of the eyes, nose, or mouth.
Appropriate attire minimizes the potential for
exposure to blood-borne and other disease producing
organism (CSA Z314.8-08 p. 35).
clean water, detergent and friction

should be used to remove soil;
cleaning may be completed manually or
by machine (mechanically);
8.2.4
Mechanical cleaning is preferable to manual cleaning

as the process is standardized and confines
potentially contaminated aerosols and thus protects
staff.
items shall be completely disassembled

for cleaning; and
items shall be thoroughly rinsed
following cleaning.
Between uses, items should be inspected to

ensure that they are:
Inspection confirms all debris has been removed, the

instrument is not damaged, and is functioning
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-clean;
-complete;
-and functional e.g., sharp, aligned, tight,
and/or free of burrs/chips/gouges/corrosion.
appropriately.
8.2.5
Damaged or poorly functioning instruments

shall be removed from circulation, labeled
and sent for repair or replacement.
8.2.6
Further reprocessing shall be based on the

Spaulding classification system:
- Critical items (contact normally sterile
body tissue or vascular system) shall be
sterilized between uses;
- Semi-critical items (contact mucous
membranes or broken skin) shall, at a
minimum, be high level disinfected
(HLD);
- Non-critical items (contact intact skin
or do not make direct contact with a
patient or staff member) must, at a
minimum, be thoroughly cleaned and
disinfected (CDC, 2008).
The Spaulding classification system separates items

into categories according to the nature of the item,
the manner in which it is used and the degree of risk
of infection during use (Gruendemann & Mangum,
2001, p. 160).
8.2.7
All instruments shall be opened and

disassembled for sterilization (CSA
Z314.8).
Allows sterilizing agent to contact all surfaces.
8.2.8
Additional preparation of items shall

depend on the method of sterilization used
e.g., narrow lumens being steam sterilized
will first require irrigation with distilled
water; very long or narrow lumens being
sterilized in a Sterrad (hydrogen peroxide
plasma) system may require a "booster"
device. Sterilizer manufacturer
recommended guidelines and CSA
Standards shall be followed.
8.2.9
Clean Instruments shall be dry prior to

storage (CSA Z314.8).
To prevent microbial growth.
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8.3 Loaned and Leased

Surgical/Medical Equipment
8.3.1
The perioperative Registered Nurse shall be

aware of the policies and procedures
associated with the use of loaned, leased or
shared surgical/medical devices.
Local, provincial, and national regulatory bodies

support the use of CSA Standards (CSA Z314.2204)
8.4 Packaging for Sterilization

8.4.1
Packaging material and design shall protect

the sterility of package contents during
sterilization, normal handling and storage.
Packaging material shall:
- be compatible with the sterilization
process, allowing both sterilant
penetration and removal without
damage to the barrier capability;
- provide a barrier to microbes,
particulate matter and fluids;
- be tear and puncture resistant;
- not leach toxic substances or contain
non-fast dyes;
- be lint free or low linting;
- protect the contents from physical
damage;
- be economical;
- allow for aseptic removal of contents;
and
- be flexible and memory free (pouches
and wrappers) (CSA Z314.3-09).
Packaging materials shall be selected that:
- remain sealed during the sterilization
process and intact until time of
opening;
- preclude open pockets or flaps where
dust can collect e.g. chevron opening
on peel pouches;
- ensure tape or adhesive labels remain
intact through all processes; and
- allow a visual indicator that the item
has in fact been exposed to a
sterilization process.
Packaging material currently in use include:
- reusable fabrics: cotton or synthetic,
woven or non-woven;
- single use fabrics: paper or synthetic;

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peel pouches: paper or Tyvek

backed; and
rigid sterilization containers.
8.4.2
Woven packaging materials shall be

laundered between uses (CSA Z314.10).
Laundering rehydrates fibres. Non laundered fabrics

may lead to superheating, damage to fibres and
potential sterilization failure (AORN, 2010).
8.4.3
An internal chemical indicator/integrator

shall be placed inside each package in the
area of the package that is least accessible to
the sterilant (CSA Z314.3-09).
There are currently 6 different classes of chemical

indicators/integrators/emulators available in Canada.
8.4.4
Each package shall be assembled, handled

and wrapped in a manner that provides for
an aseptic presentation of package contents.
Standard (square and envelope style) wrapping

techniques are described in CSA Z314.3-09 p.29 and
30.
Note: Air pockets, unless evacuated, are often not
penetrated by steam leaving unsterilized areas within
the package.
8.4.5
Prior to sterilization, a tamper evident

device shall be applied to each package
(CSA Z114.3-09).
i.e. Self-sealing pouches/ heat sealed
packages or using external autoclave tape
8.4.6
Each package shall be labeled with:

-an external chemical indicator;
-the name of the item;
-the date of sterilization;
-identification for recall purposes; and
-the initial of the person preparing the item
or set shall be included.
When writing on the paper-plastic pouch,

only a permanent, soft tip marker that has
been validated for this purpose shall be
used. Neither pens nor pencils shall be used.
There shall be no writing on the paper side
of a paper-plastic pouch (CSA Z314.3-09
p38).
8.5
The indicator/integrator/emulator monitors the

physical parameters of the sterilization process, e.g.
time, temperature, air evacuation and sterilant
contact.
The purpose of an external indicator is to

differentiate processed goods from unprocessed
goods. An external indicator does not indicate device
sterility.
Ink markers can soak through the material onto the
package contents as well as destroy the integrity of
manufactured materials. This renders the item of
questionable sterility, therefore requiring the item be
discarded or reprocessed. Pens and pencils tend to
perforate packaging materials allowing entry for
microorganisms.
Writing on the paper side of the pouch within the
sealed area can result in ink penetration or puncturing
of the pouch (CSA Z314.3-09 p38).
Rigid Sterilization Containers
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8.5.1
Rigid sterilization containers shall be

compatible with the sterilization method
chosen and the goods to be sterilized.
The health care facility shall require the container

manufacturer to provide documentation describing:
-the containers compatibility with various
sterilizing methods including the aeration
protocol to be used following ETO
sterilization; (CSA Z314.2-09);
- a decontamination protocol;
- maximum weight and density of instrument
sets that will be held in the container;
- sterilizer loading procedure; and
- sterilizing exposure and dry times (CSA
Z314.3-09, p. 12).
8.5.2
The combined weight of the instrument set

and the rigid sterilization container shall be
limited to ensure that:
- occupational health and safety
guidelines related to lifting are met;
- total metal mass of the set is evenly
distributed; and
- metal mass is limited to facilitate
heating, cooling and drying.
For safety of personnel, it is generally accepted that

instruments in a pack/pan should not exceed 7kg (16
lb); and the combined weight of the instruments and
their container should not exceed 10kg (22 lb) (CSA
Z314.3-09).
8.5.3
Containers shall be cleaned between uses

according to the manufacturers
instructions.
See CSA Z314.14-04
8.5.4
Each container shall be checked thoroughly

before reuse for:
- cleanliness, dryness and
- functionality of the following:
- sealing edges;
- filter retention devices;
- latches; and
- valves, if present (CSA Z314.14).
Damage to seals and container edges frequently

occurs and if not corrected interferes with the
integrity of the sterile product, a risk often unknown
by the users.
8.5.5
Disposable or reusable filters in rigid

containers shall be used according to
manufacturers instructions.
8.5.6
Internal pouches, wraps, towels, gauze,

baskets or trays shall not be added to a
container system unless such addition(s)
have been designed and tested for the
intended configuration, and validated by the
manufacturer.
Large weight of metal mass heats and cools more

slowly than the container resulting in condensation
and water droplets within the container, which will
present doubts as to its sterility.
In addition, a routine inspection plan by qualified

personnel needs to be a part of the preventative
maintenance program to ensure rigid sterilization
containers are in proper working order.
Internal packages, gauze and towels create additional

resistance to sterilant penetration. This may
compromise sterility of the devices within the
internal packages.
Section 2
Page 131 of 334

PRACTICE

PRACTICE
RATIONALE
8.5.7
When opening a sterilization container in

the OR, the circulating nurse shall ensure
aseptic presentation and shall:
- inspect the integrity of the tamperevident device prior to disengaging
it/them (following manufacturer's
instructions);
- completely and simultaneously open
the lid latches;
- inspect the integrity of the filter or
valve, the gasket, and the chemical
indicator;
- check the alignment of the filter system
or valve according to the
manufacturer's instructions; and
- inspect for moisture within the
container (CSA Z314.14).
8.5.8
Each facility shall develop a policy to

address the situation of condensate within
the container following steam sterilization.
Condensate within a container can compromise

sterility if the moisture is able to come in contact
with outside contaminants (CSA Z314.14 -4 p.18).
8.5.9
A sterile instrument container that has been

opened shall not be used to receive other
sterile items (CSA Z314.14- 4 p.18).
Sterile items may be contaminated by contact with

the non-sterile outer rim of the external container.
One principle of asepsis is that the edge of a sterile
package/container is considered contaminated.
8.5.10 Rigid containers shall not be used for

emergency flash sterilization unless
validated by the manufacturer.
Special emergency flash sterilization rigid containers

are available.
8.6 Sterilization
8.6.1
Instruments shall not be sterilized within a

drape bundle (CSA Z 314.3-09).
Instruments in drape bundles cool at a much slower

rate, resulting in condensation, re-wetting and
potential contamination.
8.6.2
When sterilizing any item, follow device

manufacturer's directions for method and
parameters of sterilization. CSA Z314.3
guidelines shall be followed.
Instrument manufacturers /vendors are required to

provide validated reprocessing instructions. More
complex instrument sets may require parameters that
differ from routine hospital cycles.
8.6.3
Sterilizers shall have preventative/planned

maintenance.
All sterilizers shall have preventative
maintenance and repairs documented.
Documentation provides a history of the maintenance

and repairs to the sterilizer(s).
8.6.4
The efficacy of each sterilizer shall be

monitored according to CSA Z314.3 and
CSA Z314.2 to include:

Section 2
Page 132 of 334
RATIONALE
Visual checks assist in sterilizer efficacy.
8.6.5
a mechanical or digital display visible

during each cycle.
a permanent graph, printout or
electronic record documenting cycle
parameters that shall be retained for
quality assurance purposes as per
healthcare facility policy;
an external chemical indicator (e.g.
autoclave tape) affixed to the outside of
each package;
an internal chemical indicator within
each package. The internal chemical
indicator shall be placed in the part of
the package that is least accessible to
the sterilant;
an air-removal test performed on all
"vacuum air removal" type steam
sterilizers each day prior to use;
a biological test performed each day
that the sterilizer is used. Each type of
cycle that will be run on the sterilizer
shall be tested i.e., if a steam sterilizer
can operate by either "gravity" or
"vacuum air removal" method, and both
will be used during the day, then both
cycles shall be tested;
a biological indicator (BI) validated for
its intended use e.g. flash sterilization
(unwrapped); gravity (wrapped)
sterilization or vacuum (wrapped)
sterilization; and
a biological indicator included in each
load containing implants. Sterilized
implants should not be released until
the results of the biological indicator
are known.
A recall procedure shall be established by

the health care facility and shall:
- be in writing;
- outline the circumstances for issuing a
recall order;
- designate the personnel authorized to
issue a recall order;
- outline the procedure to be followed
when a recall is necessary;
- designate the personnel responsible for
reporting on the execution of a recall
order
- implement and document all activities
related to the recall order.

PRACTICE
The recall protocol will assist with mechanical failure

tracking and infection control investigations to
promote patient safety.
See CSA Z314.3-09, p. 59
Section 2
Page 133 of 334
RATIONALE
8.7 Emergency (Flash) Sterilization

8.7.1
Flash sterilization shall not be used for

routine sterilization.
8.7.2
Flash sterilization shall not be used to

compensate for inadequate inventory
or scheduling problems. If flash sterilization
is included in emergency plans, it shall
only be as a last resort (CSA Z314.3-09 p. 62).
8.7.3
Flash sterilization shall not be used to

sterilize implants.
Although the process itself can be

similar, the lack of pre and post sterilization
precautions introduces additional risks to the use
of flashed devices (CSA Z314.3-09 p. 62).
Flash sterilization is prone to numerous errors,

any one of which could cause a sterilization
failure.
Note: Implants include but are not limited to:

- ligating clips;
- gastric staples;
- orthopedic internal fixation devices such as
- Screws;
- Staples and
- Wires;
- joint replacement prostheses; and
- Cardiac valves (CSA Z314.3-09, p. 62).
8.7.4
Flash sterilization shall not be used on

complete sets or trays of instruments
(CSA Z314.3-09 p. 62).
8.7.5
All staff performing flash sterilization shall

be appropriately trained (CSA Z314.3-09;
CSA Z314.8-08).
8.7.6
Items for flash sterilization shall be

prepared as per the manufacturers
instructions. Steps of preparation:
- disassemble;
- decontaminate;
- reassemble
- inspect;
- disassemble;
- arrange in container;
- include chemical indicator;
- package (if used);
- load the sterilizer; and
- transfer from the sterilizer to the sterile
field in an aseptic manner.
Inclusion of a chemical indicator with the device

provides the scrub nurse with the visual confirmation
that the device has been processed.
Section 2
Page 134 of 334

PRACTICE
8.7.7
Sterilization parameters shall comply with

the sterilizer manufacturer, the equipment
manufacturer, and the biological indicator
8.7.8
A closed container specifically designed for

flash sterilization shall be used to protect
sterile items during transfer from the
sterilizer to the sterile field. Follow the
manufacturer's guidelines regarding:
- exposure time and temperature;
- maintenance and cleaning procedures;
and
- length of sterility in container after
sterilization.
8.7.9
On completion of a flash sterilization cycle,

the printout/chart shall be checked for
correct sterilization conditions. For steam
sterilization, those conditions are: time and
temperature (CSA Z314.3-09).
8.7.10
The flash sterilization process shall be

documented in a manner that will correlate
the flashed items with:
- the patient;
- the surgeon
- the results of the biological and
chemical monitoring;
- the cycle printout (time and
temperature), and;
- the staff responsible for the processing
of that item.
8.7.11
Further information on Chemical Indicators

may be obtained by referencing
CLASSES OF CHEMICAL INDICATORS
(CIs) in CAN/CSA-Z11140-1-98.

PRACTICE
RATIONALE
Records to be kept as per facility policy and CSA

recommendations.
8.8 High Level Disinfection

8.8.1
As a minimum, all semi-critical devices

shall be high level disinfected (HLD)
between patient uses.
The selection of an HLD solution should be
based on the :
-type of devices to be processed;
-efficacy of the chemical;
-safety of the product; and
-its in-use characteristics.
Section 2
Page 135 of 334
RATIONALE
8.8.2
The use of a specific HLD shall be

consistent with the manufacturers
recommendations and the accepted infection
control practices of the health care facility.
8.8.3
Disinfectant manufacturers' instructions for

use shall be followed.
8.8.4
HLD may be performed manually or via an

automated process complying with device
manufacturers instructions and occupation
health and safety standards
8.8.5
Occupational Health and Safety and

WHMIS guidelines regarding personal
protection shall be followed. This may
include:
-choosing the least toxic chemical;
-environmental controls such as:
-covered containers;
-automatic endoscope
reprocessors;
-area ventilation; and
-personal protective equipment.
Spill management protocols need to be in
place and reviewed regularly with
personnel.
Health risks to personnel may result from improper

use, ventilation, and/or disposal. Chemical
disinfectant vapours may be harmful, even those
scented for aesthetic reasons.
8.8.6
Reusable solutions shall be dated when

initially opened and used. The minimum
effective concentration (MEC) of a reusable
HLD shall be tested and recorded at the
beginning of the day that the solution is
used (CSA Z314.8-08 p. 41). Solutions
shall be discarded when they fall below the
MEC or the maximum in-use date has
been reached, whichever comes first
Follow the disinfectant and test strip
Chemical disinfectants are effective for a specific

limited time.
Confirmating that the MEC is within levels specified
by the manufacturer ensures that the efficacy has not
deteriorated due to dilution from water or by
contamination from biological matter.
8.8.7
Devices shall be thoroughly cleaned and

rinsed prior to HLD. Excess rinse water
shall be removed.
If proteinaceous soil remains on devices during HLD,

the proteinaceous soil may inactivate the HLD and/or
coagulate, forming a protective barrier that may
allow pathogens to survive the HLD process.
Cleaning and decontamination are the initial and
most critical steps in breaking the chain of disease
transmission. Debris, blood, and tissue will interfere
with the action of the disinfectant and sterilization
methods.
Rinsing removes residual detergent from the
instruments and equipment.
Section 2
Page 136 of 334

PRACTICE
RATIONALE
Drying prevents dilution of the disinfecting agent
when instruments are placed in the solution. (CSA
Z314.8-08)
8.8.8
The manufacturer recommended chemical

concentration and contact time shall be
maintained during HLD.
Liquid HLDs only disinfect those areas that they

contact directly. Therefore, all air bubbles and other
barriers to contact must be removed before timing
begins.
All lumens shall be flushed and filled with

solution.
When rinsing a lumen, it shall be flushed
with a volume of water at least three times
the volume of a lumen (CSA Z314.8-08)
8.8.9
All devices shall be completely immersed in

the HLD solution (unless being processed in
an automatic endoscope reprocessor that has
been otherwise validated).
To ensure complete contact and removal of
air:
- completely disassemble the device
following manufacturers
instructions;
- fill all lumens with disinfecting
solution and ensure fluid flows
from the distal ends;
- position the device to allow
trapped air to escape; and,
- weigh down items that may float
(CSA Z314.8-08 p. 42).
8.8.10
Each device shall be thoroughly rinsed

following chemical HLD.
Devices that have been treated with liquid
chemicals to provide sterilization and rinsed
with sterile water should be used
immediately and not dried. If not used
immediately and drying is necessary, drying
should be performed with medical air or
HEPA-filtered air to ensure no particulates
or organisms re-contaminate the device by
drying.
Drying of non-critical devices may be done
by air-drying or other methods. (CSA
Z314.8-08 p. 43)
Many chemical manufacturers currently define

thorough rinsing as a triple (3 separate) rinse using
copious amounts (8 litres/2gallons in each rinse for a
flexible endoscope) of fresh water. The quality of the
water e.g. potable, filtered or sterile will depend on
the intended use of the device.
Unless a device will be used immediately, it

shall be thoroughly dried. Special care shall
be taken to ensure all lumens are completely
dry.
If devices, and especially lumens, are stored, wet,

microbial overgrowth can occur in the moist
environment during storage. Nosocomial infections
can occur.
8.8.11
Hard water ions can cause deposits or scale

formation. Free rinsing is necessary to prevent
residues of cleaning chemicals from remaining on
instruments. (IAHCSMM, 2007)
Section 2
Page 137 of 334

PRACTICE
RATIONALE
8.8.12
Disposal of HLDs shall follow written

federal, provincial, and local government
regulations and health care facility specific
procedures.
8.8.13
If flexible endoscopy is performed in the

surgical suite, the Society of
Gastroenterology Nurses and Associates
(SGNA) guidelines for reprocessing of
flexible endoscopes and the scope's
manufacturers instructions for use shall be
followed.
SGNA guidelines are available on the web at

www.sgna.org
8.8.14
Document and maintain records of the high

level disinfection process that include but
are not limited to:
- date solution was opened
- date solution was dispensed from
original container
- date test strip expire
- test date
- location
- test results
- the staff responsible for testing
- serial number of instrument
- contact time
- temperature of the solution
- concentration
Tracking or traceability of item such as scope to a

specific patient is recommended.
Solution testing will indicate diluted solution and
reduced efficacy.
REFERENCES
Center for Disease Control (CD). (2008). Guidelines for disinfection and Sterilization in Healthcare
Facilities. Atlanta: Author.
Canadian Standards Association (2008). CSA Z314.8-08 Decontamination of Reusable Medical Devices.
Toronto: Author.
Canadian Standards Association (2009). CSA Z314.3-09 Effective Sterilization in health care facilities by
the steam process. Toronto: Author.
Canadian Standards Association. (2004). CSA Z314.14 Selection and Use of Rigid Sterilization
Containers. Toronto: Author.
Canadian Standards Association. (2009). CSA Z314.2 Effective Sterilization in Health Care Facilities by the
Ethylene Oxide Process. Toronto: Author.
Section 2
Page 138 of 334

PRACTICE
BIBLIOGRAPHY
Alberta Public Health, (2008). Standards for Cleaning, Disinfection and Sterilization of Reusable Medical
Devices for all Healthcare Facilities and Settings. Edmonton, AB: Author.
ANSI/ AAMI ST 79, 2006 & 2008 Comprehensive Guide to Steam sterilization and sterility assurance in healthcare
facilities, AAMI, Arlington VA
Basile, Ralph J. (2008). The Rising Tide of Cleaning Standards. Healthcare Sterilization Horizons, 31-36.
Bayes, Nola J. (2008). Effective Cleaning: the Fundamental Step of the Decontamination Process.
Healthcare Sterilization Horizons, 37-40.
Bilyk, Candis. (2008). Dont Break the Chain: Importance of supply Change Management in the operating Room
Setting. Canadian Operating Room Nurses Journal, 26(3).
Bolding, Barbara. (2004). Choosing a Re-processing method. Canadian Operating Room Nurses Journal, 22(2).
Cardinal Health. (2006). The Care and Handling of Surgical Instruments, Independent Study Guideline. Cardinal
Health, McGraw Park, IL.
Chobin, Nancy. (2008). Are You Up to Speed on Flash Sterilization? Healthcare Sterilization Horizons,
23-26.
Crawford, A. (2007). Decontamination and traceability of flexible endoscopes. Journal of Perioperative
Practice, 17(6), 257-264.
CSA compendium of sterilization standards. Refer to list provided at the back of this publication.
Gilmour , Diane. (2008). Instrument integrity and sterility: The perioperative Practioners responsibilities. Journal of
perioperative practice, 18(7), 292-296.
Griffiths-Turner , May., Stevenson, Ruth. (2005). Improving Quality of Service in a Sterile Processing and OR
Setting, Canadian Operating Room Nurses Journal,23(4).
Healthstream. (2007). Are Your Sterilized Instruments Promoting Healthcare Acquired Infections, Independent
Study Guideline. Cardinal Health, McGraw Park, IL.
Klacik, Susan. (2008). Its About Time: Extended cycles. Healthcare Sterilization Horizons, 27-30.
Meredith SJ, & Sjorgen G (2008). Decontamination: Back to Basics. Journal of perioperative practice, 18(7), 285288.
Patterson, Pat. (2008). Heavy Instrument Sets Shed Pounds. Healthcare Sterilization Horizons, 17-22.
Section 2
Page 139 of 334

International Association Healthcare Central Services Material Management (2007) Central Services
Stewart, Sandra. (2004). Tearing Down the Walls Between OR and SPD. Canadian Operating Room Nurses
Journal, 22(2).
Shewchuk, Muriel. (2004). Leaders Role in Infection Prevention and Control, Canadian Operating Room Nurses
Journal, 22(2).
Spry, Cynthia. (2008). Understanding current steam sterilization, Recommendations and Guidelines. AORN Journal,
88(4), 537-552.
Spry, Cynthia (2008). BIs and CIs Using Sterilization Monitoring Indicators Appropriately. Healthcare Sterilization
Horizons, 9-15.
Specialized Instruments and Equipment

PRACTICE
RATIONALE
9.1 Prosthesis Care and Handling

9.1.1
The manufactuers instructions for special

care and handling of prosthesis shall be
provided and followed.
9.1.2
Prosthesis shall be meticulously handled to

prevent damage or contamination:
- powder shall be wiped from surgical
gloves;
- prosthesis shall be inspected for any
defects;
- prosthesis shall be placed on a lint-free
surface;
- prosthesis shall not contact hard surfaces
such as metal or glass;
- unprotected prosthesis shall not be
handled or transferred with any type of
forceps; and
- prosthesis shall be handled as little as
possible.
9.1.3
9.1.4
9.1.5
Decreases the risk of patient injury and the potential

of legal litigation
Skin oil, glove powder, lint, and dust particles adhere

to prostheses and cause a foreign body reaction.
The sterile prosthesis shall be opened as

close to the time of insertion as possible.
A prosthesis made of one metal should not
come into direct contact with a prosthesis
made of a different metal.
Decreases risk of contamination of the prosthesis.
A prosthesis should be supplied sterile from

the manufacturer. Manufacturers
recommendations shall be followed if the
Manufacturers specifications include the appropriate

method of sterilization if the prosthesis is supplied
unsterile.
Direct contact between different metals (i.e., plates

and screws) can cause an electrochemical reaction
(Phillips, 2007, p. 327).
Section 2
Page 140 of 334

Rutala ,William., Weber, David J. (2008). CDC Guidelines for Disinfection and Sterilization in Healthcare
Facilities. The Healthcare Infection Control Practices Advisory Committee, (HICPAC), CDC.
RATIONALE
prosethesis is not supplied sterile.

9.1.6
Every load containing implantable devices

shall be monitored using a biological
indicator. Implantable devices should be
quarantined until the results of the
biological indicator test are available
(CSA Z314.3-09).
9.1.7
The manufacturer's device "identifying"

information e.g. serial number, size and
quantity, shall be recorded in the patient's
record. See Section 3- Nursing
documentation.
Specific implants require patient registration
and communication directly with the vendor
for updates, recalls and new information.
9.2
Power Equipment Care and Handling
9.2.1
When caring for and sterilizing power

equipment, manufacturers' recommendations
shall be followed (CSA Z314.8-08; CSA
Z314.3-09). Evidence of validation that
powered devices can be sterilized using
commonly used facility sterilization
methods shall be provided by the
manufacturer.
9.2.2
CSA approval of all motors is required and

leakage testing shall be conducted at regular
intervals.
9.2.3
All power cords and plugs shall be checked

for any cracks or breaks prior to each use.
Faulty cords may result in loss of power during

surgery, electrical shorts, and fires.
9.2.4
Equipment shall be tested before being

handed to the surgeon:
- all blades and attachments shall be seated
securely before activation;
- correct pressure in pounds per square
inch (psi) shall be set while the power
tool is running or as recommended by
the manufacturer and;
Advance testing of power equipment ensures proper

working conditions, safety for the personnel and
patient, and avoids delays after surgery has begun.
Passing equipment in the 'safety' mode prevents

accidental activation and is recommended by
Occupational Health and Safety.
the safety mechanism shall be turned on

before the equipment is handed to the
surgeon and/or returned to the scrub
nurse.
In case of a recall, the implanted device must be

traceable.
Proper care and handling prolongs the life of power

equipment and prevents infection.
Excessive psi may damage the powered instrument

and/or exert stress on the hose. Under-pressurized
equipment may not perform in the designated
manner.
Section 2
Page 141 of 334

PRACTICE
9.2.5

PRACTICE
RATIONALE
During use, the hand piece and attachments

should be kept free of gross soil and debris.
Powered instruments should not rest on the
patient when not in use.
9.2.6
Attachments, such as blades or burrs, shall

be removed from the hand piece at the end
of the procedure, and before the items are
sent for decontamination.
9.2.7
Hand pieces, power cord and attachments

should be cleaned immediately after use. If
this is not possible, the items should be kept
moist in a transport container by adding a
towel moistened in water (not saline) or
foam, spray or gel product specifically
intended for this use (CSA Z314.8-08).
REFERENCES
Canadian Standards Association (2008). CSA Z314.8-08 Decontamination of Reusable Medical Devices.
Toronto: Author.
Canadian Standards Association (2009). CSA Z314.3-09 Effective Sterilization in health care facilities by
the steam process. Toronto: Author.
BIBLIOGRAPHY
International Association Healthcare Central Services Material Management (2007). Central Services
Rothrock, J. (2011). Alexanders Care of the Patient in Surgery. (14th ed.) St. Louis: Mosby.
Single Use Medical Devices (SUMeDS)

PRACTICE
10.1.1
Health care facilities shall not reprocess

medical devices labeled single use.
RATIONALE
There are primarily three major risks related to this
practice.
(reuse) practice.
Section 2
Page 142 of 334
The organization prevents the on-site

reprocessing of single use devices (SUD).
If reprocessing or sterilization of SUDs is
done outside the organization i.e. by a
recognized third party reprocessor, the
organization monitors these processes
annually (Accreditation Canada,
Infection Control p.18).
First, there can be damage to the devices functional

integrity. The effects of resterilization on the physical
and mechanical properties of the device could result
in device failure or patient injury.
Second, infection,
injury
or transmission
of disease
infection or
transmission
of disease
may
may
devices
exposed
to high
resultresult
fromfrom
devices
exposed
to high
levelslevels
of of
contamination during first use, build up of toxic
residue
residuesand
andineffective
ineffectivereprocessing.
reprocessing.
Third, there may be health risks for health care
personnel exposed to additional blood and body
fluids, or reprocessing chemicals and gases
gases.(Tapp,
(Tapp,
2003, p.18).
p. 18)
Health care facilities currently do not have the
resources to develop and maintain a comprehensive
reprocessing validation program.
REFERENCES
Tapp, A. (2003). Reuse if single-use medical devices. Canadian Operating Room Nurses Journal. Halifax:
Clockworks.
Health Canada (2005). Reprocessing and reuse of single-use medical devices April 29, 2005. Retrieved April 25,
2009 from /www.hc-sc.gc.ca/
Selection, Care and Handling of Materials
11.1
Wrappers, Surgical Gowns and Drapes
PRACTICE
RATIONALE
11.1.1
Wrappers, drapes and gowns used in a

sterile field shall meet the Canadian
Standards Association (CSA) and the
National Fire Protection Association
specifications (CSA Z314.10).
Materials meeting these standards are penetrable by

steam under pressure, gas or other sterilizing agents to
achieve sterilization and will reduce static charge.
11.1.2
Multiple-use drapes, surgical gowns and

wrapper material shall have the following
characteristics regardless of temperature or
humidity:
- adequate barrier to microbes, particulate
matter and fluids;
- tear and puncture resistant during use;
- flexible;

Section 2
Page 143 of 334

This issue is currently under review at local,

provincial and federal levels.

drapable/memory free;
firmly hold a sealing device;
free of noxious odours;
does not lint, pill or shed fibres
maintain protective barrier ability through
multiple reprocessing;
- appropriate size (for aseptic technique);
- unfrayed edges; and
- without joining seams or cross stitching.
11.1.3
Prior to each reprocessing, all multiple-use

materials shall be visually inspected over a
light table or light bar.
As per CSA Z314.10-03 Standard.
11.1.4
Holes and other defects in multiple-use

materials may be patched
according to criteria supplied by the
manufacturer.
The patched material shall retain its
required barrier and sterilant penetration
capability.
The acceptable location, number, shape and
size of patches shall be clearly delineated in
written quality standards and repair
procedures. The criteria should be
developed based on the intended use of the
textile, the required barrier properties, and
the type of sterilizer used (CSA 314.10-03;
9.2.4 p.21).
Patches shall be durable, heat-sealable, made
of the same basic material as the item being
patched, and allow for sterilant penetration.
Patches shall not be sewn.
As per CSA Z314.10-03 Standard.
11.1.5
Quality control shall be established to ensure

the effectiveness of the protective barrier for
reprocessed materials according to CSA
Z314.10.03.
Tracking number of uses and barrier testing are examples

of quality control.
11.1.6
All multiple-use drapes, surgical gowns and

wrappers shall be freshly
laundered/reconditioned and
lint-free before bundles are prepared.
Bioburden is reduced by laundering.

Reconditioned/freshly laundered materials are
dehydrated and the risk of superheating during
sterilization is reduced.
11.1.7
Single-use drapes, surgical gowns and

wrapper material shall have the following
characteristics regardless of temperature or
humidity:
- adequate barrier to microbes, particulate
matter and fluids;
- tear and puncture resistant during use;
- flexible;
- drapable/memory free;
Holes produced by stitching create breaks in the material

and reduces barrier efficacy.
Section 2
Page 144 of 334

- moisture repellent;
- an appropriate weight for the intended use;
- does not lint, pill or shed fibres
- antistatic;
- flame retardant; and
- free of noxious odours
11.2
Multiple-use Bundles
11.2.1
Prior to acceptance of any folding

configuration, tests shall be performed using
biological and chemical indicators in
multiple layers of the package to ensure
effective sterilization (CSA Z314.10-03).
11.2.2
Bundles should be configured place size,

shape, and weight from CSA Z314.1003 guidelines.
11.2.3
Bundle contents shall be arranged to allow:

-effective sterilization (large drapes may
need to be fan folded);
-aseptic opening; and
-items to be used in logical order.
11.2.4
Square or envelope wrapping method shall

be used.
Standard wrap techniques are essential for appropriate

sterilization as well as protecting sterility.
11.2.5
All bundles shall:

- be clearly labeled to identify package
contents;
- be dated;
- identify the person who prepared the
package; and
- have appropriate load labels and
include information such as
sterilization/chemical indicators inside
and outside the bundles.
Pins, staples, string or rubber bands shall
not be used to close bundles.
Provides contents and sterilization information, tracking

information, and information required for proper
inventory rotation, recalls and quality checks.
11.2.6
Pins and staples create holes in the bundle. String may

cause strike through. Rubber bands do not permit the
passage of sterilant.
REFERENCES
Canadian Standards Association (2003). CSA Z314.10-03 Selection, Use, Maintenance & Laundering of
Reusable Textile Wrappers, Surgical Gowns and Drapes for Health Care Facilities. Toronto: Author.
Canadian Standards Association (2009). CSA Z314.3-09 Effective Sterilization in health care facilities
by the steam process. Toronto: Author.
Section 2
Page 145 of 334
Sterile Processing University, LLC, (2007). The Basics of Sterile Processing (2nd ed.). Sterile Processing
University, LLC, Lebanon, NJ.
Skin Preparation (Prep)

PRACTICE
RATIONALE
12.1.1
The operative site and surrounding areas

shall be cleansed before surgical preparation
by showering or washing.
Removal of superficial soil and transient flora

reduces the risk of wound contamination (AORN,
2010; Thurston, 2007).
12.1.2
All body jewellery that pierces the skin shall

be removed and the pierced area cleaned
thoroughly prior to the surgical skin
preparation (Gruendemann & Mangum,
2001, p. 259).
12.1.3
Hair shall not be removed unless it will

interfere with access to the operative area or
fall into the wound.
If hair removal is necessary, it should be
done:
-as close to the time of surgery as possible;
Hair removal can traumatize skin and provides an

opportunity for colonization of microorganisms at the
incision site.
-in a room where the procedure will not

take place; and
The dispersal of loose hair has the potential to

contaminate the surgical site and surgical field
(AORN, 2010 p. 357).
Depilatories have caused skin reactions in some
individuals causing surgery to be cancelled.
-using clippers or a depilatory agent.
With increased time between hair removal and

surgery comes increased incidence of SSI (SHN!).
Clippers with reusable heads shall have the

head disinfected between uses.
To prevent cross contamination
12.1.4
Eyebrows shall not be shaved unless deemed

essential by surgeon. . (Fuller, 2005, p.198)
Eyebrows may fail to re-grow or grow abnormally

after surgery (Fuller, 2005, p.198). Regrowth is
uneven and not complete (Philips 2007 p. 518).
12.1.5
The antiseptic agent used in preparation of

the skin should:
- have broad spectrum antimicrobial
action and rapidly decrease microbial
count;
- be quickly applied and remain effective
against micro-organisms;
- be virucidal and active against protozoa
and yeast
- be safely used without skin irritation or
Antiseptic agents effectively applied remove many

microorganisms from skin.
Factors to be considered in skin disinfection are:
-the condition of the involved area;
-the number and types of contaminants;
-the characteristics of the skin to be
disinfected; and
-the general physical condition of the patient
(Rothrock, 2011, p.101).
Section 2
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BIBLIOGRAPHY
RATIONALE
sensitization;
remain active in the presence of alcohol,
organic matter, soap or detergent; and
be non-flammable for use with laser,
electrosurgical or other high energy
devices (Phillips, 2007, p. 517).
12.1.6
Prep solutions and irrigations shall not be

warmed unless recommended by the
manufacturer.
Heat may change the chemical properties and

efficacy of the antiseptic agent.
12.1.7
Exposure of the patient shall be confined to

the area being prepped.
The patient's dignity and privacy are maintained.
12.1.8
Antiseptic agents shall be applied by nonscrubbed personnel proceeding from the

incision site to the periphery or from clean to
soiled (bioburdened) areas.
Antiseptic agents effectively applied to the patients

skin are a method of infection control. Proceeding
from cleanest to least clean decreases the risk of
microorganisms being brought from the periphery
back to the proposed incision site.
The exception is the umbilical area, which

shall be prepped first.
Prepping the umbilicus first prevents debris from the

contaminated site splashing onto the freshly prepped
area.
A circular pattern moving outward from

proposed incision site shall be used. The
sponge shall not back track the already
prepped area (Phillips, 2007, p.519).
12.1.9
Antiseptic agents shall be applied in a

manner that prevents pooling of the agent in
skin creases, under the patient, around a
tourniquet, ESU dispersive pad site, or near
electrodes.
Agents shall be allowed to dry prior to
placement of sterile drapes.
Pooling of antiseptic agents may cause chemical

burns.
Manufacturers instructions shall be

followed when using antiseptic agents.
To ensure patient and staff safety.
Time for complete evaporation of the antiseptic agent

is required before electrosurgery or lasers are used to
prevent the possibility of fire or burns (AORN,
2010).
12.1.10 The following situations require additional

care during preoperative skin preparation:
-when a stoma is involved, a prep sponge
soaked with an antiseptic agent is placed
over the stoma and removed at completion
of the prep, then the stoma is prepped last
(Phillips, 2007, p.517; Rothrock, 2011, p.
103);
- denuded or traumatized skin should be
prepared using normal saline (AORN, 2010,
Section 2
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PRACTICE
RATIONALE
p.359); and
-mucous membranes shall not have
chlorhexadine gluconate, alcohol or alcohol
based solutions used as a prep solution.
If additional procedures are to be performed
(e.g. insertion of a Foley catheter), they shall
be done prior to the surgical site prep.
12.1.11 Limbs shall be elevated, and prepped in a
manner that provides support, safety, and
prevents contamination. A full extremity
prep may be done in two stages to provide
adequate support to joints and to ensure that
all areas are prepped (Phillips, 2007, p. 520).
12.1.12 When performing both abdominal and
perineal skin prep, the perineal area is
prepped first. Preps shall be performed
sequentially and not simultaneously, with a
new prep kit used for each area (Burlingame,
2005, p. 112).
Avoids potential contamination of the abdomen or

aerosolization of prep solution from the perineal area.
(Burlingame, 2005, p. 112)
12.1.13 The skin preparation shall be documented on

the operative record. The following
information shall be included:
-condition of the skin at the operative site (if
other than healthy and intact);
-method of hair removal, if used;
-name and concentration of antiseptic
agent(s) used;
-any skin reaction that occurred ; and
-name of person performing skin
preparation.
Documentation of preoperative skin preparation

assists in quality assurance and in infection control
follow-up.
REFERENCES
Burlingame, B. (2005). Clinical issues: Dual procedure prep. AORN, (82), 1, 112.
CAN/CSA-ISO 10993-1
Fuller, J. (2005) Surgical technology- principles and practice (4th ed.). Philadelphia: Elsevier Saunders
Gruendemann, B. & Mangum, S. (2001). Infection prevention in surgical settings. Toronto: W.B. Saunders,
258.
Phillips N. (2007). Berry & Kohns Operating room technique. (11th ed) Toronto: Mosby.
Rothrock, J. (2011) Alexanders care of the patient in surgery. (14th ed). Toronto: Mosby.
Section 2
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PRACTICE
QMENTUM Program 2010 Operating Room Standards
BIBLIOGRAPHY
Barbara DeBraun, (2008). Evaluation of the Antimicrobial Properties of an Alcohol-free 2% Chlorhexidine
Gluconate. AORN Journal, 87(5), 925-931.
Draping
PRACTICE
RATIONALE
13.1.1
The scrub nurse shall adhere to established

draping procedures, and select appropriate
drapes for each draping procedure.
When draping, the following shall be considered:

-the size of the sterile field;
-the location and size of the incision;
-the number of sterile persons at the
operative field; and
-the sterile instrumentation and equipment
on the operative field.
13.1.2
Sterile drapes shall provide a moisture

barrier between the patient and the sterile
field (Fuller, 2005, p.209).
To prevent strike-through and contamination of the

sterile field. Fanning , flipping or shaking drapes is
unacceptable. Dust, lint and droplet nuclei may
migrate on air currents from rapid drape movement.
Draping material should be maintained in a

compact manner and held higher than the
surgical site.
Use as little movement as possible when
handling drapes (Rothrock, 2011, p. 107).
Controlled placement decreases the risk of contact

with unsterile objects or surfaces.
13.1.3
Sterile gloved hands shall be protected by

cuffing the drape over hands. While draping,
gloved hands should not touch the skin of
the patient (Phillips, 2007, p.523).
Avoids the risk of contaminating the gloves

(Rothrock 2011 p.107).
13.1.4
Drape the incision area first and then the

periphery. Always drape from a sterile to an
unsterile area. Do not reach across a nonsterile surface (Rothrock, 2011, p.107).
The site of the incision will be defined and the

surgical wound will be isolated. Controlled drape
placement decreases the risk of the scrubbed
personnel contaminating their gowns.
13.1.5
An impervious drape shall be placed around

the operative site and wherever strikethrough is likely to occur.
Strike-through produces a pathway for

microorganisms.
13.1.6
Huck towels shall not be used as drapes.
Although huck towels may be used to absorb fluids,

they have no barrier properties. Their use would
Section 2
Page 149 of 334

Thurston, A.J. (2007). Sources of infection in the operating theatre in the Evidence for Orthopaedic Surgery. Edited
by David Limb and Stuart M Hay. Shewsbury, UK: tfm Publishing Limited.
RATIONALE
compromise the sterile field (CSA Z314.10, 2003).
13.1.7
A drape shall not be adjusted once it has

been placed (Rothrock, 2011, p. 107).
Shifting or moving the drape may transport bacteria

from an unprepared area of the patients skin into the
surgical field (Rothrock, 2011, p. 107).
13.1.8
Non-perforating towel clamps or devices

shall be used to hold drapes or to secure
tubing and other items on the sterile field
(Rothrock, 2011, p.107).
Perforations in a barrier provide portals of entry and

exit for microorganisms, blood, and other potentially
infectious body fluids (AORN, 2010 p. 95).
13.1.9
At the completion of the surgery, the scrub

nurse shall ensure that all instruments,
sponges, and equipment are removed from
the drapes.
Assists with completion of surgical count. Loss of

instruments and mechanical damage in the laundering
process can occur and may be very costly.
Risk of injury to personnel and the patient is
minimized.
13.1.10 Only gowned and gloved personnel shall

remove the drapes. Removal shall be
carefully controlled by rolling the drapes
into a bundle that confines the
contamination.
Controlling the removal is necessary in order to

confine and contain the contaminants.
PPE worn by scrubbed personnel supplies protection
from microbial contaminants.
13.1.11 The drapes shall be placed in the linen

hamper or garbage container (if disposable)
by gloved personnel following Routine
Practices.
REFERENCES
Canadian Standards Association (2003). CSA Z314.10-03 Selection, Use, Maintenance & Laundering of
Reusable Textile Wrappers, Surgical Gowns and Drapes for Health Care Facilities. Toronto: Author.
Fuller, J. (2005) Surgical technology- principles and practice (4th ed.). Philadelphia: Elsevier Saunders.
Phillips N. (2007). Berry & Kohns Operating room technique. (11th ed.). Toronto: Mosby.
Rothrock, J. (2011) Alexanders care of the patient in surgery. (14th ed.). Toronto: Mosby.
Dressing (s), Drain(s), Irrigation

Rationale
Practice
Section 2
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PRACTICE
Rationale

Practice
14.1
Dressing(s)
14.1.1
Appropriate dressings shall be applied to the

patient according to:
-wound requirements;
-surgeons preference; and
-patient sensitivity.
Dressings protect the wound from trauma and

contamination. Dressings will absorb drainage and
enhance the patients physical comfort and aesthetic
appearance.
Dressings protect the incision free of microorganisms,
both exogenous and endogenous.
Dressings also support, splint, and immobilize a body
part and incision area (Phillips, 2007).
14.1.2
Wound dressings shall not be opened for use until

the wound is closed and the final count is complete
(Fuller, 2005; Phillips, 2007).
Wound dressings do not have a radiopaque detectable

strip and if opened prior to closure present a risk for
being retained in the wound as a foreign object.
Dressing that are included in custom packs shall

remain sealed/isolated until the final count is
complete.
14.1.3
Before applying a dressing to a closed wound the

skin around the incision shall be cleansed of blood
with a sterile dampened sponge or towel (Phillips,
2007).
14.1.4
The scrub nurse shall hold a sterile sponge or

towel over the incision while the drapes are
removed. The dressing will be applied. If the
dressing to be used is multilayered, the scrub nurse
should place the initial dressing over the incision.
The circulating nurse will apply the remaining
dressing materials.
To protect the wound/incision area from contamination

and introduction of microorganisms.
Gloves contaminated with blood or body fluids will
contaminate the outside of the dressing.
Before taping, the patients skin condition shall be

assessed. Non allergic tape shall be readily
available.
14.1.5
A sponge with a radiopaque attached strip shall notR

be used for a dressing.
14.2
Drain(s)
14.2.1
Safety precautions and Routine Practices

shall be followed when establishing a
drainage system:
Radiopaque sponges could distort a postoperative x-ray

or cause an incorrect count if the patients incision must
be reopened.
The type of drain used depends on, surgeon preference

and the area to be drained.
Proper handling minimizes or prevents cross
contamination.
14.2.2
The circulating Registered Nurse shall

record the exact location of the drain(s), the
Complete and accurate documentation helps provide

consistency in patient care by communication of
Section 2
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Rationale
type of drain(s), and the method of securing

the drain(s) (Rothrock 2011, p. 265).
important information.
14.3
Irrigation
14.3.1
The circulating Registered Nurse shall

provide the appropriate irrigating fluid as
ordered by the surgeon.)
14.3.2

shall keep track of the amount of irrigation
fluid used when blood loss is being
calculated (Phillips 2007).
14.3.3
Solutions and medications shall be checked

for accuracy as to type and amount by the
scrub and circulating Registered Nurse
before being placed onto the sterile field
(Rothrock, 2011, p. 39).
14.3.4
Solutions and medications on the sterile

field shall be clearly labeled using a sterile
marking pen or sterile labels (Rothrock,
2011, p. 39).
14.3.5
Use of all irrigating solutions and

medications shall be documented on the
operative record (Rothrock, 2011).
14.3.6
Some special procedures may require

detailed fluid management as per the health
care facilitys policy.

Practice
Hazards may be encountered with different solutions

such as the use of sterile water versus saline in urology
procedures.
Solutions and medications that are clearly labeled reduce

the risk of patient injury.
REFERENCES
Fuller, J. (2005) Surgical technology- principles and practice (4th ed.). Philadelphia: Elsevier Saunders
Saunders.
Phillips N. (2007). Berry & Kohns Operating room technique. (11th ed) Toronto: Mosby.
Section 2
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Section 3
Safety/Risk Prevention and Management
Introduction to Risk Management ..................................................................................................................155

Risk Avoidance/Minimization ........................................................................................................................156
Patient Safety ..................................................................................................................................................160
Ambulatory Patient Care Recommendations ...................................................................................160
Patient Admission and Identification ...............................................................................................163
Consent for Surgical Intervention ....................................................................................................164
Surgical Site Verification .................................................................................................................165
Surgical Pause/Time Out .............................................................................................................166
Surgical Counts ................................................................................................................................167
Surgical Positions .............................................................................................................................178
Visitors to the Surgical Suite ............................................................................................................184
Gathering Medicolegal Evidence in the Surgical Suite ....................................................................185
Guidelines for Collection of Evidence: (Appendix E) ....................................................................189
Specimen Management ....................................................................................................................190
Medication Management ..................................................................................................................193
Nursing Documentation ...................................................................................................................196
Electronic Health Records ................................................................................................................201
Organ and Tissue Procurement Protocol ..........................................................................................203
Team Safety ....................................................................................................................................................206
Credentialing ....................................................................................................................................206
Occupational Health & Safety ..........................................................................................................207
Students/Preceptors ..........................................................................................................................209
Orientation/In-service/Continuing Education ..................................................................................211
Environmental/Equipment Safety ...................................................................................................................212

Construction/Renovation ..................................................................................................................212
Equipment Selection/Trialing...........................................................................................................221
Preventative Maintenance Programs ................................................................................................225
Risk Alerts/Recalls ...........................................................................................................................225
Intra-operative Equipment Malfunction ...........................................................................................226
Specialized Surgical Equipment ......................................................................................................226
Electrosurgery (ESU) ..........................................................................................................226
Laser Safety and Administration ..........................................................................................234
Minimally Invasive Surgery .................................................................................................242
Section 3
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Section 3 Safety/Risk Prevention and Management
The risk management process is designed to identify the scope of potential or real risk related to patients, the health
care team members and the health care facility. An effective risk management program requires the following:
-
Key Structural Elements - enables the risk manager/delegate to develop and enforce the risk
management program and enact needed changes in policy.
Scope of Risk - related to patient, medical staff and employees.
Risk Strategies - techniques to manage risk, prevent risk and/or reduce risk.
Policies & Procedures - to ensure consistency and uniformity of the program.
Health care risk management is concerned with a tremendous variety of issues and situations that hold the potential
for liability or casualty losses for an institution. To be truly comprehensive, a risk management program must
address the full scope of the following categories of risk:
- Patient care - related risks
- Medical staff - related risks
- Employee related risks
- Property related risks
- Financial risks
- Other risks
(Hagg-Rickert,1997, p. 39)
This section will identify the processes and polices required in the surgical suite to determine:
- Risk acceptance
- Risk avoidance
- Risk transfer
The content of this section is organized under the following broad headings:
- Risk Avoidance or Minimization
- Patient Safety
- Team Safety
- Environmental/Equipment Safety
- Incident Reporting
REFERENCES
Hagg-Rickert, S. (1997). Foundations for healthcare risk management: elements of a risk management program.
Risk Management Handbook. (2nd ed.). Roberta Carroll ed, American Hospital Publishing, pp. 35-51.
BIBLIOGRAPHY
Health Canada retrieved November 6, 2008 www.hc-sc.gc.ca
Woodhead, K and Wicker, Paul. (2005). Textbook of Perioperative Care. Toronto: Elsevier
RESOURCES
Canadian Nurses Association (CNA) Patient Safety Resource Guide.
http://www.cna-nurses.ca/CNA/practice/environment/safety/guide/intro-e.aspx
Section 3
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Introduction to Risk Management
CIHI- Canadian Institute of Health Information. www.cihi.ca

Safe Surgery Saves Lives, campaign from WHO challenging the world to make global surgery safer.
http://www.who.int/patientsafety/safesurgery/
WHO World Health Organization www.who.int
Risk Avoidance/Minimization
The following policies and procedures, information and/or processes should be developed for the perioperative
setting:
PRACTICE
1.1 Physical layout of the department.
RATIONALE
Facilitates patient and staff security and safety.
1.2 Hours of operation of the department.

1.3 Use of the surgical suite after hours and an
auditing process of this use.
Most departments have reduced resources. Access is

for emergent/urgent case type.
Monitoring of this utilization will determine overuse
and/or violation of access.
1.4 Physician/dentist credentials and privileges shall

be available to staff and processes defined
related to when physician/dentist exceeds
privileges.
1.5 Identification of minimum educational
requirements for health care professionals.
1.6 Annual confirmation of license/registration
of health care professionals.
1.7 Utilization of unlicensed assistive personnel
(UAP) to include:
- scope of practice of UAP;
- education of the UAP in assigned tasks;
and
- mechanism to monitor performance of
UAP. (AORN, 2004, p. 167)
1.8 Education to include but not limited to:
- staff orientation;
- in-service; and
- regulations/requirements for WHMIS,
CPR, Fire and other mandatory
review/certification programs.
Section 3
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Canadian Nurses Association (CNA) (2006). Staffing for Safety http://www.cna-nurses.ca
1.9
RATIONALE
The use of agency staff, as it relates to:

- basic orientation;
- reporting relationship to a regular staff
member; and
- reference package so agency staff have
information readily accessible in
written/electronic format.
1.10 Visitors (e.g., sales reps, students, etc.) in the

surgical suite as it relates to:
- privileges;
- acceptable behaviour; and
confidentiality.
There is a legal precedent where a sales

representative assisted during a surgical procedure
resulting in a lawsuit to the health care facility.
1.11 Staff communication regarding new and revised

policies and procedures:
- circulation to all staff; and
- retention of outdated policies.
Staff need to be aware of new policies and

procedures.
1.12 Reporting of sentinel events, incidents and near

misses, including a clear definition of each
type.
Reporting assists in identifying trends, where policy

& process development/revision is required.
1.13 Dissemination of information related to

equipment/medical surgical device risk alerts
and re-calls.
The health care facility needs to have a common

entry and exit point for these alerts and recalls to
ensure no areas are missed.
1.14 Equipment as it relates to selection,

preventative maintenance and transportation
from site to site.
Patient safety, team safety and risk need to be

considered in the selection process.
Preventative maintenance and routine maintenance
assist in minimizing potential functionality problems
of complex medical devices.
Confidentiality and privacy is a great concern.
Old policies may be required for legal defence.
1.15 Consent to treatment shall follow provincial

legislation and health care facility guidelines for
the following:
- telephone consent;
- emergency life/limb saving surgery
consent;
- age of consent;
- medicated patients giving consent;
- alternate/substitute decision-maker
giving consent;
- blood and blood products; and
- interpreters.
1.16 Verification of surgical site as it relates to:
- verification of patient identity;
- verification of surgical intervention
site(s) and side (when involving
laterality);
Clear indication/understanding of what is being

marked (surgical site or non-surgical site) is required
for patient safety.
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PRACTICE
RATIONALE
marking the surgical site(s); and

collaboration of team members for
verification process is necessary.
REFERENCES
Association of PeriOperative Registered Nurses. (2004). Position Statement on Use of Unlicensed Assistive
Personnel. Standards, Recommended Practices, and Guidelines. Denver: Author.
BIBLIOGRAPHY
Accreditation Canada www.accreditation-canada.ca - formerly known as Canadian Council on Health Services
Accreditation (CCHSA).
Allan, Sheila S, (2007). Creating a Culture of Safety. Journal of Perioperative Practice, 17(6), 244-246.
Allen, Sheila S, (2007). Conflict in the Perioperative Environment. Journal of Perioperative Practice, 17(3), 96-97.
Amato-Vealey, Elaine J, & Barba, Marianne, P, (2008). Hand-off Communication: A Requisite for Perioperative
Patient Safety, AORN Journal, 88(5), 763-772.
AORN, (2009). Perioperative Standards and Recommended Practices. Denver: Author.
Baker, R et al, (2004). The Canadian adverse events Study: the incidence of adverse events among hospital patients
in Canada. CMAJ, 170(11), 1678-1686.
Beaumont, Kate, (2008). Recognizing and Responding to the Deteriorating Patient, Institute for Innovation and
Improvement, NHS, http://www.library.nhs.uk/theatres/page.aspx?pagencine=ED11
Bilyk, C. (2008, September). Do not break the chain: importance of supply chain management in the operating room
setting. Canadian Operating Room Nursing Journal, 26, (3), 21, 22, 30-32, 34.
Brown, Y. (2004). Learning in a preceptorship. Canadian Nurse. 100 (6), Ottawa:
CNA.
Canadian Council on Health Services Accreditation (CCHSA). (2004). Human Resources. AIM,
Achieving Improved Measurement, Accreditation Program. 3rd ed. Now known as Accreditation Canada.
www.accreditation-canada.ca
Carney, Brenda L, (2006). The Evolution of Wrong Site Surgery, AORN Journal, 83(5), 1115-1122.
Cutler I, (2008). The safety of Medical Devices: The tools of your working day. Journal of Perioperative Practice,
18(9), 396-403.
Edwards P. (2008). Ensuring Correct Site Surgery. Journal of Perioperative Practice, 18(4), 168-171.
Edwards P. (2006). Promoting Correct Site Surgery: A national approach. Journal of Perioperative Practice, 16(2),
80-86.
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PRACTICE
Haines, Ted & Stringer Bernadette, (2007). Could the Death of a BC OR Nurse have been Prevented by Using the
Hands-Free Technique? Canadian Operating Room Nurses Journal, 25(4).
Hamlin, Lois, Richardson-Tench, Marilyn & Davies, Menna, (2009).Perioperative nursing an introductory text.
Elsevier/Mosby, Sydney AU
Giles, Sally G et all (2006). Experience of Wrong Site Surgery and Surgical Marking practices among clinicians in
the UK. Qual Saf Healthcare, 15, 363-368. http://www.bmj.com/cgi/reprintfromjournals
Haynes, Alex B et al, (2009). A surgical checklist to Reduce morbidity and Mortality in a Global Population. NEJM,
360(5), 491-499.
Higgins Jackee, (2004). Thinking Outside the Box: Perioperative Preceptorship. Canadian Operating Room Nurses
Journal, 22(1).
Huff, Brenda, (2004). Leadership and Mentoring. Canadian Operating Room Nurses Journal, 22(1).
International Federation of Perioperative Nurses (IFPN) & European Operating Room nurses Association
(EORNA), (2005). Joint Position Statement on Patient Safety 1011, IFPN & EORNA, accessed April 16,
2009 from http://www.ifpn.org.uk
Keith, N., & O'Reilly, Y. (2003). The legal connection: soon to be law corporate decision - makers are accountable
for employee safety. Canadian Occupational Health & Safety. 41(5).
Kwaan Mary K et al, (2006). Incidence, Patterns and Prevention of Wrong Site surgery, Arch Surg, 141. Accessed
April 15, 2009 www.archsurg.com
Lingard, Lorelei, et al, (2008). Evaluation of a Perioperative checklist and Team Briefing Among Surgeons, nurses
and Anesthesiologists to Reduce Failures in communication, Arch Surg, 143(1), 12-17.
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recurrent types and effects. Qual Saf Healthcare, 13, 330-334.
Makary, Martin A, et al (2006). Operating Room Teamwork Among Physicians and Nurses: Teamwork in the Eye
of the Beholder. Journal of American College of Surgeons, 202, 746-752.
McNair, W, & Smith B, (2007). A Vision of Mentorship. Journal of Perioperative Practice, 17(9),421-430.
Phillips, N.M. (2007). Berry & Kohns operating room technique. (11th ed.) St Louis: Mosby.
Porteous, J. (2008). Oh By the Way the Patient is Pregnant. Canadian Operating Room Nurses Journal, 26(2).
Robson, R., & Marshall, P. (2003). Using dispute resolution to resolve health care conflicts: an essential tool in
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2(8), accessed April 12, 2009, from http://www.pssjournal.com/content/21/21
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Forster, Alan J, (2004). Ottawa Hospital Patient Safety: Incidence and timing of adverse events in patients admitted
to a Canadian teaching hospital. Canadian Medical Association Journal, 170(4), 1235-1240.
Stringer B & Haynes T, (2006). Hands-free technique: preventing occasional exposure during surgery. Journal of
Perioperative practice, 16 (10), 495-500.
Vincent, C.(2006). Patient Safety. London, UK.: Churchill Livingstone.
Watson, V., & Steiert, M.J. (2002). Verbal abuse and violence: the quest for harmony in the OR. Surgical Services
Management. 8(4), pp. 16-22.
Westhead, Cameron, (2007). Perioperative nursing management of the elderly Patient, Canadian Operating Room
Nurses Journal. 25 (3).
Patient Safety
2.1 Ambulatory Patient Care
In recognition of the ambulatory patients short stay the following best practices include but are not limited to:
PRACTICE
2.1.1
2.1.2
2.1.3
The patient/ shall be educated about:

- the importance of complying with
health care facility guidelines, e.g.
nothing by mouth (NPO)/anesthesia
considerations;
- importance of not driving or operating
machinery post-operatively as per
facility protocol;
importance of not making important
decisions;
- requirement of discharge in the
company of a responsible adult; and
- compliance with post-discharge
instructions.
Ambulatory surgical patients shall be

provided with:
- contact information for agencies
providing information and assistance
following discharge (i.e. help line); and
- appropriate post-operative teaching
instructions as per facility protocol.
RATIONALE
The patient is informed about risk of aspiration with
non-compliance.
Presents a hazard to the patient and others.

Medications used for induction and/or maintenance
of anesthesia require a specified period for
metabolism. Insurance providers do not provide
coverage for policy holder for a specified period
post-operatively.
The responsible adult must be available to call for
help if it is required.
Patient/responsible adult will be made aware of who

to contact if a concern arises post-discharge (nursing
and physician).
Patient/ responsible adult should be able to
understand and verbalize post-discharge information.
The perioperative Registered Nurse is

responsible for:
- documenting patient teaching as per

Section 3
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Spry, Cynthia, (2008). Essentials of Perioperative Nursing (4th ed.). Philadelphia: Jones & Bartlett.
RATIONALE
facility protocol;
discharging patient according to the
health care facility discharge criteria;
and
following health care facility process
for patient(s) who do not meet the
discharge criteria or are non-compliant
with discharge criteria.
BIBLIOGRAPHY
Accreditation Canada www.accreditation-canada.ca - formerly known as Canadian Council on Health Services
Accreditation (CCHSA).
Allan, Sheila S, (2007). Creating a Culture of Safety. Journal of Perioperative Practice, 17(6), 244-246.
Allen, Sheila S, (2007). Conflict in the Perioperative Environment. Journal of Perioperative Practice, 17(3), 96-97.
Amato-Vealey, Elaine J, & Barba, Marianne, P, (2008). Hand-off Communication: A Requisite for Perioperative
Patient Safety, AORN Journal, 88(5), 763-772.
AORN, (2010). Perioperative Standards and Recommended Practices. Denver: Author.
Baker, R et al, (2004). The Canadian adverse events Study: the incidence of adverse events among hospital patients
in Canada. Canadian Medical Association Journal, 170(11), 1678-1686.
Beaumont, Kate, (2008). Recognizing and Responding to the Deteriorating Patient. Institute for Innovation and
Improvement, NHS, http://www.library.nhs.uk/theatres/page.aspx?pagencine=ED11
Bilyk, C. (2008, September). Dont break the chain: importance of supply chain management in the operating room
setting. Canadian Operating Room Nursing Journal, 26, (3), 21, 22, 30-32, 34.
Brown, Y. (2004). Learning in a preceptorship. Canadian Nurse, 100 (6), Ottawa: Author.
Canadian Council on Health Services Accreditation (CCHSA). (2004). Human Resources. AIM,
Achieving Improved Measurement, Accreditation Program. 3rd ed. Now known as Accreditation Canada.
Carney, Brenda L, (2006). The Evolution of Wrong Site Surgery, AORN Journal, 83(5), 1115-1122.
Cutler I, (2008). The safety of Medical Devices: The tools of your working day. Journal of Perioperative Practice,
18(9), 396-403.
Edwards P. (2008). Ensuring Correct Site Surgery. Journal of Perioperative Practice, 18(4), 168-171.
Edwards P. (2006). Promoting Correct Site Surgery: A national approach. Journal of Perioperative Practice, 16(2),
80-86.
Forster, Alan J, (2004). Ottawa Hospital Patient Safety: Incidence and timing of adverse events in patients admitted
to a Canadian teaching hospital. Canadian Medical Association Journal (CMAJ), 170(4), 1235-1240.
Section 3
Page 161 of 334

PRACTICE
Haines, Ted & Stringer Bernadette, (2007). Could the Death of a BC OR Nurse have been Prevented by Using the
Hands-Free Technique? Canadian Operating Room Nurses Journal. 25(4).
Hamlin, Lois, Richardson-Tench, Marilyn & Davies, Menna, (2009).Perioperative nursing an introductory text.
Sydney AU: Elsevier/Mosby.
Haynes, Alex B et al, (2009). A surgical checklist to Reduce morbidity and Mortality in a Global Population. NEJM,
360(5), 491-499.
Higgins Jackee, (2004). Thinking Outside the Box: Perioperative Preceptorship. Canadian Operating Room Nurses
Journal, 22(1).
Huff, Brenda, (2004). Leadership and Mentoring. Canadian Operating Room Nurses Journal, 22(1).
International Federation of Perioperative Nurses (IFPN) & European Operating Room nurses Association (EORNA),
(2005). Joint Position Statement on Patient Safety 1011, IFPN & EORNA, accessed April 16, 2009 from
http://www.ifpn.org.uk
Keith, N.,& O'Reilly, Y. (2003). The legal connection: Soon to be, law corporate decision - makers are
accountable for employee safety. Canadian Occupational Health & Safety. 41(5).
Kwaan Mary K et al, (2006). Incidence, Patterns and Prevention of Wrong Site surgery, Arch Surg, 141. Accessed
April 15, 2009 www.archsurg.com
Lingard, Lorelei, et al, (2008). Evaluation of a Perioperative checklist and Team Briefing Among Surgeons, nurses
and Anesthesiologists to Reduce Failures in communication, Arch Surg, 143(1), 12-17.
Lingard, Lorelei, et al, (2004). Communication failures in the Operating Room: an observational classification of
recurrent types and effects. Quality Safe Healthcare, 13, 330-334.
Makary, Martin A, et al (2006). Operating Room Teamwork Among Physicians and Nurses: Teamwork in the Eye of
the Beholder. Journal of American College of Surgeons, 202, 746-752.
McNair, W, & Smith B, (2007). A Vision of Mentorship. Journal of Perioperative Practice,17(9), 421-430.
Porteous, J. (2008). Oh By the Way the Patient is Pregnant. Canadian Operating Room Nurses Journal, 26(2).
hospital risk management. Risk Management in Canadian Health Care, 4 (7).
Stahel, P. F. (2008). Learning from aviation safety: a call for readback in surgery Patient Safety in Surgery. 2 (8)
accessed April 12, 2009 from http://www.pssjournal.com/content/21/21
Spry, Cynthia, (2008). Essentials of Perioperative Nursing(4th ed.). Philadelphia: Jones & Bartlett.
Stringer B & Haynes T, (2006). Hands-free technique: preventing occasional exposure during surgery. Journal of
Perioperative Practice, 16 (10) 495-500.
Section 3
Page 162 of 334

Giles, Sally G et all (2006). Experience of Wrong Site Surgery and Surgical Marking practices among clinicians in
the UK. Quality Safe Healthcare, 15, 363-368. http://www.bmj.com/cgi/reprintfromjournals
Westhead, Cameron, (2007). Perioperative nursing management of the elderly Patient, Canadian Operating Room
Nurses Journal. 25 (3).
2.2 Patient Admission and Identification

The perioperative Registered Nurse provides safety and comfort to each patient on admission to the operating room.
2.2.1
PRACTICE
RATIONALE
The surgical suite policy and procedure

manual shall address the procedure and
delegation of responsibilities for admitting a
patient to the surgical suite.
Provides quality assurance for a consistent practice to

reduce risks from errors and omissions.
The perioperative Registered Nurse is responsible for:

2.2.2
Admitting the patient in a professional

manner.
This reduces anxiety.
2.2.3
Identifying themselves (including name

and job title) and asking the patient's name.
Active communication reduces risk of error.
2.2.4
Verifying the patient's identification with two

patient identifiers i.e. name , facility
identification number on arm band, date of
birth (orally) with the patient or responsible
adult identifier shall not be room number or
patient location (Catalano and Fickenscher,
2008).
2.2.5
Reviewing the patients health record to

confirm at minimum the presence
and completeness of:
- documentation of consent;
- pre-op checklist; and
- history and physical
The responsibility for the consent lies with the

surgeon; however, it is the perioperative Registered
Nurse's responsibility to confirm all relevant records
are present and complete prior to admission to the
operating room.
2.2.6
Verifying the operative site, surgical site

marking if laterality is involved, the
procedure, documentation of consent for
accuracy/completeness. Taking the
appropriate action according to the health
care facilitys policy when a surgical
consent is inadequate/incomplete.
Protects patient from potential injury and the health

care facility from litigation.
2.2.7
Assessing the patient's emotional and

physical condition and intervening as
appropriate.
2.2.8
Caring for the patient's personal belongings
Some items may be required for the emotional and
Section 3
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Vincent, C.(2006). Patient Safety. London, UK.: Churchill Livingstone.
RATIONALE
according to written protocols. No personal

belongings other than the following
exceptions should accompany the patient:
- items for pediatric patients;
- religious medals/symbols;
- clothing (when appropriate);
- hearing aids;
- eye glasses
- dentures; and
- prostheses.
physical well being of the patient.
Verifying the preoperative checklist is

complete The checklist will include but not
be limited to:
- patient identification band;
identification card if used in facility;
- consent/documentation of consent
completed and signed;
- consent or withdrawal of consent for
blood products, if applicable;
- surgical site identification;
- history and physical assessment;
- all diagnostic reports present;
- preoperative vital signs ;
- allergies;
- NPO status;
- prostheses
hearing aids;
- eye glasses
- dentures; and
- jewellery,
- medication including herbal remedies;
and
- presence of an advanced directive as
necessary.
This step prevents oversights and omissions. The

preoperative checklist should be a permanent part of
the clinical record.
Items may be misplaced.
2.3 Consent for Surgical Intervention

PRACTICE
2.3.1
2.3.2
Checking the clinical record for

documentation of consent and using active
communication to verify the surgical
procedure, site, and the patients
understanding of the procedure.
RATIONALE
Patient has the right to decide what or what will not
be done to them. (CPSO, 2004) Patient understanding
is a component of informed consent.
The ultimate responsibility for obtaining informed
consent is with the health care practitioner proposing
the intervention.
Exercising professional judgment and

following the guidelines established by their

Section 3
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2.2.9
PRACTICE
REFERENCES
College of Physicians and Surgeons of Ontario. (2004). A guide for Canadian Physicians. www.cpso.on.ca
BIBLIOGRAPHY
Bernat, James L & Peterson, Lynn M, (2006). Patient-centered Informed Consent in Surgical practice. Arch Surg,
141; 86-92.
Corfield L & Pomeroy A, (2008). Perioperative Consent: how to make sure your practice is legal part 1. Journal of
Perioperative Practice, 18 ( 8) 326-328.
Corfield L & Pomeroy A, (2008). Perioperative Consent: how to make sure your practice is legal part 2. Journal of
Elke-Henner, W Kluge, (2008). Remains of the Body, Human Tissue, Competence and Consent in an Age of Profit,
Canadian Operating Room Nurses Journal, 26 (2).
Kuz, K.M. (2006). Young teenagers providing their own surgical consents. Canadian Operating Room Journal, 24
(2). 6-15.
Rozovsky, L.E. (2003). The Canadian Law of Consent to Treatment (3rd. ed.). LexisNexis Butterworths: Markham.
Stevenson G, (2006). Informed Consent, Journal of Perioperative Practice, 16(8) 384-388.
2.4 Surgical Site Verification

Surgical site verification reduces the risk of adverse patient outcomes/events during a surgical experience.
Surgical facilities shall have a policy in place regarding surgical site verification.
PRACTICE
2.4.1
Following the facility policy regarding

surgical site verification.
2.4.2
Verifying the surgeon has marked the site (if

applicable) prior to admission to the
operating room.
2.4.3
Verifying the correct surgical procedure

and site with patient/responsible adult.
RATIONALE
Section 3
Page 165 of 334

regulatory body, health care facility policy

and provincial legislation with respect to the
patient's capability to give informed consent
for the proposed intervention.
Confirming surgical site, site marking (if

laterality, multiple sites, spine levels is/are
involved), and procedure with the surgical
team in the theatre.
The surgeon is responsible for marking the site.
BIBLIOGRAPHY
Beyea, S. (2002). Ensuring correct site surgery. AORN Journal, 76 (5) 880-882.
Canadian Patient Safety Institute Surgical Safety Checklist & Scorecard: Canada, Version 1. Edmonton, AB:
Canadian Patient Safety Institute; 2009 Jan 9. www.safesurgerysaveslives.ca
OR Manager: Patient Safety. (2003). Air Force's 11 patient safety tools build better team communication. OR
Manager, 19(2), pp. 12-18. Santa Fe: OR Manager Inc.
OR Manager: Patient Safety. (2003). Frequent questions on marking the surgical site. OR Manager, 19(2)18-19.
Patient Safety First Alert Implementing a Correct site Surgery Policy and Procedure. (2003). AORN Journal. 76
(5), 785-788.
2.5 Surgical Pause/Time Out

The World Health Organization (WHO) endorsed this procedure to reinforce safety practices and to foster better
communication and teamwork between clinical disciplines.
Surgical facilities shall have a policy regarding the requirement for the surgical pause.
2.5.1
2.5.2
2.5.3
Complying with the pause/time out policy.

"Pausing" (following prepping and draping
and before the incision is made) to
verbally re-confirm:
- correct patient;
- surgical procedure(s);
- correct surgeon;
- correct operating room;
- correct site(s); and
- the administration of antibiotics
if applicable.
Reduces risk of wrong site surgery.
Confirming (prior to incision being made)

that all documentation agrees including:
- documentation of consent;
- history and physical, service consults;
- nursing assessment;
- surgical schedule; and
- any discrepancies should be reported
and resolved prior to surgical
intervention.
Documenting the pause process.
Evidence the process was completed.
Section 3
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2.4.4
Canadian Patient Safety Institute. Surgical Safety Checklist & Scorecard: Canada, Version 1. Edmonton, AB:
2009 Jan 9. www.safesurgerysaveslives.ca
2.6 Surgical Counts

The purpose is to protect the patient from the unintentional retention of a foreign body by accounting for any and
every thing that could be left behind.
PRACTICE
RATIONALE
Procedures, General Considerations

2.6.1
The health care facility surgical count

policy and procedure shall define:
- the materials to be counted;
- the times when the surgical count
shall be performed;
- actions to be followed for an incorrect
surgical count; and
- the documentation required.
The surgical count policy and procedure ensures

standardization within the health care facility and is
a legal document.
2.6.2
Instrument sets should be standardized

within each facility.
Standardization assists in accuracy, efficiency, and

continuity.
2.6.3
The count shall be the responsibility of the

scrub personnel and the circulating
perioperative Registered Nurse(s).
Perioperative nurses are accountable for the count.
2.6.4
The scrub personnel shall be aware of all

counted items throughout the operative
procedure and be involved in all parts of the
count.
Consistent organization and tidiness of the sterile

field reduces risk of error.
2.6.5
Counts shall be performed by two people,

one of whom shall be a perioperative
Registered Nurse. All items shall be visually
observed and audibly counted concurrently
by the scrub and circulating perioperative
Registered Nurses.
Counts are a shared responsibility and both the scrub

and circulating perioperative Registered Nurse are
accountable.
2.6.6
All counts shall be conducted according to

2.6.7
All perioperative personnel involved in the

count shall sign the count record.
2.6.8
If there is no scrub nurse, two perioperative

personnel, (one of which must be a
perioperative Registered Nurse) shall count
Healthcare facility policy will determine who

initiates the count, i.e. scrub or circulating nurse.
Section 3
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BIBLIOGRAPHY
RATIONALE
together. If only one perioperative

personnel are available, it must be a
perioperative registered nurse who shall
count with the surgeon. The perioperative
Registered Nurse should print the surgeons
name and/or follow facility policy.
A count of sponges, needles, suture reels,
blades and designated miscellaneous items
shall be performed for all procedures,
except for those cases clearly defined as
superficial as per health care facility policy.
Examples of sharps includes scalpel blades,

hypodermic needles, suture needles.
2.6.10
Radiopaque materials should be used in

surgery.
Radiopaque materials are more easily detected on xray if they are missing during the count.
2.6.11
Counts shall be done:

- prior to commencement of surgery;
- at the first layer of closure, depending
on the cavity entered ;
- at the skin closure (instruments do not
require recounting at skin closure);
- an additional count of sponges, sharps
and suture reels and designated
miscellaneous items shall be done
prior to closure of a cavity within a
cavity, e.g., closure of the uterus
during a Caesarean Section, and
vaginal vault following hysterectomy;
- a full instrument count shall be
completed if likelihood exists that an
instrument could be retained in a
surgical site or as per facility policy;
- a full count should be done at the time
of permanent relief of the scrub and/or
circulating perioperative Registered
Nurse by the relief personnel; and
- during a changeover, when the
situation does not allow visualization
appropriate to the level of the count
required, those items not visualized
should be documented on the count
sheet.
Additional areas requiring a full surgical count may

be indicated by the surgeon and/or health care
facility policy.
2.6.9
Examples of designated miscellaneous items

include, but not limited to: delicate instrument tip
protectors; clip cartridges; ligaclip bars; vessel
loops, clamps, inserts; umbilical and hernia tapes;
ESU (cautery) pencils, blades, and scraper/scratch
pads; wing nuts; screws; small endoscopic parts
(i.e. trocar sealing caps, washers, O-rings, springs,
caps); and any other small items in a surgical count
that have the potential for being retained in a
surgical wound.
Section 3
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PRACTICE
RATIONALE
2.6.12
The recommended sequence of surgical

counts is: sponges, sharps, miscellaneous
items and instruments.
Counts can be performed during the surgery at any

time deemed necessary with minimal disruption of
the surgical team.
2.6.13
Items should remain together until the

initial count is done (e.g. sets/trays stay
together & no setup can occur until count is
complete).
A standard method of counting provides accuracy

and consistency and reduces risk of errors.
2.6.14
Interruptions during a count should not

occur. Once a count has been started, it
should be completed. If an interruption
occurs, the count shall be resumed at the
end of the last recorded item.
This prevents items being missed from the count and

assists in preventing commencement of case prior to
the completion of the initial count.
2.6.15
All items shall be recorded as they are

counted, before proceeding to the next item.
Assists in reducing errors.
2.6.16
Articles given to the scrub personnel during

the procedure shall be immediately
counted, recorded, and initialed on the
count sheet.
Keeps an accurate account of items on the surgical

field.
2.6.17 Once a count is initiated, items shall not be

removed from the theatre, including
garbage and laundry, until the final count is
complete.
Confinement allows for complete checking should a

counting error occur.
2.6.18 Needles that have fallen to the floor or have

been removed from the sterile field shall be
clearly displayed for both the scrub and
circulating perioperative Registered Nurses
to count.
2.6.19 At closure, items shall be counted according
to the protocol established by the health
care facility. The recommended sequence
of surgical counts is: sponges, sharps,
miscellaneous items and instruments
starting from the sterile field to the mayo
stand, to back table and then any item
removed from the sterile field.
2.6.20
If the care of the patient requires more than

one surgical instrument set-up, a separate
count sheet shall be used for each set-up
(e.g. Vaginal Repair and Abdominal
Hysterectomy). The extent of the count for
each set-up will default to the most
extensive count performed.
A standard method of counting provides accuracy

and consistency.
Consistent counting sequence may assist in
decreasing confusion and error.
Section 3
Page 169 of 334

PRACTICE
RATIONALE
Items shall not be exchanged from one setup to another.

The final count shall not be confirmed with
the surgeon until the last operative
procedure is completed (e.g. multiple
procedures with multiple tables for one
surgical case). When performing bilateral
procedures counts shall be completed at
each incision closure. (e.g. Bilateral Knee
Arthroplasty)
2.6.21
Results of all counts shall be announced

audibly to the surgeon. The circulating
perioperative Registered Nurse shall
receive verbal acknowledgement from the
surgeon.
Aids in obtaining an accurate count for both set-ups.

Individual table/procedure counts may be relayed
but the final surgical count is not confirmed until all
procedure counts have been completed.
2.6.22
If an incision is re-opened after the final

count, the closure count shall be repeated
and documented as re-closure.
The surgeon shall be notified of the count outcome.

An interruption of the closure may be required if the
count is incorrect.
2.6.23
In a procedure where the necessity of a

complete count is questionable, the count
shall be done in its entirety prior to
commencement of surgery. The count
required at closure will be determined by
the cavities entered.
2.6.24
In an emergency when an initial count is

not performed, the scrub nurse shall attempt
to account for items. The circulating
perioperative Registered Nurse shall:
- document on the perioperative record
the reason an initial count was not
performed and the action taken at
completion of the procedure;
- notify the appropriate management;
- arrange for an x-ray at completion of
the procedure and prior to the patient
leaving the operating theatre, if patient
status permits;
- if the surgeon refuses the x-ray,
document on the clinical record
according to the health care facility
policy; and
- complete an incident report.
If a cavity is not entered, a full count may not be

required.
The health record must reflect what occurred

including the count results and action taken.
Section 3
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PRACTICE

PRACTICE
RATIONALE
Incorrect Counts
2.6.25
If a miscount occurs:
- notify the surgeon;
- recount;
- search the floor, garbage, laundry,
drapes;
- notify the appropriate management;
- in consultation with the surgeon
arrange for an x-ray at completion of
the procedure and prior to the patient
leaving the operating theatre, if patient
status permits;
- document the appropriate x-ray results
if known. If the surgeon refuses the xray, document on the clinical record
according to the health care facility
policy;
- complete an incident report according
to the health care facility policy; and
- record the incorrect count on the count
sheet, and document actions taken on
the clinical record according to the
health care facility policy.
2.6.26
If an item is inadvertently left in the patient,

the surgeon assumes the responsibility of
retrieval/non-retrieval and the circulating
perioperative Registered Nurse will
document this occurrence.
Documentation of Surgical Counts

2.6.27
The perioperative count record shall

be included on the patients permanent
record.
2.6.28 All personnel involved in the count shall

sign the perioperative count record.
Signatures identifying initials shall be
recorded.
The perioperative count record is a legal document

and part of the patients health record.
The perioperative circulating Registered

Nurse is responsible to confirm that all
personnel involved in the surgical count
have signed the perioperative count record
or appropriate document according to the
2.6.29 When sterile items are added to the surgical
field, during a procedure, the circulating
Documentation of nursing activities related to the

patients perioperative care provides an accurate
Section 3
Page 171 of 334
RATIONALE
nurse shall document the items. A

recommended practice for documenting
includes writing the symbol +, the
number, and the initials above and to the
right of the number,
picture of the nursing care administered and the

outcomes of the care delivered.
i.e.
JD
+5
When large quantities sterile items (i.e.

sponges/needles) are removed from
(counted off of) the surgical field, during a
procedure, the circulating nurse shall
document the items. A recommended
practice for documenting includes circling
the number, and initialing the bottom right
corner of the entry,
i.e.
+5
JD
2.6.30
Items being counted in a final count should

be checked off, ticked off, or totaled in a
column designated for the final count. Each
and every item that has been presented to
the sterile field shall be included in the final
count. Documenting in a manner that will
not obliterate the clarity of each number.
The number of times items are counted
shall be clearly identifiable on the record.
2.6.31
Health care facility policy shall be followed

for incorrect entries on the client record.
2.6.32
Routine audits to determine compliance

with count policy and procedure should
occur.
White-out, eraser, or cross-outs are not legally

acceptable. A single line through an entry with
documenters initials identifies an error. All errors
must remain visible or retrievable and do not
obliterate or change another professionals
documentation. (Canadian Nurses Protective
Society, 2007; College & Association of Registered
Nurses of Alberta, 2006; Hamlin, et al, 2009; Perry
& Potter, 2006)
Audits are a component of quality assurance and
may identify deficiencies in policy and/or procedure.
Sponges
2.6.33 Sponges used for surgery shall be
radiopaque and not cut during the
procedure. Both the scrub and circulating
perioperative Registered Nurse shall see the
Periodically in manufacturing, the radiopaque

thread/tag is missed.
Cutting of sponges will alter the counts and increase
the potential for loss of a sponge portion.
Section 3
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PRACTICE
RATIONALE
radiopaque marker on each sponge during

counts.
2.6.34 Sponges shall be separated and counted
audibly twice (x2) at initial count and as
dispensed. Count each dispensed package
of sponges twice before counting the next
package. Laparotomy sponges with
tapes/tags shall be pull-tested to verify
security.
2.6.35 Packages containing incorrect numbers of
sponges shall be contained/bagged, labeled,
isolated from the rest of the sponges and/or
removed from the operating room as per
facility policy.
Errors in manufacturers packaging can occur.

Confirming the correct number of sponges in the
package reduces the risk of error in subsequent
sponge counts. Removal of the entire package from
the sterile field and/or operating room helps avoid
errors in subsequent counts.
2.6.36 When large quantities sterile items (i.e.

sponges/needles) are removed from
(counted off of) the surgical field, during a
procedure, the circulating perioperative
Registered Nurse must document the items
removed. A recommended practice is
circling the number, and initialing the
bottom right corner of the entry,
i.e.
5
MS
2.6.37 Sponges documented on the count sheet

shall remain in the theatre until the final
count is complete.
2.6.38 Radiopaque sponges shall not be used for
gauze dressings. Gauze dressings shall not
be added to the sterile field until the final
count is complete.
Tapes/tags may not be radiopaque. Radiopaque

sponges, if used for gauze dressings/prep may cause
confusion with the count.
2.6.39 Sponges without radiopaque marker used

for prep sets shall be discarded from the
sterile field prior to the incision being
made.
2.6.40
If towels are used to protect the viscera or

as packing, they shall be single-use,
radiopaque, counted and shall be
documented. The scrub personnel shall
audibly notify the circulating perioperative
Registered Nurse that a towel has been
inserted. This shall be documented to serve
as a safeguard that the towel has been
Surgical towels have been the subject of retained

surgical item law suits.
Section 3
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PRACTICE

PRACTICE
RATIONALE
removed prior to closing.

2.6.41
Small sponges such as peanuts, pushers,

dissectors, kitners, gauze, etc., shall be
attached to an instrument when used in a
body cavity.
2.6.42 All counted sponges intentionally left in the

patient as packing at the end of surgery
shall be radiopaque. The type and number
of sponges shall be documented.
Reduces risk of loss in the surgical site.
This shall be documented as an incomplete

count with number of sponges remaining in
surgical site.
2.6.43 Patients returning to the operating room
with radiopaque packing insitu:
- packing sponges will be removed by the
surgeon, removed from the sterile field,
bagged and identified as packing material;
- document the type and number of sponges
removed from the wound on the
intraoperative record; and
ff the surgical site is being permanently
closed i.e. all packing material removed
and no new packing material added an xray should be completed when patient is
prepared to leave the operating room
This reduces confusion on the number of sponges

used in the surgical procedure
Increased incidents of incorrect counts occur where
sponges were used as packing and/or for retraction.
(OR Manager, 2003, p. 11)
Identifies risk of inadvertent packing being retained.
Sharps
2.6.44 Suture needles should be counted according
to the number marked on the outer package
and verified by the scrub and circulating
perioperative Registered Nurses when the
package is opened.
Initial counts establish a baseline for subsequent

counts.
2.6.45 Needles shall be counted initially, at time of

dispensing, and required closure counts.
Opening all packages during initial needle count is

not recommended and will result in needles being
exposed during the entire surgical procedure. This
will create additional opportunity for lost or retained
needles during the procedure.
2.6.46 Multi-packaged needles shall be verified by

the scrub and circulating perioperative
Registered Nurses as each package is opened
for use.
There may be a discrepancy between the number of

needles stated on the package and the actual number
in the package.
2.6.47 All needles on the set-up shall be mounted
Reduces risk of lost needles and needle stick
Section 3
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on a needle driver, sealed in packages, or

confined on a needle counter.
RATIONALE
injuries.
2.6.48
All segments of broken needles shall be

accounted for.
Reduces risk of unintentional retention of a foreign

body.
2.6.49
Needles should be handed to the surgeon on

an exchange basis using a hands free
technique. If the surgical procedure does
not allow for needle exchange, the scrub
person should keep account of all needles
on the field and retrieve them as soon as
possible.
Assists the scrub nurse in accounting for needles and

is a safety measure.
2.6.50
If a glove is punctured with a needle, the

glove, needle, and needle driver shall be
removed from the sterile field. Blood
should be removed from the hand before
regloving. If injury has occurred, follow
the health care facility's Occupational
Health and Safety protocols.
Needle stick injury may subject the patient and the

health care team member to blood borne infection.
2.6.51 Surgical team members should use a hands

free technique/Neutral Zone whenever
possible instead of passing needles and
other sharp items.
Studies show that most sharps injuries occur when

suture needles or sharps are passed between
perioperative team members.
Instruments
2.6.52 Instrument sets shall be counted, if
appropriate for the procedure, by the scrub
person and circulating perioperative
Registered Nurse immediately before the
procedure.
Pre-counting of instrument sets (before
sterilization) is not to be considered the
initial count before the surgical procedure.
The scrub and the circulating nurses are accountable

for their supplies.
2.6.53 Instruments should be inspected to ensure

that all parts are present and functional.
Instruments that are broken or disassembled
during the procedure shall be accounted for
in their entirety.
Facilitates efficiency and may prevent patient injury

from retained foreign body.
2.6.54 Each health care facility policy shall state

which instruments may be counted in a
category (e.g., scissors are counted
together).
Facilitates consistency and reduction in counting

errors.
A count performed outside the operating room that

is considered an initial count increases the number of
variables that can contribute to an inaccurate count
and unnecessarily extends the responsibility to
personnel both involved and not involved in direct
patient care.
2.6.55 All instruments having component parts

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PRACTICE
RATIONALE
shall be counted in a consistent manner

according to the health care facility policy.
2.6.56 Instruments shall not be removed from the
theatre prior to the final count.
Minimally Invasive Surgery

2.6.57 The sponges, needles, suture reels, blades,
designated miscellaneous items, and
instruments (includes endoscopic and nonendoscopic instruments), shall be counted
initially. Hospital policy should direct the
counting of individual instrument pieces or
assembled instruments.
2.6.58
Reduces risk of inadvertent retained foreign body.
If the procedure remains endoscopic (i.e.

does not convert to an open procedure) only
a final count of sponges, needles, suture
reels, blades, and designated miscellaneous
items is required.
2.6.59 If the care of the patient requires more than

one surgical instrument set-up, a separate
count sheet shall be used for each set-up
(i.e. Laparoscopic assisted vaginal
hysterectomy). The extent of the
count for each set-up will default to the
most extensive count performed.
Items shall not be exchanged from one setup to another.
2.6.60 The final count shall not be confirmed
with the surgeon until the last operative
procedure is completed (e.g. multiple
procedures with multiple tables for one
surgical case).
REFERENCES
Canadian Nurses Protective Society. (2007). InfoLAW Quality Documentation: Your Best Defence. Ottawa;
Author.
College & Association of Registered Nurses of Alberta. (2006). Documentation Guidelines for Registered Nurses.
Edmonton; Author.
Hamlin, Lois, Richardson-Tench, & Davies Menna, (2009). Perioperative nursing an introductory text. Sydney:
Elsevier/Mosby.
Section 3
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PRACTICE
Perry, A & Potter, P. (2006). Clinical Nursing Skills and Techniques. (6th ed.). St. Louis: Elsevier Mosby.
BIBLIOGRAPHY
Accreditation Canada. Formerly known as CCHSA. www.accreditation-canada.ca
Association of PeriOperative Registered Nurses. (2010). Recommended practices for sponge, sharp, and instrument
counts. Perioperative Standard and Recommended Practices. Denver: Author.
Downey, C. (2007). Counting as caring. Canadian Operating Room Nursing Journal, 25 (3),
6,8,10,11,13.
Gawande, A., Studdert, D., Orav, E., et. al. (2003). Risk factors for retained instruments and sponges after surgery.
New England Journal of Medicine, 348, 229-235.
Gibbs, Vera et al, (2005). The Prevention of Retained Foreign bodies After Surgery. Bulletin of American College
of Surgeons. 90 (10).
HealthStream, (2007). Ensuring Patient Safety During Laparascopic Procedures Study Guide. Denver: Author.
HealthStream, (2006). Hand-Assisted Laparascopic colectomy: a minimally invasive Approach, clinical Study
Guide. Denver: Author.
Holm R & Bakewell, S (2008). Performing Surgical Counts. AORN Journal, 87 (2), 329-332.
International Federation of Preoperative nurses (IFPN), (2006). Guideline 1002 for Surgical Counts-sponges, Sharps
and Instruments, IFPN accessed April 12, 2009 from http://www.ifpn.org.uk
Lincourt, E et al, (2007). Retained foreign bodies after surgery. Journal of surgical research, 138 (2),170-174.
McLeod, R.S. & Bohnen (2004). Canadian association of general surgeons evidence based reviews in surgery 9
risk factors for retained foreign bodies after surgery. Canadian Journal of Surgery , 47(February), 57-59
OR Manager. (2003). Patient safety: auditing and improving the sponge count process. 19(3), 13-14.
OR Manager. (2003). Patient safety: study offers evidence on items left behind during surgical cases. OR Manager.
19(3), 1-10.
Pare, Judy, (2006). Laparoscopic Radical prostatectomy: a Less Invasive Approach, Canadian Operating Room
Nurses Journal, 24(3).
Phillips, N.M. (2007). Berry & Kohns operating room technique. (11th ed.). St. Louis: Mosby.
Porteous, J. (2004). Surgical counts can be risky business! Canadian Operating Room Nursing Journal, 22 (4), 6-12.
Rothrock, J. (2007). Alexanders care of the patient in surgery. (13th ed.). Toronto: Mosby.
Shack, Carol, (2007). Laparoscopic Bowel Surgery. Canadian Operating Room Nurses Journal, 25 (2).
Spry, Cynthia, (2008). Essentials of Perioperative Nursing (4th ed.). Toronto: Bartlett & Jones.
Section 3
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OR Manager. (2003). Patient safety: projects for improving safety of counts in the OR. OR Manager, 19(3), 11-12.
2.7.1
2.7.2
PRACTICE
RATIONALE
Applying knowledge of the various surgical

positions and the impact of the positions on
the circulatory, respiratory, musculoskeletal
and neurological body systems; and
being a patient advocate throughout the
positioning process.
The position should be consistent with proper

anatomical alignment and physiological functioning
in order to promote the safety and comfort of the
patient during surgery.
Assessing the patient's positioning needs

prior to transferring the patient to the OR
bed. The assessment shall include patient
and intra-operative factors.
To promote patient safety and comfort.
Under general anesthesia, patients are unable to

indicate when there is a problem.
Patient factors include, but are not limited

to:
- age, height and weight;
- skin condition;
- nutritional status;
- pre-existing conditions (vascular,
respiratory, circulatory, neurological,
and immunocompromised); and
- physical/mobility limits (i.e., range of
motion, implants, prostheses, etc).
Intra-operative factors include, but are not
limited to:
- type of anesthesia;
- length of surgery; and
- position required.
2.7.3
Confirming adequate staff are available and

trained for transferring patients to and from
the OR bed. The OR bed and stretcher/bed/
wheelchair shall be locked in place.
Transfer devices are recommended for
patients with a mobility deficit including but
not limited to patients post general
anesthesia;
The circulating perioperative Registered Nurse

monitors safety of the patient at all times. Transfer
devices assist in protecting staff and patients from
injury.
2.7.4
Confirming that the patient is not left

unattended on the OR bed;
Protection from potential injury is essential.
2.7.5
Confirming that a safety strap is applied

prior to induction;
Safety measures help prevent injury.
2.7.6
Confirming that arm boards are secure on


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2.7. Surgical Positions
the OR bed prior to induction. Each arm

board should have a security device for
hand/wrist to prevent the arm from falling
off the arm board during the procedure.
Ulnar nerve padding shall be used under the
arm before the security device is employed;
- the arm board shall not be extended
greater than a 90 angle.
- The height of the arm board mattress
should align with the OR bed mattress;
RATIONALE
Padding the elbow reduces the risk of ulnar nerve

damage. Additional padding may not be required;
follow bed manufactures recommendations.
Brachial plexus damage may result from

hyperextension of the arm over 90.
2.7.7
Being aware of the function and use of the

OR bed and accessories. Following
equipment manufacturers instructions.
Selection criteria for positioning equipment
and devices include but are not limited to:
- availability in a variety of appropriate
shapes and sizes;
- ability to allow normal capillary
interface pressure;
- resistance to moisture and
microorganisms;
- fire resistance;
- non-allergenic to the patient;
- ease of use;
- durable material and design;
- radiolucency;
- easily cleaned and disinfected (if not
disposable);
- easily stored, handled, and retrieved;
and
- cost effectiveness.
Properly functioning equipment and devices

contribute to patient safety and assist in providing
adequate exposure of the surgical site.
2.7.8
Having available the appropriate OR table

and positioning equipment and devices
which are in proper working order prior to
positioning the patient for surgery;
Firm and stable devices help distribute pressure

evenly and decrease the potential for injury.
Patient safety may be compromised if appropriate
equipment not used.
2.7.9
Collaborating with the anesthesiologist and

the surgeon when positioning the patient for
surgery;
Surgical positioning of the patient is a shared

responsibility. Maintaining the patient's correct body
alignment and supporting extremities and joints
decreases the potential for injury during transfer and
positioning. (AORN, 2010)
2.7.10 Confirming safety precautions related to

positioning in the supine position have been
implemented. Measures include but not
limited to:
- elbows are padded and placed either
comfortably at the side with the palm
facing the thigh and secured using a
sheet or an arm support; or on an arm
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PRACTICE
board and secured; and

feet/legs are not crossed
2.7.11 Confirming safety precautions related to

positioning the patient in lithotomy position
are implemented. Measures include but not
limited to:
- Stirrups shall be securely attached to the
bed at a uniform height;
- legs shall be raised/lowered
simultaneously in a slow controlled
manner (with 2 people);
padding shall be applied to any part of
the leg or foot which comes in contact
with the stirrups. Legs should not come
in contact with the post of stirrups;
- verify position of hands/fingers as foot
of OR bed is manipulated both at the
beginning and end of the procedure;
- scrubbed personnel shall not lean on the
patients legs/thighs; and
- hips shall not extend beyond the end of
the OR bed.
2.7.12
2.7.13
Confirming safety precautions related to

positioning the patient in prone position
are implemented. Measures include but
not limited to:
sufficient staff shall be available to
safely turn a patient into the prone
position allowing cervical and general
body alignment to be maintained;
padded head rest shall be used;
arms shall be tucked at the side or
placed on arm boards(less than 90
degrees);
prone positioning devices(i.e. bolsters)
shall allow for chest movement and not
apply pressure to the abdomen; and
feet shall be supported so the toes can
hang freely.

positioning the patient in lateral position
are implemented. Measures include but not
limited to:
- sufficient staff shall be available to
safely turn a patient into the lateral
position allowing general body
alignment to be maintained;
- anesthesia controls the patients head
RATIONALE
This prevents circulatory impairment that could result

in pressure sores or nerve damage
Prevents muscle strain.

Maintains hemodynamic status.
Injury to the peroneal nerve can occur.
Fingers can become pinched by the hinged section of

the OR bed during movement of the bottom section
of the bed.
Avoids muscle strain.
Reduces risk of injury for both patient and staff.
Reduces direct pressure on the eyes. Allows access

for airway management.
Respiratory function may be affected.
Maintains alignment of cervical and thoracic spine.
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PRACTICE
2.7.14
2.7.15
2.7.16
and neck as the patient is turned

maintaining the airway;
the head is placed on a pillow or donut
positioning device;
for kidney procedures, the iliac crest is
positioned just below the break in the
OR bed;
the lower leg is flexed with knee
padded;
the upper leg is straight and placed on
pillow(s);
the upper arm should be placed on an
arm board or pillows, and secured;
depending on the procedure being done,
the lower shoulder should be slightly
forward, with a roll just posterior to
axilla; and
positioning devices such as vac
mattresses, peg boards, etc. should be
padded wherever they come in contact
with the patient.

positioning the patient in Trendelenburg
position are implemented. Measures include
but not limited to:
- knees should be positioned over the
break in the OR bed;
- shoulder braces should only be used if
absolutely necessary, and must be well
padded if used;
- after positioning, ensure there is no
pressure on the feet by the mayo or over
bed table; and
- movement into and out of trendelenburg
should be done slowly to allow
respiratory and circulatory systems to
adjust to changes.
positioning the patient in reverse
Trendelenburg position are implemented.
Measures include but not limited to:
- padded foot board may be used; and
- sequential compression
stockings/devices may be used
RATIONALE
Protects peroneal nerve from damage.

Maintains alignment
Reduces pressure on the brachial plexus and can

facilitate chest expansion.
The foot of the bed may be adjusted to maintain

position.
High risk of injury to brachial plexus.
Trendelenburg position increases intrathoracic and

intracranial pressure.
Reduces venous stasis.

positioning the patient in sitting or semisitting position are implemented. Measures
include but not limited to:

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PRACTICE
arms should always be supported;

all pressure points shall be padded with
special attention to the ischial
tuberosities and sacrum;
the patient shall be secured to the table
which is providing support to the upper
torso with a strap or tape;
the head shall be supported with a head
rest such as a cranial headrest; and
sequential compression devices should
be used.
RATIONALE
These points are supporting the weight of upper

body.
Maintains alignment and eliminates movement

during surgery.
Reduces venous stasis.
2.7.17 Implementing measures, which reduce the

risk of injury to the patient or the healthcare
team when positioning morbidly obese
patients. Measures include but not limited
to:
- confirming that positioning equipment
as well as the OR table is designed to be
safely used with morbidly obese
patients. Table extensions may be
required depending on the patients
size. Thicker mattress may be needed to
provide adequate support, extra wide,
extra long safety straps;
- all OR tables should be labeled with
maximum weight restrictions; and
- an adequate number of staff to safely
position patient,
2.7.18 Limiting exposure of patient's body during
positioning.
Maintaining the dignity and privacy of the patient is

important, and covering also assists in preventing
loss of body temperature.
2.7.19
Respiratory function can be decreased by mechanical

restriction of the rib cage. Circulatory function is
influenced by anesthetic agents and surgical
techniques that may result in vasodilatation,
hypertension, decreased cardiac output, and
inhibition of normal compensatory mechanisms.
Nerve and muscle trauma result from stretching or
compression when upper extremities are abducted at
greater than 90 degrees to the body, hips are placed in
excessive external rotation, and/or the head and neck
is hyper-flexed or hyper-extended. Skin injury is a
function of unrelieved pressure, duration of the
pressure, and the location of the pressure on the body
surface. Both high pressure for a short duration and
low pressure for extended duration are risk factors.
Other extrinsic factors for skin injury are shear forces
and friction. (AORN, 2010, p. 343)
In collaboration with anesthesiologist and

surgeon, evaluate the patient's body
alignment and tissue integrity after
positioning. The evaluation should include
but not be limited to the following systems:
-
Respiratory;
Circulatory;
Neurological;
Musculoskeletal; and
Integumentary.
After repositioning or any movement of the

patient, OR bed, or devices the patient
should be re-assessed for body alignment
and assessment of pressure points by the
surgical team.
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PRACTICE
RATIONALE
Documentation including but not limited to:

- preoperative assessment;
- type of position and any changes of
position;
- type and location of
positioning/padding devices;
- postoperative assessment; and
- healthcare team members involved in
positioning the patient.
Documentation provides an accurate picture of the

patient's status and surgical position during surgery.
2.7.21 Actively participating in the healthcare

facilitys, Falls Prevention program.
Awareness reduces risk.
REFERENCES
Association of PeriOperative Registered Nurses. (2010). Recommended practices for positioning the patient in the
perioperative practice setting. Perioperative Standards and Recommended Practices. Denver: Author
BIBLIOGRAPHY
Goldman, Maxine A, (2008). Pocket Guide to the Operating Room (3rd ed.). Philadelphia: FA Davis.
Goodman, Terri (2006). Positioning a Patient safety Initiative Study guide for Nurses. Aurora: Pfiedler Enterprises
Hamlin, Lois, Richardson-Tench, & Davies Menna, (2009). Perioperative nursing an introductory text. Sydney:
Elsevier/Mosby.
Heizenroth, P. (2003). Positioning the patient for surgery. In Rothrock, J. (2003). Alexanders care of the patient in
surgery. (12th ed.). Toronto: Mosby.
Lord, Ellen V, (2005). Patient Positioning Competency Assessment Module, Denver: Competency & Credentialing
Institute (CCI).
Macapagal, M. (2004). Protect your patient-Its never too late to reposition. AORN Journal, 79(5), 1017-1018.
OConnel, M. (2006). Positioning impact on the surgical patient. Nursing Clinics of North America, 41, 173-192.
Power, H. (2002). Patient positioning outcomes for women undergoing gynaecological surgeries. Canadian
Operating Room Nursing Journal, 20(3), 7-30.
Rothrock, Jane C (2007). Alexanders Care of the Patient in Surgery. (13th ed.). Toronto: Mosby.
Spry, Cynthia, (2008). Essentials of Perioperative Nursing (4th ed.). Toronto: Bartlett & Jones.
Section 3
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2.7.20
PRACTICE
Walton-Geer, Patina S, (2009). Prevention of Pressure Ulcers in the Surgical Patient. AORN Journal, 89 (3).
2.8 Visitors to the Surgical Suite

All visitors should be authorized in advance.
PRACTICE
2.8.1
The surgical suite management shall

collaborate with risk management/delegate to
develop an appropriate definition of a visitor
and/or observer. Visitors/observers may
include but are not limited to the following:
- health care industry representatives;
- health care students;
- visiting health care providers;
- media;
- law enforcement; and
- family members.
2.8.2
The perioperative Registered Nurse shall

confirm that visitors/observers to the
surgical suite agree not to interfere with the
well-being, comfort, privacy, or
confidentiality of patients and families.
2.8.3
Patients/designate should give consent to

have a visitor/observer present.
2.8.4
Maximum recommended number of

visitors/observers in an occupied theatre
should be determined by surgical suite
management in collaboration with infection
control, taking into consideration the
following:
- type of surgical procedure;
- size of theatre;
- air handling capability;
- type of visitor; and
- purpose of visitor/observer.
2.8.5
All Visitors/External contractors must be

provided with the necessary theatre attire
and understand how it is worn.
Visitors/External contractors should be
clearly identified as such (i.e.: with a visitor
nametag). (NATN, 2004, p. 80)
2.8.6
A visitor log should be kept to:
RATIONALE
Provides a mechanism to track those in contact with
Section 3
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St-Arnaud, Danielle & Paquin, Marie-Josee, (2008). Safe Positioning for Neurosurgical Patients. AORN Journal, 87
(6), 1156- 1172.
monitor the name of the visitor and

designation;
theatre attended;
intent of the visit (i.e. education,
equipment instruction);
duration of the visit; and
authorization of visit.
2.8.7 Health care industry representatives may act

only as a resource regarding the
representative product, and may not scrub or
actively participate in patient care. (NATN,
2004, p. 81)
the patient. Documentation is necessary for the

duration of the visit in case of a health care facility
emergency/disaster.
Health care industry representatives can provide

technical assistance that expedites the procedure and
facilitates the intended outcome for the patient.
REFERENCES
National Association of Theatre Nurses (NATN). (2004). Visitors/External Contractors. Standards and
Recommendations for Safe Perioperative Practice Harrogate: UK.
BIBLIOGRAPHY
Association of PeriOperative Registered Nurses (2010). Guidance Statement Role of the Health care Industry
Representative in the Perioperative Setting. Perioperative Standards and Recommended Practices.
Denver: Author, 657-659
Phillips, N.M. (2007). Berry & Kohns operating room technique (11th ed.). St. Louis: Mosby.
CMAJ. (2007). Traffic Controls, News, Health Authority Bans Physician Shadowing. CMAJ, 77 (1), 1339-1340.
2.9 Gathering Medicolegal Evidence In The Surgical Suite

Patient safety and expedition of the case is the first priority. The following information is to assist the
perioperative Registered Nurse with preserving forensic evidence.
PRACTICE
RATIONALE

2.9.1
Observing and documenting the patients

appearance and behavior on arrival to the
theatre.
2.9.2
Recording any comments made by the

patients family or persons accompanying
the patient.
2.9.3
2.9.4
Recording patient comments as quotes.

Documenting all body marks accurately to
help preserve evidence.

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RATIONALE
2.9.5
Describing blood stain patterns and bloody

fingerprints that are visible on the patients
body or clothing.
2.9.6
Collecting evidence (see Appendix E) in all

suspicious or unclear cases.
2.9.7
Confirming that the police have the patients

or substitute decision-makers consent for
disclosure of information or that the officer
has a warrant for the release of information.
2.9.8
Maintaining patient confidentiality by not

releasing patient information over the phone.
2.9.9
Obtaining a warrant for seizure (verbal or

written) from the coroner. Documenting the
verbal warrant for seizure or attaching the
written warrant for seizure to the chart.
This warrant allows the police to take evidence

including the patients chart.
2.9.10
Establishing a chain of custody and

documenting each person involved with
custody of evidence.
For results of sample testing to be relied on by the

court, the chain of events between taking the sample
from the patient and presenting the test results in
court must be proven and unbroken. Throughout the
process, proper handling and labeling of samples is
essential.
2.9.11
Establishing possession and proof of the

integrity (clearly labeled identification of
specimens) of evidence obtained; and
2.9.12
Obtaining a business card, badge number or

name from the investigating officer and
placing it on the chart.
There must be evidence of consent or a warrant

before information/evidence is given to the police.
Legal authorities decide whether to retain or discard

evidence.
Collection of Evidence: (see Appendix E)

2.9.13
Wearing gloves at all times. Changing

gloves, if possible, for handling each piece
of evidence.
Wearing gloves avoids the presence of extra

fingerprints on the evidence. Changing gloves
between each piece of evidence avoids forensic cross
contamination.
2.9.14
Preserving the integrity of the metal

evidence by not using metal instruments.
Metal can mark or damage metal evidence.
2.9.15
Identifying the evidence from each wound

separately if two or more wounds.

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PRACTICE
2.9.16
If not taken immediately, maintaining

evidence in a locked cupboard until picked
up by the police or the coroner; and
2.9.17
Contacting the police/coroner for directions

and documenting if evidence is not picked
up within one week.

PRACTICE
RATIONALE
Death of a Victim or Suspected Perpetrator

2.9.18
Confirming the body is not moved unless

directed to by the coroner.
2.9.19
Telephoning the coroner for directions if the

body must be moved. Keeping the body in a
secure area until transported to the morgue.
2.9.20
Obtaining directions from the coroner

regarding visitation.
2.9.21
Observing, monitoring and documenting any

visitation. Visitation is limited to viewing
only, but touching as per direction of the
coroner may be allowed. Do not leave the
family/visitors alone with the patient.
The family/person accompanying the patient may be

the perpetrator.
Preparation of the Body:

2.9.22
Placing a brown paper bag over each hand.
2.9.23
Positioning the hands at the side, do not tie.
2.9.24
Marking with a small X attempted IV

access sites and documenting same.
2.9.25
Retaining all evidence for the police.

Do not clean blood stained areas. If cleaned
prior to death, do not dispose of items used,
i.e., sponges.
Plastic bags cause condensation and trace evidence

may be lost.
It is easier for the pathologist to distinguish between

medical intervention and criminal evidence.
Documentation
2.9.26
Documenting any information pertaining to

the injuries:

Section 3
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RATIONALE
- wound;
- location;
- size; and
- evidence given to the chain of
custody;
the chain of custody;
how evidence was preserved (see
Appendix E); and
all interactions with police,
including what has been released
and the authority by which it was
released.
This information will be invaluable in defense of a

subsequent complaint for breach of confidentiality.
REFERENCE
Easter, C.R., & Muro, G.A. (1994) Clinical forensics for perioperative nurses. AORN Journal, 60(4), 585-591.
Porteous, J. (2005) Dont tip the scales! Care for patients involved in a police investigation. Canadian Operating
Room Nursing Journal, 23(3), 12-14, 16.
BIBLIOGRAPHY
Association of PeriOperative Registered Nurses. (2010). Recommended practices for the care and handling of
specimens in the perioperative environment. Perioperative Standards and Recommended Practices.
Denver: AORN.
Fatality Investigations Act. Nova Scotia Government (2004) Nova Scotia Legislature
Coroners Act. Ontario Government reconfirmed. (2002, April). Ministry of Public Safety and Security. Ottawa.
Wick, J. (2000). Dont destroy the evidence! AORN Journal, 72 (5). 807-827.
Section 3
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PRACTICE
Label all specimens with patient identification and the following information:
Specimen
Body fluid
Examples
Blood, urine, gastric
contents, seminal
fluid
Hair, fibres
Loose hair, strands,

shaved hair from
around wound sites,
carpet remnants,
strings
Glass, paint chips,
wood splinters,
animal teeth
Bullets, fragments,
pellets, knives
Debris
Foreign Objects
Fabric, clothing
All garments, pieces

of garments,
footwear, bed linen home and hospital.
Tissue, bone
Bone flap
Preservation Methods
collect large amounts of fluid
in dry tubes or dry specimen
containers.
collect fluids around the
wounds or wet body fluid
stains with a swab;
absorb stain onto clean cotton
swab;
allow swab to air dry;
place swab in dry container.
collect and place in separate
dry container.
Rationale
Patient may have swallowed
containers (e.g. balloons) of drugs.
Leakage of a lethal substance could be
the cause of death. Body fluids may
be used to associate the crime victim
and suspected perpetrator or eliminate
suspected perpetrator from
consideration.
collect and place in separate

dry containers.
May connect the victim or suspected

perpetrator with the crime scene.
handle as little as possible.

remove with rubber-tipped
forceps or latex gloves;
rinse with water;
when rinsing a bullet, be
aware of and collect any
foreign material attached,
such as fabric, etc.
place in a cushioned box or
zippered plastic bag.
remove carefully as intact as
possible;
avoid cutting through holes,
tears or rips.
hang to air dry, if possible and
place paper under it.
place on a flat piece of paper;
insert paper between the
layers of clothing;
roll or leave in a flat position;
place each article in a separate
bag;
include all linen from
transporting device and OR
bed.
collect and place in a separate
dry container.
Excess handling may alter the

specimen. Rinsing off blood/tissue
prevents microscopic markings from
being destroyed. Soft packaging
protects the specimen integrity.
Hair and fibres may be transferred

between the victim and the crime
scene.
Minimizing the number of pieces

facilitates reconstruction. Shoes may
bear imprints of gas/brake pedals,
which may assist in accident
reconstruction. Close examination by
experts of clothing tears and gunshot
wound residue patterns provides
information about firearm distance
and direction of a bullet or other
assault instrument. Blood/body fluid
on clothing deteriorates if not dried.
Bacterial/fungal growth increase when
evidence is stored in a closed, plastic
bag.
Facilitates reconstruction, i.e., blunt
trauma to the head. Bone flap could
assist in the identification of the
weapon.
(Easter & Muro, 1994)


Guidelines for Collection of Evidence:
APPENDIX E
Section 3
Page 189 of 334
PRACTICE
RATIONALE
2.10.1
Surgical specimens shall be saved unless

designated for discard by provincial
legislation, and/or health care facility policy.
Surgeons/Registered Nurses may not
override this legislation and policy.
The accurate and efficient care of specimens is

essential in assisting the surgeon, pathologist, and
laboratories to establish an accurate diagnosis and for
future treatment of the patient.
2.10.2
The circulating perioperative Registered

Nurse shall be prepared to respond to a
request for specimen analysis throughout the
procedure.
2.10.3

shall preserve all specimens in the state
received and assure that sterility of the
specimen is preserved, when required.
2.10.4
The perioperative Registered Nurse shall

verbally confirm with the surgeon the
identity of the specimen and the testing
required.
2.10.5
The perioperative Registered nurse shall

accurately document information on the
specimen label, including:
- two unique patient identifiers(i.e.
patient name and hospital number),
- specimen type;
- specimen site; and
- current date and time. (AORN, 2010)
2.10.6
The circulating perioperative Registered

Nurse shall add appropriate
fixative/preservatives in consultation with
the surgeon and/or pathologist. Specimens
requiring formalin should be placed in
containers as soon as possible.
Compliance with lab protocol is essential for proper

care and handling of specimens. Staff should be
aware that formaldehyde is a potent allergen,
mutagen, and carcinogen. (Gruendemann &
Mangum, 2001, p. 294)
2.10.7
Action should be taken to prevent drying-out

of specimens. Specimens and cultures
should be handed off the sterile field as soon
as they are taken, and the surgeon has given
consent.
This prevents inadvertent discard of specimen during

or at the end of the procedure. (Gruendemann &
Mangum, 2001, p. 293)
2.10.8
During special testing or research projects,

the appropriate health care facility protocol
should be followed (i.e., special consent).
2.10.9
Tissue and calculi should not be given to

patients.
Specimens may require analysis and present a

contamination risk.
Section 3
Page 190 of 334

2.10. Specimen Management
2.10.10 When laboratory personnel are in the

theatre, the circulating perioperative
Registered Nurse should:
- assure the dress code is followed;
- prevent unnecessary materials from
entering the theatre;
- provide supplies and forms; and
- prevent counted instruments or sponges
from leaving the theatre.

PRACTICE
RATIONALE
Removed items may interfere with the count.
2.10.11 The circulating perioperative Registered

Nurse in preparing specimen(s) for the
laboratory shall:
- verify specimen identity with the scrub
nurse;
- provide a separate container for each
specimen, if required;
- prevent contamination of the outside of
the container;
- use a hospital grade disinfectant to
remove contaminants from the outside
of the container; (Gruendemann &
Mangum, 2001, p. 294)
- sequentially number the specimens;
- confirm that the label contains the
required information, including:
-patient name;
-identification (ID) number;
-identity of specimen;
-side if appropriate;
-date;
-any times as required; and
-initials of person completing
label.
- after putting specimen in container
confirm that the patient's name and
identification (ID) number on the
specimen label(s) match those on the
requisition and operative nursing
record;
- protect the requisition form from
contamination;
- wear gloves when handling specimens;
and
- arrange transport of the specimen(s) to
the appropriate location.
Care in handling of specimens will:

- prevent specimen contamination;
- avoid cross-contamination;
- protection of individual (self); and
- avoid mislabeling or loss of specimen(s).
2.10.12 The circulating perioperative Registered

Nurse shall document:
- required information on the appropriate
requisition; and
Recording specimen(s) sent to the lab assists in

control and may prevent loss. This process may
assist in error analysis when a specimen is lost.
(Slavin, Best, & Aron, 2002, p. 55)
Incorrectly, labeled specimens could result in an

incorrect diagnosis, with possible critical
implications for two patients. The loss of a specimen
could prevent a definitive diagnosis and subsequent
initiation of therapy.
Section 3
Page 191 of 334
RATIONALE
type and number of specimens sent to

the lab on the operative record
according to the health care facility's
policy.
2.10.13 A log should be kept to track the specimen

from the theatre/surgical suite to the
laboratory or pathology department. The
log may include:
- patient identification;
- source of culture or type of tissue;
- date & time of specimen log in;
- name & signature of person sending
specimen;
- name of person in lab to receive
specimen; and
- time of transfer of specimen to
laboratory.
Proper documentation allows tracking of a specimen

from its source to its disposition. (Gruendemann &
Mangum, 2001, p. 297)
2.10.14 Reference material with samples of

incomplete and completed requisitions
should be available in the theatre.
2.10.15 Incident reports shall be completed for all
errors related to specimen management.
2.10.16 There shall be a written policy and
procedure regarding:
- the handling of legal specimens (bullets,
knives, other foreign bodies);
- presence of police officers in the
theatre; and
- cooperation with police officers in the
course of an investigation.
(See ORNAC Standards for Gathering Medicolegal

evidence). The perioperative Registered Nurse is
accountable for forwarding the specimens(s) to the
pathology department and may be called upon to
attest to that continuity of care (or chain of custody)
in a court of law.
REFERENCES
Association of PeriOperative Registered Nurses. (2010). Recommended practices for the care and handling of
specimens in the perioperative environment. Perioperative Standards and Recommended Practices.
Denver: Author.
Slavin, L., Best, M., & Aron, D. (2002). Gone but not forgotten: The search for the lost surgical specimens:
Applications of quality improvement techniques in reducing medical error. Journal of Nursing Care
Quality, 16 (3), 50-59.
Section 3
Page 192 of 334

PRACTICE
Gruendemann, B., & Mangum, S. (2001). Infection prevention in surgical settings. Toronto: W.B. Saunders.
Rothrock, J. (2007). Alexander's care of the patient in surgery. (13th ed.). Toronto: Mosby.
Watson, D. & Crum, B. (2005). Improving specimen practices to reduce errors. AORN Journal, 82(6), 1051-1054.
2.11 Medication Management

Safe delivery of medications should be a collaborative effort between all members of the surgical team.
Medication Handling and Administration in the Surgical Suite
PRACTICE
RATIONALE

2.11.1
Verifying medication orders according to

the health care facility policy and procedure.
2.11 .2 Sharing with the surgical team information

learned from the preoperative checklist that
may have an impact on the administration of
medications i.e., allergies, herbal
medications, etc.
Medication errors can occur as a result of having

numerous providers involved in the patient's care as
the patient moves from pre-op through ambulatory
care to the surgical suite.
2.11.3 Verifying all medications and solutions

listed on the surgeon's preference list with
the surgeon before administering or
delivering to the sterile field. (AORN, 2010)
The Joint Commission on Accreditation of
Healthcare Organizations (JCAHO) Do Not
Use list for abbreviations shall be applied
to all medication orders. (Rothrock, 2007)
Improperly maintained preference cards result in

inconsistencies in preference cards giving a false
sense of security and may increases risk of error.
( Dawson, 2005)
2.11.4 Confirming medication orders are

documented according to the health care
facility policy. Confirm verbal orders by
repeating them back to the physician.
Only physicians or Registered Nurses should receive

verbal orders.
Complies with Goal #2 of the 2008 National Patient
Safety Goals (USA)
2.11.5 Facilitating the administration of preoperative

IV antibiotics in a timely, safe manner.
Timely and appropriate administration of IV

antibiotics plays a significant role in reducing
surgical site infection risks. (Safer Healthcare Now)
2.11.6
Verbally and visually verifying all

medications and solutions (i.e. Sodium
Chloride 0.9% and Sterile Water).
(Accreditation Canada,2008)
Distractions are one of the main causes of medication

errors in the perioperative setting. (Wanzer, 2005)
2.11.7
Delivering medications to the sterile field

using aseptic technique. (Gruendemann &
Some abbreviations, acronyms and symbols are

confusing thus increasing risk to patient.
Section 3
Page 193 of 334

BIBLIOGRAPHY
RATIONALE
Mangum, 2001, p. 254)
2.11.8
Using commercially available sterile transfer

devices whenever possible e.g. sterile vial
spike, plastic catheter, etc.
Reaching over the sterile table compromises the

sterile field.
2.11.9
Confirming every medication or solution on

the sterile field is labeled. Confirming that
all medications & medication containers (i.e.
med cups, syringes, basins) on and off the
sterile field are labeled even if there is only
one
Medications on the sterile field that are not labeled

increase the r isk of error. (AORN, 2010)
2.11.10 Any medication or solution on or off the

sterile field which is not labeled shall be
discarded
2.11.11.Labels can be developed by the facility or

available commercially. All labels should be
verified verbally and visually by the
professional perioperative scrub and
circulating Nurses concurrently.
Medications on the sterile field that are not labeled

increase the risk of error. (AORN, 2010)
2.11.12 Labeling should include:

- name;
- strength; and
dose of the medication.
(AORN, 2010)
2.11.13 When using medication intended for topical
use, such as concentrated epinephrine, place
medication in a solution bowl not parenteral
syringe.
2.11.14 When using medication intended for
injection by the surgeon, the medication is
drawn up into a syringe directly from the
vial not from an open solution bowl
To prevent the risk of injection of the topical

medication into the vascular system (ISMP Canada,
2010)
2.11.15 Verifying any medication discrepancies as it

relates to patient allergies, drug dosage and
drug compatibilities.
To reduce the risk of substitution error between

medications intended for topical application and
those intended for injection (ISMP Canada, 2010)
2.11.16 Communicating all medication(s) on the

sterile field at shift change or break relief;
and verifying the amount of medication
administered. All medication calculations
should be verified and independently double
checked by an RN or another qualified
Medication errors can occur because of lack of

communication/documentation at shift change or
break relief.
Section 3
Page 194 of 334

PRACTICE
RATIONALE
individual, (AORN 2008).

2.11.17 Retaining containers, in the theatre, of all
medications used on sterile field until the
end of the surgical procedure.
Narcotics and Controlled Drugs

2.11.18 Following the healthcare facility policy and
procedure related to narcotics and controlled
drugs
The protocol for control of narcotics/controlled drugs

is under federal jurisdiction.
REFERENCES
Association of PeriOperative Registered Nurses. (2010) AORN Guidance Statement: Safe medication practices in
perioperative settings across the life span. Perioperative Standards and Recommended Practices. Denver:
Author.
Catalano, K., Fickenscher, K. (2008). Complying with the 2008 National Patient Safety Goals. AORN Journal, 87(3),
547-556
Dawson, A., Orsini, M., Cooper, M., Wollenburg, K. (2005). Medication safety: Reliability of preference cards.
AORN Journal, 82(3), 399-414.
ISMP Canada www.ismp-canada.org
Safer Healthcare Now. www.saferhealthcarenow.ca
BIBLIOGRAPHY
Case update: epinephrine death in Florida. ISMP Medication Safety Alert Newsletter, Acute Care. 1996 Dec 4
[retrieved 2010 Jun 18];1(21):1. Available from: http://www.ismp.org/Newsletters/acutecare/articles/19961204.asp
Gruendemann, B., & Mangum, S. (2001). Infection prevention in surgical settings. Philadelphia: W.B. Sanders.
HealthStream, (2005). Medication errors in the OR Study Guide. Denver:. HealthStream,
Hendrickson, T. (2007). Verbal medication orders in the OR. AORN Journal, 86(4), 626-629.
Phillips N.M. (2007).Berry & Kohns operating room technique. (11th ed.). Toronto: Mosby.
Shumaker, R., Hickey, P. (2006) Medication diversion in the perioperative setting. AORN Journal, 83(3), 745-749.
Wanzer, L. (2004) Perioperative initiatives for medication safety. AORN Journal, 82(4), 663-666.
Venkatraman R & Durai R (2008). Errors in Medicine Administration: how can they be minimized? Journal of
perioperative Practice, 18 (6), 249-53.
Section 3
Page 195 of 334

PRACTICE
Nursing documentation shall occur for every procedure as per facility policy.
PRACTICE
RATIONALE
2.12.1 Documentation of the diagnostic and/or

operative procedure plus nursing
interventions is required by Accreditation
Canada (previously known as the Canadian
Council on Health Services Accreditation).
All documentation is part of the patients
legal chart.
The perioperative record provides an accurate

contemporaneous account of nursing and/or medical
activities throughout the perioperative phase. It
provides a method to retrieve information for
research, statistics (staffing, financial planning,
patient acuity, and utilization), quality assurance, and
legal/ risk management purposes. (Phillips, 2007)
2.12.2 Documentation shall be done in ink or

electronically (if implemented by the
facility).
All entries are to be made in black pen. (Phillips,

2007; NATN, 2004) They shall be written clearly and
in such a manner that the text cannot be erased.
(NATN, 2004, p. l28)
2.12.3 Duplicate documentation by perioperative

Registered Nurses and Anesthesiologists
should be avoided.
Duplicate documentation may lead to questions

regarding the accuracy of the documentation.
2.12.4 Documentation should be logically organized,

easily communicated, and retrievable:
- use check boxes whenever possible;
- avoid blank spaces, skipped lines or
crowded entries;
- write or print legibly using clear,
objective language;
- use only health care facility approved
abbreviations; and
- names and signatures shall be followed
by the professional designation, e.g.
RN.
Documentation indicating the care given and patient

response provides continuity of care and ensures
communication among team members.
2.12.5 A single line shall be drawn through an

incorrect entry, initialed, and marked
according to the health care facility policy.
Whiteout, eraser, or excessive cross-outs are not

legally acceptable.
2.12.6 Late entries shall be accurately dated, timed

and signed according to the health care
facility policy. (NATN, 2004, p. 28)
Documentation that occurs at/or near the time of the

event is considered to be more accurate and reliable.
2.12.7 Preoperative admission to the surgical suite

should be documented and signed. The
following information should be present and
reviewed:
- patient identification band;
- identification card (if used in facility);
- consent/documentation of consent
completed and signed;
- consent or withdrawal of consent for
Information is required to provide safe care; and to

meet legal and health care facility requirements.
Section 3
Page 196 of 334

2.12 Nursing Documentation
RATIONALE
blood products, if applicable;

surgical site identification;
history and physical assessment;
all diagnostic reports present;
preoperative vital signs ;
allergies;
NPO status;
prosthesis (i.e. denture, glasses/contact
lens, hearing aids, );
jewellery,
medication including herbal remedies;
and
presence of an advanced directive as
necessary.
2.12.8 A preoperative assessment of the patient

should be present and should include but is
not limited to:
- level of consciousness;
- baseline physical data;
- psychosocial status;
- relevant nursing diagnoses;
- a nursing care plan;
- cultural concerns; and
- spiritual concerns.
Assists with the perioperative nursing care plan for

positioning, to prevent injury, and to document any
pre-existing conditions.
2.12.9 Perioperative event times should be defined

and include but not be limited to:
- start of room setup;
- patient entry to theatre;
- time of anesthesia start (induction);
- surgeon enters room;
- position/prep start;
- procedure start (incision start);
- procedure stop (dressing stop); and
- patient exits theatre.
An accurate recording of time is required for legal

purposes.
2.12.10 All personnel should use the same clock in

theatre to document time.
Allows that all documentation done in that theatre is

accurate to the same clocks time.
2.12.11 Document name and professional

designation of all personnel involved in
patient care and any visitors.
This is required for statistical,legal and quality

assurance purposes.
2.12.12 Document the patient's positioning

including:
- restraints and positioning devices;
- padding/supports; and
- skin condition.
Accurate documentation is a medico-legal

requirement. Information is necessary for monitoring
patient outcomes and provides information in the
event of an injury.
Provides data (average times) for booking surgical

cases.
Section 3
Page 197 of 334

PRACTICE
RATIONALE
2.12.13 Document any warming or cooling units

used, including the serial number of the unit,
temperature setting, and placement.

event of an injury.
2.12.14 Documentation of a pneumatic tourniquet

should include:
- time of inflation/deflation;
- pressure setting;
- location and size of the cuff;
- unit serial number, model, or designated
number;
- equipment check with a pressure gauge
(for manual units);
- surgeon notification of elapsed time;
and
- condition of the skin following removal
of the cuff.

event of an injury.
2.12.15 Documentation of laser use should include

but not be limited to:
- type of laser;
- laser use time;
- wattage;
- laser safety precautions taken; and
name of Laser Safety Officer (LSO),
etc. as per health care facility policy.
Accurate documentation is a medical legal

event of an injury.
2.12.16 Documentation of the Electrosurgical Unit

(ESU) should include:
- type of unit and serial number;
- hair removal;
- location of dispersive electrode;
- cutting and coagulation settings;
- condition of skin after removal of the
dispersive electrode; and
- teaching done if patient refuses/cannot
remove jewellery.
Accurate documentation is a medical legal

event of an injury.
2.12.17 Documentation of insufflators used in

minimally invasive surgery should include:
- model and serial number;
- preset pressure, upper limit maximum;
- flow rate; and
2.12.18 Documentation of mechanical irrigation
devices regulating the infusion of irrigation
fluid should include:
- fluid type infused;
- preset pressure; and
Information is necessary for monitoring patient

outcomes.
Section 3
Page 198 of 334

PRACTICE
RATIONALE
- volume used.
2.12.18 Documentation of surgical equipment used
during a procedure.
This could include devices such as harmonic scalpel

consoles.
2.12.19 Document the application of monitoring

devices not documented by the
Anesthesiologist, or when doing local or
monitored anesthesia care cases.
2.12.20 Document the skin preparation:
- skin integrity;
- hair removal;
- type of solution used; and
- condition of prepped skin at end of
surgery.
2.12.21 Document the surgical wound classification
as per health care facility policy.
2.12.22 Document the following information for
prostheses/implants:
- quantity, size and type;
- manufacturer;
- lot number; and
- serial number.
Records allow for recall of potentially defective

prostheses and as a reference for removal.
2.12.23 Document packing including:

- removal
- insertion
- number, size, and type;
- location; and
- method of securing.
(NATN, 2004, p. 235)
2.12.24 Document drains and/or catheters remaining
in the patient. Include:
- number, size, and type;
- location;
- method of securing; and
- presence of a collection device.
(NATN, 2004, p. 235)
2.12.25 Document specimens and/or cultures taken,
as per health care facility policy. Document
if sent to an area other than labs to which
specimens are routinely sent.
Section 3
Page 199 of 334

PRACTICE

PRACTICE
RATIONALE
2.12.26 Document use of intraoperative X-rays,

fluoroscopy and type of patient protection
including area(s) protected. (AORN, 2008,
p. 312)
2.12.27 Document surgical counts and results and
have them signed by those performing the
counts as per health care facility policy.
2.12.28 Document medication, hemostatic agents,

dyes, and irrigation administered by the
surgeon and/or the nursing staff. Include:
- dosage;
- volume; and
- method of administration
2.12.29 Document urinary output, blood loss and IV
infusions, if not already documented by the
Anesthesiologist, according to
procedure/health care facility policy.
2.12.30 Document the exact surgical procedure(s)
performed (confirm with surgeon) using
only health care facility approved
abbreviations.
2.12.31 Blood and blood products should be
checked, administered, and documented
according to the health care facility's
policy.
2.12.32 Document the initiation of special
precautions used with patients having a
latex allergy, and/or malignant
hyperthermia.
2.12.33 Document any unusual occurrences,
according to the health care facility policy,
that are directly related to patient care and
are pertinent to patient outcomes.
Incident reports are for the health care facility use

only and do not become a permanent part of the
patient record.
Documentation and incident analysis are part of a
facility's risk management and can be used to
increase safety and effectiveness in patient care.
2.12.34 The documentation method should reflect

patient care needs and be congruent with the
Some facilities combine elements of different

documentation methods to document care including
but not limited to the following systems:
- critical path/variance analysis (care mapping);
- focus/charting; and
- narrative. (CNO, 2002, p. 13)
Section 3
Page 200 of 334
Association of PeriOperative Registered Nurses. (2008) Recommended practices for documentation of perioperative
nursing care. Perioperative Standards and Recommended Practices. Denver: Author.
College of Nurses of Ontario (2002). Nursing Documentation Standards. Toronto: CNO.
National Association of Theatre Nurses (NATN). (2004). Recommendation for local policy. Standards and
Recommendations for Safe Perioperative Practice. Harrogate: U.K: Author.
Phillips, N.M. (2007). Berry & Kohns operating room technique. (11th ed.). Toronto: Mosby.
2.13 Electronic Health Records

Electronic documentation systems must capture the same information as manual systems.
PRACTICE
RATIONALE
2.13.1 Electronic Health Records will comply with

national/provincial legislation related to
patient information and any privacy acts
enacted.
2.13.2 Selection of an electronic system shall be a
collaborative decision involving but not
limited to:
- RNs;
- RPNs/LPNs/ORTs;
- managers;
- medical records manager;
- information technology; and
- risk managers.
Collaboration assists in selecting a system that meets

everyone's needs.
2.13.3
Access to the system shall be controlled and

granted as per facility policy.
This assists in ensuring system security and patient

confidentiality. (CNO, 2002).
2.13.4
The system should have back-ups so

deletion/loss of information is prevented.
Contingency for the system shall be in place
for documenting during system failure
including but not limited to paper
documentation.
A complete picture of the patient encounter is

necessary to provide proof of appropriate care.
Effective patient care relies on documentation. May
result in temporary return to paper documents used
prior to electronic inputting.
2.13.5 Any changes to documentation should be

clearly noted. Systems shall include tracking
and audit tools.
Legal defense may require proof of changes made to

documentation.
2.13.6 Retrieval of information shall be available.

(CNO, 2002, p. 14)
Legal defense may rely on the ability to retrieve

information.
2.13.7
Legal defense may rely on credible proof that this has

occurred.
Systems may allow corrections and clearly

identify them as corrections, and ensure the
Section 3
Page 201 of 334

REFERENCES
RATIONALE
original entry is maintained. This may be

done using a tracking and audit system.
2.13.8 Electronic signatures shall be verifiable.
(CNO, 2002, p. 14)
2.13.9
Access to the electronic medical record shall

be provided for temporary users according to
healthcare facility policy depending on
facility policy. (CNO, 2002, p. 14)
Agency staff and student nurses require access to

deliver appropriate care and document care provided.
2.13.10 Electronic systems shall have integration

with other departments, as appropriate,
(pharmacy, laboratory, diagnostic imaging)
dependant on the scope of the system.
Communication of care across the facility assists in

providing patient focused care.
2.13.11 Policies and procedures shall be in place to

ensure accuracy/verification of
documentation when default fields are
utilized in electronic systems.
Many electronic systems use defaults to assist in

electronic documentation. These fields require
verification by the documentor that the default does
apply to a specific patient.
2.13.12 Electronic systems shall have security

measures in place such as but not limited to
the following:
- passwords;
- virus protection;
- encryption;
- firewalls;
- unauthorized access to confidential
client information; and
- system failure.
Provisions for patient care and integrity of the data in

the electronic health record rely on the security
systems in place. Passwords must remain confidential
and shall be changed based on facility policy.
Logging off when not using or leaving the terminal is
essential to maintain patient privacy and to ensure
accurate documentation by the intended care
provider.
2.13.13 A process that allows healthcare providers to

audit or track entries to the electronic health
record shall exist.
Breaches in security need to be tracked and dealt

with.
2.13.14 Data entry shall occur at point of care.
This supports the requirement for contemporaneous

entries.
2.13.15 Data entry should occur in a space within the

theatre that allows the perioperative
Registered Nurse to observe the patient and
surgical team while documenting.
The circulating perioperative Registered Nurse needs

to have the ability to observe the patient and team on
a continuous basis to meet patient care needs.
2.13.16 Information technology system support

should be available to perioperative
Registered Nursing staff.
Operating rooms provide patient care on a 24hr/365

day a year basis and need the back up support to
assist in the delivery of care.
Section 3
Page 202 of 334

PRACTICE
College of Nurses of Ontario (2005). Nursing Documentation Standards. Toronto: CNO.

www.cno.org/docs/prac/41001_documentation.pdf
2.14 Organ and Tissue Procurement Protocol

The field of donation and transplantation of cells, tissues and organs (CTOs) continues to change as the science
evolves. All establishments that procure, import, process, distribute, and cells, tissues or organs must be
registered with Health Canada, or do so under the direction and guidance of an establishment registered with
Health Canada. Policies and procedures developed for ORs participating in any aspect of donation and
transplantations should be developed in collaboration with the registered Health Canada establishment. The
establishment registered with Health Canada is responsible for all donor suitability assessments, prior to CTO
procurement.
PRACTICE
2.14.1 Facilities that procure, process, screen, import,
or distribute CTOs must be either registered
with Health Canada for those activities or
under the guidance/direction of a registered
establishment.
2.14.2
RATIONALE
Organ and tissues procurement requires vigilant
monitoring and regulation to assist in preserving the
safety of CTOs for transplant
Organ donors fall within one of the

following categories:
Living Donors
-
Living-related
Living-related donors are generally relatives of the

recipient and often are preferred as donor-recipient
HLT tissue typing are typically more compatible.
Paired-Exchange
Paired-Exchange or Paired Donation involves two

pair of living kidney donors and transplant candidates
who have incompatible blood types. The two
candidates trade donors so that each candidate
receives a kidney from a donor with a compatible
blood type. In some cases, this type of exchange may
involve multiple living kidney donors/transplant
candidate pairs.
Deceased Donors
-
NDD
NDD (Neurological Determination of Death) refers

to the clinical determination of brain death following
which the donor is maintained on mechanical
ventilation to prevent ischemic damage to vital
organs suitable for procurement until procurement
occurs.
Section 3
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REFERENCE
RATIONALE
DCD (Donation after Cardiac Death), refers to when

the donor has sustained non-recoverable neurological
injury and the family has decided to withdraw life
support, but still wish to donate. Organs are
surgically removed after cardiac death occurs. Organs
must be retrieved within a specified time frame
following cardiac cessation, to be viable for
transplant.
DCD
Tissue donors can be living or deceased

Living Donors
Living tissue donors generally refers to situations

such as Surgical Bone and Amniotic Membrane
Donation, where tissue is removed during a surgical
procedure.
Deceased Donors
Any death can result in a potential tissue donation.

Tissue donation from deceased donors may include
skin, musculoskeletal tissue, heart valves, blood
vessels, amniotic membrane and ocular tissue.
2.14.4 Policies and procedures specific to

retrieval/transplant of CTOs, should be
established by the health care facility in
collaboration with the registered Health
Canada establishment and may include the
following:
- confirmation of documented NDD
(when applicable) in addition to
consent, as part of usual confirmation
check;
- provision of psychological/spiritual
support to family members pre, intra,
and post procurement;
- protocol for supplies and equipment
related to organ/tissue procurement;
- documentation, procedures for handling
the procured organ(s)/tissue(s); and
- protocol for identification of
recipient(s).
2.14.5
Perioperative considerations by the

procurement team should include but not be
limited to:
- accurate and complete documentation
as per Federal regulations and health
care facility policy;
- removal of organ(s) and/or tissue(s)
under sterile conditions;
All potential donors and families must be treated with

respect and dignity.
For traceability, documentation must be kept for 10
years.
In some cases, multiple transplant procedures can
occur simultaneously.
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2.14.3
PRACTICE
RATIONALE
preservation, labeling, packaging and

transport of tissue or organs to the
recipient(s)following Federal
regulations;
provision of respect and care as given to
any other patient;
surgical counts; and
appropriate after death care as per
2.14.6
Perioperative considerations for the

transplant of organs and/or tissues include
but are not limited to:
- accurate documentation per facility and
Federal regulations; and
- accurate identification of both the
recipient and the donor tissue/organ.
2.14.7
Debriefing sessions, if required, should be

available to applicable heath care team
members as soon as possible.
Sharp, sponge, and instrument counts should be

considered for the safety of personnel and for
inventory control.
The importance of the role of the health care

professional in donor care cannot be overemphasized. Issues related to ethical dilemmas
arising from beliefs, values and attitudes can be
addressed through these sessions and may help to
reduce stress levels.
BIBLIOGRAPHY
American Association of Tissue Banks, (AATB) (2006). Standards for Tissue Banking, 11th edition, AATB
Association of PeriOperative Registered Nurses. (2010). Recommended practices for surgical tissue banking.
Perioperative Standards and Recommended Practices. Denver: Author.
Bernat, James L (2008). The boundaries of Organ donation After circulatory Death. New England Journal of
Medicine, 359 (7), 669-671.
Canadian Council for Donation and Transplantation. (2003). Severe Brain Injury to Neurological Determination of
Death: A Canadian Forum held in Vancouver, B.C. Edmonton: CCDT.
Canadian Medical Association. (2000). CMA Policy Statement: Organ and Tissue Donation and Transplantation
(Update 2000). Ottawa: Author.
Canadian Neurocritical Care Group. (1999). Guidelines for the diagnosis of brain death. Canadian Journal of
Neurological Science, 26, 64 66.
Canadian Nurses Association. (2000). CNA Fact sheet: Organ donation and tissue transplantation. Ottawa: CNA.
Canadian Standards Association. (2003). CSA Z900.1-03 Cells, Tissue and Organs for Transplantation and Assisted
Reproduction: General Requirements... Toronto: Author.
Canadian Standards Association. (2003). CSA Z900.2.4-03 Ocular Tissues for Transplantation. Toronto: Author.
Section 3
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PRACTICE
Canadian Standards Association. (2003). CSA Z900.2.3-03 Perfusable Organs for Transplantation. Toronto: Author.
Health Canada: Health Products and Food Branch. (2003). Guidance document: basic safety requirements for human
cells, tissues and organs for transplantation. Ottawa: Author.
Hill, Sonia June (2008). Placental amniotic Membrane: the Pathway to Ocular transplantation, AORN Journal, 88
(5) 731-744.
Howard, R., Cornell, D., Koval, C. (2008). When the donor says yes and the family says no. Progress in
transplantation, 18(1), 13-16.
Humphries, L., Mansavage, V., (2006) Quality control in tissue banking: Ensuring the safety of allograft tissues.
AORN Journal, 385-398.
Edwards, J., Mulvania, P., Robertson, V., George, G., Hasz, R., DAlessandro, A. (2006) Maximizing organ
donation opportunities through donation after cardiac death. Critical Care Nurse, 26(2), 101-115.
National Association of Theatre Nurses (NATN). (2004). Procedures related to organ donation. Standards and
Recommendations for Safe Perioperative Practice. Harrogate: U.K: Author..
OHara, J., Bramstedt, K., Flechner, S., Goldfarb, D. (2007) Ethical issues surrounding high-risk kidney recipients:
Implications for the living donor. Progress in Transplantation, 17(3), 180-182.
Poser, K. (2008) Ensuring there are more opportunities to give. Canadian Nurse, April, p. 10-11
Shemie, S., Doig, C., Belitsky, P. (2003). Advancing toward a modern death: the path from severe brain injury to
neurological determination of death. CMAJ, April, 168(8).
Team Safety
The following items need to be addressed to ensure team safety:
3.1 Credentialing
PRACTICE
3.1.1 A process is required to verify if regulated
professionals have the necessary credentials to
practice. The areas which need to be verified
are:
- education / training licensure; and
- ability to perform the procedures for which
they are being hired.
RATIONALE
Regulation of Health Professionals is a provincial
mandate and varies from province to province.
Regulation of Health Professions provides the public
with a mechanism to file complaints related to the
practice of the professional. These complaints may
be filed outside the employing institution and
investigations are deemed to be unbiased and have a
Section 3
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Canadian Standards Association. (2003). CSA Z900.2.2-03 Tissues for Transplantation. Toronto: Author.
RATIONALE
greater degree of credibility for the complainant.
(Phillips, 2007)
3.1.2 The process should be initiated but not limited

to:
- upon hiring;
- annually at a specified time of year;
- upon transfer from one department to
another; and
- after suspension of credentials when the
professional has satisfied the requirements
for re-instatement.
3.1.3 Job descriptions should be reviewed to ensure
understanding and adherence to provincial
scope of practice legislation.
Scope of practice of health professionals varies from

profession to profession and province to province.
REFERENCE
Phillips, N.M. (2007). Berry & Kohns operating room technique. (11th ed.) P. 58-59. St Louis: Mosby
3.2 Occupational Health and Safety

PRACTICE
3.2.1 Policies and procedures to ensure adherence to
Occupational Health and Safety regulations
are required and should include but not be
limited to the following:
- Workplace Hazardous Materials
Information System (WHMIS) legislation;
- fire safety specific to the surgical suites;
- laser safety;
- radiation safety;
- exposure to hazardous materials/chemicals;
- Personal Protective Equipment (PPE) use
and adherence;
- sharps safety;
- electrical safety;
- biological ( blood, and /or potentially
infectious body substances);
- ergonomics;
- physical safety, e.g. lifting heavy weights;
- personal safety, e.g. workplace violence and
or harassment;
- environmental safety;
- workplace stress,
- pandemic planning (SARS, Avian Flu,
pH1N1) and
RATIONALE
Surgical suites have many pieces of equipment,
chemicals and routines that hold significant potential
for injury to staff.
In June 2003 new legislation, Bill C-45 was
introduced to hold corporate decision makers
accountable for workplace accidents and fatalities.
(Keith & O'Reilly, 2003)
The health care facility is committed to the
occupational health and safety of staff, independent
practitioners, volunteers and students. (CCHSA,
2004, p. 24)
Musculo Skeletal Injury Prevention Programs
Workplace Violence Prevention Programs
(Accreditation Canada, 2010)
More information on Environmental and Workplace
Health- Fitness to Work may be found at http://hcsc.gc.ca/ewh-semt/occup-travail/index-eng.php
(Government of Canada Occupational Health and
Safety, 2010)
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PRACTICE
- employee assistance.
3.2.2 Orientation programs for new staff should
include but not be limited to the following:
- WHMIS review;
- fire review;
- electrical safety;
- radiation safety;
- laser safety, if applicable;
- sharps safety; and
- use of Personal Protective Equipment
RATIONALE
Employees need to understand expectations related to

these issues within individual practice settings.
The health care facility needs to create a safe,
healthy, and positive work environment. (CCHSA,
2004, p. 22)
3.2.3
A process of due diligence that demonstrates

regular auditing of adherence to policies and
procedures related to safety.
This data may be required for legal defense of the

health care facility.
3.2.4
A policy and procedure related to Workplace

Violence that includes but is not limited to
the following:
- definition of workplace violence i.e.
Workplace violence includes:
- threatening behaviour - such as
shaking fists, destroying property or
throwing objects;
-verbal or written threats - any
expression of an intent to inflict
harm;
- harassment - any behaviour that
demeans, embarrasses, humiliates,
annoys, alarms or verbally abuses a
person and that is known or would be
expected to be unwelcome. This
includes words, gestures, intimidation,
bullying, or other inappropriate
activities;
-verbal abuse - swearing, insults or
condescending language;
- physical attacks - hitting, shoving,
pushing or kicking; and
- Rumours, swearing, verbal abuse,
pranks, arguments, property damage,
vandalism, sabotage, theft,
psychological trauma, anger-related
incidents, rape, arson and murder.
Most people think of violence as a physical assault.

However, workplace violence is a much broader
problem. It is any act in which a person is abused,
threatened, intimidated or assaulted in his or her
employment. Canadian Centre for Occupational
Health and Safety at,
http://www.ccohs.ca/oshanswers/psychosocial/violen
ce.html (2010)
process for reporting incidents;

process to seek assistance during the
violent episode; and
clear expectations regarding reporting
investigation, and timelines for
completion of the process.
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PRACTICE
Accreditation Canada (2010) http://www.accreditation.ca/educational-resources/education-materials

Canadian Centre for Occupational Health and Safety (2010)
http://www.ccohs.ca/oshanswers/psychosocial/violence.html
Canadian Council on Health Services Accreditation. (2004). AIM, Achieving Improved Measurement, Accreditation
Program. 3rd ed. Human Resources.
Government of Canada Occupational Health and Safety Fitness to Work ( 2010) http://hc-sc.gc.ca/ewhsemt/occup-travail/index-eng.php
Keith, N., & O'Reilly, Y. (2003). The legal connection: soon to be law - corporate decision - makers are accountable
for employee safety. Canadian Occupational Health & Safety, 41(5).
hospital risk management. Risk Management in Canadian Health Care, 4(7).
Watson, V., & Steiert, M.J. (2002). Verbal abuse and violence: the quest for harmony in the OR. Surgical Services
Management, 8(4).
3.3 Students/Preceptors
PRACTICE
RATIONALE
3.3.1 Guidelines related to preceptorship of

students should include but not be limited
to:
- clear communication processes
between student, educator and
preceptor;
- role definition for each educator and
preceptor;
- requirements of a preceptor, which
should include:
interest, education and
experience with adult
learners; (Phillips, 2007)
- understanding of various
learning styles; (Phillips, 2007)
- ability to assess learning needs
through interview, observation,
and -a skills checklist; (Phillips,
2007)
- competent and confident;
- consistent in their relationship
with the learner;
- supportive and respectful;
- open and honest;
This may be required for legal defense of the

student, the educator/educational institution,
the preceptor and the health care facility
should an untoward event occur.
Working closely with the educator, the
preceptor will assist in assessing the students
abilities, assigning activities accordingly,
assisting in carrying out duties safely
(Phillips, 2007) and will aid in solving
problems that arise during the clinical
experience. (Ryan-Nichols, 2004, p. 21-22)
The purpose of preceptorship is to enhance
the quality of learning in the clinical
environment, which in return helps novice
nurses achieve excellence and confidence in
their professional practice. (WillemsenMcBride, 2010)
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REFERENCE

PRACTICE
RATIONALE
able to set clear expectations;

able to mutually negotiate
learning objectives with the
learner;
able to build on positive
experiences, and the strengths
and success of the preceptee;
willing to customize the
learning experience to meet
individual learning needs;
patience;
able to guide the learner and
the learning experience;
knowledgeable about a wide
range of learning resources;
knows the norms and
culture of the setting;
an advocate for the learner
(RNAO, 2004); and
designated supervision for the
entire preceptorship period.
3.3.2 Requirements of the student should

include:
- an expectation that the student
should inform the responsible
person (preceptor) if he/she is
not qualified to perform an
assigned task (Phillips, 2002,
p. 25) ; and
- adherence to the policies and
procedures of the health care
facility.
REFERENCES
Brown, Y. (2004). Learning in a preceptorship. Canadian Nurse. 100(6).
Phillips, C. (2002). Managing legal risks in preceptorships. Canadian Nurse, 98(9).
Registered Nurses Association of Ontario. (2004) Preceptorship Resource Kit
RNAO publisher
Ryan-Nicholls, J. (2004). Preceptor recruitment and retention. Canadian Nurse. 100(6).
Willemsen-McBride, T. (2010) Preceptorship planning is essential to perioperative nursing retention: Matching
teaching and learning styles. Canadian Operating Room Nursing Journal, Volume 28, Issue 1(pg. 8-21).
Section 3
Page 210 of 334
Allen, S. A. (2006, December). Mentoring: the magic partnership. Canadian Operating Room Nursing Journal, 24
(4), 30-32, 37, 38.
Huff, B. (2004). Leadership and mentoring. Canadian Operating Room Nurses Journal, 22(1), 20-21.
Higgins, J. (2004). Thinking outside the box: perioperative preceptorship. Canadian Operating Room Nurses
Journal, 22(1), 33-40.
3.4 Orientation/In-service/Continuing Education

PRACTICE
RATIONALE
3.4.1
A comprehensive orientation program for

new and/or returning employees should
- philosophy, goals and role
expectations of the health care
facility (Phillips, 2007) ;
- physical facilities specific to the
health care facility(Phillips, 2007) ;
- policies and procedures for the practice
area;
- process for informing staff of new
policies;
- process for introduction to new surgical
procedures;
- emergency code policy reviews (fire,
disaster, bomb threat, etc.);
- process for reporting near misses,
errors, incidents, and sentinel events;
- policies and procedures specific to
occupational health and safety;
- policies and procedures related to
patient confidentiality;
- process to evaluate performance
expectations; (Phillips, 2007); and
- assignment/buddied with a preceptor for
the entire period of the scheduled
orientation.
Given that maternity paternity leave may last up to

one calendar year, refreshing the returning nurse may
require a full reorientation.
3.4.2
In-service programs should include but not

be limited to:
- review of new policies and procedures;
- instruction related to new equipment,
procedures;
- notification of any patient safety issues;
- review of professional responsibilities
and accountability; and
- procedures mandated annually

Section 3
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BIBLIOGRAPHY

PRACTICE
RATIONALE
according to provincial/national
legislation such as BCLS and WHMIS.
3.4.3
Policies, procedures and philosophy of the

health care facility as it relates to continuing
education should include but not be limited
to:
- expectations of the health care facility
as it relates to continuing education
(delegated acts, advanced competencies,
certifications);
- expectations of the health care facility
related to personal accountability for
continuing education/learning;
- expectations around performance
review and personal educational goals
setting;
- documentation of the above
information; and
- identification of funding assistance
available to employees.
3.4.4
Policies and procedures related to the use of

purchased/contract staff (agency) and casual
staff should include but not be limited to:
- basic orientation to the surgical suite;
- identification of a reporting relationship
for staff; and
- introduction to a "reference package"
that is readily available to staff in case
of confusion/question
REFERENCES
BIBLIOGRAPHY
Phillips, C. (2002). Managing legal risks in preceptorships. Canadian Nurse, 98(9).
Robson, R. & Marshall, P. (2003). Using dispute resolution to resolve health care conflicts: an essential tool in
hospital risk management. Risk Management in Canadian Health Care, 4(7).
Environmental/Equipment Safety
4.1 Construction/Renovation
Section 3
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Planning & Design Phase

PRACTICE
RATIONALE
Consideration
4.1.1
The following steps should be taken to

design or redesign surgical suites:
- assess current and future needs;
- define goals and develop a master plan;
- procure technical design and planning
expertise;
- develop a project budget;
- select staff members to provide front
line input;
- select the right products; and
- select vendors/suppliers with expertise
in equipment, installation and services.
Attention to detail in the planning stages will ensure

correct processes are in place for the construction
phase.
All specifications and contracts should

include comprehensive infection control,
risk management and OHS clauses that
clearly identify legislative requirements,
site-specific requirements and impose
sanctions for non-compliance. (CSA
Z317.13-07)
Planners require expertise and knowledge about

individual provincial guidelines and CSA Standards
(Z317.13-07) for Construction and Renovation of
Health Care Facilities.
Risk assessment plays a crucial step in identifying
potential hazards and the necessary containment
required to carry out services.
Assess areas adjacent to the site including

areas on the floor, above and below for
potential risks. Assess potential risks to
patients, staff and services.
4.1.2
Commit to vendor (contract or partnership

agreement) early in the process to
maximize the benefits of their
knowledge/expertise.
Often room design and fixture placement is

dependent on equipment/vendor chosen because of
equipment specifications and dimensions.
4.1.3
All construction/renovation projects should

have a project manager.
To co-ordinate all the meetings, functions and

actions required to plan, design, build, commission
and move into new/renovated space.
4.1.4
Establish a multidisciplinary team to

include members outside the surgical
suite. Responsibilities of the team include
but is not limited to:
- considering business and service
continuity;
- coordinating demolition, construction
and renovation;
- occupational health and safety
A construction project affects many disciplines

including people and other departments outside the
surgical suite. Input is necessary from all involved
stakeholders.
Section 3
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Overview
Preplanning prior to beginning a construction project is critical to the success of the project.
4.1.5
RATIONALE
regulations
reviewing and implementing
infection control practices for patients,
staff and contractors;
ensuring compliance with technical
standards, contract revisions and
regulations;
a project schedule; and
maintaining summary statements of
activities
Clear lines of communication shall be

established with all the team members.
To facilitate efficiency and comprehensiveness

throughout the project. .
The roles/responsibilities of each team

member should be outlined and documented.
The team should include but not be limited
to the following members:
- Director and Manager of the Surgical
Suite;
- Surgical Suite staff;
- Nursing;
- Ancillary Staff; and
Business Director
- Surgeon(s);
- Anaesthesiologist(s);
- PACU staff
- Architects;
- Construction Project Manager;
- Engineering, Facilities Director;
- Materials Management;
- Equipment planner;
- Infection Prevention and Control
Practitioners;
- Reprocessing Department personnel;
- Environmental Services personnel;
- Information services/technology;
- Medical Radiation Technologists;
- Epidemiologists; and
- Vendor representatives (as required
through the project build).
To enable the team to work effectively together,

with a clear understanding of their respective roles.
4.1.6 Construction and renovation projects involve

different phases which may overlap each other
including but may not be limited to:
-
Each team member provides a distinct area of

expertise.
Breaks the project down into manageable, organized

steps providing a building block to the end product.
needs assessment;
preplanning;
site selection and acquisition;
programming;
budgeting;

Section 3
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PRACTICE
RATIONALE
schematic design;
equipment selection;
design review;
design development;
preparation of construction documents;
bid/negotiation; and
construction
4.1.7 Infection Control Practitioners should educate

all perioperative staff involved regarding
activities that can reduce the spread of
microbial contamination.
Construction and renovation projects in the

operating room increase the risk of infections such
as aspergillus. Infection control personnel play a
major role in educating hospital staff, architects,
engineers, and all people involved in any stage of
the construction and/or renovation process.
4.1.8 Infection prevention measures shall be clearly

outlined in relevant construction documents
(e.g., drawings, specifications, tender or bid
documents) before any construction project is
started, and they shall be maintained for the
duration of the project. (CSA Standard
Z317.13-07, 2007, p. 9)
The Health Canada publication Constructionrelated Nosocomial Infections for Hospitalized

Patients: Decreasing the Risk of Aspergillus
Legionella and Other Infections cites 25 outbreaks
of nosocomial Aspergillus sp infections over a
twenty year period resulting in 106 deaths. These
deaths were either suspected or confirmed as being
caused by construction activity. (Loddon Mallee
Region Infection Control Resource Centre, August
2005).
Health Canada has carried out an extensive review
of literature of nosocomial infections over a 20-year
period (1978-1998) and found numerous nosocomial
outbreaks related to construction or renovation
projects. (American Industrial Hygiene
Association, Controlling Hospital Acquired
Infections, 2008 p.1)
Numerous published reports have linked
construction activities in hospitals to outbreaks of
Aspergillosis which have had fatal outcomes to
multiple patients. It is essential that preventative
measures be undertaken to decrease patients or
residents exposure to dust particles contaminated
with aspergillus spores. (Camille Atrache, spring
2008 p.14)
4.1.9 Newly constructed/renovated facilities should

give consideration to the ability to provide
enhanced respiratory precautions.
Air sampling should be carried out before,
To establish site-specific infection control protocols

which will aid in preventing unnecessary exposures
of patients, visitors, staff and workers to infectious
agents.
Recent fears such as SARS among health care
Section 3
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PRACTICE
during and at the end of the project. Samples

should be taken by a technique that allows the
analyst to provide results to the species level.
RATIONALE
workers and patients have highlighted the
importance of facility design for enhancing the
control of infectious disease.
To evaluate barrier integrity.
To provide data in case there is an outbreak during
or after the project.
4.1.10 Planning should include consideration for

future upgrades of the surgical suite including
but not limited to the following:
- flow of patients, staff and materials;
placing a high priority on patient needs
when planning for orientation of the OR
bed, location of all doors, set-up area,
and privacy;
- review departmental adjacencies such
as the sharing of procedural and exam
spaces, as well as patient, staff and
public support spaces.
- advanced technology; consider pipe
and power (conduit, electrical power
and ceiling structure) to support future
technology;
- plan for digital information images and
remote conferencing;
- consider flat-screen versus cathode-ray
tube monitors;
- give control to the OR team; and
- integration of wireless technology.
The integration of multiple discreet systems under

one centralized control system will be essential for
both Minimally Invasive Surgery (MIS) and Open
Suites.
4.1.11 Continual observation and routine visits must

be carried out through all phases of
construction.
Things can go wrong during any part of the

construction phase. Routine visits are crucial to
ensure processes are set in place, and the project is
monitored
4.1.12 Plan the environmental infection-control and

ventilation measures for operating rooms:
- maintain air pressure in the OR greater
than corridors and adjacent areas
- maintain a minimum of 15 air
exchanges per hour with at least 3 of
these being fresh air; filter all recirculated and fresh air through the
appropriate filters, providing 90%
efficiency (during spot testing) at a
minimum;
- in rooms not engineered for horizontal
laminar airflow, introduce air at the
ceiling and exhaust near the floor;
do not use ultraviolet (UV) lights to
Use the architect, staff and physicians to identify sites

to visit.
Site visits can assist in identifying design features
that may be applicable/not applicable to the health
care facilitys needs.
Maintains unidirectional airflow in the room and
minimizes the amount of corridor air (less clean air)
entering the OR.
Ultraviolet light must be out of the direct line of
vision and positioned so that air will pass over it as it
is exhausted from the room; usually at ceiling level.
Non-sealed areas are difficult to clean and keep
cleaned.
Appropriate environmental controls are crucial to
infection prevention.
To focus on the processes and methods that will

improve efficiency, productivity and outcome.
PACS.
Flat screens and other display are less cumbersome
and easily accommodated overhead.
Section 3
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PRACTICE
prevent surgical-site infections;

walls, ceilings and floors must be
sealed; and
keep operating room doors closed
except for passage of equipment,
personnel, and patients and limit entry
to essential personnel
Requirements for environmental controls

such as HVAC systems air flow/exchange,
lighting etc. shall meet the specified
recommendations as outlined by Canadian
Standards and other recognized groups such
as the Canadian Healthcare Engineering
Society.
4.1.13
Ergonomics.
4.1.14
Patient flow:
access;
- signage;
- reception area;
- restricted, semi restricted and
unrestricted access;
- washroom location
- staff efficiency related to layout;
- work areas for nursing documentation
and physician dictation;
- traffic patterns/flow between theatres,
and other nursing units i.e. PACU, ICU;
and
- transportation of patients (wheelchairs,
stretchers, walking).
4.1.15 Seek feedback from patients and staff

in regards to privacy, traffic patterns,
work areas etc.
4.1.16 Supply & Instrument Movement Logistics:

- which type of cart system will be
utilized;
- sterilizer location in relation to the
theatre;
- location of basic and back-up supplies;
- supply replenishment system;
- implant storage, dispense of and
accountability;
- equipment storage area; and
- space for sales representatives and
teaching functions.
Design should consider patient feedback around

access, privacy and efficiency.
Workflow should consider feedback from staff on
work areas, traffic patterns and efficiency.
Patient comfort, privacy and staff efficiency play a

major role in a smooth patient transfer/discharge
from the surgical suite.
Front line staff who are directly involved with the

day to day running of the surgical suite and patients
provide valuable information during the designing
stage.
To determine space needs for supplies and transport
systems
Rapid technological change requires that planning be

for five years. (Mauck & Tolhurst, 2001, p. 29)
4.1.17 Room Set-up

Section 3
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4.1.18 A foot printing exercise should occur.

(This exercise allows the group to move
blocks of space (e.g., the surgical suites)
around to determine the best location in
relationship to other departments/services.)
4.1.19
Equipment:
- a designated person responsible for
equipment planning
- what equipment to re-locate from the
old area or structure;
- what vendors the health care facility has
agreements with;
- acquisition and in-service education of
staff; and
- a designated person to manage the
tracking of equipment.
Some dedicated rooms may be required for some

specialties. Dedicated rooms should be kept to a
minimum as multifunction rooms provide more
flexibility.
Architects will develop plans based on square

footage. This exercise allows the team to move
equipment within the space to determine the best
equipment placement and traffic flow for efficiency
To avoid conflicts between equipment and other

aspects of the design.
If the health care facility has contracts and/or
preferred vendor agreements, selection of equipment
may be limited to these vendors.
Vendors are also a valuable resource regarding
construction infrastructure required for the product
(i.e., ceiling structure required to support a
microscope or lights).
The timing of these functions is critical to meet
deadlines.
Other areas that should be considered in the design phase:

4.1.20
4.1.21
Patient focus groups will assist in

identifying what patients expect/desire
during their surgical experience. This may
- family waiting areas during surgery;
- private interview rooms for consultation
and discussion with
surgeon/anesthetists;
- space for complementary therapies such
as massage;
- clerical space;
- music before, during and after surgery.
- on call or sleep areas
Improve or increase patient satisfaction.
A lounge, which provides space for

relaxation, eating, kitchen utilities i.e.
microwave oven, refrigerator, sink and
With the shortage of qualified staff, this may be a

recruitment incentive. Pleasant space contributes to
staff health and well-being, which is cost effective.
Providing an environment which goes beyond

clinical skills and technology assists in the healing
process.
Section 3
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A focus group of anaesthesiologists,

surgeons and staff for each surgical specialty
should be established to determine room setup, according to but not limited to the
following criteria:
- size of theatres, attempting to maintain
flexibility of the theatre;
- door locations and size, patient
orientation, x-ray view boxes, cabinets,
telephones, and computer access
locations; and
- fixed room equipment such as surgical
lights, gas columns, and room systems.
Construction Phase
PRACTICE
4.1.22 The project manager shall be available at all
times to oversee every step of the
construction phase.
A system should be in place to manage major

breaches.
RATIONALE
The role of the project manager is to coordinate all
functions and teams.
Constant vigilance is required to ensure adherence to
project plans.
Things can go wrong during the construction phase.
4.1.23
Project team leaders should develop and

review regularly check-lists of all items to
be addressed.
To remain on the target timeline.
4.1.24
Project manager shall work closely with

architects and construction foreman.
This ensures cost, timelines and any discrepancies are

addressed.
4.1.25
Project manager should be involved in

inspections for code requirements.
This allows the project manager to follow through

any deficiencies identified.
4.1.26
The project team should do regular tours of

the work site and include physician and staff
in the tours.
This will assist to identify issues that may be

corrected. (e.g., stretcher alcove not large enough for
stretcher, doors located incorrectly).
4.1.27 The team, in conjunction with the Infection

Prevention Officer, shall plan for the
confinement and containment of dust, water,
etc. during construction/renovation. (CSA,
Z317.13.03-07)
Many construction/renovation projects are in close

proximity to areas, which will continue to provide
patient care.
A formalized approach to risk management in
conjunction with sound infection control procedures,
greatly reduce the risk to patients from construction
and maintenance activities.
4.1.28 The team shall discuss and plan how to deal

with noise, vibration, and temperature
fluctuations that may impact patient care in
adjacent spaces.
Some equipment and surgical procedures require

precision, which would be negatively impacted by
vibrations.
4.1.29 Upon completion thoroughly clean and

decontaminate all surfaces including but not
limited to:
- walls;
- ceilings,
- windows;
- high-risk area ventilation systems;
- service cavities; and
- ceiling spaces.
Upon completion of the project, clean the
work zone according to the facility
To provide an environment that is safe, and decrease

the risk of infection due to dust and debris
Section 3
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counter space.

PRACTICE
RATIONALE
procedures, and install barrier curtains to

contain dust and debris before removing
rigid barriers.
(Chinn & Sehulster, 2003, p. 12)
Operational Phase
PRACTICE
RATIONALE
4.1.30
A plan shall be developed to coordinate all

aspects of system changes.
Allows teams to identify and plan for required

changes prior to moving into new space.
4.1.31
Changes which should be considered

include but are not limited to the following:
- policy & procedure changes (patient
flow, fire plan, evacuation routes, etc);
- education of all staff and physicians
about new equipment, safety, traffic
flow and infection control.;
- potential changes in staffing plans, skill
mix and multi-tasking;
- signage of all spaces;
- labeling of all supply shelves and
equipment locations;
- security issues; and
- the moving plan.
4.1.32
A systems check of all gas, electrical

systems, humidity, air flow and exchanges
should be done with maximum load. All
systems should be stressed at the same time
to mimic actual operations prior to the first
day of operating.
To recognize and eliminate system failure and

provide a smooth transition at surgical start-up.
4.1.33
A documented back-up plan for possible

system failure shall be developed.
Provides a tool for transition during system failure.
Moving Phase
4.1.34 Consideration should be given but not limited
to:
- when the move will occur;
- whether the surgical schedule continue
in an adjacent space;
- who needs to be present for the move;
- developing a detailed plan/timeline for
moving day;
- what the role for each staff type will be
on moving day; and
- a plan for a trial surgical case.
To organize and prepare staff for a smooth transition.
Section 3
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American Industrial Hygiene Association. (2008). Controlling Hospital Acquired Infections.

Canadian Standards Association. (2007). CSAZ317.13-07 Infection control during construction, renovation, and
maintenance of health care facilities. Toronto: Author.
Camille, A. (spring 2008) Building Strategies - Minimize Patient Exposure and Possible Litigation.
http://www.pcbdisposal.com/documents/bscorner3.pdf
Chinn, R., & Sehulster, L. (2003). Guidelines for Environmental Infection Control Health-Care Facilities.
Recommendations of CDC and the Healthcare Infection Control Practices Advisor Committee (HICPAC).
June 6, 2003/52 (rr10); 1-42 http:/www.cdc.gov/mmwr/preview/mmwrhtml/rr5210a1.htm
Loddon Malle Region Infection Control Resource Centre, (August 2005). Infection control principles for the
management of construction, renovation, repairs and maintenance within health care facilities. A Manual
for Reducing the Risk of Health Care Associated Infection by Dust and Water Borne Microganisms, (2nd
Ed.) http://ihea.com.au/technical_resources/infection_control/InfectionControlManual.pdf
Mauck, J., & Tolhurst, S. (2001). Constructing and designing a new OR. Surgical Services Management. 7(4).
BIBLIOGRAPHY
Cantrell, S. (April 2008). Renovating the surgical suite reaps sweet rewards. Healthcare Purchasing News.
http://findarticles.com/p?articles/mi_m0BPC/is_/ai_n25151351
Malik, O., Arabzadeh, H., & Singh, J. (2008). Controlling Hospital-Acquired Infections. American
Industry Hygiene Associate.
http://www.aiha.org/content/accessinfo/press/controlling+hospital-acquired+infections
Health Care Standards CSA International Organization for Standardization ISO (issue 03 spring 06). Safety
considerations in health care facility renovation its all in the design
http://www.csa.ca/standards/health_care/newsletter/archive/issue%203/default.asp?load=news1&langauge=english
OR Manager. (2002). OR design & construction: Every project needs infection risk plan. OR Manager, 18(3).
OR Manager. (2002). OR design & construction: Healing environments in surgical suites. OR Manager, 18(3).
OR Manager. (2001). OR design & construction: planning for upgradeable ORs. OR Manager, 17(12).
Stouffer, J. (2001). A high-touch approach to design. Surgical Services Management, 7 (4), pp. 33-38.
Wetzel, J. (2001). Planning for effective OR design. Surgical Services Manager. Vol. 7 (4).
4.2
Equipment Selection/Trialing
Surgical equipment and supply acquisitions need to be managed by having appropriate processes in place to ensure
that the right product is available for the right application. Patient safety and staff safety should be considered.
Section 3
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REFERENCES
RATIONALE
4.2.1
Health care facilities should establish a

multidisciplinary committee to review
equipment/supply requests. This committee
should include but not be limited to the
following:
- OR Manager/Leader;
- OR Educator;
- Perioperative nurses;
- Infection Control personnel;
- Finance representative;
- Biomedical representative;
- Maintenance representative;
- Anaesthesiologist;
- Surgeon;
- Allied Health Professionals:
- Materials management; and
- Sterile Processing personnel
(CSA Z318.8-08)
Surgical suite equipment is expensive and technology

is rapidly changing. Input from a variety of users is
required to make the best purchase decision. The
amount of dollars available for technology purchases
is usually far less than the dollar value of requests
made, so decisions must be sound.
4.2.2
A systemized process (Request For

Proposal- RFP) for equipment requests
should be in place and the process should
include a feedback mechanism to inform the
requester of the status of the request.
Most health care facilities have specific timelines for

capital budget item requests. Non-capital items may
be purchased within operating budgets.
4.2.3
Standardization, appropriate use and price

reduction are the best way to reduce supply
expenses.
4.2.4
The following criteria should be considered

by the committee to narrow the choice of
product/equipment to select/trial:
- size, weight and specifications fit into
the physical environment;
- the cost of the item falls into budgeted
dollars;
- the item has the functionality to meet
the clinical end use;
- the equipment is approved for use in
your jurisdiction (HPB/CSA approval);
- the company or manufacturer shall
provide validated cleaning/reprocessing
instructions for the equipment; and
- the necessary infrastructure is in place
to support the use of the equipment.
(CSA Z314.22-04)
Reviewing the equipment in this context will assist in

creating a "short list" of products/equipment to
evaluate.
On site equipment evaluation should be

completed prior to purchase.
To ensure equipment is functioning and suitable to

patient, staff and departmental needs.
Contact and/or visit other sites to gather
Input from other centres and staff provide valuable
4.2.5
To decrease problems related to inappropriate

equipment size, selection etc., avoid costly mistakes
and waste of valuable time.
Section 3
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PRACTICE
RATIONALE
information such as:

- does the equipment meet the needs
specified;
- what is the cost and is it acceptable;
- are educational sessions offered through
the vendor;
- how is the equipment reprocessed;
- are staff satisfied with the product;
- is the equipment reliable;
- does the vendor provide
service/maintenance vendor;
- what is the cost of upkeep;
- was this the preferred choice; and
- would they purchase the same item if
they had that choice
information related to equipment function, use and

reliability.
To be used for future reference and decision making.
Document and save all information.

4.2.6
The decision to trial new

equipment/technology should consider but
not be limited to the following:
- do physicians and staff require training
prior to the use of the equipment;
4.2.7
To plan the necessary arrangements for training.

The presence of a sales representative to lend
technical assistance related to the device should not
substitute for orientation and training of nursing staff
members in the use of the equipment; neither should
such presence substitute for formal instruction of the
surgeon before using new equipment in the OR.
(Murphy, 2001, p. 824)
is the presence of the sales

representative necessary to support the
use of the technology; and
The sales rep should be readily available to assist in

appropriate equipment selection/use.
should the patient be informed that new

technology is being used
To acknowledge the patients input and provide the

necessary information required for consent.
The patients decision to consent to (or refuse)
treatment must be informed; that is, the patient must
receive information about the nature of the proposed
treatment, its expected benefits, the material risks,
special risks or material side effects associated with
it, alternative courses of action and the likely
consequences of not having the treatment. (CPSO,
2001, p. 3)
Sales representatives are not employees of the

hospital and therefore should not be regarded as an
extra set of hands for tying gowns or opening
supplies. The representatives legitimate role is to
provide technical assistance related to the device for
the safe care of the patient. (Murphy, 2001, p. 824)
Health care facilities should develop policies

and procedures related to equipment trials
involving but not limited to:
- Risk manager;

Section 3
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PRACTICE
4.2.8
RATIONALE
Bioethicist;
Physicians;
OR Manager;
Perioperative Registered Nurses;
Allied Health Professionals; and
Infection Control Practitioners.
Develop a user friendly evaluation tool to

provide objective criteria for decision
making when assessing different
technologies.
The decision to purchase a piece of
equipment should include but not be limited
to the following considerations:
- does it meet the clinical need;
- does it pose a safety concern for the
patient or team; for the patient
- ergonomics
- what are the ongoing costs of
consumable items;
- is physician, staff and biomedical
education included (videos, CDs,
manuals);
- are operating/reprocessing instructions
resources included (videos, CDs,
manuals);
- are maintenance instructions available
for biomed/maintenance department;
- are preventative maintenance contracts
available with the vendor (videos, CDs,
manuals);
- what is the warranty on the item; and
- are there opportunities to lease or leaseto-own.
A user friendly tool may increase completion and

return rate.
Sound business principles combined with knowledge

of clinical practice should drive the acquisition
decision. (Berhardy, 2001, p. 26)
REFERENCES
Beney, D. (March 2005). OR design: four steps for success, Resources for OR Design and Construction
http://www.ordesignandconstruction.com/dp/foursteps.htm
Berhardy, J. (2001). Strategies for successful technology assessment. Surgical Services Management.
7 (6).
Canadian Standards Association. (2004). CSA Z314.22-04. Management of Loaned, Shared and Leased Medical
Devices. Toronto: Author.
Canadian Standards Association. (2008). Z314.08-08. CAN/CSA. Decontamination of reusable medical
devices. Toronto: Author.
Cantrell, S. (April 2008). Renovating the surgical suite reaps sweet rewards. Healthcare Purchasing News.
Section 3
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PRACTICE
College of Physicians and Surgeons of Ontario. (2001). Consent to Medical Treatment.

http://www.cpso.on.ca/Policies/consent.htm
Murphy, E., (2001). The presence of sales representatives in the OR. AORN Journal. 73(4), 822-824.
BIBLIOGRAPHY
Baker, D., & Hale, D. (2003). Potential cost-saving opportunities in the supply chain. Surgical Services
Management. 9 (2).
OR Manager (2003). Technology in surgery: top ten safety issues with medical devices. OR Manager, 19 (4).
OR Manager (2003). OR technology: are you planning for staff training and safety for new energy modes? OR
Manager, 19 (6).
OR Manager (2003). Materials management: strategies for involving physicians in a product conversion project.
OR Manager, 19 (7).
4.3 Preventative Maintenance Programs

PRACTICE
RATIONALE
4.3.1
All equipment should be on a preventative

maintenance program. The frequency of the
routine will vary according to the risk class of
the equipment.
Equipment is classified according to the potential of

the equipment to injure/malfunction and according to
the severity of an injury should one occur.
4.3.2
Documentation of preventative maintenance

checks should include but not be limited to:
- date of inspection/intervention;
- identity of equipment inspected (serial
number, asset number);
- type of inspection that was carried out;
- results of inspection;
- name and title of person carrying out the
inspection/intervention; and
- any repairs/replacement of parts.
Provides the information required for an investigation

should an incident occur.
4.3.3
Documentation should be retained and

immediately available to perioperative staff.
May be required for legal defence and/or quality

control.
4.4 Risk Alerts/Recalls
4.4.1
PRACTICE
RATIONALE
Health care facilities shall have a process that

defines how "recalls" or risk alerts will be
Having a policy in place to define the recall process

and outline to whom the recall notice will go to
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http://findarticles.com?p?articles?mi_m0BPC/is_/ai_n25151351
increases efficiency and helps eliminate confusion.
Recall notices are generally sent to the risk

manager, materials management or the
biomedical technician for further
dissemination to department heads and or
departments.
Documentation may assist in legal defence.
4.5 Intra-operative Equipment Malfunction

4.5.1
PRACTICE
Health care facilities shall have clear
policies and procedures related to the
reporting of equipment failures during
surgery.
RATIONALE
Documentation of events may assist in identifying
equipment that needs replacement, processes that
require revision, and/or equipment that may lead to
patient injury in the future.
REFERENCES
Canadian Standards Association. (2004). CSA Z314.22-04. Management of Loaned, Shared and Leased medical
Devices. Toronto: Author.
BIBLIOGRAPHY
Accreditation Canada. Formerly known as CCHSA. www.accreditation-canada.ca
Canadian Patient Safety Institute (CPSI). www.patientsafetyinstitute.ca
OR Manager (2002). What you should know about device recalls. OR Manager.18 (4), p. 21. Santa Fe: OR
Manager Inc.
4.6 Specialized Surgical Equipment

4.6.1 Electrosurgery Unit (ESU)
Whenever an Electrosurgery Unit is used, it shall be operated in conjunction with a smoke evacuator.
Section 3
Page 226 of 334

handled. The policy should include, but not

be limited to:
- defining common entry point/person for
recall notices;
- defining distribution of the recall notice
to all departments/individuals;
- defining action to be taken for specific
types of recall;
- consistency in the approach to manage
recalls;
- documentation of action taken should be
retained by a designated individual; and
- discontinuation of the sterilizer until its
performance can be verified.
RATIONALE

PRACTICE
4.6.1.1 Initial education and ongoing continuing
education regarding the use of ESUs shall be
provided to all perioperative staff.
Education decreases errors and potential injuries to

patients and staff.
4.6.1.2 Perioperative nursing staff should understand

the principles of electricity.
Understanding these priniciples enhances the nurses

ability to operate the machine safely and troubleshoot
appropriately. (Megadyne, 2010)
4.6.1.3 As part of an ongoing preventative

maintenance program ach ESU shall have an
identification number.
The identification number will assist in the follow-up

record of repairs and checks and will assist in the
investigation of a sentinel event.
4.6.1.4 All defective or suspect equipment shall be

removed from service immediately, labeled
for repair and checked by biomedical
engineering or maintenance personnel (as
authorized by the facility).
Defective equipment may result in patient or staff

injury.
4.6.1.5 A brief set of clearly readable operating

instructions should be readily accessible with
each system. These instructions should be
placed on or attached to each ESU for
reference (AORN, 2008, p. 316). A complete
manufacturer's operational manual should also
be readily available.
Provides a quick reference for equipment review and

use.
4.6.1.6 Metal jewellery should be removed.
Metallic jewellery, including that used in body

piercing, presents a potential risk of burn from directed
current (i.e. active electrode touching it), heat
conducted before an electrode cools, and leakage
current. Small metal objects touching the electrode can
concentrate current and result in patient injury.
Eliminating contact with metal minimizes the risk.
(AORN, 2008)
4.6.1.7 Electrical cords, plugs and footswitch cords

shall be checked for fraying and damage prior
to each procedure.
Electrical cords in good repair will prevent potential

injuries to patients and staff.
4.6.1.8 The ESU footswitch should be covered with a

clear, impervious cover if there is a potential
for fluid spills.
Liquids may pose an electrical hazard.

This facilitates easier cleaning.
4.6.1.9 ESU units shall be completely visible when in

operation.
Visual accessibility allows for continuous monitoring.
4.6.1.10 Supplies, solutions and drapes shall not be

placed on the unit.
Fluid spills may cause the unit to short circuit
4.6.1.11 The alarm system and audio signal shall be

functional, loud enough to be heard over other
Ensures awareness of the ESU activation and alerts

personnel to mechanical or electrical malfunction.
Section 3
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RATIONALE
sounds and shall not be turned off.

PRACTICE
4.6.1.12 Follow manufacturers instructions for

compatibility and proper function when using
two or more electrosurgical units
simultaneously.
To ensure safe practice.
4.6.1.13 Confirm that the prepped area is dry prior to

applying surgical drapes. Plastic adhesive
drapes may also be used to cover the surgical
area.
Flammable agents such as alcohol are potential fire

hazards. Alcohol based surgical prep solutions can
ignite with the use of electrocautery and lead to fire in
the operating room. Covering the skin with a clear
plastic adhesive drape also reduces the collection of
alcohol vapor at the site, thus reducing the chances of
fire. (Batra, S. & Gupta, R. Patient Safety in Surgery
2008)
4.6.1.14 The ESU should be operated at the lowest

effective power setting for coagulation and
cutting. Increased power settings beyond
recommended levels should be questioned
and documented.
Excessive power may indicate an operational or

mechanical problem.
4.6.1.15 If the operator requests a continual increase in

power, personnel should check the entire ESU
and accessories circuit for correct/complete
installation.
To confirm the system is functioning appropriately.
4.6.1.16 Assess the patients skin integrity pre and

postoperatively for alternate site burns.
Ensure the area under ECG leads, and any
other potentially grounded sites are included
in the assessment.
Patients are exposed to alternate site burns because

(1) current follows the easiest, most conductive path;
(2) any grounded object, not just the generator, can
complete the circuit; (3) the surgical environment
offers many alternative routes to ground; (4) if the
resistance of the alternative pathway is low enough and
the current flowing to the ground in that path is
sufficiently concentrated, an unintended burn may be
produced at the alternate ground site. (Valleylab,
2007 )
Although sticky adhesive patient return pads rarely
cause pressure ulcers, the adhesives can contribute to
skin problems that break down further during a
patients recovery period. (Megadyne, 2010, pdf
pg.10)
4.6.1.17 Any adapters used must be approved by the

manufacture and shall not impede the safety
features of the generator.
To ensure patient safety .
4.6.1.18 Documentation should include :

- type of unit and serial number;
- hair removal, if applicable;
- location of dispersive electrode;
Documentation helps health risk management in the

event of an injury to patients or staff.
Documentation provides a baseline assessment and
future reference. It may also be used as a legal
Section 3
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RATIONALE
document.
cutting and coagulation settings;

name of the perioperative Registered
Nurse applying the dispersive electrode;
and
condition of skin after removal of the
dispersive electrodes.
Disposable Dispersive Electrode Pad

4.6.1.19 Manufacturers recommendations shall be
followed related to the type of disposable
dispersive electrode pad to be used with the
ESU.

PRACTICE
4.6.1.20 A dispersive electrode pad should not be

applied when using only bipolar
electrosurgery accessories.
The current flows between the tines of the bipolar

forcep and not through the patient. If a pad is applied,
the electrosurgical effect may not be limited to the
tissue between the bipolar electrodes.
4.6.1.21 Pre-gelled disposable dispersive electrode

pads should remain in a sealed protective
outer package until time of use.
Integrity of the gel/adhesive is protected while in a

sealed package.
4.6.1.22 Pre-gelled disposable electrode pads shall be

checked for expiry date and discarded if
expired.
Integrity of the pad may be altered over time.

Manufacturer cannot be held accountable if the product
that was used has expired
4.6.1.23 Appropriate sized, disposable dispersive

electrode pad shall be used for adult,
paediatric, infant and neonate patients.
Using the appropriate size pad will minimize the

potential for patient injuries. With extremely obese
patients, a second parallel dispersive electrode may
sometimes be used to increase the overall dispersive
pad surface area, decrease the electrode-to-skin contact
impedance, and reduce current density. Some ESU
manufacturers provide adapters that permit users to
attach two return electrodes to their units when used
with obese patients. (ECRI, 2008)
4.6.1.24 The disposable dispersive electrode pad shall

not be cut or adjusted in size and should be
visually inspected for integrity, discoloration,
and insufficient amounts of conductive
adhesion.
The size of the pad is proportionate to the current it can

disperse.
To ensure a damaged or faulty pad is not used.
4.6.1.25 Excessive hair, oils, or lotions should be

removed prior to application of the disposable
dispersive electrode pad.
Excessive hair, oils, and chemicals interfere with

current conduction and adherence of the disposable
An unshaved area underneath the dispersive electrode
will inhibit complete electrode-to-skin contact, result
in high electrode-to-skin contact impedance, and lead
to heating of or arcing to the tissue under the electrode.
(ECRI 2008)
Section 3
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RATIONALE

PRACTICE
be applied to a well-muscled, clean, dry area
as close to the operative site as possible,
ensuring that uniform body contact is
maintained.
Vascular supply in muscle assists in the dispersal of

heat generated thereby reducing the potential for skin
burns. Uniform application prevents wrinkling and
tenting and ensures adequate grounding of the patient.
4.6.1.27 Avoid placing the disposable dispersive

electrode pad on areas of the body with bony
prominences, skin folds, scar tissue,
prostheses, areas of erythema or other skin
lesions, or areas of impaired circulation.
Pad placement on healthy, intact skin will minimize

risk of patient injury. Fatty tissue may impede
electrosurgical return current flow
Surface area impedance can be compromised by:
excessive hair, adipose tissue, bony prominences, fluid
invasion, adhesive failure, scar tissue, and many other
variables. (Valleylab 2007)

be positioned and protected from areas of
potential fluid spills. A disposable dispersive
electrode pad subjected to spills shall be
replaced.
See rationale 4.6.1.22. Fluid may cause loosening of

the disposable dispersive electrode pad and increase
the susceptibility of the patient to thermal or chemical
burns.
4.6.1.29 Disposable dispersive electrode pad shall be

positioned away from implantable devices i.e.
pacemakers, metal prostheses and areas distal
to the tourniquet if used.
Electrical interference may occur with multiple

medical devices. Burns may also occur when the
electrical current seeks an alternate device or pathway.
Adequate tissue perfusion is necessary for the
promotion of electrical conductivity and heat
dissipation.
4.6.1.30 The disposable dispersive electrode pad that is

removed shall not be re-applied or re-adjusted.
The adhesive and gel portion of the electrode may be

rendered ineffective after removal or repositioning.
4.6.1.31 Tape shall not be used to secure disposable

dispersive electrode pads in position.

be applied after all positioning is complete. If
the patient is repositioned during surgery, the
disposable dispersive electrode pad and cable
shall be checked for contact and adherence to
the skin and replaced if necessary.
Non-adherence of the tape to the skin may result in a

patient burn.
The disposable dispersive electrode pad and cable may
be dislocated or damaged by repositioning.
4.6.1.33 Personnel should place the dispersive

electrodes as close as possible to their
respective surgical sites and ensure that
single-use dispersive electrodes do not
overlap. (AORN, 2008, p. 320)
4.6.1.34 The cable attached to a disposable dispersive
electrode pad shall be in good repair and fit
snugly into the correct receptacle of the ESU
machine.
Damaged or poorly fitting cables are potentially

hazardous and may cause patient injury.
Section 3
Page 230 of 334
4.6.1.35 The cable length should be adequate to

prevent tension on the disposable dispersive
electrode pad.
RATIONALE
Cable tension may result in disconnection from
electrosurgery unit, and/or tenting of the disposable
Reusable Capacitively - Coupled Return Electrode

4.6.1.36 A commercially prepared reusable capacitivelycoupled return electrode may be used.
It provides a larger area for dispersal of current and

therefore, potential injury to delicate, fragile skin is
lessened.
4.6.1.37 Inspect reusable return electrode for integrity and

expiration date. Never cut or adjust the size of the
return electrode.
Damaged and expired return electrodes may not

provide the necessary protection required.
If used the manufacturer may not accept any
responsibility should the patient endure injury.
Cutting or altering the return electrode may interfere
with the electrodes ability to protect the patient and
properly alert the system of failure.
4.6.1.38 The cable attached to a reusable capacitive return

electrode shall be in good repair and fit snugly into
the correct receptacle of the ESU machine.
Damaged or poorly fitting cables are potentially

hazardous and may cause patient injury.
4.6.1.39 The surface of a reusable return electrode pad shall

be free from cracks, tears, and holes. If a sheath
covering is used it shall be clean and intact.
4.6.1.40 Manufacturer's recommendations shall be
followed regarding the use of reusable return
electrode pads including but not limited to:
- patients age and size;
- type of generator it may be used with;
- positioning; and
- settings
This electrode pad is inappropriate for patients

weighing less than 25 lb because adequate contact
(weight-bearing area) could not be achieved.
(Rothrock, J. 2007, p. 222)
4.6.1.41 Manufacturer's recommendations shall be

followed in the cleaning and storage of reusable
electrode pads.
To decrease potential cross contamination to the

patient and increase life expectancy of the pad.
Cord/Hand Piece - Active Electrode

4.6.1.42 Verify that the activation tone functions at the
minimum control setting during all acceptance
and routine ESU inspections. Check the ESUs
in inventory to be sure the activation tone is
functioning properly. (ECRI, 2008)
Testing ensures the activation tone is functioning and

can be heard appropriately.
Section 3
Page 231 of 334

PRACTICE
RATIONALE

PRACTICE
4.6.1.43 Single-use active electrodes shall not be
reused.
Single-use medical devices are not sold with

reprocessing instructions.
4.6.1.44 The integrity of the active electrode shall be

checked prior to each use (metal has smooth
surface, with no chips or grooves; Teflon coat has
no chips or cracks).
To ensure the electrode is safe to use and has not been

damaged in the shipping or with reprocessing
4.6.1.45 A non-piercing clip or a cloth/Velcro fastener

should be used to secure the active electrode cord
to the drape.
Prevents the electrode from falling off the sterile field.

Piercing towel clips may damage the cord of the active
electrode.
4.6.1.46 Place electrodes in a clean, dry, well-insulated

protective holder when not in use.
Reduces the risk of injury due to accidental activation

of the ESU.
4.6.1.47 Activation of the electrode should occur when

ready to deliver the electrosurgical current and
the tip of the active electrode is in view.
Deactivate the electrode before the tip leaves
the surgical site.
Required as a patient safety measure.
4.6.1.48 When foot controlled active electrodes are used,

the foot pedal shall be activated by the operator
holding the active electrode being activated.
Reduces the potential for injury to the patient and/or

members of the surgical team.
4.6.1.49 Prolonged activation of the active electrode should

be avoided.
Short bursts rather than continuous activation reduces

the chance of burns.
4.6.1.50 A disposable scratch pad should be used to

decrease the build-up of eschar on the electrode tip
(except if using Teflon coated electrode
tips/blades). Sponges should not be used to clean
active electrode tip.
The tip of the active electrode must be kept free from

debris to function properly.
A clean tip decreases activation time to produce the
desired effect. Use of a sharp to clean the electrode
may damage the electrode and is a potential for injury
to staff. The potential for fire is increased if a sponge
is used to clean tip (accidental firing of electrode).
Wet sponges will conduct electricity.
4.6.1.51 Check your provincial legislation regarding

the authority to deliver an electrical current to
the patient. If not authorized directly, this will
require a delegation from medicine to nursing.
Legislation regarding the application of energy.

Delegation is a legal process within the legislation of
each province.
Use of Electrosurgery in Laparoscopic Procedures

For electrosurgery unit issues related to laparoscopic procedures see Section 3 - Minimally Invasive Surgery
4.6.2. Argon-Enhanced Coagulation

An argon enhanced electrosurgical device combines argon gas with electrosurgical energy to improve the effectiveness of
the electrosurgical current (Rothrock, J. 2007, p. 225).
Section 3
Page 232 of 334
RATIONALE

PRACTICE
4.6.2.1 The following recommendations should be
followed when using argon-enhanced
coagulation (AEC):
- Limit the argon flow settings to the lowest
levels that will provide the desired clinical
effect (i.e., 4 L/min or less);
- Purge the electrode and argon gas tank line of
air according to the manufacturers
instructions;
- Always leave one instrument cannula vent
open to the atmosphere during AEC, and
remove the electrode from the body cavity
when AEC is not being performed;
- Use only laparoscopic insufflators with
nondefeatable audible and visual
overpressurization alarms;
- Use patient monitoring (e.g., end-tidal carbon
dioxide Doppler flow) that is considered
effective for early detection of venous or
pulmonary gas embolism; and
- Follow the manufacturers specific
recommendations, and continue to follow
established procedures to prevent gas
embolism during laparoscopic surgery; ensure
that staff is properly trained to detect and
manage gas embolism in laparoscopic
procedures (ERCI)
The flow of argon gas clears the surgical site of blood

and fluids and blows away oxygen. Argon gas is
heavier than air, inert, and non-combustible,
providing an efficient pathway for the electrosurgical
energy from the electrode to the target tissue.
Provides better visibility of the bleeding site or target
area and decreases the chance of combustion and
surgical smoke.
4.6.2.2 Manufacturer's safety and cleaning instructions

shall be followed.
To prevent injury or cross contamination to the

patient.
Minimizes risk of potential injury to patients and

staff.
The pressure of the Argon gas clearly exceeds the

pressure in the venous system.
To decreases the risk of gas embolism.
4.6.3 Ultrasound Technology

4.6.3.1 Manufacturer's recommendations shall be followed
relating to the safe use and cleaning of equipment.
Minimizes risk of potential injury to patients and

staff.
REFERENCES
Association of PeriOperative Registered Nurses. (2008). Recommended practices for electrosurgery. Perioperative
Standards and Recommended Practices. Denver: Author.
Batra, S. & Gupta, R. (2008). Alcohol based surgical prep solution and the risk of fire in the operating
room: a case report. Patient Safety in Surgery, 2008-10-14 http://www.pssjournal.com/content/2/1/10
ECRI, (2008). Electrosurgical Unit Activation Tone Control,
http://www.mdsr.ecri.org/summary/detail.aspx?doc_id=8189
Section 3
Page 233 of 334
ECRI, ( 2008). Electrosurgery Checklist. http://www.mdsr.ecri.org/summary/detail.aspx?doc_id=8271

ECRI, ( 2008). Fatal Gas Embolism Caused by Overpressurization during Laparoscopic Use of Argon Enhanced
Coagulation, http://www.mdsr.ecri.org/summary/detail.aspx?doc_id=8248
Megadyne, (2010) Principles of Electrosurgery,
http://www.megadyne.com/pdf/Electrosurgery1.pdf
Rothrock, J. (2007). Alexanders care of the patient in surgery, (13thed.) Toronto: Mosby.
Valleylab, (2007). Principles of Electrosurgery, http://www.valleylab.com/education/poes/poes_02.html
BIBLIOGRAPHY
Australian College of Operating Room Nurses Ltd. (2004) ESU equipment in the perioperative setting. Standards,
Guidelines & Policy Statements. Reference A5
Canadian Standards Association (2008). CSAZ305.13-09 Plume scavenging in surgical, therapeutic, diagnostic and
esthetic settings. Toronto: Author.
Cunnington, J (2006). Facilitating benefit, minimizing risk: responsibilities of the surgical practioner during
electrosurgery, 16 (4), 195-202.
HealthStream, (2005). Measuring Competency in electrosurgery A Study guide. Denver: Author.
HealthStream, (2005). Understanding Electrosurgery from Active electrodes to Return Electrodes. Denver: Author.
National Association of Theatre Nurses (NATN). (2004). Electrosurgical Equipment. Standards and
Recommendations for Safe Perioperative Practice. NATN: Harrogate: UK: Author.
Phillips, N.M. (2007). Berry & Kohn's operating room technique (11th ed.). Toronto: Mosby.
4.6.4
Laser Safety/Administration
Light Amplification by Stimulated Emission of Radiation

Medical Lasers are Class III and Class IV lasers.
PRACTICE
RATIONALE
Laser Committee
4.6.4.1 Health care facilities in which laser
technology is used shall have a laser
committee (LC).
Laser committee is responsible for:

-setting the credentialing parameters for laser use
in the facility;
- providing oversight of the laser safety program
- promoting safe laser use;
Section 3
Page 234 of 334

ECRI, (2008). ESU Burns from Poor Dispersive Electrode Site Preparation,
http://www.mdsr.ecri.org/summary/detail.aspx?doc_id=8204
RATIONALE
- reviewing and assessing incidents; and
- planning educational needs.
4.6.4.2 Membership should include but not be

limited to:
- facility administrator;
- medical laser safety officer;
- risk manager;
- manager surgical suite;
- perioperative laser nurse;
- physicians from every specialty using
lasers;
- clinical educator;
- biomedical engineer;
- occupational health and safety officer;
and
- anaesthesiologist.
Each member will bring input from his/her own

experience and specialty in order to create a safer
environment.
To provide a consistent and efficient laser service
within the institution.
Educators may be called on to assist with policy

statements.
Credentialing
4.6.4.3 Perioperative Registered Nurses shall be
made aware of those physicians who have
been credentialed and granted privileges by
the facilities Laser Committee to use a laser.
This information will include the type of
laser they are credentialed for.
4.6.4.4 Perioperative Registered Nurses shall be
credentialed/recredentialed annually to
operate the laser The course consists of,
but is not limited to:
- laser physics and laser tissue
interaction;
- laser type classifications;
- clinical applications
- laser safety issues for the patient and
operator;
- laser hazards; and
- hands-on experience.
4.6.4.5 A record of physicians with laser privileges,
Laser Safety Officers, and perioperative
Registered Nurses, who are credentialled in
lasers and their use, should be available and
updated regularly according to the
institutions laser policy.
To ensure a safe laser program is implemented

throughout the institution.
To maintain an updated list of staff with laser

privileges and education.
To provide proof of certification and/or

recertification
Medical Laser Safety Officer (LSO)

4.6.4.6 Responsibilities include but are not limited
Provides a nationally recognized standard of care
Section 3
Page 235 of 334

PRACTICE
RATIONALE
to:
- implementing CSA Z386-08 standards;
- being responsible for knowing and
understanding both the Nominal Hazard
Zone (NHZ) and the Maximum
Permissible Exposure (MPE) for each
type of laser used in the surgical suite;
- being responsible for all laser activity
and reporting to the Laser Committee;
(CSA Z386-08);
- reviewing the manufacturers
instructions for installation and
maintenance of the laser equipment and
ensuring the equipment is properly
installed;
- confirming the currency of the health
care facility policy and procedure
manual yearly based on CSA Standards;
(CSA Z386-08);
- monitoring and enforcing compliance
with required standards and regulations;
- assessing educational needs and
planning in-services (yearly or as
needed); (CSA Z386-08);
- organizing safety audits (at least
yearly); (CSA Z386-08);
- appointing LSO deputies if required;
(CSA Z386-08);
- confirming a current list of credentialed
physicians and perioperative Registered
Nurses, if health care facility
determines it to be necessary. (Ball,
2004., p. 62);
- confirming that the laser operating
manual and the laser policy and
procedure manual are easily accessible;
(CSA Z386-08);
- confirming that a maintenance file be
kept for every laser and preventive
maintenance be done by authorized
personnel; (CSA Z386-08); and
- collaborating with the Laser Committee
analyzing all accident reports and
recommending changes as required.
(CSA Z386-08).
Is a resource person for all staff.

Provides a safe environment.
CSA Standards provide a basis for revision as

required.
Ensures a safe environment for patients and staff.

Improves safety in the laser program.
Maintains safety in laser program.

Assistance may be required at times.
For legal purposes and patient safety.
For reference if required.
To maintain laser in full operating function. Also

may be used for legal purposes.
Analysis determines the cause and prevents similar

incidents from occurring by modification of the
laser policy and procedure manual.
Laser Perioperative Registered Nurse

4.6.4.7 Responsibilities include but not limited to:
- understanding the terms controlled area,
NHZ and MPE and ensuring these areas
Section 3
Page 236 of 334

PRACTICE
have the appropriate signage and

personal protective equipment.
transporting appropriate laser-related
equipment to the theatre/treatment room
and assembling all needed equipment
and disposable items;
completing the listed responsibilities as
outlined within the controlled area.
turning off the laser machine and
removing the key if the machine is left
unattended in the theatre; (CSA Z38608)
allowing the laser to run through a self
check program noting any errors;
errors will be documented and the laser
will be taken out of service until cleared
by biomedical engineering;
prior to bringing the patient into the
room calibrating and/or test firing
according to manufacturers instructions
where applicable; If unable to test fire
prior to patient entering the theatre, then
test fire should be completed prior to
applying the laser to the patient;
positioning the foot pedal when the
surgeon is ready to operate the laser and
removing all other foot pedals away
from the surgeon;
the laser foot pedal shall be operated by
the surgeon;
constantly being in attendance while the
laser machine is in use;
the laser machine shall be in standby
mode at all times unless verbally
directed by the surgeon to the ready
mode;
when the laser is in the ready mode, the
laser nurses responsibility will be
entirely directed to the laser and the
surgeon;
covering exposed tissue around the
surgical site with wet towels, sponges or
non-flammable materials;
making sure all personnel in or about to
enter the laser treatment area are
wearing appropriate protective
equipment and apparel. This includes
goggles designed for the wavelength of
the laser being used, long sleeve warm
up jackets or gowns to reduce the
amount of exposed skin;
RATIONALE
Affirms equipment is in proper working order.
Prevents inadvertent activation of the laser.
The moisture disperses the energy of the beam in

the non-operative areas
To decrease potential injury due to abherrant
beams in the nominal hazard zone (NHZ).
Section 3
Page 237 of 334

PRACTICE
remove any volatile solutions and have

appropriate fire extinguisher
immediately available;
ensure skin prep solutions have dried
before applying drapes;
entering data in a log book for each
laser procedure i.e., patient name, file
number, treatment performed, name of
physician activating the laser , name of
the perioperative Registered Nurse
attending the laser, laser, hand piece or
fibre used and parameters used; (CSA
Z386-08);
completing a laser safety checklist for
each procedure; (CSA Z386-08) and
removing laser keys and storing away
from the laser when not in use (CSA
Z386-08).
4.6.4.8 Documentation should include but

not be limited to :
- type of laser (fibre, handpiece) used;
- eye protection used by the patient and
the health care team;
- skin protection and if wet towels were
applied;
- parameters set;
- length of treatment and power used;
and
- use of smoke evacuation equipment.
(CSA Z386-08).
RATIONALE
Alcohol based prep solutions may ignite if the

alcohol has not evaporated off
For reference purposes.
Log book is kept for legal purposes. Retain records
as per health care facility policy
For legal purposes and to confirm delivery of

patient care.
Removal of keys prevents unauthorized use of the
laser by untrained personnel. (Some newer
machines have a numeric code that is to be entered
in order to activate the laser) .
Controlled Area
4.6.4.9 The Laser Perioperative Registered Nurse
shall be aware of the controlled area for safe
laser use. The treatment room or theatre
becomes that controlled area and she/he
shall:
- restrict traffic to key personnel only;
- place warning signs conspicuously at all
entrances to the theatre/treatment room
to alert bystanders to the type of laser in
use;
- signage will include: the word,
Danger, the starburst symbol, the
precautions to take-including the optical
density of the glasses required, the laser
type, class and wavelength;
- remove signs when the laser procedure
To protect the patient and the health care team.
Avoids unnecessary risk to other health care team

members.
Warning signs and/or light systems alert personnel

to implement laser safety requirements, which
reduce exposure of eyes and skin to hazardous
levels of laser radiation.
Section 3
Page 238 of 334

PRACTICE
is complete;
lighted signs are optional;
Keep doors to the room closed and
cover windows and openings (i.e. space
between the door frame, observation
deck etc.) with a barrier that blocks
transmission of a beam as appropriate to
the type of laser being used;
reduce reflective surfaces as much as
possible;
have an appropriate fire extinguisher
immediately available; and
if laser safety protocols are being
breached , inform the MLSO, follow the
healthcare facilitys laser policy and
risk management process.

PRACTICE
RATIONALE
Safe and appropriate use of the laser during

surgical intervention is a priority.
Eye Protection
4.6.4.10 Personnel:
Eye protection specific to the wavelength of
the laser in use:
- shall be worn by all health care team
members in the controlled area;
- shall be approved by the MLSO;
- shall be permanently labeled with the
wavelength and the ocular density;
- shall be available at each entrance to the
controlled area;
- shall be inspected prior to each use for
damage/scratches. If there is a concern,
consult the manufacturer of the eye
wear;
- should have side-shields; and
- should be stored in individual cases or
sleeves when not in use.
4.6.4.11
If the patient is awake for treatment:

same eye protection worn by the health
care team shall be worn by the patient.
Ensure that in the supine position, there
are no gaps between the goggles and the
patients face.
4.6.4.12
For a patient requiring general

anaesthesia, eye protection is provided
by:
- using a water-based lubricant on the
conjunctiva gently closing the patients
eye lids and securing with tape;
- covering the eyes with moistened eye
To protect health care team members against eye

injuries from an unwanted reflected beam, a break
in a fibre or a sudden disconnection of a laser
coupler. Prescription glasses do not provide
adequate protection with CO2 laser. (Ball, 2004).
Different laser wavelengths require different
eyewear.
Coating degradation or scratched surfaces of
glasses/goggles may allow the laser beam to
penetrate which may damage the wearer's eyes.
Scratches can change the optical density and leave
the wearer vulnerable to a laser injury
To protect them from damage.
Prevents injury to eyes.
Avoids creating lid injuries.

Water-based gel is not flammable whereas an oilbased ointment is.
Wet eye pads will diffuse the beam and the
Section 3
Page 239 of 334
pads (there should be aluminum foilshiny side up or black felt between 2

wet eye pads for wavelengths between
0.4 and 1.4 micrometers) and securing
with waterproof tape;
covering the eyes with a wet towel; and
water-base gel and special corneal
shields should be used for treatment
close to the eyes or on the eyelids.
RATIONALE
waterproof tape will help retain moisture in the
pads.
Provides the best protection available.
Fire Safety
4.6.4.13 Patients and health care team members
should be protected from fire hazards
associated with laser use. Including but
not limited to:
-
Never use flammable solutions on the

surgical field if laser is planned;
skin preparation
should be non flammable;
ensure the area prepped is dry before

applying drapes;
Drape the rectum with wet towels or
use a saline-soaked radiopaque sponge
in the rectum to prevent unintentional
expulsion of methane gas. (Andersen,
2004);
protect tissue adjacent to laser impact
site, with wet or fire retardant drapes;
(CSA Z386-08)
water based gels only should be used on
the patient (e.g. to slick down hair);
a bowl of sterile water or normal saline
solution and wet towels should be
readily available on the sterile field; and
a fire extinguisher shall be available in
each room. (CSA Z386-08)
4.6.4.14 For upper airway laser procedures the

Perioperative Registered Nurse should be
aware that the anesthesiologist will
require:
a laser- safe endotracheal tube
( already contains the dye in the cuff)
a back-up tube tested and ready for use
inflating the endotracheal tube cuff
with dyed saline if laser safe tubes are
not available. (AORN, 2008, )
a tracheostomy set available in the
Laser beams can cause fires if they strike directly

or are reflected onto combustible material i.e.
rubber, paper alcohol based-preparations etc.
To decrease the potential for fire.
Methane gas (i.e. flatus) is a concern when the

surgeon is working in the perineal area with a CO2
laser. (Andersen, 2004)
To avoid thermal burns.
Water based gels are not flammable.
To extinguish a small fire on the patient or drapes.
To control a fire in the room and/or laser system.

Class IV laser beams can ignite flammable
materials.
To recognize punctures and take immediate action.
A solution in the cuff will absorb more energy
before perforating. Surface of these tubes will give
diffuse reflections if hit by the beam.
If the airway cannot be re-established following an
airway fire, a tracheostomy must be performed.
Section 3
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PRACTICE

PRACTICE
RATIONALE
room.; and
a flexible bronchoscope shall be
available.
4.6.4.15 The Perioperative Registered Nurse will

collaborate with the anesthesiologist
regarding facility protocol for dealing
with jet ventilation using hunsaker
ventilation tubes when laser surgery is
required.
Instruments
4.6.4.16 Anodized, dull non-reflective or matte
finished instruments shall be used near the
laser site. Instruments that have been coated
(i.e. ebonised) should be inspected regularly
to ensure the integrity of the coating.
To reduce the reflectivity of laser beams
Plume (Laser Smoke)

4.6.4.17 Laser plume shall be evacuated at the
source by a smoke evacuator in compliance
with CSAZ305.13-09.
Carcinogenic substances along with chemicals and

viruses are present in plume.
4.6.4.18 Wear a surgical masks that provides

adequate filtration(0.1micron filtration)
fitted snugly around the face.
Laser-specific masks are intended to minimize

inhalation of particles and viruses in plume. A
mask, if not worn properly, will not protect the
user.
For further information on laser plume

evacuation, refer to Smoke Evacuators,
Section 3.
REFERENCES
Andersen, K. (Jan. 2004). Safe use of lasers in the operating room: what a perioperative nurse should know. AORN
http://www.findarticles.com/p/articles/mi_m0FSL/is_/ai_112686288
Ball, K. A. (2004). Lasers: The perioperative challenge. (3rd ed.). Denver: Author.
Canadian Standards Association (2008). CSA Z386 01-08 Laser Safety in Health Care Facilities. Toronto: Author.
BIBLIOGRAPHY
Association for Perioperative Practice (United Kingdom). Prior to 2005 known as National Association of Theatre
Nurses (NATN). www.afpp.org.uk
Association of PeriOperative Registered Nurses. (2008). Recommended practice for perioperative nursing laser
safety in the practice setting. Perioperative Standards and Recommended Practices. Denver: Author.
Section 3
Page 241 of 334
Ball, K.A. Surgical Modalities in Rothrock, J.C.(2003) Alexanders Care of the Patient in Surgery. (12th ed.)
Toronto: Mosby.
Canadian Centre for Occupational Health and Safety Lasers Health Care Facilities, Documented last updated July
4, 2003 Copyright 1997-2008 http://www.ccohs.ca/oshanswers/phys_agents/lasers.html
Canadian Standards Association. (2008). CSAZ305.13-09 Plume scavenging in surgical, therapeutic, diagnostic and
esthetic settings. Toronto: Author.
Koivula, Brenda & Minielly, Brenda, (2006). Canadian Introduction to Green Light Laser. Canadian
OperatingRoom Nurses Journal. 24 (1).
National Association of Theatre Nurses (NATN). (2004), Lasers. Standards and Recommendations for Safe
Perioperative Practice. NATN: Harrogate: UK.: Author.
York University (September 2008), Laser Safety Program. http://www.yorku.ca/dohs/documents/lasersafety.pdf
The University of Western Ontario, Human Resources Occupational Health and Safety. Laser Safety Manual (April
1, 2006). http://www.uwo.ca/humanresources/docandform/docs/ohs1/manuals/laser_safety_manual.pdf
4.7 Minimally Invasive Surgery (MIS)

PRACTICE
RATIONALE
The Perioperative Registered Nurse is responsible

for:
4.7.1
Understanding the differences between

endoscopic and non endoscopic reusable
instruments.
To provide safe, efficient care.
4.7.2
Obtaining and maintaining skill in the care,

handling and management of equipment
including scopes, light sources, microendoscopic instrumentation, video cameras
and insufflators.
To provide safe, efficient care.
4.7.3
Monitoring the functioning of equipment

and the integrity of endoscopic instruments
in collaboration with other health care team
members.
To ensure equipment is safe and

functioning appropriately.
4.7.4
Confirming a brief set of operational

directions are readily accessible with
each system . These instructions should
Availability of proper written instructions

assists in the safe use and handling of
equipment and thereby reduces the potential
Section 3
Page 242 of 334

BC Centre for Disease Control, Radiation Protection Services (September 2005). Laser Hair Removal Devices
Safety Guidelines for Owners/Operators
http://www.bccdc.org/downloads/pdf/rps/reports/Guidelines%20of%20Hair%20Removal%20Laser%20Workers%20
Rev5RR9external%20revBPrevRBPrevvRR1final.pdf

PRACTICE
RATIONALE
be placed on or attached to the

equipment in the theatre. A complete
manufacturers operational manual
should be available.
risk of patient injury.
4.7.5
Ensuring information regarding correct

assembly and intended use is available .
Assists in the safe use of equipment.
4.7.6
Having a clear understanding of the

instructions for reprocessing including
disassembly; and reassembly.
Assists in the safe use of equipment.
4.7.7
Monitoring that disposable, reusable and

multi-use instruments are used according to
manufacturer's recommendations. This
includes endoscopic trocars meeting the
safety criteria established for the practice
setting.
The most frequent catastrophic patient

injury involves trocars. Organ and vessel
trauma may occur from excessive use of
pressure during trocar insertion (AORN,
2008, p. 336)
4.7.8
Confirming that sharps such as trocars and

varres needles are handled, processed, and
stored appropriately.
Reduces the risk of injury to patients and

staff.
4.7.9
Confirming that:
- each piece of endoscopic equipment
(i.e. video camera, monitor, insufflator)
has an assigned identification number;
- video monitors are secured to carts or
ceiling mounts and are positioned for
good visibility by surgical team
members;
- a new single use compatible
hydrophobic filter is attached to the
carbon dioxide insufflator for each
case;
- the insufflation tubing is flushed with
gas before connecting to the cannula;
- the insufflator is elevated above the
level of the operative site;
- the tubing is disconnected before
turning of the insufflators
- disconnect the tubing from the cannula
- if CO2 is not piped in a second full gas
cylinder is readily available;
- the ESU is set at the lowest setting to
achieve the desired tissue effect;
- cannulae are all metal or all plastic and
not a hybrid system;
- electrodes are visually inspected preoperatively and post-operatively for

Section 3
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PRACTICE
RATIONALE
possible loss of insulation integrity and
replaced as necessary;
the power is decreased on light sources
prior to turning the machine off;
endoscopic light cords not connected to
the telescope are turned off or placed in
standby mode;
appropriate precautions (e.g. eye
protection) are taken during
endoscopic surgery and at the time of
release of CO2 from the abdomen;
if an active electrode monitoring
device is to be used with an ESU, it is
turned on; and
instruments and supplies for an open
procedure are readily available.
4.8 Flexible Endoscopes

4.8.1
Manufacturers instructions must be

followed for the use, care and reprocessing
of flexible endoscopes.
Endoscopes are complex, delicate

structures.. Manufacturers instructions are
crucial to ensure the endoscope is safe for
patient use and to prevent damage to the
scope.
4.8.2
Flexible endoscopes shall be inspected for

functionality and cleanliness prior to and
following use.
Inspection includes but is not limited to :
- the control section and the endoscope
connector for loose parts, irregularities,
and deformities;
- the angulation knobs for ease and
control;
- the boot and entire insertion tube for
dents, bulges, holes, cracks and other
irregularities;
- the lens at the distal end of the
insertion tube for scratches, cracks,
stains or other deformities; and
- running your fingers down the entire
length of the insertion tube to check
for smoothness and to ensure no
objects are protruding through the tube.
Using an endoscope that is not functioning

properly may cause injury to the operator or
patient and result in more severe damage to
the endoscope.
4.8.3
Manual cleaning shall commence

immediately following the clinical
procedure. It is recommended that the
manufacturers recommendations for leak
Poorly cleaned endoscopes pose an

infection-control risk to the patient and/or
operator performing the procedure.
Section 3
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PRACTICE
RATIONALE
testing and manual cleaning be followed.

This includes but is not limited to:
- removing debris from instruments by
wiping with a soft cloth;
- Leak test as per manufacturers
Instruction;
- if scope fails leak test, remove
from service and send to biomedical
department or service contract holder;
- if scope passes leak test continue;
- disassemble the instruments;
- remove sealing caps; and
- pen all stopcocks.
4.8.4
Thoroughly rinse all instrument

components with water. The water
temperature should not exceed 20 C
(68F).
4.8.5
Use a medical-grade, low-foaming,

neutral pH detergent or enzymatic
detergent and follow the manufacturer's
dilution and temperature
recommendations.
4.8.6
When instruments with lumens are

cleaned, ensure that the cleaning solution
contacts all surfaces of the lumen. Always
rinse residual cleaning solution and debris
from lumens by connecting them to a
water hose or a syringe.
4.8.7
Thoroughly rinse all of the instruments

components with deionized or sterile
water to remove all disinfectant residues.
4.8.8
If non-sterile water is used for rinsing,

wipe the instrument components and flush
the channels with 70% ethyl or isopropyl
alcohol.
4.8.9
After the alcohol rinse, flush air through

the channels to remove all alcohol. Do
not reuse rinsing water.
4.8.10
Do not immerse instrumentation in

cleaning solution for more than 1 hour.
4.8.11
Use a soft cloth to wipe off any remaining
Leaks in the endoscope can lead to fluid

invasion escalating damage to the
endoscope and increasing the risk of crosscontamination. Perforation of the sheath
may have occurred during the procedure
Lumens are very difficult to check, debris

left sitting will dry quickly making it
difficult to effectively reprocess. Channels
with debris can not be disinfected or
sterilized.
Clogged nozzles and channels jeopardize
patient safety.
Cleaning solutions may contain various

aggressive compounds (e.g. chlorine)
which can corrode the instrument.
To remove all residues, rinse the instrument
thoroughly with deionized or
sterile water.
Section 3
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PRACTICE
RATIONALE
water.
4.8.12
Automatic washer disinfectors may be

used. Use only washer-disinfectors which
are intended specifically for cleaning and
disinfection of endoscopic instruments
and accessories by the washer disinfector
manufacturer. Also refer to the washerdisinfector's instruction manual.
4.8.13
Reprocess according to manufacturers

recommendations. This may include:
- Steam sterilization;
- Ethylene oxide sterilization;
- Peracetic Acid sterilization; or at a
minimum,
- high level disinfection.
4.8.14
Documentation of decontamination
and/or reprocessing should include but
is not limited to:
- the patients name;
- record number;
- procedure performed;
- date and time;
- serial number;
- person manually decontaminating
scope; and
- method of reprocessing.
Each scope is numbered for tracking

purposes.
To assist in outbreak investigation.
REFERENCES
Association of PeriOperative Registered Nurses. (2010). Recommended practices for endoscopic minimally invasive
surgery. Standards, Recommended Practices and Guidelines. Denver: AORN.
CSA Z 314.8-08 Decontamination of reusable medical devices
Olympus System Guide-Endoscopy, Olympus publisher (2010)
Ontario Provincial Infectious Disease Advisory Committee. (2007) Best Practices for Infection Prevention and
Control Programs in Ontario in All Health Care Settings. Retrieved April 26, 2009 from
http://www.health.gov.on.ca/english/providers/program/infectious/pidac/pidac_fs.html
4.9 Telerobotics
4.9.1
Perioperative Registered Nurses should

understand the goals and the objectives of
Telerobotics has evolved from a diagnostic

modality and minimally invasive surgical
Section 3
Page 246 of 334
4.9.2
Telerobotic surgery requires that the

perioperative Registered Nurse has
additional education and training.
technique to advanced information

technology offering treatments and
procedures over long distances.
Telerobotic surgery programs allow distant
experts to assist physically in operations
through the use of a robotic device.
To assist surgeons in telerobotic surgery.
BIBLIOGRAPHY
Chapman, T., Jansen, H., Tyler, L., Prowse, C., Little, C., McGrinder,D. (2001). iView Centre for minimal access
surgery nursing program. (Version 1.0) [CD ROM]: Hamilton, ON: Chapman Interactive.
Ellis, K. (11/07/2006). Endoscope Cleaning and Repair Keeping valuable scopes fit for duty. EndoNurse.
http://www.endonurse.com/articles/681feat2.html
Gandsas, A. (n.d.). Internet site for laparoscopic surgery. Retrieved April 28, 2003, from
http://www.laparoscopy.com
John, A., Clement, L., & Strul, T. (May 05, 2007). Sharpen your focus on endoscope reprocessing
http://www.matmanmag.com/manmatmag_app/jsp/articledisplay.jsp?dcrpath=MATMANMAG/PubsNewsArticleGe
n/data/05MAY2007/0705MMH_FEA_Hotline
Rothrock, J. (2007). Alexanders care of the patient in surgery. (13th ed.). Toronto:Mosby.
Schraag, J. (05/01/2007). Ask the experts: endoscope reprocessing.
http://www.surgicenteronline.com/articles/751feat.html
Section 3
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telerobotic surgery.

Section 4
Environmental Hazards and Responsibilities
Physical Hazards ............................................................................................................................................250

Environmental Factors .....................................................................................................................250
Light ......................................................................................................................................250
Noise......................................................................................................................................251
Ventilation/Temperature/Humidity .......................................................................................252
Electricity .........................................................................................................................................254
Radiation Safety ...............................................................................................................................256
Fire/Explosion ..................................................................................................................................260
Chemical Hazards...........................................................................................................................................263
Anesthetic Agents ............................................................................................................................263
Sterilizing Agents - Ethylene Oxide .................................................................................................264
Other Sterilizing Agents ...................................................................................................................264
Formaldehyde ........................................................................................................................265
Glutaraldehyde ......................................................................................................................265
Methyl Methacrylate ........................................................................................................................265
Drugs: Cytotoxic, Dyes, Pharmaceuticals ........................................................................................266
Waste Management ........................................................................................................................................266
Infectious/Biohazardous Waste ........................................................................................................266
Latex Sensitivity/Allergy: Staff ......................................................................................................................268
Environmental Hazards/Responsibility
Section 4
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Section 4 Environmental Hazards and Responsibilities
1.1 Environmental Factors

1.1.1 Light
PRACTICE
RATIONALE
1.1.1.1 Lighting levels shall be maintained to

provide safe patient care.
Provides adequate illumination for assessment and

treatment of patient.
Allows acceptable visualization of surgical field.
Inadequate lighting (i.e. intensity, glare, and colour)
can distort tissue appearance.
Excessive glare causes eye fatigue and strain.
1.1.1.2 Consideration should be given to the

purchase of matte, satin or grey coloured
finished instruments.
Matte, satin or grey-coloured finishes eliminate glare

and reduce eyestrain.
1.1.1.3 Appropriate colour selection for surgical

drapes, walls, and ceilings should be
considered to facilitate the reduction of glare
causing eyestrain and fatigue.
Soft, cool colours, especially blues, greys, and

greens, are less reflective for drapes and walls than
white is.
1.1.1.4 An emergency lighting system must provide

dependable illumination while the primary
lighting system is off.
Failure of a lighting system could create conditions

dangerous to the health and safety of patients and
members of the healthcare team. An emergency
lighting system must be provided for the workplace
and the exit routes.
1.1.1.5 In the event that the emergency lighting

system does not automatically activate, an
alternate means of illumination should be
readily available.
It is essential that in the event of a power outage, and

no back up generation, those illumination devices
such as flashlights be easily accessible. Flashlights
should be available in every OR, they should be
available in the same location in each OR (locating
items in the dark is a challenge) and a regular
maintenance schedule for the batteries should be set.
BIBLIOGRAPHY
Canadian Centre for Occupational Health and Safety.
http://www.ccohs.ca/oshanswers/phys_agents/noise_basic.html
Canadian Standards Association compendium of Occupational Health and Safety Standards.
http://csa.ca/standards/occupational/Default.asp?language=english (CSA Standands Z1000-06 Occupation
Health and Safety Management)
Section 4
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Physical Hazards
1.1.2 Noise
1.1.2.1 The theatre should be as quiet as possible
except for the essential sounds of
communication between team members
directly concerned with the patient's care.
Talking can increase airborne microorganisms.

Working in a quiet environment produces fewer
psychological and physiologic patient adverse effects
and is less fatiguing to healthcare team members.
Talking should be limited to the essential.
Annoyance, stress and interference with oral
communication are of primary concern in a noisy
OR. Effective communication is essential to
minimize the potential for error.
Even during deep stages of anaesthesia, an
anaesthetized patient may perceive noises and
conversations that occur during the surgical
procedure and may have recall.
1.1.2.2 Noise levels should not exceed the

provincial Occupational Health & Safety
parameters or impede hearing in the room.
Extreme noise from drills, fan motors in equipment,

and other sources can be annoying and potentially
dangerous to patients and personnel. The noise can
become intense enough to increase blood pressure
and to provoke peripheral vasoconstriction, dilation
of the pupils, and other subtle physiologic effects. It
can also interfere with necessary communication and
thereby provoke irritation. (Phillips, 2007, p. 215)
1.1.2.3 Consideration should be given to the use of

appropriate, low volume music to reduce
anxiety and/or distract the patient during the
procedure.
Study results indicate that patients who listen to their

choice of music during surgery experienced
significantly lower anxiety levels, heart rates, and
blood pressure than patients who did not listen to
music.
1.1.2.4 Music should be selected in collaboration

with the patient.
Music may be relaxing for the patient and effect

efficiency of the health care team.
1.1.2.5 Music should be turned off at the request of

the patient or any member of the health care
team.
To provide a respectful environment.
REFERENCES
Nilsson, U. (2008).The anxiety and pain reducing effects of music interventions: a systematic review. AORN
Journal. 87(4), 780-807.
Section 4
Page 251 of 334

Philips, N.M. (2007). Berry & Kohns operating room technique. (11th ed). Toronto: Mosby
Canadian Centre for Occupational Health and Safety.

http://www.ccohs.ca/oshanswers/phys_agents/noise_basic.html
Canadian Standards Association compendium of Occupational Health and Safety Standards.
http://csa.ca/standards/occupational/Default.asp?language=english
Hamlin, L., Richardson-Tench, M. & Davis, M. (2009). Perioperative nursing an introductory text.
Sydney: Elsevier.
Nilsson, Ulrica. (2008). The anxiety-and pain-reducing effects of music interventions: A systematic review. AORN
Journal, 87(4), 780-807.
Worley, D. J. & Hohler, S. E. (2008). OR Construction & Renovations. AORN, 88 (6) 917-941.
1.1.3
Ventilation/Temperature/Humidity
PRACTICE
RATIONALE
1.1.3.1 The ventilating system in the perioperative

environment shall provide air exchanges as
recommended by provincial and/or CSA
(Z317.2.10) standards. Ventilation should
consider asepsis as well as physical comfort.
Ventilation enables air dilution and the removal of

airborne microorganisms. This minimizes the
potential for infection via airborne/droplet
transmission.
1.1.3.2 A scent free environment should be part of

the institutions policies and procedures.
Perfume and other odours can cause nausea or

respiratory congestion in sensitive persons.
1.1.3.3 Ventilation systems should help remove

toxic fumes and anesthetic gas waste.
Removal of air pollution protects surgical suite

personnel.
1.1.3.4 OR ventilation shall be maintained at

positive pressure with respect to the
corridors and adjacent areas.
Positive air pressure prevents infiltration of

microorganisms from the corridor and adjacent areas.
Note: it may be necessary to reverse the air pressure
to negative in the presence of an operative patient
carrying an airborne disease such as TB or measles.
1.1.3.5 All air should be introduced at the ceiling

level and evacuated near the floor level.
OR air may contain microbial laden dust, lint, skin

squamous or respiratory droplets and is directly
proportional to the number of personnel moving about
in the room.
1.1.3.6 Efforts shall be made to minimize personnel

traffic and ensure that the OR doors remain
closed.
Closed doors maintain positive pressure.
Section 4
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BIBLIOGRAPHY
PRACTICE
RATIONALE
1.1.3.7 The temperature of an OR should be

maintained between 20-24 degrees C
(AORN, 2010). Exceptions may include
pediatric, burn, geriatric, or hypothermic
patients.
An OR temperature in this range may inhibit bacterial

growth.
This range is one that most patients can
tolerate and is most comfortable for personnel.
Increased room temperature may be necessary to
attain and maintain normothermia.
Environmental Factors- Humidity

RATIONALE
PRACTICE
1.1.3.8 Surgical suites shall maintain a relative
humidity of 30-60% (CSA Z317.2.10).
A relative humidity of 30% to 60% inhibits bacterial

growth and decreases the potential for static
electricity. A relative humidity that is too high can
result in damp or moist supplies with added
opportunities for mold growth.
A relative humidity that is too low can result in
excessive bacteria laden dust within the surgical
environment.
1.1.3.9 Humidity levels should be reviewed on a

regular basis to ensure compliance with CSA
Z317.2.10 Standards.
Relative humidity levels may be difficult to maintain

in certain geographical locations and during certain
times of the year
REFERENCES
Association of PeriOperative Registered Nurses. (2010). Recommended practices for a safe environment of care.
Perioperative Standards and Recommended Practices. Denver: AORN.
Canadian Standards Association (2010). CSAZ317.2-2.10) Special requirements for heating, ventilation, and air
conditioning (HVAC) systems in health care facilities. Toronto: Author.
BIBLIOGRAPHY
Canadian Standards Association compendium of Standards for Health Care Facility Engineering.
www.csa.ca
Gruendemann,B., Mangum, S., (2001). Infection Prevention in the Surgical Setting. Philadelphia: Saunders
Mayhall, C. G. (2004). Design & Maintanence of hospital ventilation systems and the prevention of airborne
Section 4
Page 253 of 334

Environmental Factors- Temperature
Phillips, N.(2007)Berry & Kohns operating room technique. (11th ed). Toronto: Mosby.
Phippen, M. & Wells, M. (2002). Patient care during operative and invasive procedures. Toronto: W.B. Saunders.
Woodhead, K. & Wicker, P (2005). A textbook of Perioperative care. Philadelphia: Churchill Livingstone
1.2
Electricity
PRACTICE
RATIONALE
1.2.1 Only CSA-approved electrical equipment

shall be used.
Safe electrical equipment reduces injury potential to

patients and members of the health care team.
1.2.2 A qualified biomedical electrical staff member

shall check the electrical safety and integrity
of each piece of equipment prior to entering
the workplace.
Equipment may be damaged during

shipment/movement.
1.2.3 The circulating Perioperative Registered

Nurse shall have knowledge of the safe use
and function of each piece of electrical
equipment. Operator manuals shall be
available for each electrical device.
Malfunctioning equipment and non-compliance with

manufacturers instructions may put patients and
healthcare team members at risk.
1.2.4 The circulating Perioperative Registered

Nurse is responsible to provide the healthcare
team with properly maintained equipment and
to report deficiencies to management.
The circulating perioperative Registered nurse is

responsible for confirming equipment is available
and working order.
1.2.5 Staff members shall be competent using

electrical equipment. Electrical equipment
should be inspected before use; including
review of outlets and switch plates for
damage, checking power cords and plugs for
fraying or other damage.
Defective equipment may result in patient or staff

injury.
1.2.6 All defective or suspect equipment shall be

removed from service immediately, labeled
for repair and checked by authorized
personnel.
1.2.7 Follow facility policy and procedures
regarding faulty/damaged/dropped electrical
Section 4
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infections, Hospital epidemiology & Infection Control (3rd ed.). Philadelphia: Lippincott Williams &
Wilkens
RATIONALE
equipment.
1.2.8 All electrical devices used for patient care
shall be included in a preventative
maintenance program incorporating specific
manufacturers recommendations.
A systematic program helps identify when each piece

of equipment is due for a routine check or
preventative maintenance.
1.2.9 Electrical "alerts" from external agencies shall

be provided to surgical suite management,
following health care facility policy.
Recall and removal of defective equipment is an

important risk management function.
1.2.10 Line isolation monitoring systems or ground

fault interrupting systems should be provided
for continuous monitoring of current leakage.
Surgical suite personnel shall follow the
facilitys procedure when a warning signal is
activated.
Systems that monitor current leakage and ground

integrity identify the potential risks of shock, cardiac
fibrillation, or burns produced by electrical current
flowing through the patients body to ground hazards
in the surgical environment.
1.2.11 Liquids shall never be placed on an electrical

device.
A spill could cause an internal short circuit and injury

to a patient or members of the healthcare team.
1.2.12 The electrical device shall be turned off when

plugging into or unplugging from the power
receptacle.
When disconnecting the plug from the
electrical outlet, the plug rather than the cord,
shall be handled.
Proper handling prevents fibre breakage within the

electrical equipment.
1.2.13 Electrical extension cords should not be used

in operating rooms. If necessary, use only
power bars with built in breakers that have
been approved by the Biomedical Department.
Electrical cords of adequate length should be
attached to equipment. Cords shall not be
revised unless specific manufacturer's
approval is obtained.
Extension cords are associated with current leakage.
1.2.14 Cords lying on the floor shall be secured

(taped/covered) to prevent tripping.
Securing cords can prevent accidental unplugging of

equipment and injury from tripping.
1.2.15 If power bars are used, they must not be

placed on the floor.
Fluids may enter the bar causing a loss of power.
Section 4
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PRACTICE
RATIONALE
1.2.16 Electrical cords shall be loosely coiled during

storage.
1.2.17 Electrical/biomedical departments shall be
consulted in the decision to purchase,
replace/repair electrical equipment.
1.2.18 In the event of a power failure, Perioperative
Registered Nurses should be aware of the
effects to critical equipment during transfer
from regular power to generated power i.e.
automatic shut down of equipment, or data
loss.
BIBLIOGRAPHY
Association of PeriOperative Registered Nurses. (2010). Recommended practices for a safe environment of care.
Perioperative Standards and Recommended Practices. Denver: AORN.
Canadian Standards Association (2008). Z462-08 Workplace Electrical Safety Standard. Toronto: Author.
Phillips, N.(2007). Berry & Kohns operating room technique. (11th ed.). Toronto: Mosby.
1.3
Radiation Safety
PRACTICE
RATIONALE
1.3.1
Radiation Protection Acts of each province

and CSA Standards shall be followed.
Provincial and federal legislation regulates the

recording and reporting process of radiation
monitoring.
1.3.2
Health care facility policies and procedures

shall be developed and implemented in
accordance with provincial and federal
government regulations.
Current radiation safety policies and procedures will

contribute to quality patient and personnel care.
1.3.3
All persons exposed to ionizing radiation

with significant frequency or during
prolonged procedures may be required to
wear a dosimeter, a device used to measure
levels of ionizing radiation in the workplace.
A dosimeter will allow monitoring of exposure to

radiation on a regular basis and will help
occupational health specialists assess the risk in case
of accidental exposure. A dosimeter can help ensure
that best practices are followed to keep doses as low
as can reasonably be achieved.
Section 4
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PRACTICE
RATIONALE
1.3.4
Dosimeters are worn on the area of the body

with the highest likelihood of radiation. A
dosimeter is assigned to a specific
individual. Do not loan or exchange your
dosimeter with another person.
Thermoluminescent dosimeter = TLD
1.3.5
Radiation safety policies and procedures

should be included in the orientation and
annual education of all members of the
healthcare team.
Radiation safety practices will be reinforced and

misconceptions or unrealistic practices related to
radiation exposure and monitoring will be corrected.
1.3.6
Diagnostic Imaging (DI) equipment shall be

operated by, or under the direct supervision
of, qualified individuals (Health Canada,
2008).
Optimum safety for patients and personnel is

achieved by safe work practices.
1.3.7
During a procedure, the constant monitoring

of radiation safety precautions for patients
and personnel shall be a shared
responsibility between perioperative
Registered Nurses, Diagnostic Imaging
Technicians and Physicians.

1.3.8
Confirming that safety precautions are in

place to protect patients and members of the
healthcare team from the potential hazards
of ionizing radiation.
X-rays of all frequencies can damage tissues and

may produce long-term effects. The effects of
radiation are dose-dependent and cumulative: the
larger the dose or the more frequent the exposure, the
greater the risk of the effects of radiation (Rothrock,
2007, p. 20). Ionizing radiation can accumulate in
human tissue and alter cell composition. Exposure to
ionizing radiation should be kept as low as possible.
1.3.9
Providing patient protection during DI

procedures by:
- maintaining the integrity of the sterile
field during radiographic examination;
- using an appropriate lead shield
positioned between the patient and
radiation sources if it will not interfere
with the sterile field or visualization for
the DI study. Shields should be placed:
- over reproductive organs during
radiographic studies of the
abdomen, hips, and upper legs,
Being cognizant of the key factors of radiation

protection: time, distance, and shielding.
Section 4
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PRACTICE
where possible; and

over the thyroid/sternum during
radiographic studies of the head
neck, and upper extremities;
using a lead shield to protect the fetus
of a pregnant patient;
reconciling an incorrect surgical count
before using a radiological examination;
documenting on the perioperative
record; type of radiographic equipment
used, type of patient protection used and
area(s) protected.
RATIONALE
1.3.10
1.3.11
Confirming the following precautions for

the health care team are used to limit the
length of exposure to radiation:
- pregnant staff should wear a lead apron
which wraps around and covers the
back;
- provide relief/replacement staff, where
possible, for pregnant staff to
eliminate/reduce exposure during
pregnancy;
- radiation equipment is turned off when
not in use;
- Regulations related to specific
radioactive materials shall be available
to the health care team including
handling of the material/containers, safe
proximity to the radiated patient,
handling of body tissues or fluids
emitting radioactivity.
Confirming the following precautions are
used to distance personnel as far as possible
from the source of ionizing radiation:
- unsterile team members who can safely
do so should leave the theatre during
each single DI exposure;
- sterile team members and others who
cannot leave the theatre should stand 2
meters (6 ft) or more from the patient,
and behind a portable lead screen which
is positioned behind a portable x-ray
machine if possible, and out of the
direct beam during exposure;
- lead shielding shall be provided to
Low levels of ionizing radiation may be harmful to a

fetus if x-ray is done in close proximity.
Although radiation is present only when the

equipment is energized, turning off the unit when not
in use will prevent inadvertent activation.
Exposure is significantly reduced at this distance.
Section 4
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PRACTICE
personnel who cannot stand 2 meters (6

ft) away from the x-ray tube and
patient, or follow equipment
that if the lead apron does not wrap
around the body, team members should
face the radiation source;
holding devices, such as slings, traction

devices, sandbags, and cassette holders,
should be used to maintain the position
of the patient and x-ray film; and
wearing of radio protective gloves in

addition to aprons and thyroid
shields/collars if the patient must be
held;
RATIONALE
To provide protection, the lead apron must be

between the source of radiation and the body.
Lead screens and/or lead aprons and thyroid shields
minimize exposure to scattered ionizing radiation.
Holding devices allow personnel to reduce their
exposure by distancing themselves from direct and
scattered ionizing radiation.
1.3.12
Confirming that during fluoroscopy, in

addition to leaded aprons, personnel should
wear:
- thyroid shields if they are in proximity
to the patient;
- eye protection (lead-glass lenses or face
masks with lead-acrylic windows) if
they are next to the patient during
frequent or long periods of fluoroscopy;
and
- radio protective gloves if their hands are
exposed to the direct beam.
The potential for exposure to radiation is greater

during fluoroscopy than during conventional
radiographic studies due to increased radiation scatter
and exposure time.
1.3.13
Confirming that lead aprons and thyroid

collars are appropriately hung or laid flat
when not in use;
Folding can crack the lead, making the shield

ineffective.
1.3.14
Confirming that lead shields/aprons and

thyroid collars be tested upon receipt and
routinely by the diagnostic imaging
department to fulfill provincial
requirements;
Defects may not be visually detected.
1.3.15
Confirming that warning signs for DI

equipment are affixed to the theatre door(s)
when radiographic equipment is in use.
Personnel are alerted to the presence of ionizing

radiation being used, and can take appropriate
radiation protection precautions before entering the
theatre.
Section 4
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PRACTICE
Health Canada. (2008). Safety procedures for the installation, use and control of x-ray equipment in large medical
radiological facilities. Safety Code 35, Ministry of Health: Ottawa.
Phillips, N.M. (2007). Berry & Kohns operating room technique. (11th ed.). Toronto: Mosby
BIBLIOGRAPHY
Association of PeriOperative Registered Nurses. (2010). Recommended practices for reducing radiological exposure
in the perioperative practice setting. Perioperative Standards and Recommended Practices. Denver:
AORN.
Canadian Standards Association (2005). CSA C22.2 number 114-M90 Diagnostic Imaging & Radiation therapy
Equipment . Toronto: Author.
Chaffins, J. (2008) Radiation protection and procedures in the OR. Radiologic Technology, 79(5), 415-428.
Ursprung, W., Howe, J., Yochum, T., Kettner, N. (2006) Plain film radiography, pregnancy, and therapeutic abortion
revisited. Journal of Manipulative and Physiological Therapeutics, 29(1), 83-87
1.4
Fire/Explosion
PRACTICE
RATIONALE
1.4.1
The potential of fire should be a matter of

prime concern in the surgical suite.
The fire triad/triangle in the perioperative setting

consists of fuel (flammable and combustible liquids,
vapours, and gases, prep solutions, drapes, sponges, etc)
and an ignition source (ESU, Laser, electrical
equipment) in an oxygen-rich environment.
1.4.2
All personnel shall be educated about the fire

safety program during initial orientation and
reviewed on a regular basis according to
facility/regional policy. Specific instructions
about the expectations for the perioperative
setting and the response and role of each
employee in the event of a fire should be
described.
Expedient and proficient performance is required in a

disaster
1.4.3
Practice drills should be conducted routinely

according to facility/regional policy.
This represents a key component of fire safety

preparedness. Annual fire and patient safety training
Section 4
Page 260 of 334

REFERENCES
RATIONALE
programs can help to maintain skills and knowledge.
1.4.4
Surgical suite personnel should be

knowledgeable regarding:
- the location of fire alarms;
- the location of exits;
- the evacuation routes and techniques;
- the steps in reporting a fire;
- automatic fire detection and suppression
systems;
- the location of shutoff valves for oxygen
and other gases; and
- the types, uses and location in the unit of
the fire extinguishers.
1.4.5
Precautions shall be taken when using heatgenerating equipment. Surgical suite personnel
shall identify fire hazards and apply
appropriate safeguards, such as:
- the anaesthesia machines, cylinders of
compressed gas, and flammable liquid
containers should be kept away from any
source of heat and must not touch each
other;
- oil or grease is not used on oxygen valves
or parts of anesthetic machines. Oil or
grease should not contact any cylinders,
including those containing ethylene oxide,
compressed air, or nitrogen;
- if flammable antiseptics and fat solvents
are used for preoperative skin preparation
before laser and electrosurgery, they shall
be allowed to dry; following
manufacturers recommendations;
- precautions shall be taken when using a
possible ignition source, such as laser, the
electrosurgical unit or fiber optic light
cables;
-
1.4.6
precautions shall be taken when using

heat generating equipment such as the
operating microscope; and
apply a small drip of sterile water on a
moving drill/burr of power tools.
Volatile liquids shall be stored according to

manufacturers recommendations and
provincial fire codes.
A mixture of gases under high pressure is hazardous.
Spontaneous combustion can occur when flammable

agents are exposed to an ignition source in the presence
of oxygen.
Pooled solutions and vapours can ignite.
Laser and other heated objects can cause fire or

explosion. Light cords can spontaneously ignite drapes.
Connect all light cords to telescopes prior to turning the
light source on. Always use a safety holster for
electrosurgical tips.
Heat may build up under coverings of heat generating
equipment.
Helps to reduce heat build-up as drill/burr moves
through the bone.
Chemical components may be altered by temperature
and lighting variances.
Section 4
Page 261 of 334

PRACTICE
RATIONALE
1.4.7
Fire extinguishers shall be regularly

maintained and dated according to provincial
regulations.
Outdated extinguishers present an additional hazard.
1.4.8
Instructions for activating fire alarms shall be

posted at each alarm location.
1.4.9
If fire blankets are available for use, follow

Fire blankets shall not be used for a fire
burning on a patient.
The fire can continue to burn unobserved under the

blanket.
REFERENCES
Canadian Standards Association. (2009). Z 305.13-09 CAN/CSA Plume scavenging in surgical, diagnostic,
therapeutic, and aesthetic settings. Toronto: Author.
BIBLIOGRAPHY
AMT Electrosurgery. Nurses Advocating Smoke free Theatres Immediately.
http://www.becomenasti.com/resources.htm
Association of PeriOperative Registered Nurses AORN (2010). Perioperative Standards and, Recommended
Practices.Denver: Author.
Association of PeriOperative Registered Nurses. (2005). Recommended practices for electrosurgery. Standards,
Recommended Practices, and Guidelines. Denver: AORN.
Sydney: Elsevier.
National Institute for Occupational Safety and Health (NIOSH 1998). Control of smoke from laser/electric surgical
procedures. NIOSH Publication No. 96. p. 128. http://www.cdc.gov/niosh/hc11.html
Phippen, Mark L., Wells, Maryanne Papanier, Patient Care during Operative and Invasive Procedures, 2000, p. 155,
W.B. Saunders Company Toronto.
Taylor, S. (2009). The OR: Smoking in a Designated Non-Smoking Area. Canadian Operating Room Nurses
Journal, 27( 1).
Section 4
Page 262 of 334

PRACTICE
Monitoring of exposure to Chemical Hazards shall comply with provincial legislation/guidelines.
2.1
Anesthetic Agents
PRACTICE
RATIONALE
2.1.1
A waste gas control program using

scavenging equipment and procedures shall
be used.
Personnel exposure is reduced by 90-95% with

proper use of scavenging equipment. (Rothrock,
2011)
2.1.2
The air quality should be checked according

to the health care facilitys policy and
provincial guidelines.
Safe air quality will improve the environment for the

health and safety of the healthcare team.
2.1.3
The manufacturers liquid anesthetic

dispensing devices shall be used when
transferring anesthetic agents into
vaporizers.
Control of anesthetic agents pollution into the

environment protects the health care team.
2.1.4
Qualified personnel shall maintain

anesthetic machines daily and provide
routine preventative maintenance.
2.1.5
Engineering control procedures should

maintain a high flow rate of fresh air into the
air-conditioning system.
The rate of removal of gases by the disposal system

depends on the rate at which fresh air enters the
surgical suite and the pattern taken by the air currents
as they circulate through the theatre.
2.1.6
A surgical suite atmospheric monitoring

program shall be utilized to record trace
anesthetic levels.
Monitoring devices (i.e. personal dosimeters) will

determine the effectiveness of the waste anesthetic
gas control measures.
REFERENCES
BIBLIOGRAPHY
Ontario Occupational Health and Safety Act. Control of exposure to biological or chemical agents. Regulation
833,am. O. Regs. 513/92: 592/94.
Workers Compensation Board of British Columbia, Occupational Health & Safety Regulation 296/297. Core
Requirements (parts 5-19) pp. 5-10 to 5-14
Section 4
Page 263 of 334

Chemical Hazards
2.2
Sterilizing Agents Ethylene Oxide (EtO)

PRACTICE
RATIONALE
2.2.1
Items sterilized with EtO shall be thoroughly

aerated prior to handling or use according to
the device manufacturers instructions.
Personnel shall not interrupt the aeration
cycle to remove items for use. (CSA
Z314.2-09)
Residual by-products of EtO gas can be toxic in

direct contact with the skin or by inhalation.
Exposure can cause dizziness, nausea, and vomiting.
EtO is known to be a mutagen and carcinogen.
2.2.2
EtO gas shall be vented from the sterilizer to

the outside atmosphere according to CSA
and provincial guidelines to avoid personnel
exposure and environmental pollution.
Audible and visual alarm systems shall be
installed to indicate a failure in the
ventilation system.
Toxic emissions and residues of EtO present health

hazards to patients, members of the healthcare team
and the environment.
2.2.3
An evacuation plan shall be in place, posted

and initiated in event of an alarm/leak.
2.2.4
Air quality monitoring shall be in place and

comply with OH&S and CSA standards.
2.3
Other Sterilizing Agents
2.3.1
Manufacturers instructions for use shall be

followed. Material Safety Data Sheets
(MSDS) shall be available.
OH&S is responsible for monitoring this process.
Examples of sterilizing agents include but

are not limited to:
- Para Acetic Acid;
- Hydrogen Peroxide Plasma;
- Ozone Gas; and
- Chemical sterilant in solution i.e.
Glutaraldehydes or
orthophthalaldehyde (OPA).
2.3.2
Provincial/municipal and occupational

health regulations shall be adhered to as they
relate to:
- personal exposure limits;
Section 4
Page 264 of 334

CAN/CSA Anesthetic Gas Scavenging Disposal Systems. CAN/CSA-Z7396.2-09
2.3.1
monitoring of exposures;
installation of systems;
mixing of chemicals;
testing of solutions;
venting of systems; and
disposal of end products.
Formaldehyde
2.3.1.1 Care shall be taken to provide adequate

protection for workers to prevent exposure
to skin and respiratory tract.
Use of Personal Protective Equipment (PPE) and

adequate ventilation, along with routine periodic
monitoring of the environment, protects employees.
Formaldehyde is a potent allergen, mutagen, and
carcinogen, and is NOT recommended for use.
Vapors may be toxic (Phillips, 2007, p 321).
2.3.2 Glutaraldehyde
2.3.2.1 MSDS shall be available.
The Public health agency of Canada issues

regulations to educate and communicate material
hazards under legislated Workplace Hazardous
Information System (WHMIS) in the form of
Material Safety Data Sheets (MSDS).
2.3.2.2 Protective apparel to be worn per

manufacturers instructions when using
chemical disinfectants.
The fumes from the liquid form of Glutaraldehyde

may be irritating to the eyes, nose and throat.
Contact dermatitis has been reported.
2.3.2.3 Glutaraldehyde shall be used according to

2.3.2.4 Glutaraldehyde air monitoring systems
should be used.
An exposure limit of 0.2 ppm in room air averaged

over 8 hours has been established by OSHA.
(Phillips, 2007, p 321).
2.4
Methyl Methacrylate
2.4.1
A closed mixing system should be used

according to manufacturers instructions.
The vapours released during mixing are irritating to

the eyes and can damage soft contact lenses. The
vapours are also irritating to the respiratory tract and
they may cause drowsiness. Methyl Methacrylate
may be a mutagen, a carcinogen, or toxic to the liver.
Pregnant personnel are encouraged to leave the room
during mixing and application.
2.4.2
Eye protection shall be worn when

handling/mixing methyl methacrylate.
The liquid solvent can cause corneal burns if it

splashes into the eyes. It can also diffuse through
Section 4
Page 265 of 334

2.5
Drugs: Cytotoxic, Dyes, Pharmaceuticals
2.5.1
All chemical agents should be prepared and

administered to minimize unnecessary
exposure for both patients and personnel.
latex gloves to cause an allergic dermatitis.
Antineoplastic cytotoxic drugs used for

chemotherapy can be hazardous, as can laser dyes
and other pharmaceuticals.
REFERENCES
Canadian Standards Association. (2009). CSA Z 314.2-09 Effective sterilization in health care facilities by the
ethylene oxide process. Toronto: Author.
BIBLIOGRAPHY
Canadian Standards Association. (2009). CSA Z314.9-09 Installation, ventilation, and safe use of ethylene oxide
sterilizers in health care facilities. Toronto: Author.
Canadian Standards Association. (2009). CSA Z314.1-09 Ethylene oxide sterilizers for health care facilities.
Toronto: Author.
Cloft, H. J,. Easton, D. N,. Jensen, M. E., Kallmes, D. F. & Dion, J. E (2006) . Exposure of Medical Personnel to
Methylmethacrylate Vapor during Percutaneous Vertebroplasty. American Journal of Neuroradiology.
Retrieved April 26, 2009 from http://www.ajnr.org/cgi/content/full/20/2/352
Murphy, L. (2006). Ozone-The Latest Advance in Sterilization of Medical Devices. Canadian Operating Room
Nurses Journal 24 (2).
Workers Compensation Board of British Columbia, Occupational Health & Safety Regulation 296/297 Core
Requirements (parts 5-19) pp. 5-27.
Waste Management
3.1
3.1.1
Infectious/Biohazardous Waste
PRACTICE
RATIONALE
Local/provincial/federal requirements shall

be followed when handling potentially
infectious/biohazardous waste.
Medical waste that poses public health and

environmental risks is regulated.
Section 4
Page 266 of 334

Gloves that are impermeable to this solvent

are available.
RATIONALE
3.1.2
Potentially infectious waste shall be

segregated from general waste at point of
use as outlined in CSA Z317.10-09.
3.1.3
Potentially infectious waste shall be placed

in leak proof containers or bags strong
enough to maintain integrity during
transport to biohazardous waste disposal.
Biohazardous Bags shall be colour-coded
according to local/provincial/federal
requirements to differentiate infectious
waste.
3.1.4
Needles and sharps shall be put into tamper

proof, puncture-resistant containers clearly
labeled as biohazardous.
3.1.5
Fluid containers with blood and body fluids

shall be handled with care.
Containers shall be impermeable to
moisture, resistant to puncture/rupture and
sealed to prevent leakage.
Reduces the risk of healthcare team exposure.
3.1.6
Potentially infectious substances and

contaminated equipment shall be handled
carefully by the health care team and
discarded or decontaminated as appropriate
i.e. double bagging if outside of the
container has been contaminated.
Treat all blood and body fluids as potential sources of

infection.
3.1.7
Liquid contaminated waste shall be

transported by:
- solidifying at point of use
- contained containers.
All handlers of infectious waste must be protected

from risk of infection/contamination with proper
containment that remains intact to the point of final
disposal.
Suctioned blood and body fluids shall be

disposed of according to
local/provincial/federal requirements.
Fluids may be poured down a drain
connected to a sanitary sewer.
Team members shall take caution when
pouring liquids, and wear Personal
Protective Equipment such as mask and
glasses when disposing of liquids.
Caution must be taken when pouring liquids to

minimize the aerosols.
Section 4
Page 267 of 334

PRACTICE
RATIONALE
Perioperative Registered Nurses should be

aware of and participate in recycling
according to the healthcare facilitys policies
and procedures.
Reduces environmental impact of high volume long

lasting waste materials. A successful program can
promote health care team satisfaction.
REFERENCES
Canadian Standards Association. (2009). CSA Z317.10-09 Handling of waste materials in health care facilities and
veterinary health care facilities. Toronto: Author.
BIBLIOGRAPHY
CCME Canadian Council of Ministers of the Environment (CCME) http://www.ccme.ca
WHO Health Care Waste Management http://www.healthcarewaste.org/en/en/115_overview.html
Latex Sensitivity/Allergy: Staff

True latex allergies are a serious risk to patient and personnel; latex sensitivities may lead to true allergy, therefore
all reasonable attempts to reduce latex items from the operating room should be taken.
PRACTICE
RATIONALE
4.1
All staff should receive an annual

educational session on the following:
- awareness of the potential risk of
sensitization to latex and other allergic
sensitizers; and
- awareness of products, which contain
latex and available alternatives.
Latex allergy is a reaction to certain proteins in

natural rubber latex.
4.2
Health care team members should limit their

exposure to latex by:
- appropriate use of unsterile latex
gloves. Latex gloves are the glove of
choice for high risk situations,
involving potential exposure to blood
borne pathogens. (Gruendemann &
Mangum, 2001, p. 133);
- drying hands thoroughly before donning
latex gloves;
Latex allergy rates among surgeons and direct care

providers are reported between 6-12%.
Warm, wet skin absorbs latex particles more readily

than dry skin.
Section 4
Page 268 of 334

3.1.8
PRACTICE
RATIONALE
avoiding touching eyes, nose, and

mouth while wearing latex gloves;
removing gloves in a gentle manner;
and
Latex protein molecules can be transferred to

sensitive mucous membranes.
Glove powder has been shown to bind to free natural
rubber latex protein in latex gloves, becoming
airborne during glove donning and removal and
leaving residue to be inhaled by people in the
immediate environment or settle on furniture and
equipment. (Cumming, 2002, p. 288)
washing hands immediately after

removing latex gloves.
Latex proteins and other contaminants, which are

present in powder, are removed by hand washing.
4.3
Avoid lotions that contain oils including

mineral, lanolin, coconut, palm or jojoba, as
well as Vaseline and other petroleum-based
products. Use only water or silicone based
moisturizing creams. Confirm with
manufacturers of skin care agents to verify
latex compatibility.
Petroleum/oil-based products can compromise the

integrity of latex by breaking down chemical bonds
in the material. Through chemical-mechanical
means, the oils disrupt the protective molecular
bonds within the glove, compromising protection.
(Truscott & Stoessel, 2002, p. 26)
4.4
Surgical latex gloves should be of lowprotein construction and powder-free.

(NIOSH, 1997, No. 97-135)
Latex proteins bound to cornstarch are allergens,

which may induce allergic reactions and increase the
risk of upper airway allergies.
4.5
Health care facilities should promote

purchasing and/or tender practices indicating
that non-latex products are preferred.
4.6
Health care facilities should advocate that

latex content be well labeled on all products.
Immediate knowledge of latex content of product

may avoid potential reaction for latex sensitive staff
and patients.
REFERENCES
Cumming, R. G. (2002). Reducing the Hazards of Exposure to Cornstarch Glove Powder. AORN Journal. 76(2).
Denver: AORN.
Saunders.
Truscott, W., Stoessel, K. (2002, May). Factors Impacting the Infection Control Capability of Gloves. Managing
Infection Control. 18-32.
BIBLIOGRAPHY
Association of PeriOperative Registered Nurses. (2010). AORN latex guideline. Perioperative Standards and
Section 4
Page 269 of 334

PRACTICE
Australian College of Operating Room Nurses. www.acorn.org.au

DeFreitas Saab, T. (2008). US Dept of Labor Office of Disability Employment, Accommodation and Compliance
Series, Employees with Latex Allergy, Job Accommodation Network, Morgantown, WV.
Fuller, J. (2005). Surgical technology- principles and practice (4th ed). Philadelphia: Saunders.
Goldman, M. A. (2008). Pocket Guide to the Operating Room (3rd ed.). Philadelphia: FA Davies.
Sydney: Elsevier.
Health Canada. http://www.hc-sc.gc.ca
International Federation of Perioperative Nurses. www.ifpn.org.uk
International Association Healthcare Central Services Material Management (2007) Central Services Technical
Manual. Author. http://iahcsmm.org/
Public Health Agency of Canada www.publichealth.gc.ca .
Spry, C. (2009). Essentials of Perioperative Nursing (4th ed.). Toronto: Jones & Bartlett.
Woodhead, K and Wicker, Paul. (2005). Textbook of Perioperative Care. Toronto: Elsevier.
Workplace BC (2005). Dealing with Latex Allergies at Work. Workers Compensation Board of BC, Vancouver
BC.
Section 4
Page 270 of 334

Recommended Practices. Denver: Author.

Section 5
Nursing Care of the Anesthetized Patient
Preoperative Considerations ...........................................................................................................................273

Intraoperative Considerations .........................................................................................................................275
Postoperative Considerations..........................................................................................................................279
Local Anesthesia.............................................................................................................................................281
Procedural Sedation/Analgesia .......................................................................................................................283
Intravenous Regional Anesthesia (Bier Block) ..............................................................................................288
Regional Anesthesia-Spinal, Epidural, Peripheral Nerve Blocks ...................................................................290
Herbal Remedies.............................................................................................................................................292
Blood and Blood Products ..............................................................................................................................294
Emergency Situations .....................................................................................................................................296
Malignant Hyperthermia ..................................................................................................................296
Latex Allergy....................................................................................................................................298
Cardiac Arrest ..................................................................................................................................300
Disseminated Intravascular Coagulation ..........................................................................................302
Death ................................................................................................................................................304
Section 5
Page 272 of 334

Section 5 Nursing Care of the Anesthetised Patient
PRACTICE
RATIONALE

1.1
Performing a perioperative nursing

assessment and review of the health care
facilitys Preoperative Checklist prior to
patient transfer to the OR theatre. This
includes but is not limited to:
- verification of patient
- physiological systems risks i.e. injury,
infection:
- psychological response to surgical
intervention i.e. NPO status; and
- relevant allergies are identified and
confirmed
Perioperative knowledge to create an individualized

patient care plan facilitates patient safety.
Perioperative assessment is a key component in the
assessment and management of risk. It enhances
patient care and improves efficiency.
The perioperative nurse shall ensure the

patients chart includes but is not limited
to:
- history and physical examination;
a surgical consent that is complete and
matches the planned procedure ; and
- any other documents as required by the
health care facilitys policy.
Sources of assessment data include but
are not limited to:
- the patient;
- patients record; and
- patients family support
1.2
Establishing a supportive and caring

relationship by:
- introducing him/herself by name and
designation;
- speaking directly to the patient using
eye contact (without a mask);
- actively listening to the patient; and
- using touch to convey support and
caring.
1.3
Establishing nursing diagnoses and

planning interventions that are
individualized and culturally sensitive,
based on assessments that may consider:
- co-morbidities;
- physical limitations;

Section 5
Page 273 of 334

Preoperative Considerations
infection;
fluid balance;
temperature regulation;
pain;
anxiety;
privacy and confidentiality.
glycemic indications
antibiotic prophylaxis; and
risk for venous thromoembolism
(VTE)
1.4
In collaboration with the anesthetic care

provider, providing and updating a list of
the routine supplies, equipment, and drugs
required for the administration of
anesthesia and confirming that the listed
items are available in the theatre and
functioning prior to the patients
admittance to the operating room.
1.5
Communicating key information identified

in the preoperative assessment to the
surgical team
1.6
Applying knowledge and skills in assisting

the anesthesia care provider to assemble,
prepare for use, and disassemble anesthetic
equipment and supplies required for
administration of a specific anesthetic
technique i.e. regional blocks, epidurals,
spinals, neurolept analgesia, conscious
sedation and general anesthesia.
1.7
Confirming that equipment has been

properly cleaned, decontaminated,
disinfected, and/or sterilized between each
patient as required by healthcare facilitys
policies and procedures, provincial and/or
federal regulations, and according to
manufacturers recommendations.
Anaesthesia equipment that has come in contact

with mucous membranes, blood or body fluids is
decontaminated and reprocessed after use to render
it safe for handling and for subsequent patient use.
The anaesthesia equipment may harbour
microorganisms that spread infections.
1.8
Overseeing a safe transfer to the OR bed

by:
- locking the wheels;
- securing and protecting the IV,
drains, tubes and other necessary
equipment; and
- providing support to the head,
arms, and legs.
To prevent injury to the patient or equipment

damage.
Resources are necessary for the anaesthetic care

team to function efficiently.
Section 5
Page 274 of 334

Association of PeriOperative Registered Nurses. (2008). Perioperative Standards and Recommended Practices.
Denver: Author.
Australian College of Operating Room Nurses. www.acorn.org.au
Canadian Standards Association PLUS 1112 (2nd ed.). (Mr. 2004) Infection prevention and control in office-based
health care and allied health.
Canadian Standards Association. (2008). Decontamination of reusable medical devices. CSA Standard Z314.8-08.
CSA: Toronto.
Crenshaw, J., Winslow, E. (2008). Preoperative fasting duration: Are we improving. AORN Journal, 88(6), 963-976.
Fuller, J. (2005). Surgical technology- principles and practice (4th ed). Philadelphia: Saunders.
Goldman, M. A. (2008). Pocket Guide to the Operating Room (3rd ed.). Philadelphia: FA Davies.
Sydney: Elsevier.
Neil, J. (2008). Caring for patients with tuberculosis. AORN Journal, 88(6), 942-958.
Philips, N. (2007). Berry & Kohns operating room technique. (11th ed.). Toronto: Mosby.
Provincial Infectious Diseases Advisory Committee (PIDAC). (April 30, 2006) Best Practices for cleaning,
disinfection and sterilization (April 30, 2006). Ontario. Retrieved April 26, 2009 from
Rothrock, J. (2010). Alexanders care of the patient in surgery. (14th ed). Toronto: Mosby.
Ryan, K., Johnson, S. (2009). Preventing DVT: A perioperative perspective. AORN Journal, 19(2), 55-59.
Spry, C. (2008) Essentials of perioperative nursing. (4th ed.). Mississauga: Jones and Bartlett.
Wicker, P., Smith, B. (2006). Checking the anesthetic machine. Journal of Perioperative Practice, 16(12), 585-590.
Woodhead, K., & Wicker, P. (2005). A textbook of perioperative care. Toronto: Elsevier.
Intraoperative Considerations
PRACTICE
RATIONALE
The perioperative Registered Nurse is responsible for::

2.1
Ensuring availability and functionality of

equipment prior to admission of the patient

Section 5
Page 275 of 334

BIBLIOGRAPHY
2.2
Remaining at the patients side during

induction. Being alert to potential
induction/intubation complications and
able to acquire appropriate and immediate
assistance, i.e. suction, difficult intubation
equipment.
2.3
Assisting the anesthesia care provider

during induction and as required during the
intraoperative period.
2.4
Under direction of the anesthesia care

provider, applying effective cricoid
pressure, support head positioning, and
oxygen administration.
Cricoid pressure will prevent aspiration of

regurgitated stomach contents and is maintained
until:
- intubation is accomplished;
- the cuff on the endotracheal tube is inflated;
- bilateral breath sounds have been verified; and
- instructed by the anesthesia care provider.
Cricoid pressure is contraindicated when:
-there is trauma to the anterior neck
- unstable C spine
-patient is actively vomiting prior to induction
2.5
Maintaining awareness of patient

monitoring and
communicating/collaborating with the
anesthesia care provider during anesthesia.
Observation will immediately detect changes in

the patients condition during the perioperative
phases so that adjustments in treatment, as
warranted, can be made.
2.6
Avoiding undue stimulation and providing

a quiet environment that supports
anesthetic readiness, patient safety and
comfort during induction.
Tactile or auditory stimulation may produce

excitement in the patient during induction.
2.7
Practicing patient advocacy and taking

appropriate action regarding instances of
incompetent, unethical, or illegal acts by
any member of the health care team or
system.
The perioperative Registered Nurse has the unique

opportunity to speak on behalf of the patient and
interpret individual needs and responses to others
who participate in his/her care.
Advocacy is a critical issue for surgical patients
who are unconscious or sedated and unable to
make decisions related to their care.
(Boyle, 2005, p 250)
2.8
Keeping the patient appropriately covered.
To maintain patient dignity and privacy; and

facilitate normothermia.
2.9
Providing appropriate care to pediatric

patients by considering the following:
- allowing parental/care giver to be
present if the health care facility
The presence of the parent/care giver may decrease

anxiety.
To provide physical protection, and emotional

support.
Anesthesia involves the administration of
potentially lethal drugs and gases. Interaction of
these with human physiology can be profound.
(Philips, 2007)
Section 5
Page 276 of 334

to the OR theatre. (i.e. fully lighted

laryngoscope and suction).
policy allows;
allowing security/comfort items; such
as blanket, toy, under garments;
employing age appropriate distraction
techniques; and
preventing falls without using a safety
strap.
Security and comfort provides a safe environment

for the child.
Safety straps may be anxiety inducing for children.
2.10
Applying knowledge of the medications

being administered, i.e. induction,
maintenance, muscle relaxants, emergency
drugs.
2.11
Assisting in establishing patient specific

invasive and non-invasive monitoring
including but not limited to:
- temperature, pulse and respiration
(TPR);
- blood pressure (BP);
- electrocardiogram (ECG);
- oxygen saturation ( SAO2);
- end tidal carbon dioxide ( ETCO2);
- central venous pressure (CVP),
pulmonary artery (PA) and arterial
lines;
- fluid and electrolyte status;
- urinary output; and
- lab tests/results.
2.12
Providing personal protective equipment

(PPE) for the health care team during the
induction period
2.13
Confirming that contaminated designated

single use items are discarded, (i.e.
endotracheal tubes, needles, syringe).
The practice of reusing disposable medical devices

introduces risks to the patient as well as the health
care facility. Liability reverts to the user if the
item is reprocessed.
2.14
Assisting to position the patient in a safe

manner for the administration of a specific
anesthetic, i.e. general, regional, etc.
Certain methods of anesthetic administration

require particular positioning.
2.15
Moving an unconscious patient in

collaboration with the anesthesia care
provider and the health care team
employing appropriate lifting/moving
devices.
An inadequate number of personnel and/or

insufficient equipment can result in patient and/or
personnel injury.
2.16
Anticipating, prioritizing, and preparing

for the management of anesthetic
emergency situations and responding
collaboratively with the anaesthesia care
provider to complications and unexpected
The perioperative Registered Nurses response

may assist in preventing complications or may
prevent complications from deteriorating.
Airway management difficulties are related to
morbidity and mortality. Quick access to
Perioperative Registered Nurses must respond

immediately and competently to adverse
events/reactions.
Section 5
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2.17
events including but not limited to:

aspiration;
rapid sequence induction;
difficult intubation;
airway obstruction and
bronchospasm;
malignant hyperthermia;
hypovolemia;
dysrhythmias and cardiac arrest;
defibrillation;
- external cardiac pacing;
- acidosis, alkalosis; and
- anaphylaxis.
advanced airway equipment is essential for the

provision of safe anesthesia and improves the
management of anesthetic emergencies.
Ensuring guidelines for the management of

rare emergencies, such as malignant
hyperthermia, anaphylaxis and pre-arrest
arrhythmias are posted or immediately
available.
Enables the team to respond quickly and

efficiently.
REFERENCES
Boyle, Heather J. (2005). Patient advocacy in the perioperative setting. AORN Journal, 82(2), 250-262.
Philips, N.M. (2007). Berry & Kohns operating room technique. (11th ed). Toronto: Mosby.
BIBLIOGRAPHY
Association of PeriOperative Registered Nurses. (2010). Standards Professional Practice. Perioperative Standards
and, Recommended Practices. Denver: AORN.
Ball, K. A. (2009). Do-Not-Resuscitate Orders in Surgery: Decreasing the Confusion. AORN Journal,. 89 (1)
140-146.
Canadian Anaesthesia Society (CAS) www.cas.ca
CAS Practice of Anaesthesia Guidelines (2008) link on www.ornac.ca
Canadian Patient Safety Institute (CPSI). www.patientsafetyinstitute.ca
Doddamanegowda, B., Chetlan, & Hughes, R. (2008). Tracheal Intubation, tracheal tubes& Laryngeal Mask
Airway. Journal of Perioperative Practice, 18 (3) 88-94.
Faber, P & Klein, A. (2008). Theoretical & Practical Aspects of Anaethesia for Thoracic Surgery. Journal of
Fuller, K. (2005). Surgical technology principles and practices. (4th ed). St. Louis: Elsevier.
Hamlin, L., Richardson-Trench, M., Davies, M. (2009). Perioperative nursing: An introductory text. Sydney:
Elsevier.
Hardcastle, T. (2009). Anesthesia for repair of cleft lip & palate. Journal of Perioperative Practice, 19 (1) 20-23.
Section 5
Page 278 of 334

Nunny, R. (2008). Inadvertent hypothermia: A literature review. Journal of Perioperative Practice, 18(4), 148-154.
Peiris, K. & Frerk, C. (2008). Awake Intubation. Journal of Perioperative Practice, 18 (3), 96-104.
Poulikas, A. (2008). Preventing Unplanned Hypothermia. AORN Journal, 88 (3), 358-364.
Provincial Infectious Diseases Advisory Committee (PIDAC). (April 30, 2006). Best practices for cleaning,
disinfection and sterilization. Ontario. Retrieved April 26, 2009 from
Ryan, K & Johnson, S. (2009). Preventing DVT: a perioperative perspective. AORN Journal,
19 (2), 55-59.
Schroeter, Kathryn. (2002). Ethics in perioperative practice. AORN Journal, 75(5), 941-949.
Smith, B. & Rawling, P. (2008). Anesthetic Assistant Competencies: our experience. Journal of Perioperative
Practice , 18(5), 190-192.
Wicker, P &Smith, B. (2006). Checking the Anesthetic Machine. Journal of Perioperative practice,16 (12),
585-590
Postoperative Considerations
PRACTICE
RATIONALE

3.1
Assisting the anesthesia care provider

with reversal of anesthesia and
extubation; and remaining with the patient
until ready for transfer, being prepared to
assist with suctioning, oxygenation and
potential complications.
Assists with safe emergence from anesthesia.

Helps prevent injury.
Availability of equipment and supplies ensures
preparedness for potential emergencies.
3.2
Assisting with the transfer of the patient

from the OR bed by:
- using appropriate number of health
care team members;
- transfer devices; and
- applying principles of positioning.
The patient is adequately supported.

Prevents potential injury to patient and personnel.
3.3
Overseeing a safe transfer from the OR

bed by:
- locking the wheels;
- securing and protecting the IV,
drains, tubes and other necessary
To prevent injury to the patient and equipment

damage.
Section 5
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Middleton, P. (2009). Insertion techniques of the laryngeal mask airway: A literature review. Journal of
PerioperativePractice, 19(1), 31-35.
equipment;
providing support to the head, arm
and legs; and
elevating the side rails.
3.4
Accompanying the patient from the OR

theatre to the receiving care unit with the
completed chart and proper records.
Nursing intervention may be required during

transport. Fluctuation in vital signs, airway
obstruction, and vomiting may occur.
The patient should be observed by someone
familiar with his or her condition.
3.5
Transferring care of the patient to the

appropriate health care professional.
Provides continuity of care from one health care

professional to another.
3.6
Giving a concise verbal report of nursing

care provided to include, but not limited
to:
- name and age of patient;
- pre-op diagnosis;
- medical problems (i.e. diabetes);
- pre-op medications given;
- time of the next dose of antibiotic;
- operative procedure done;
- intake and output;
- vital signs;
- allergies;
- drains(whether sutured or not);
- foley catheter, nasogastric tube;
- packing (type and amount/ sutured or
not);
- any problems with anaesthesia not
reported by anaesthesia care
provider;
- position on the operating bed and
devices attached to the skin;
- presence of loose/capped teeth;
- medications given (excluding
anaesthesia care providers) during
surgery;
- physical limitations such as deafness,
blindness, arthritis;
- intraoperative complications;
- psychological disorders;
- patient belongings;
- special order(s) for PACU;
- language barriers; and
- existence of advanced directives.
Accurate thorough reporting enables the patient to

receive effective continuing care and decreases the
risk of error.
Section 5
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Association of PeriOperative Registered Nurses. (2010). Recommended practices for positioning the patient in the
perioperative practice. Perioperative Standards and Recommended Practices. Denver: Author.
Fuller K.J. (2005). Surgical technology principles and practice (4th ed.). St. Louise: Elsevier.
Hamlin, L., Richardson-Trench, M., Davies, M. (2009). Perioperative nursing: An introductory text. Sydney:
Elsevier.
National Association of PeriAnesthesia Nurses of Canada (NAPAN). (2008). Standards for Practice. Pembroke:
Pappin Communications.
Philips, N. (2007). Berry & Kohns Operating room technique (11th ed.). Toronto: Mosby.
Rothrock, J., (2007). Alexanders care of the patient in surgery. (13th ed). Toronto: Mosby
The Royal College of Anaesthetist. Intraoperative care. Retrieved January 24, 2008 from
http://www.rcoa.ac.uk/docs/arb-section2.pdf
Younker, J. (2008). Care of the Intubated Patient in the PACU: the ABCDE Approach. Journal of Perioperative
Practice, 18(3), 116-120.
Local Anesthesia
PRACTICE
RATIONALE

4.1
Comprehensively assessing the patient

prior to transfer to a theatre for:
- physiological systems risks, i.e.
injury, infection; and
- psychological response to surgical
intervention, i.e. anxiety, pain;
Sources of assessment data shall include
but not be limited to:
- the patient;
- patients record; and
- patients family/support.
Preoperative assessment is a key component in the

assessment and management of risk. It enhances
patient care and improves efficiency
4.2
Confirming that the surgeon/physician is

available prior to administering any
medications.
Patients can respond adversely to the medication.

To ensure the patient receives a favourable
analgesic/sedative response during the procedure.
4.3
Monitoring the patients physiologic

status and safety during local anesthesia.
This should be the only activity assigned
to this nurse for the duration of the
procedure. He or she should not perform
Continuously monitoring the patients

physiological and physical status facilitates early
detection of potential complications.
Section 5
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BIBLIOGRAPHY
4.4
Providing support and reassurance

throughout the perioperative experience.
4.5
Assessing the need for IV access in

collaboration with the surgeon.
4.6
Ensuring oxygen and suction are

available and in working order (turned
on) if needed.
4.7
Monitoring of the patient and

documenting the following:
- nursing interventions and patient
responses;
- patients comfort level;
- BP, heart rate and regularity,
respirations and O2 saturation
(frequency dependent on patients
condition and procedure);
- drug dosage and time of
administration
- effects of agents used;
- any adverse reaction to the drug
administered;
- additional monitoring may be
necessary including but not limited to
skin temperature and color;
- oxygen administration;
- intravenous infusion; and
- other pertinent information.
Support and reassurance increases comfort levels

and assists in reducing anxiety.
Documentation establishes accountability,

promotes quality nursing care, facilitates
communication between Registered Nurses and
other healthcare providers and conveys the
contribution of nursing to care.
4.8
Being clinically competent in the function

and use of the monitoring equipment to be
used, the placement of connections, and
the interpretation of data.
Serious cardiac or respiratory complications can

occur after administration of local anesthetic
medication. Monitoring equipment provides the
perioperative Registered Nurse with patient data to
identify risks and/or complications during a
procedure. Knowledge of the function and proper
use of monitoring equipment is essential to
provide safe patient care.
4.9
Notifying the surgeon when changes

occur in the patients physiological or
psychological status.
Good communication is essential for optimal

patient care.
4.10
Confirming the availability of emergency

equipment and supplies.
Administration of local anesthetic medications can

result in sudden cardiac and respiratory
complications.
4.11
Assessing the patients postoperative

status and documenting appropriately.

Section 5
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circulating duties simultaneously.

(Philips, 2007, p. 443).
Transferring care of the patient to another

healthcare professional by providing a
report of the patients status.
Proper reporting is required for continuity of

patient care.
REFERENCES
Philips, N. (2007). Berry & Kohns operating room technique. (11th ed). Toronto: Mosby.
BIBLIOGRAPHY
Association of Anaesthetists of Great Britain and Ireland. (2007). Guidelines for the management of severe local
anesthetic toxicity. Retrieved January 15, 2008 from
http://www.aagbi.org/publications/guidelines/doc/guidelines07.pdf
Association of Anaesthetists of Great Britain and Ireland. (Nov. 2001). Pre-operative assessment the role of the
anaesthetist. Retrieved January 16, 2008 from http://www.aagbi.org/publications/guidelines/doc/preoperative01.pdf
Association of perioperative Registered Nurses. (2010). Recommended practices for managing the patient receiving
local anesthesia. Perioperative Standards and Recommended Practices. Denver: Author.
Association of Registered Nurses of Newfoundland and Labrador (2010) Documentation Standards for Registered
Nurses Retrieved Nov 5, 2010 from
http://www.arnnl.nf.ca/publication/DocumentationStandards2010.pdf
Canadian Anaesthesia Society (CAS) www.cas.ca
Rothrock, J. (2010) Alexanders care of the patient in surgery. (14th ed). Toronto: Mosby
Procedural/Conscious/Moderate Sedation, & Analgesia
PRACTICE
RATIONALE

5.1
5.2
Being cognizant that procedural

sedation/analgesia refers to a drug
induced state that produces a condition in
which the patient exhibits a depressed
level of consciousness but retains the
ability to maintain a patent airway
independently and respond to verbal
commands.
The primary goal of procedural sedation/analgesia

is to reduce the patients anxiety and discomfort
level.
Administration of procedural sedation by nurses is
an advanced skill and requires training and
certification by the healthcare facility.
Patients requiring greater than moderate

sedation/analgesia must be attended by an
anesthesia care provider, surgeon or other
physician.
During deep sedation individuals cannot be easily

aroused and the ability to independently maintain
ventilatory function may be impaired.
Assessing each patient physiologically
A preoperative assessment helps determine a
Section 5
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4.12
patients suitability for RN-monitored

sedation/analgesia by identifying potential risk
factors for undesirable outcomes.
Demonstrating the following skills and

knowledge of:
- proper patient selection and
screening;
- anatomy and physiology;
- total patient care parameters,
including but not limited to:
respiratory rate, oxygen saturation,
blood pressure, cardiac rate, and level
of consciousness;
- pharmacology of medications used to
induce and reverse
sedation/analgesia;
- respiratory physiology, airway
management, and the use of oxygen
delivery devices;
- the function and use of monitoring
equipment;
The monitoring methods for patients receiving

procedural sedation, the medications
administrated, and the interventions initiated must
be within the scope of nursing practice.
Written and verbal information reduces anxiety in

patients and helps recovery.
Monitors assist with the early detection of adverse

incidents.
Section 5
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5.3
before the procedure, including data from

numerous sources, such as chart review,
and consultation with other health care
providers as appropriate. This assessment
should include, but not be limited to:
- chief complaint;
- potential airway problems;
- orientation and cognitive state;
- emotional state;
- communication ability;
- patients perception and
understanding of the procedure and
sedation/analgesia;
- history and physical examination;
- current laboratory values;
- current medications, including
alternative and/or complementary
preparations;
- medication allergies/sensitivities;
- current medical problems;
- surgical history;
- tobacco use and substance abuse
history; and
- baseline information, including vital
signs, height, weight, and age.
During the preoperative assessment visit,
the patient shall be given written and
verbal information on the procedure and
on sedation/analgesia. The patient must
be informed that they cannot drive or
operate heavy machinery for 24 hours (or,
as per health care facility policy)
following sedation/analgesia.
cardiac dysrhythmia interpretation;

possible complications and
contraindications related to the use of
moderate sedation/analgesia
medications; and
age-appropriate needs and responses
of patients.
Sedation and analgesic agents may cause

hypersensitivity reactions, respiratory depression,
hypotension, and impaired cardiovascular
function.
5.4
Providing psychological support and

reassurance before and during the surgical
procedure. The patient should be told
what to expect and what is expected of
him/her.
Support and reassurance increases comfort levels,

assists in reducing anxiety and helps recovery.
5.5
Remaining with the patient and having no

other responsibilities that would leave the
patient unattended or compromise
continuous monitoring during the
procedure.
Continuous monitoring of the patients

physiological and psychological status by a
perioperative Registered Nurse leads to early
detection of potential complications and increases
the likelihood of positive outcomes.
An additional perioperative Registered

nurse must be present in the room and
perform the circulating role during any
procedure in which a patient receives
procedural sedation/analgesia.
5.6
Developing a nursing care plan and

documenting the findings in the patients
record.
Enables the patient to receive effective continuing

care and provides written communication to the
healthcare team.
Documentation provides evidence of continuity of
care.
5.7
Being clinically competent in the function

and use of the monitoring equipment to be
used, the placement of connections, and
the interpretation of data.
Monitoring equipment provides the perioperative

Registered Nurse with patient data to identify risks
and/or complications during a procedure.
Ensuring the following equipment is

available and ready for use in the room:
- oxygen and delivery devices;
- suction apparatus;
- non-invasive blood pressure device;
- electrocardiograph; and
- pulse oximeter.
Improves the management of anesthetic

emergencies.
Provides a safe environment for the patient.
5.8
Inspecting equipment for proper function

and replacing when necessary.
Improperly functioning equipment may jeopardize

patient safety.
5.9
Maintaining competence in Basic Life

Support and having experience and
knowledge in providing procedural
sedation/analgesia.
Ensuring that either an anesthesia care
The risk associated with procedural sedation may

be low, but the outcome of adverse events can be
life threatening.
Section 5
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5.10
Providing continuous monitoring of the

patient and documenting the following:
- nursing interventions and patient
responses;
- patients comfort level;
- BP, heart rate and regularity;
- respirations and O2 saturation;
- body temperature;
- skin temperature and colour;
- drug dosage and time of
administration;
- effects of agents used;
- any adverse reaction to the drug
administered;
- oxygen administration;
- intravenous infusion; and
- other pertinent information.
Documentation establishes accountability,

promotes quality nursing care, facilitates
communication between Registered Nurses and
other healthcare providers and conveys the
contribution of nursing to care.
5.11
Ensuring an IV access line is established

to facilitate administration of conscious
sedation/analgesia medications and
emergency medications and fluids if
needed.
IV access provides a means for administering

medications used for procedural
sedation/analgesia, emergency medications and/or
fluids.
5.12
Ensuring that an emergency cart with

resuscitative equipment and emergency
drugs, including narcotic and sedative
reversal medications are immediately
accessible.
Medication overdoses or adverse reactions may

cause respiratory depression, hypotension, or
impaired cardiovascular function requiring
immediate intervention and/or cardiopulmonary
resuscitation.
Being prepared decreases the response time during
adverse reactions.
5.13
Understanding the usual dosages,

contraindications, interactions with other
medications, onset and duration of action,
desired effects, adverse reactions, and
emergency management techniques; and
monitoring for adverse reactions to
medications and for physiological and
psychological changes.
To recognize normal and abnormal reactions to

medications and respond appropriately.
Provides a safe level of care and may predict and
prevent potential adverse reactions.
It has become accepted that core data (heart rate,

BP and peripheral oxygen saturation) should be
recorded at intervals no longer than every five
minutes and more frequently if the patient is
unstable. (The Association of Anaesthetists of
Great Britain and Ireland, 2007, p. 5)
Assess and monitor the patients:

- response to verbal command;
- respiratory rate and effort;
- oxygen saturation;
- blood pressure;
Section 5
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provider or a healthcare professional with

ACLS skills are readily available during
all procedures involving procedural
sedation/analgesia.
cardiac rate and rhythm;

comfort level;
skin condition; and
tolerance to the procedure.
5.14
Notifying the surgeon when unfavourable

changes occur in the patients
physiological or psychological status.
Clear and concise communication is essential for

optimal patient care.
5.15
Assessing the patients ability to retain

information before discharge.
Medication used for sedation/analgesia often

produces anterograde amnesia, which may be
present even when consciousness appears
otherwise normal.
Discharge criteria should include but not

limited to:
- adequate respiratory function;
- stable vital signs;
- return to pre-procedure level of
consciousness;
- intact motor reflexes;
- return of motor and sensory control;
- absence of significant pain; and
- satisfactory surgical site and dressing
condition (when present).
A responsible adult must be available at
discharge to accompany the patient home.
(Rothrock, 2007, p 123).
5.16
Providing safe transport to PACU or to

another unit according to healthcare
facility policy.
The patient may be transferred to the day-surgery

and discharge area or returned directly to the
hospital room.
5.17
Reporting to the receiving nurse the type

and amount of drugs given and any
adverse reaction noted, the IV site and
type and amount of solution infused,
intraoperative vital signs, the surgical
procedure performed, and the type of
dressing(if any). Also reported are any
special postoperative orders, allergies and
a general statement of the patients
tolerance of the procedure.
Allows the patient to receive effective continuing

care while providing continuity of care from one
healthcare provider to another.
REFERENCES
Association of perioperative Registered Nurses. (20010). Recommended practices for managing the patient
receiving moderate sedation/analgesia. Perioperative standards and recommended practices. Denver:
Author.
Association of Anaesthetists of Great Britain and Ireland. (Fourth ed.). (2007 March). Recommendations for
standards of monitoring during anesthesia and recovery, p. 5. Retrieved January 7, 2008 from
http://www.aagbi.org/publications/guidelines/doc/standardsof monitoring07.pdf
Rothrock, J. (2010). Alexanders care of the patient in Surgery (14th ed.). Toronto: Mosby.
Section 5
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Association of Anaesthetists of Great Britain and Ireland. (2005). Day surgery. Retrieved January 16, 2008 from
http://www.aagbi.org/publications/guidelines/docs/daysurgery.pdf
Association of Anaesthetists of Great Britain and Ireland. (Oct. 2, 2007). Managing patients undergoing sedation.
Retrieved January 16, 2008 from http://www.aagbi.org/publications/guidelines/docs/managing07.pdf
Association of Anaesthetists of Great Britain and Ireland. (2007 June). Peri-operative management of The morbidly
obese patient. Retrieved January 7, 2008 from
http://www.aagbi.org/publications/guidelines/docs/obesity07.pdf
Canadian Anaesthesia Society (CAS). www.cas.ca
Johnston, M. & Liebelt, E. (2004). Acute pain management and sedation in children. Emergency Medicine: A
Comprehensive Study Guide. (6th ed). Retrieved January 7, 2008 from
http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=940&FxId=80&Sc
Nicolaou, D. (2004). Procedural sedation and analgesia. Emergency Medicine: A Comprehensive Study Guide. (6th
ed). Retrieved January 7, 2008 from
http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=940&FxId=80&Sc
Royal College of Nursing (02, Oct. 2007). Managing patients undergoing sedation. Retrieved January 7, 2008 from
http://www.rcn.org.uk/__data/assets/pdf_file/0007/78622/002436.pdf
Intravenous Regional Anesthesia (Bier Block)
PRACTICE
RATIONALE

6.1
Ensuring that the surgical site is marked

prior to the Block being administered.
6.2
Maintaining awareness of the patients

physiological status in conjunction with
constant monitoring by an anesthetic care
provider.
6.3
In collaboration with the anesthetic care

provider or physician, assisting with the
placement of the pneumatic tourniquet
cuff to the proximal position of the
affected extremity.
6.4
Assisting the anesthetic care provider or

physician by elevating the limb and
wrapping it with an elastic wrap, i.e.
Adverse reactions to local anesthetic agents are

potential complications.
This achieves exsanguination.
Section 5
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BIBLIOGRAPHY
6.5
Inflating the pneumatic tourniquet to an

acceptable level as requested by the
anesthetic care provider or physician and
assisting in the removal of the elastic
wrap, i.e. Esmarch bandage.
Refer to Pneumatic Tourniquets, Application and

Use in section 3.
6.6
Being cognizant, that premature loss of

pneumatic pressure in the tourniquet can
cause both a toxic reaction and a loss of
anesthesia.
An inadvertent bolus of local anesthetic can cause

a toxic reaction in the central nervous system (i.e.
ringing in the ears, tingling, numbness, loss of
consciousness, convulsions) and cardiac
complications.
6.7
Assisting the anesthetic care provider or

physician with the gradual deflation of the
cuff.
Overdose or toxic reactions to the lidocaine are

rare if the tourniquet has been inflated more than
20 minutes. The risk also is minimized by
intermittently deflating the cuff for a few seconds
at a time for several cycles when the surgical
procedure is over. This method reduces the
transient peak blood level of the local anesthetic in
the central nervous system and heart. (Rothrock,
2007)
REFERENCES
Rothrock, J. (2007) Alexanders care of the patient in surgery. (13th ed). Toronto: Mosby
BIBLIOGRAPHY
Association of PeriOperative Registered Nurses. (2010). Recommended practices for the use of the pneumatic
tourniquet in the perioperative practice setting. Perioperative Standards and recommended practices.
Denver: Author.
Litz, R. J.; Popp, M.; Stehr, S. N.; Koch, T. (2006). Successful resuscitation of a patient with ropivacaine-induced
asystole after axillary plexus block using lipid infusion. [Case report] Anaesthesia, 61(8), 800-801.
Sawyer, R. & Schroeder, H. (2002). Temporary bilateral blindness after acute lidocaine toxicity. Retrieved January
18, 2008 from http://www.anesthesia-analgesia.org/cgi/reprint/95/1/224
Smith, T. (2007). System toxic effects of local anesthetics. Retrieved January 18, 2008 from
http://docs.ksu.edu.sa/pdf/articles36/article360043.pdf
Wilhelmi, B. & Weiner, L. (June 28, 2006) Hand, anesthesia: blocks. Retrieved January 18, 2008 from
http://www.emedicine.com/plastic/topic297.htm
Section 5
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Esmarch.
PRACTICE
RATIONALE

7.1
Recognizing that regional anesthesia can

be accomplished by injecting a local
anesthetic anywhere along the pathway
of a nerve from the spinal cord (spinal
anesthesia) via epidural, and/or
peripherally.
7.2
Being aware of the contraindications for

spinal or epidural anesthesia such as
abnormal bleeding and clotting times,
patients receiving anticoagulants, and
those with severe fluid loss.
Contraindications to local anesthetic
nerve blocks include:
- patient refusal;
- drug allergy;
- coagulopathy; and
- infection at the injection site (Spinal
Anesthesia, 2007, p. 2)
Provides a level of safety for the patient and

prevents potential complications.
7.3
Preparing and monitoring the patient in

the same manner as required for general
anesthesia.
(See ORNAC Standards for Nursing Care
of the Anesthetized Patient).
Prevention of complications requires patient

assessment and preparation, knowledge of
anatomy and physiology, and attention to detail.
Continual monitoring leads to early detection of
potential complications and increases the
likelihood of positive outcomes.
7.4
Ensuring that resuscitative equipment and

drugs immediately available.
Excessive or inappropriate doses and inadvertent

high blocks can lead to total paralysis, cardiac and
respiratory depression.
7.5
Assisting the anesthesia care provider by:

- placing the appropriate monitors such
as pulse oximetry, ECG, and blood
pressure;
- providing supplemental oxygen;
- reassuring the patient; and
- properly positioning the patient.
Provides a safe, comfortable environment.
7.6
Monitoring the patient for any substantial

change in vital signs or untoward
reactions until the patient is transferred to
the OR, if the block is done in another
area.
To allow adequate time for the local anesthetic to

penetrate the peripheral nerve, blocks in the head
area and upper or lower extremities are often
completed in a preoperative holding area.
Section 5
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Regional Anesthesia Spinal, Epidural and Peripheral Nerve Blocks
Recognizing a change in position

following a spinal anesthetic can direct
the block up, down, or to one side of the
spinal cord.
Positioning is crucial for a successful block.
7.8
Being cognizant of physiological

responses that may occur following spinal
anesthesia such as:
- hypotension related to leakage of
cerebral spinal fluid (CSF);
- total spinal anesthesia related to an
inadvertently high block;
- positioning problems due to blockage
of pain and sensory inputs to a
portion of the patients body; and
- post dural puncture headache (PDPH)
believed to be related to leakage of
CSF through the hole in the dura
typically occurring when the patient
assumes an upright position.
Epidural anesthesia may evoke several

physiological responses that can result in major
problems if not properly managed
7.9
Recognizing the complications of

epidural anesthesia such as:
- inadvertent dural puncture with the
epidural needle causing a PDPH;
- subarachnoid injection caused by the
needle or catheter unintentionally
inserted into the subarachnoid space;
- migration of the epidural catheter
caused by patient movement; and
- vascular injection occurring
inadvertently with the initial or
subsequent dose.
7.10
Recognizing peripheral nerve blocks may

cause the following complications:
- inadvertent intravascular injection;
- overdose of local anesthetic; and
- rarely, nerve damage from trauma
caused by the needle or compression
from the volume of local anesthetic
injected.
Peripheral nerve blocks may evoke several

physiological responses that can result in major
problems if not properly managed
7.11
Being prepared for complications should

they arise and assisting the anesthetic care
provider as required in emergency
situations.
Prompt treatment provides the best outcome for

the patient.
REFERENCES
Spinal Anesthesia (10/12/2007) Retrieved January 22, 2008 from
www.virtualbonecentre.com/treatments.asp?sid=111&title=spinal-anesthesia
Section 5
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7.7
Association of perioperative Registered Nurses. (2010). Perioperative Standards and Recommended Practices.
Denver: Author.
Dalens, B. (APA Manchester 2007). Development in peripheral nerve blockade. Retrieved January 22, 2008 from
http://www.apagbi.org.uk/docs/2.pdf
Mariano, E. (Feb. 28, 2007). Nerve blocks: surgery without anesthesia presents alternatives. Retrieved January 22,
2008 from http://ts-si.org/content/view/2822/992/
Saha, S. & Turner, J. (January 2006). Risks associated with your anesthetic. Retrieved January 22, 2008 from
http://www.rcoa.ac.uk/docs/nerve-peripheral.pdf
Wikipedia (Oct. 25, 2007). Local anesthesia. Retrieved January 22, 2008 from
http://en.wikipedia.org/wiki/local_anesthesia
Herbal Remedies
PRACTICE
RATIONALE

8.1
Assessing surgical patients for use of

herbal remedies, and over the counter
drugs including but not limited to: dietary
supplements, teas and weight loss
remedies.
Herbal, over the counter drugs and prescribed

medication interactions may interfere with the
bodys ability to: absorb medications; potentiate
cardiotonic medications; modify blood sugar in
insulin dependent diabetics; modify the effects of
prothrombopenic anticoagulants; and be
incompatible with gastrointestinal
medications.(Blumenthal, 2000)
8.2
Documenting the name of the remedies,

dosage, frequency and duration of use on
the patients health record.
Documentation is a form of communication.
8.3
Verbally communicating drug

information to other members of the
health care team.
Some herbal remedies can affect clotting time, act

like MAO inhibitors, and interfere with blood
glucose levels and electrolytes. Toxic effects of
some preparations cause arrhythmias,
hypertension, ECG changes and may need to be
discontinued before surgery.
8.4
Requesting that a current list of herbal

remedies, including common name, uses,
side effects and precautions, be available
to the health care team.
There are hundreds of these remedies available on

the Canadian market. The expectation of the nurse
to remember them all is unrealistic.
The hospital pharmacist(s) may be available to
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BIBLIOGRAPHY
8.5
Providing patient teaching regarding

herbal remedies and possible drug
interactions.
Patients may not think of herbal remedies as drugs.

They may perceive herbal remedies as being
natural therefore benign, and drugs as chemicals,
not natural, and harmful. (Downey, 2002 )
8.6
Encouraging patients to disclose the use

of these remedies to the health care team.
There may be a perceived discomfort by patients

with discussing the use of herbal remedies with the
health care team. (Downey, 2002)
REFERENCES
Blumenthal, M. (2000). Interactions between herbs and conventional drugs: Introductory considerations. In F.
Chandler (Ed.), Herbs: Everyday reference for health professionals (pp. 9-20). Nepean ON: National
Printers (Ottawa).
Downey, C. (2002). Complementary Medication Use: Perceptions and Practices of Pre-Surgical Women.
Unpublished masters thesis, Queens University, Kingston, Ontario, Canada.
BIBLIOGRAPHY
Crowe, S., Lyons, B. (2004). Herbal medicine use by children presenting for ambulatory anaesthesia and
surgery. Pediatric Anaesthesia, 14, 916-919.
McKenzie, A., Simpson, K (2005). Current management of patients taking herbal medicines: a survey of
anesthetic practice in the UK. European Journal of Anaesthesiology, 22, 597-602.
Trapskin, P., Smith, K. (2004). Herbal medications in the perioperative orthopaedic surgery patient.
Orthopedics, 27(8), 819-822.
Additional Resources
Health Canada website- www.hc.gc-sc.ca
HerbMed, www.herbmed.org
Consumerlab, www.consumerlab.com
USDA Agricultural Research Service Quackwatch, http://www.ars-grin.gov/duke/
National Council against Health Fraud, http://www.ncahf.org/
Section 5
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assist in the creation of a list and keep it current.
The perioperative registered nurse is responsible for:

PRACTICE
RATIONALE
9.1
Assessing the patient for the potential

need for blood/blood products, verifying
that crossmatch and typing have been
done, and confirming that any requested
blood products are available.
Blood replacement may be necessary during

surgical procedures, i.e. cardiovascular, organ
transplantation, trauma, orthopaedic.
Blood typing and cross matching are necessary to
determine compatibility between donor and
recipient.
9.2
Verifying that written, informed

consent/refusal for blood products is
completed per Healthcare facility policy
and procedure. Clearly document the
refusal of blood transfusion in the
patients medical record following
Healthcare facility policy.
Because of religious/cultural beliefs, some patients

will not accept allogenous blood but may accept
Autotransfusion while others may refuse all blood
transfusions.
Patients have a right to refuse blood transfusions.
Consent for blood transfusion is a medical
responsibility (Transfusion Medicine, 2009).
9.3
Obtaining blood products from

Transfusion Medicine according to
Healthcare facility policy.
Patient safety measures must be strictly observed.
9.4
Ensuring that blood products are stored in

a temperature controlled refrigerator
approved for this use.
Red blood cell components must be stored at 1

6 C in a temperature controlled refrigerator with
an alarm system, air circulating fan and continuous
monitoring device (Canadian Blood Services,
2006, p. 17). Red blood cells (RBCs) deteriorate
with fluctuations in temperature. Unrefrigerated
blood allows increased risk of bacterial
contamination.
9.5
Confirming that all information

associating the blood component with the
intended recipient has been matched and
verified in the presence of the recipient.
This includes:
- verifying ABO and RH (if
applicable) compatibility of the
product and recipient;
- verifying that the unique patient
identifiers applied to the product
match those of the intended recipient;
and
- verifying that the unique product
identifiers on the product label match
those on the accompanying
transfusion service
form/tag.(Canadian Blood Services,
2006, p. 79)
The perioperative Registered Nurse or anesthesia

care provider may administer blood products after
confirmation of the patients identification, the
label on the bag and the blood requisition form.
This information shall be confirmed by two health
care professionals per health care facility policy.
The most common cause of ABO incompatible
blood administration is improperly identified
patients
Transfusion medicine applies unique identifiers to
each unit of product issued.
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Blood and Blood Products
Ensuring that if transfusion will not be

initiated within 30 minutes of removal
from the controlled temperature blood
fridge, the unit shall be labeled and
returned for disposal.
Blood is deemed to be safe if transfusion is

initiated within 30 minutes of removal from a
controlled refrigerated environment. It cannot be
returned to Transfusion Medicine for reissue.
9.7
Ensuring an approved blood warmer is

available and in working order.
Hypothermia due to rapid transfusion of large

amount of cold blood can cause arrhythmias or
cardiac arrest. Hemolysis may occur if temperature
exceeds 43 C.
9.8
During transfusion, ensuring that a sterile

pyrogen-free transfusion set with a filter
is used and is changed as per
manufacturer's recommendations.
Filters should be completely wet and the
drip chamber 1/3 to full prior to
initiating the transfusion.
Vented tubing should not be used when
administering blood components.
The administration set should be changed
if there will be a delay of one or more
hours between transfusing another unit.
The transfusion filter prevents potentially harmful

pyrogens from being transfused to the patient.
9.9
Notifying Transfusion Medicine if more

blood is needed than initially anticipated.
This allows time for Transfusion Medicine to

prepare a specified number of units in advance
decreasing the risk of rushing and jeopardizing
patient safety.
9.10
Ensuring that a second intravenous line is

initiated for drug administration. Drugs
should not be administered through the
same IV as blood.
Drugs combined with blood may cause a reaction.
9.11
Being aware of the signs and symptoms

of a transfusion reaction. Under
anesthesia, these may be accompanied by
temperature change, profound
hypotension, blood in urine, diffuse
oozing and/or skin rash.
Common chills and physical reactions are not seen

in the anesthetized patient.
9.12
If transfusion reaction is suspected, in

conjunction with the anesthesia care
provider following the facilities policies
and procedures related to the management
of transfusion reactions.
The probability of a transfusion reaction increases

in direct proportion to the number of units
transfused.
These filters are intended to remove clots, cellular

debris and coagulated protein.
Vented tubing may introduce air into the bag.
The filter can create an ideal environment for
bacterial growth and contribute to sluggish flow
slowing the transfusion.
REFERENCES
Canadian Blood Services. (2006) Clinical guide to transfusion (4th ed.). Ottawa: Author.
Transfusion Medicine. Informed consent for transfusion. Retrieved April 24, 2009 from
http://www.transfusionmedicine.ca/
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9.6
Blood Services. www.bloodservices.ca/

Canadian Society for Transfusion Medicine. (2007). Standards for Transfusion Medicine. (7th ed.).
Canadian Standards Association. (2004). CSA Z902-04 Blood and Blood components. Toronto: Author.
Diseases and Disorders: A Nursing Therapeutics Manual 3rd Ed. (2007). Blood transfusion reaction. Retrieved
January 7, 2008 from http://online.statref.com/document/documentbodycontent.aspx?docid=36&fxid62&scr
Merck Manual of Diagnosis and Therapy, 18th Ed. (2006). Transfusion medicine. Retrieved January 7, 2008 from
http://onlin.statref.com/document/documentbodycontent.aspx?docid=511&fxid-21&sc
Emergency Situations
10.1 Malignant Hyperthermia (MH)

Malignant Hyperthermia (MH) is an uncommon hypermetabolic disorder usually triggered by potent halogenated
inhalation anesthetic agents and depolarizing skeletal muscle relaxants.
PRACTICE
RATIONALE
10.1.1
Treatment of MH requires the

participation of all members of the health
care team.
Treatment of MH requires that many interventions

occur simultaneously to attain efficient
management and expected outcomes.
10.1.2
The health care team should be familiar

with the location and contents of a fully
stocked MH emergency cart, the treatment
protocol, and attend annual in-service
education in dealing with MH.
Knowledge, skills, and equipment can prevent

death of a patient from MH and its complications.
Rapid, well coordinated responses contribute to
desired patient outcomes.
10.1.3
A MH emergency cart with the

recommended stock supply of thirty-six
(36) vials of Dantrolene Sodium should be
available, as well as sterile water with no
preservative for reconstitution. A
standard crash cart with emergency
resuscitation drugs and equipment should
also be available.
Since the incidence of MH is rare, the continuance

of current knowledge and skills and proper
equipment can prevent death of a patient from MH
and its complications. Thirty-six vials of
Dantrolene would be needed to treat and stabilize a
70 kg patient (Philips, 2007, p 639).
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BIBLIOGRAPHY
Perioperative Registered Nurses shall be

familiar with aspects of Dantrolene
Sodium
including:
- mechanism of action;
- pharmacokinetics;
- side effects;
- preparation; and
- special precautions.
Current information based on the health care

facility's policy/protocol may reduce the effects of
MH.
10.1.5
Management of patients susceptible to

MH should include but not be limited to:
- monitoring BP, ECG, respirations,
oximetry, end-tidal carbon dioxide,
arterial blood gases, electrolytes and
magnesium, urinary output and core
body temperature;
- familiarity with non-triggering
anesthetic agents;
- use of a clean or "purged" gas
machine; and
- having a MH emergency cart
available.
Elimination of triggering agents must be done to

prevent the patient from having an MH crisis.
All volatile inhalation anesthetic agents and
depolarizing neuromuscular blocking agents (i.e.
Succinylcholine) have been identified as triggering
agents.
10.1.6
Recognition of the following early signs

and symptoms of MH crisis:
- increased CO2 production;
- muscle rigidity (especially masseter
muscle);
- unexplained sinus tachycardia;
- tachypnea;
- oxygen desaturation;
- unstable blood pressure;
- peripheral mottling, cyanosis; or
sweating;
- fever(temperature rising 1-2 degrees
q5minutes);
- cardiac arrythmias, ventricular or
atrial tachyarrythmias;
- metabolic and respiratory acidosis;
- increased serum concentrations of
potassium (K+), calcium (Ca+) and
creatinine phosphakinase (CPK);
- hot soda lime in the CO2 absorbers of
the anesthetic machine; and
- myoglobinuria (Rothrock).
Note: Not all of the signs and symptoms may be

present.
Increased CO2 is the most common symptom.
Muscle rigidity is one of the earliest signs.
Patient's jaw may be rigid and the mouth cannot be
opened for intubation.
10.1.7
The post anesthetic care unit or intensive

care unit shall be notified in advance to
expect the patient.
Further observation, monitoring, and treatment will

be required. Advance notification allows for
adequate preparation of essential equipment and
supplies.
10.1.8
Monitor for at least 24 hours for

recurrence or late complications.
Fever may occur late in the reaction and be very

dramatic or may not occur at all. Cooling such
areas as the axilla and groin may be sufficient.
Excessive cooling can cause severe shivering
which can precipitate ventricular tachycardia.
When muscles break down, proteins are released

into the bloodstream and are filtered out through
the kidneys producing "cola" coloured urine.
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10.1.4
MH crisis may be prevented by:

- accurate preoperative diagnosis and
awareness of the disease by both
patient and physician:
- avoid triggering agents;
- prophylactic Dantrolene in certain
susceptible patients; and
- intra-operative monitoring.
A positive muscle biopsy confirms the diagnosis of

MH. However, a negative biopsy is not reliable
enough to eliminate the diagnosis. (Buckley, 2006,
p 9.)
MHAUS HOTLINE
(US and Canada)
1 800-644-9737
REFERENCES
Buckley, D. (2006) Learning about Malignant Hyperthermia. Hamilton, ON: Hamilton Health Sciences.
Malignant Hyperthermia Association of the United States (MHAUS). http://www.mhaus.org/
Rothrock, J. (2007). Alexanders care of the patient in surgery. (13th ed). Toronto. Mosby.
BIBLIOGRAPHY
Association of PeriOperative Registered Nurses. (2008). AORN malignant hyperthermia guideline. Perioperative
Standards and Recommended Practices. Denver: Author.
Hommertzheim, R., Steinke, E. (2006) Home Study Program: Malignant Hyperthermia-The Perioperative nurses
role. AORN Journal, 83(1); 149-164.
Spry, C. (2008). Essentials of Perioperative Nursing. (4th ed.). Maryland: Aspen Publishers.
For additional information: MH hotline 1-800-644-9737
10.2
Latex Allergy
Latex is produced from the rubber tree, Hevea brasiliensis, and contains a water soluble protein antigen that can
cause a fatal allergic reaction. Latex allergies may produce local or systemic reactions that may affect patients and
the health care team. Latex sensitivities may lead to true allergy, with the risk of anaphylaxis, therefore all
reasonable attempts to reduce latex items from the operating room should be taken.
10.2.1
PRACTICE
RATIONALE
A current Policy and Procedure Protocol

to safely manage a patient with potential
or actual latex allergy shall be available
for the health care team.
A severe latex allergic response can be sudden and

fatal.
The aim is for latex avoidance, as a latex-free
environment is not readily achievable
Section 5
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10.1.9
Patients with latex allergies should:

- be booked as the first case of the day,
if possible;
- have an alert noted on the health
record;
- have an alert noted on the OR
schedule;
- wear an alert bracelet which is not
removed; and
- carry an epinephrine syringe.
Significant time may be required to ensure the air

ventilation system has removed all traces of
airborne latex proteins when latex products have
been used during the previous procedure.
The aim is for latex avoidance, as a latex-free
environment is not readily achievable.
10.2.3
Surgeon offices, preoperative clinics, and

nursing units must have the information
and consistent means to communicate the
allergy in advance of surgery to prevent
patient risk, delays and cancellations.
Advance notice for the perioperative team to safely

prepare the environment is essential.
10.2.4
The healthcare team shall assess surgical

patients for the risk of latex sensitivity
and potential allergy.
Food allergies that may suggest a latex allergy

include papain (meat tenderizer also present in
papaya), kiwi fruit, avocado, bananas, papaya,
chestnuts, potatoes, tomatoes, celery, peaches,
stone fruit, molds and pollen. Patients with
multiple true allergies are also at higher risk.
Limited information is known about the latex-fruit
possible cross reactivity.
10.2.5
A current latex allergy protocol shall be

available including:
- a list of sample admission assessment
questions;
- list of signs and symptoms;
- identification of high-risk groups;
- preparation requirements for the
theatre in advance of admission;
- documentation required;
- equipment and supplies needed; and
- actions for an anaphylactic latex
emergency.
In addition to food allergies, questions to consider

including in patient assessment include:
-do you have a confirmed allergy?
-do you have spina bifida?
-do you have hives, itchy rash, swelling
after contact with rubber products i.e.
balloons, condoms, mouth dams at dentist
offices.
Further investigation is needed if the patient gives
a positive response to any of these questions, in
order to determine if the patient has a true latex
allergy. Testing for IgE antibodies is used for latex
allergy.
10.2.6
Pediatric facilities should reduce the

amount of latex as much as possible.
High-risk groups include but are not limited to:

- spina bifida patients;
- health care workers;
- atopic individuals (allergic to banana, kiwi,
avocados, chestnuts); and
- patients with genitourinary tract anomalies.
Research suggests the risk of latex allergy as high
as 73% for spina bifida patients.
10.2.7
A latex allergy cart/box providing latexfree equipment shall:

- be available;
The product list identifies articles that are latexfree and products that contain latex.
Section 5
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10.2.2
10.2.8
be restocked immediately after use;

contain the latex allergy protocol and
product list; and
have a designated person(s)
responsible for review and
maintenance.
Facilities should provide and encourage

use of powder free latex gloves.
Common items in use such as tubing on blood

pressure cuffs, connectors, cords on pulse
oximeter, EKG leads and cords, donut, positioning
devices, elastic bandages, tape, esmarch rubber
bandage for tourniquet, stoppers in multidose
vials, connecting tubing on insufflators, drains,
and warming blankets may present an
unsuspecting reaction.
The less powder to carry the latex protein, the
safer the environment.
Gloves with latex protein <100ug/gm show little
reactivity.
BIBLIOGRAPHY
Association of PeriOperative Registered Nurses, (2008). AORN latex guideline. Perioperative Standards and
Recommended Practices. Denver: Author.
Phillips, N.M. (2007). Berry & Kohns operating room technique. (11th ed). Toronto: Mosby.
Additional Resources:
Centre for Disease Control & Prevention http://www.cdc.gov/niosh/latexalt.html
http://latexallergylinks.tripod.com
www.healthline.co.uk/latex.html
Spina Bifida Association, www.sbaa.org
www.latexallergyresources.org- American Latex Allergy Association
www.childsdoc.org Dr Patrick Birmingham anesthesia .pdf 1999
10.3 Cardiac Arrest
10.3.1
PRACTICE
RATIONALE
Perioperative Registered Nurses shall

maintain competence in Basic Life
Support (BLS) for Healthcare Providers
according to provincial guidelines and
Healthcare facility guidelines.
Perioperative Registered Nurses shall
attain and maintain competency to
defibrillate if required by Healthcare
facility protocols.
Early qualified action enhances chances of

survival.
Nurses may choose to upgrade their skill set to
Advanced Life Support (ACLS) and/or Pediatric
Advanced Life Support (PALS) to increase their
comfort level in cardiac emergencies.
Current knowledge and practice assists in the
handling of sentinel events and in the safe
management of the perioperative environment.
Current knowledge of CPR/BCLS is necessary to
assist theatre personnel with resuscitation.
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Nursing personnel should maintain

knowledge of the healthcare facilitys
current Code Blue policy.
Under usual circumstances, the surgical
team will manage a cardiac arrest within
the surgical suite. In the event of
inadequate resources, multiple arrests or
other unusual circumstances, the Hospital
Code Team may be accessed.
The dress code, traffic flow/patterns, and aseptic

practices may lapse when a cardiac arrest occurs
and additional health care facility members are
required.
10.3.3
A Cardiac Arrest cart with defibrillator,

resuscitation equipment and supplies shall
be immediately available. This cart
should be placed in the same strategic
location at all times, when not in use.
Immediate response/defibrillation offers a greater

chance of survival.
10.3.4
The crash/code cart should be routinely

checked per the protocol established in
the facility for completeness, medication
expiration dates, and properly functioning
equipment.
Perioperative Registered Nurses shall be familiar

with the location of all supplies and equipment to
enhance their ability to assist and use all items
within their scope of practice.
10.3.5
External defibrillating pads (hands free)

and defibrillating paddles with gel pads
(hands on) should be appropriately
connected/available on the crash cart
defibrillator. Sterile internal paddles
should be available according to
10.3.6
A resuscitation protocol should be

established and understood by all
members of the Healthcare Team.
Periodic practice sessions (mock code)
for delegated duties should be scheduled
as part of the safety program.
10.3.7
During a cardiac arrest, if circumstances

allow, the scrub nurse shall:
- protect the integrity of the sterile
field whenever possible;
- track sponges, needles and
instruments; and
- complete closing counts as quickly as
possible.
Sterility is secondary to resuscitation efforts.
Documentation of a cardiac arrest should

include, but not be limited to:
- time of arrest;
- time the code was called;
- time of arrival of code members;
- time CPR was initiated and by
whom;
Document Cardiac Arrest as per facility policy.
10.3.8
Health care facilitys written policies and

procedures for counts are followed during
emergency situations.
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10.3.2
10.3.9
time(s) of medication(s) and

dosage(s);
medications administered by;
infusion/transfusions; and
patient outcome.
Spiritual/supportive care should be

arranged for the family.
10.3.10 Critical Incident Management should be

offered to all team members involved in a
code situation.
Healthcare team members should be given time to

express their feelings and debrief.
10.3.11 Routine preventative maintenance on the

defibrillator will be completed and
documented by healthcare facility
biomedical department.
BIBLIOGRAPHY
Phillips, N.M. (2007). Berry & Kohns operating room technique. (11th ed). Toronto: Mosby.
www.heartandstroke.ca
10.4. Disseminated Intravascular Coagulation (DIC)
Disseminated Intravascular Coagulation (DIC) is not a disease but a complication of a variety of conditions that can
initiate activation of the coagulation process (Porth, 2007). DIC manifests on a continuum that begins with
activation of either the intrinsic or the extrinsic coagulation pathways and results in multiple thrombi that lead to
vessel occlusion, tissue ischemia, and organ failure. All available coagulation proteins and platelets are consumed by
the thrombi and the result is bleeding in the form of petechiae, purpura, oozing from tissues, or massive hemorrhage
due to an imbalance between coagulation, anticoagulation and fibrinolysis (Porth, 2007, p.207-8; Sivula, et al,
2005).
PRACTICE
RATIONALE
10.4.1
Treatment of DIC requires the

participation of all members of the health
care team.
Treatment of DIC requires that many interventions

occur simultaneously to attain efficient
management and expected outcomes.
10.4.2
The Perioperative Registered Nurse

should:
Knowledge about DIC and relevant nursing skills,

may prevent the condition from causing the death
of a patient.
recognize the risk factors for DIC;

understand potential complications;
formulate potential nursing
diagnosis;
anticipate the needs of the patient and
if the surgical team(the common and
probable treatment protocols); and
Risk factors associated with DIC include but are

not limited to:
-
Endothelial damage caused by viruses,

infection, temperature extremes, stasis of
blood, or immune mechanisms i.e.:
Section 5
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expedite the care sequence to

maximize patient outcomes (by
knowing the immediate location, and
protocols for use of required
medications, blood products, and
necessary equipment).
- trauma;
- burns;
- gram-negative Sepsis;
- hypoxia;
- acidosis;
- shock; and
- vasculitis
-
10.4.3
Nursing personnel shall maintain

knowledge of the health care facilitys
current cardiac arrest code policy.
10.4.4
Seek resources and/or in-service

education regarding DIC.
Release of tissue factors from:

- obstetrical complications (includes:
necrotic fetal tissue; necrotic placental
tissue; or amniotic fluid emboli. This is
the cause of 50% of all DIC cases);
- trauma;
- complications from cancer;
- bacterial sepsis;
- immunological disorders;
- severe toxic reactions;
- hematological disorders iatrogenic and
non-iatrogenic; and
- cardiac surgery.
Current knowledge and practice assists in the

handling of sentinel events and in the safe
management of the perioperative environment.
REFERENCES
Porth, C.M., (2007). Essentials of Pathophysiology. (2nd ed.). Philadelphia: Lippincott, Williams, & Wilkins.
Porth, C.M., (2005). Pathophysiology Concepts of Altered Health States. (7th ed.). Philadelphia: Lippincott,
Williams, & Wilkins.
Sivula, M., Yallgren, M., Pettila, V. (2005). Modified score for disseminated intravascular coagulation in the
critically ill. Intensive Care Medicine, 31, 1209-1214.
Toh, C.H. and Dennis, M. (2003). Disseminated intravascular coagulation: old disease, new hope. (Clinical review).
British Medical Journal, October 2003, 974.
Zeerleder, S. and Wuillemin, W. (2005). Disseminated intravascular coagulation in sepsis. Chest, 128(4), 28642875.
BIBLIOGRAPHY
Jones, K.J., adapted by DOnofrio, L. (2006). Nursing management haematological problems in Lewis, S.M.,
Heitkemper, M.M., & Dirksen, S.R. (2006). Medical Surgical Nursing in Canada. Toronto: Elsevier
Mosby.
Pillitteri, A. (2003). Maternal and Child Health Nursing. Philadelphia: Lippincott, Williams, & Wilkins.
Section 5
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10.5 Intraoperative Death
10.5.1
10.5.2
PRACTICE
RATIONALE
Perioperative Registered nursing

personnel shall provide nursing care to
support the patient to a dignified death.
Provide a continuum of care

Cardiac arrest, standstill or fibrillation may occur
in patients undergoing surgical procedures due to
hazards of surgery including but not limited to
unavoidable reactions to anesthesia such as
hypoxia, or poor ventilation, blood loss, shock
(Rothrock, 2007, p 42).
Notification of manager or designate shall

take place as soon as possible (Phillips,
2007, p123).
Provides the department with notification to assist

with the process of after death care, arrangement
of viewing by family if requested, assists with
appropriate transfer of patient, assists with
following of facility, local, provincial or federal
regulations.
A current and dated procedure/policy for

the management of death and care of the
body shall be available and may include:
- provincial and health care facility
regulations;
- notification of the authorities, such as
the Coroner, administration, and the
healthcare facility unit;
- preparation of the body according to
the Medical Examiner/coroners
wishes;
- documentation required including
time of death;
- documentation if religious rites were
performed
- removal of the body, records, and
belongings;
- a list of devices that should remain in
place for potential medical
investigations;
- provisions of a private room in the
surgical suite for family viewing of
their loved ones body; and
- emotional support by the health care
team members to family during
viewing
- be sure identification of the patient is
correct; and
- completion of an incident report as
required by facility.
Medical examiner/coroner may wish to view

patient with all lines/devices attached
Support to family is essential. Never leave family

members alone while viewing the body
Section 5
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White, A. (2006). Emergency care for patients with HELLP Syndrome. Advanced Emergency Nursing Journal,
28(4), 338-345.
All surgical items/instrumentation shall

be removed from the patient and a final
count be performed unless otherwise
instructed by the medical
examiner/coroner.
Fulfills surgical counting policies & procedures

dependent upon facility. May provide information
for the coroner.
10.5.4
Foreign bodies removed during surgery

shall be handled via facility
laboratory/histology departments or may
be handled as forensic evidence.
Data collection begins prior to the operating room.

Patients who are critically injured may be taken
directly to the operating room. (Phillips, 2007, p
119).
Law enforcement or coroner may request/require
specimens, examination of body, or removal of
evidence and/or body.
10.5.5
Nursing personnel should have

knowledge of facility protocol for organ
& tissue donation and advanced
directives.
To preserve organs &/or tissue and have

appropriate knowledge of organ and tissue
donation procurement processes, assist in retrieval
procedures and appropriate perioperative
documentation. (Rothrock, 2007, p1197)
10.5.6
Healthcare team members should be

given time to express their feelings and
deal with a death within the surgical suite.
Critical incident debriefing should be
considered.
Death may be a result of surgery and debriefing is

a means of providing support to members of the
health care team.
Allows staff to discuss the process, grieve, &
relieve personal stress related to the incident.
REFERENCES
Rothrock, J. (2007). Alexanders Care of the Patient in Surgery, (13th ed.). Toronto: .Mosby.
Philips, N. (2007). Berry & Kohns Operating Room Technique, (11th ed.). Toronto: .Mosby.
BIBLIOGRAPHY
Association of PeriOperative Registered Nurses, (2008). Perioperative Standards and Recommended Practices.
AORN: Author.
Becker, Gerhild et all, (2007). End-of-Life Care in Hospital: Current Practice and Potentials for Improvement.
Journal of Pain and Symptom Management, 33(6), 711-719.
Ewanchuk, Mark & Brindley, Peter G. (2006). Ethics Review: Perioperative do-not-resuscitate Orders doing
nothing when something can be done. Critical Care, 10, 219
Fallat, Mary E. & Deshpande, Jayant K. (2004). Do-Not-Resuscitate Orders for Pediatric Patients Who Require
anesthesia and Surgery. American Academy of Pediatrics, 114 (6), 1686-1692.
Mulley, AG, (2007). Do You Know All your Medical Options? A new approach to getting the information you
need. Bottom Line Health, 21(9), 5-6.
Porteous, Joan (2005). Dont Tip the Scales! Care for patients involved in forensic evidence gathering, Canadian
Operating Room Nursing Journal, 23(3).
Woodhead, K., Wicker, P. (2005). A textbook of Perioperative Care. Elsevier: Toronto
Section 5
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10.5.3

OPERATING ROOM NURSES ASSOCIATION OF CANADA

(ORNAC)
Glossary
The definitions have come from multiple sources and are applicable to Perioperative Registered Nursing Practice
and the environment within the context of each section.
AAAANI: American Academy of Allergy, Asthma & Immunology.

AANA: American Association of Nurse Anesthetists.
AAMI: Association for the Advancement of Medical Instrumentation.
Accountability: Is answerable for activities and/or outcomes. Accountable is used to denote liability for individual
activities, a group of activities, and those activities delegated.
ACAAI: American College of Allergy, Asthma and Immunology.
Accreditation Canada: Formerly known as CCHSA provides guidance to reach standards of excellence. Mission
is to drive quality in healthcare via accreditation process, it is a national non-profit organization.
ACORN: Australian College of Operating Room Nurses. www.acorn.org.au
Active communication: An affirmation, orally or by some action, that the patient, procedure, and site are correct.
Active communication involves everyone's participation.
Active electrode: The electrosurgical accessory that directs flow of electrical current to the operative site.
Active electrode monitoring: A dynamic process of searching for insulation failures and capacitive coupling during
monopolar surgery. If the monitor detects an unsafe level of stray energy, it signals the generator to deactivate.
Advanced Nursing Practice: The scope of Advanced Nursing Practice focuses on a specialty clinical service (i.e.
Perioperative), providing support to clients and the healthcare team, as a consultant, researcher, administrator,
educator, and clinical practitioner. Advanced Practice Nurses include Nurses Practitioners (NP) and
Clinical Nurse Specialists (CNS).
Administration: A process of senior management, which provides the structure/framework, facilities, policies, and
business operations to support human, materials, and fiscal resources to work toward predetermined goals and
outcomes.
Adverse Drug Event: Injury as a result of medical intervention related to a medication. The onset of the adverse
reaction may be sudden or develop over time.
Adverse event: An untoward incident, therapeutic misadventure, iatrogenic injury, or other wrongful occurrence
directly associated with patient care. Not all adverse events are preventable, and they can be classified by severity significant, serious, life threatening, or fatal.
Adverse Medical Event: Broad term to describe unexpected events as a result of medical intervention. The event
maybe related to medication, surgical technique, and/or related to the use of technology.
Advocacy: The unique position of the perioperative Registered Nurse as a member of the health care team to speak
on behalf of patients and interpret individual needs and responses to others who participate in their care.
AER: Automated Endoscope Reprocessor.
Aeration: Method by which absorbed ethylene oxide is removed from EtO-sterilized items by circulating warm air
in an enclosed cabinet specifically designed for this purpose.
Revision Date: June 2009
Glossary
Page 307 of 334

Aerosolization: the suspension of microscopic particles in air or gas.

AfPP: Association for Perioperative Practice (United Kingdom). Prior to 2005known as National Association of
Theatre Nurses (NATN). www.afpp.org.uk
Airborne precautions: Precautions that reduce the risk of an airborne transmission of infectious airborne droplet
nuclei. (i.e. small particle residue 5mm or smaller).
Air-removal test: A diagnostic test to determine the adequacy of air removal from the chamber of a prevacuum
steam sterilizer. The air removal test is not a test for sterilization. (i.e. Bowie-Dick test)
AJIC: American Journal of Infection Control.
Allograft: A graft of tissue between individuals of the same species, donors, may be cadaveric, living related, or
living unrelated.
Alcohol-based preparations: Products used for hand antisepsis that are increasingly being used as an alternative to
the traditional surgical hand scrub using detergent-based antiseptic agents. Formulations include foams, gels and
liquid rinses. These products do not remove soil; therefore, application must be preceded by a soap and water wash
when used by surgical team members.
A.L.E.R.T. Inc.: Previously known as American Latex Allergy Association. A national non profit organization
providing information about latex allergy and support to individuals with latex allergy.
Allogenous: Having different genetic constitution but from same species. (Tabers 2005).
Ambient air: The surrounding environmental air.
Aneroid gauge: A pressure registering system that does not use mercury (Hg): it uses a mechanical amplifier
system to transmit the motion of metal bellows to the indicator needle of the dial.
ANSI: American National Standards Institute, www.ansi.org
AORN: Association of PeriOperative Registered Nurses, Inc. Home office is in Denver, Colorado. A professional
perioperative group for registered nurses in the United States of America. www.aorn.org
AORNJ: Association of PeriOperative Registered Nurses Journal.
APIC: Association for Professionals in Infection Control and Epidemiology.
ARO: Antibiotic Resistant Organisms.
Arterial calcification: Calcification of the arteries renders the vessels incompressible by the inflated tourniquet cuff;
a bloodless field cannot be obtained. This problem also occurs in rheumatoid arthritis patients on steroid therapy
because steroid induced vascular calcification contributes to arterial occlusion.
ASA: American Society of Anesthesiologists.
Aseptic technique: Conditions and procedures used to exclude the introduction of microbial contamination.
Assessment: A continuous activity to collect and document data about the patient's health status.
ASPAN: American Society of Perianesthesia Nurses.
Glossary
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Aerosol: Suspension of ultramicroscopic solid or liquid particles in air or gas: a spray (IAHCSMM, 2007, p. 464).
Autotransfusion: a method of returning the patients own extravasated blood to the circulation (Tabers 2005, p.
207).
B
Bariatric: overweight, obese, large, heavy & is a branch of medicine dealing with cause, prevention, & treatment of
obesity; (Canadian Association of Bariatric Physicians & surgeon (CABPS). http://www.cabps.ca)
BCORNG: British Columbia Operating Room Nurses Group.
Best Practice: evidence-based, proven nursing practices which assist in the provision of optimal outcomes or best
result.
Bibliography: cites works for background or for further reading a may include descriptive notes (APA, 2001, p.
215).
Bioburden: Contamination of the environment, supplies, and/or equipment with microorganisms.
Biofilm: a group, groups or collections of microorganisms which adhere to the surfaces of items such as
instruments causing the formation of a layer or film. As the microorganisms multiply the film may be come slimy
and may be very difficult to remove.
Biohazardous: A biological agent that is hazardous to humans or the environment.
Biological Indicator (BI): A sterilization process monitoring device consisting of a standardized, viable population
of microorganisms (usually bacterial spores) known to have a high resistance to the mode of sterilization being
monitored.
BJPN: please see JPP
BMI: Body Mass Index a scientific formula used to calculate body mass, MBI=weight (Kg) /height (m)2 for
example a BMI of 30 is considered obese
Brightness ratio: For any 2 surfaces in the field of vision, the ratio of the luminance of one surface to the luminance
of the other surface, expressed as a percentage.
BSE: Bovine Spongiform Encephalopathy. Commonly referred to as Mad Cow Disease. A fatal, slow progressive
degenerative disease caused by a prion protein which affects the Central Nervous System of adult cattle.
Body Piercings: the practice of adorning the body with jewelry that penetrates the flesh.
C
Calibration: A method of measuring the accuracy of the tourniquet pressure display. To standardize (as a measuring
instrument), by determining the deviation from a standard, in order to ascertain the proper correction factors.
Calibration kit: A method of measuring the accuracy of the tourniquet pressure display.
Capacitive-Coupled Return Electrode: A large non-adhesive return electrode placed close to and forming a
Glossary
Page 309 of 334

Autogenous: Self producing; originating within the body (Tabers 2005).
Canadian Blood Services: a national not for profit organization which manages and supplies blood & blood
products in all provinces and Territories outside of Quebec, www.blood.ca
CAS: Canadian Anesthesia Society.
Cautery : See Electrosurgical Unit (ESU).
CCDT: Canadian Council for Donation and Transplantation; mandate is to provide advice to Federal, Provincial &
Territorial Conference of the Deputy Ministers of Health in order to improve organ & tissue donation &
transplantation in Canada. Http://www.ccdt.ca/
CCHSA: Canadian Council of Hospital Services Accreditation. Is now known as Accreditation Canada.
www.cchsa.ca
CDC: Centers for Disease Control and Prevention, in the United States of America. www.cdc.gov
Canadian Standards Association (CSA): An organization that develops and publishes standards for many devices
and operational procedures. Volunteers help develop the Standards. The Standards are reviewed every five years.
(ORNAC members participate in development, revisions, and support the Standards). www.csa.ca
Chemical burns: These burns are caused by solution seeping under the tourniquet cuff or when antiseptic solutions
pool under the patient during skin prep, and remain in contact with the patients skin.
Chemical disinfectant/germicide: A generic term for a government-registered agent that destroys microorganisms.
Germicides are classified as sporicides, general disinfectants, hospital disinfectants, sanitizers, and others.
Chemical Indicator (CI): A sterilization monitoring assistive device used to monitor certain parameters of a
sterilization process by means of a characteristic color change. (e.g., chemically treated paper, pellet sealed in a
glass tube, pressure-sensitive tape.)
CHICA: Community and Hospital Infection Control Association. Is a national multidisciplinary volunteer
organization of Infection Control Professionals (ICP), http://www.chica.ca
CIDPC: Centre for Infectious Disease Prevention and Control- a division of Health Canada &. CTO-cells, Tissue &
Organs
CIHI: Canadian Institute of Health Information. http://secure.cihi.ca
Circulating Nurse: A Perioperative Registered Nurse who provides leadership and coordinates the individual care
of the patient and needs of the surgical team by: disseminating information; planning; organizing; delegating;
implementing; coordinating; and evaluating the perioperative activities. This term may be reduced to "Circulator".
CJD: Creutzfeldt-Jakob Disease http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc02vol28/28s5/index.html
Cleaning: The removal of soil. Note: Soil includes, but is not limited to, the bioburden plus the patient-derived
cells, secretions, or excretions.
Clinical Nurse Specialist: A registered nurse who holds a masters or doctoral degree in nursing with experience
in a clinical nursing specialty; uses in-depth knowledge and skills, advanced judgment and clinical experience in a
nursing specialty to assist in providing solutions for complex health-care issues (CNA, 2008, p. 40).
Glossary
Page 310 of 334

capacitor with the patient, returning electrical current from the patient back to the electrosurgical unit (ESU).
CNA: Canadian Nurses Association. A federation of provincial and territorial registered nurses associations acting as
the voice of RNs in Canada. www.cna-nurses.ca
CNPS: A not for profit society, owned & operated by nurses offering legal liability protection to registered nurses in
provinces & territories, http://www.cnps.ca
Collaborate: Advise, consult, cooperate, support, and willingly assist others in assessing, planning, implementing,
and evaluating activities.
Competence: The demonstration of the knowledge, skills, abilities, attitudes, and judgement required in the
professional care of patients by the perioperative Registered Nurse. The perioperative Registered Nurse functions
with care and regard for the welfare of the patient and in the best interest of the public, perioperative Registered
Nurses, and the nursing profession.
Competency: A statement of the combined knowledge, skills, attitudes, and judgment derived from the nursing roles
and functions within a specified context to meet a specified level of performance expectation.
Confine and contain: A principle that recommends prompt cleanup of items contaminated with blood, tissue or
body fluids.
Contact precautions: Precautions designed to reduce the risk of transmission of epidemiologically important
microorganisms by direct or indirect contact.
Container: See rigid sterilization container.
Contaminated: The presence of potentially infectious pathogenic microorganisms on animate or inanimate objects.
CORL: Canadian Operating Room Leadership Network. www.operatingroomleaders.com
CORNJ: Canadian Operating Room Nursing Journal. A peer reviewed quarterly publication of ORNAC since 2002.
First published in 1983. www.ornac.ca
CORNQ/CIIS: Corporation of Operating Room Nurses of Quebec.
CORR: Canadian Organ Replacement Registry.
CPR: Cardiopulmonary resuscitation.
CPSI: Canadian Patient Safety Institute. www.patientsafetyinstitite.ca
CRT: Cathode - ray tubes.
Credential: Something that gives a basis for credit or confidence such as letters or a certificate showing ones right
to position or authority.
Creutzfeldt-Jakob Disease (CJD): A fatal central nervous system degenerative disorder of humans. It is one of the
Transmissible Spongiform Encephalopathys (TSE). Classic CJD has 3 known types:
1. Inherited
2. Iatrogenic
3. Sporadic
Glossary
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Clostridium Difficile (CDiffe): A bacterium causing diarrhea being found with increasing frequency in our
population.
Critical item: Instruments and devices that enter sterile tissues, including the vascular system. Critical items present
a high risk of infection if the item is contaminated with any spores. Reprocessing critical items involves meticulous
cleaning followed by sterilization.
CSGNA: Canadian Society of Gastroenterology Nurses and Associates. www.csgna.com
CTO: cells, tissues and organs
D
Daily exposure: The amount of noise, chemical and gas to which a worker is exposed during the workday.
DCD: Donation after Cardiac Death.
Decibel: A unit for measuring the relative loudness of sounds.
Decontamination: The process of cleaning, followed by the inactivation of pathogenic microorganisms, in order to
render an object safe for handling.
Diligence: Steady, earnest and energetic effort.
Disinfection: A process that destroys some forms of microorganisms excluding bacterial spores; a process that kills
most forms of microorganisms on inanimate surfaces.
Dispersive electrode: A conductive plate or pad that recovers the therapeutic current from the patient during
electrosurgery, disperses it over a wide surface area, and returns it to the electrosurgical generator.
The Dissector: Quarterly Perioperative Nursing Journal of the New Zealand Perioperative Nurses College,
http://www.nzno.nz/groups/colleges/perioperativenursescollege
Dispute resolution: A process to facilitate a positive and effective resolution to a conflict.
Droplet Precautions: Precautions that reduce the risk of large particle droplet (i.e., 5mm or larger) transmission of
infectious agents.
Due diligence: The attention and care legally expected or required.
Dust cover: An optimal, unsterile cover used to help protect clean or sterile packages during routine storage,
handling, and transportation.
E
Electrosurgery: The cutting and coagulation of body tissue with a high radio frequency current.
Glossary
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Criminal coroners case: A situation where police may act under the authority of the coroner. Under the Coroners
Act, coroners have broad powers of entry and inspection and the Act authorizes the delegation of these powers to
police officers.
Emergency: An unexpected situation in which there is a pressing threat to patient life or health. Note: For the
purpose of this Standard, an emergency situation is one so pressing as to warrant the omission of specified
requirements of this Standard, as detailed in the Risk Management policy of the health care facility.
Emergency sterilization: A special steam sterilization cycle designed for the unplanned sterilization of unwrapped
surgical goods. Note: Cycles currently employed for emergency sterilization are gravity displacement, dynamic air
removal, and a cycle that may be available on some steam sterilizers that is designed to permit the use of a single
wrapper on the instrument tray.
Emulator: "Emulating indicators are indicators designed to react to all critical parameters over a specified range of
sterilization cycles, for which the stated value are based on the settings of the selected cycles. (ISO11140-1, sub
clause 4.6) "
End of procedure cleaning: Cleaning that is performed at the end of one surgical procedure and before the start of
another surgical procedure in the same room.
Endogenous: Substance which arises from within an organism, cell or tissue
ECRI: Emergency Care Research Institute. www.ecri.org
EORNA: European Operating Room Nurses Association. This group is a member of IFPN, officially named
EORNA in 1992 and is a federation of 23 countries. http://www.eorna.eu/
Ergonomic: The science concerned with fitting a job to a persons anatomical, physiological and psychological
characteristics in a way that enhances human efficiency and well-being.
ESBL: Extended Spectrum Beta-Lactamase (ESBL), organisms are bacteria found in the bowel, urine, blood, skin
wounds or sputum.
Esmarch bandage: An elastic bandage applied around an extremity from distal to proximal in order to expel blood
from it. The limb is often elevated as the elastic bandage is applied. Used to control bleeding and exsanguination
prior to tourniquet use.
ESU: Electrosurgical Unit. Commonly called a cautery.
Expiry Date: A date marked on a product or supply noting it is no longer guaranteed or in Date after the date
marked. Best before, similar to food labels. For example sutures commonly have expiry dates.
Exogenous: From a source other than the patient (e.g., personnel, equipment, the environment, instruments,
supplies).
Exposure time: Time during which the sterilizer chamber is maintained within a specified range for temperature,
sterilant concentration, pressure, and humidity.
Expanded Nursing Practice: An umbrella term for an advanced level of clinical nursing practice that maximizes
the use of graduate educational preparation, in-depth nursing knowledge and experience in meeting the health needs
of individuals, families, groups, communities and populations (CNA, 2008, P. 40).
External chemical Indicator: Are used to provide healthcare facilities & workers with the knowledge a
package/container has been in contact with a sterilization process such as autoclave tape or tags which turn colour.
Glossary
Page 313 of 334

Electrosurgical Unit (ESU): A machine used to deliver a high frequency current to cut and to coagulate body
tissue.
Evidence: Information on which to base proof of/or establish truth of a lie In law, evidence is demonstrative or
physical and cannot be introduced without a witness or something physical that a judge and jury can observe.
Eckert,W., Wright,R. (1997) Scientific Evidence in Court. CRC Press Inc.
Exsanguination: The process of removing / losing large volumes of blood.
F
Fatal-Familial Insomnia (FFI): A TSE, one of the fatal degenerative brain diseases.
FIFO: A form dated stock rotation, First In First Out, employed in areas of storage such as processing, operating
rooms, warehouses
Filter: A component of a rigid sterilization container system that allows the passage of air and sterilant during
sterilization yet provides a barrier to bacterial penetration. Note: The filter media may be removable (either reusable
or single-use), or it may be permanently affixed to the container.
Flash sterilization: See emergency sterilization.
Fluoroscopy: The observation of the internal features of an object by means of the fluorescence produced on a
screen by x-rays transmitted through the object.
Forensic documentation: Written or diagrammatic record of injuries to include wound measurement, location and
pattern of injuries.
G
Gasket: A pliable strip that serves as a seal between the lid and the base of a rigid sterilization container.
Generator: The machine that produces radio frequency waves (e.g., cautery unit, power unit).
Geobacillus stearothermophilus: A nonpathogenic microorganism used for biological testing (challenging) steam
sterilizers.
Gerstmann-Straussler-Scheinker (GSS): This is a rare type of inherited human TSE.
Glare: Brightness within the field of vision that causes eye fatigue or loss in visual performance.
Gravity displacement: A sterilization system in which incoming steam displaces residual air by gravity as opposed
to vacuum pumps through a port or drains that is situated at the lowest point of the sterilizer chamber.
H
Hands free transfer: Instrument transfer between scrub perioperative Registered Nurse and surgeon/delegate such
that neither person touches the same sharp instrument at the same time.
Glossary
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Event-related: Storage and transportation practice that operates on the principle that a properly packaged item that
has successfully undergone a validated sterilization process is considered sterile until an event occurs that could
breach the protection provided by the packaging (e.g., wetting, tearing, or dropping).
HARP: Healing Arts Radiation Protection Act.

HBV: Hepatitis B virus.
HCV: Hepatitis C virus.
Health Canada: Is the federal department responsible for helping Canadians improve, and maintain their health.
http://www.hc-sc.gc.ca/
Health care facility: A facility where people are accommodated on the basis of medical and/or nursing need,
including but not restricted to public and private hospitals, nursing homes, extended care facilities, long-term care
facilities, clinics, medical and dental offices, and health units in industry.
Health care personnel: Individuals directly involved with patient care.
Health care professional : an educated person licensed/registered by a regulatory body to practice within a
defined scope of practice.
HEPA filter: A high efficiency particulate air filter. The industry minimum standards, as defined by the Institute of
Environmental Sciences (IES) for HEPA filters is 99.97% efficiency in capturing particles of 0.3 um and larger.
Three particles out of 10,000 pass through the filter.
High filtration mask: Surgical masks that filter 1 - 5 microns in diameter nuclei with 95% efficiency.
H.L.D.: High level disinfection.
High Level Disinfection: Level of disinfection required when processing semicritical items. High-level disinfection
processes destroy vegetative bacteria, myobacteria, fungi and enveloped (lipid) viruses, but not necessarily bacterial
spores. High level disinfectant chemicals (also called chemisterilants) must be capable of sterilization when contact
time is extended. Items must be thoroughly cleaned prior to high level disinfection.
High risk: Patients at risk if the aspect of care is not provided correctly and in a timely manner.
H.I.R.O.C.: Hospital Insurance Reciprocal of Canada.
HIV: Human immunodeficiency virus causing AIDS.
Hole: An aperture; a perforation.
HVAC: Heat, ventilation and air-conditioning
Hydrodissection and irrigation: Hydrodissection assists with visualization of the operative area through irrigation.
Irrigation can be passed through irrigating channels built into the endoscope or through pump irrigation systems.
Some systems incorporate electrosurgical capabilities as well.
Hyperemia: A normal circulatory response involving a higher-than-normal blood flow to an ischemic or anoxic
body area; after tourniquet release, hyperemia refers to the flow of blood back into the exsanginuated limb.
Hypothermia: A decrease in core body temperature to a level below the normothermic range.
Glossary
Page 315 of 334

Hand hygiene: decontamination of the hands by one of two methods- hand washing with either an antimicrobial or
plain soap and water, or use of an antiseptic hand rub.
IAHCSMM: International Association of Healthcare Central Service Materials Management, the primary goal is to
put members on the path to quality & professional excellence; has been in existence for over 50 years.
http://www.iahcsmm.org/
ICN: International Council of Nurses. www.icn.ch
ICP: Infection Control Professional refer to CHICA.
Ideal body weight: Male; 49.9 + 0.89kg/cm above 152.4 cm height. Female; 45.4kg + 0.89 kg/cm above 152.4 cm
height (Schneider, 2008).
IFPN: International Federation of Perioperative Nurses.
IHI: Institute for Healthcare Improvement. This is an independent not for profit organization working to improve
healthcare globally.http://www.ihi.org/
Illumination level: The amount of light falling on a surface.
Implantable devices: Devices placed into a surgically or naturally formed cavity of the human body if it is intended
to remain there for a period of 30 days or more.
Implementation: The phase of the nursing process in which the nurse initiates and completes the action necessary to
accomplish definite goals.
Incident: An unintended event, no matter how trivial, that could potentially have harmed, or actually harmed a
patient. A clinical incident is an occurrence inconsistent with accepted professional standards of patient care or
routine organizational policies and procedures.
Incident reporting: A process to document occurrences inconsistent with routine hospital operation, policies or
procedures, or patient care.
Infectious waste: Medical waste (e.g., blood, body fluids, and sharps) that is capable of producing infectious
diseases.
Informed consent: is a process. A consent granted by a patient or family member, if required, for treatment after
the following was explained by the attending physician:
- the condition for which the treatment is proposed;
- the nature of the proposed treatment;
- reasonable alternative treatments; and
- the material risks, expected benefits, likely effects and side-effects of the proposed treatment and
of alternative treatments, including no treatment.
The patient and/or family have an opportunity to ask questions and receive answers about the proposed treatment
before consent is granted.
Initial count: The surgical count done immediately prior to the start of the procedure by the perioperative scrub and
registered circulating perioperative nurse concurrently.
Injuries: Specific aspects of injuries to reflect cause and effect.
Inservice: A planned education session conducted within an agency and directed towards personnel development,
job enhancement, and functional requirements.
Glossary
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Intermediate Level Disinfection: Level of disinfection required for some semi-critical items. Intermediate
disinfectants kill vegetative bacteria, most viruses and most fungus but not resistant bacterial spores.
Internal Chemical Indicator: A device placed inside a package for sterilization to verify the process has reached
inside the container package, for example a Class V Integrator. Comes in various levels difficulty from 1-6.
Instruments: Surgical tools or devices designed to perform a specific function, such as cutting, dissecting,
grasping, holding, retracting, or suturing.
Insulation failure: Damage to the insulation of the active electrode that provides an alternate pathway for the
current to leave that electrode as it completes the circuit to the dispersive electrode.
Intraoperative: Begins when the patient is transferred to the operating room bed and ends when he or she is
admitted to the postanaesthesia area.
Invasive procedures: The surgical entry into tissues, cavities, or organs or repair of major traumatic injuries.
Ionizing radiation: Electromagnetic radiation (e.g., x-rays, gamma rays) that yields ions as it passes through tissue.
ISMP: The Institute for Safe Medication Practices Canada (ISMP), is an independent Canadian non-profit agency
established for the collection & analysis of medication error reports & developing recommendations to enhance
patient safety. http://www.ismp-canada.org/
ISO: International Standards Organization.
J
JACHO: Joint Commission on Accreditation of Healthcare Organizations in the United States & has an
international section as well. www.jacho.org
Journal of Perioperative Practice (JPP): Is the official perioperative nursing monthly journal of the Association
for Perioperative Practice (AfPP) formerly known as the National Association of Theatre Nurses (NATN) and the
British Journal of Perioperative Nursing (BJPN)
Joint Commission: works to improve the safety & quality of care provided to the public of the USA via accreditaion
and support to improve performance. www.jointcommision.com
K
KURU: A type of human TSE, which occurred in epidemic form in the FORE people Papua New Guinea in the
1950s and was linked to ritualistic cannibalism.
L
LC: Laser committee.
Glossary
Page 317 of 334

Integrator: Integrating indicators are indicators designed to react to all critical parameters over a specified range of
sterilization cycles.
LCDC: Laboratory Centre for Disease Control. Canadian government national centre for control of human disease.
Laser: A device that produces an intense, coherent, directional beam of light by stimulating electronic or molecular
transitions to lower energy levels. An acronym for "light amplification by stimulated emission of radiation".
Laser Safety Officer (LSO): Person responsible for effecting the knowledgeable evaluation of laser hazards and is
authorized and responsible for monitoring and overseeing the control of such laser hazards.
Laundering: The sequence of activities (including preparation, washing, and drying) undertaken to make a new or
soiled reusable textile clean, dry and fit for service.
Latex: The milky cytosol tree sap acquired by tapping the commercial rubber tree, Hevea brasiliensis, which is
grown on large plantations in Africa and Central Asia. Also known as natural rubber latex (NRL).
Latex allergy: (Type I IgE-mediated/immediate hypersensitivity response): A systemic or local allergic response to
various latex proteins to which the individual has been sensitized.
Leaded apron: A leaded-rubber material worn to protect personnel from scattered radiation.
Legal aspects: Established legal policies, procedures, and precedents related to such activities as documentation,
informed consents, patient identification, controlled drugs, unusual incidents, negligence, and other such activities.
Light cord: A cable of fiberoptic filaments used to transport light to the surgical field.
Limb occlusion pressure (LOP): The minimum pneumatic pressure needed at a specific time in a given tourniquet
cuff applied to a specific patients limb, to stop the flow of arterial blood into that limb distal to that tourniquet cuff.
Limb paralysis: Also referred to as nerve paralysis or tourniquet paralysis syndrome. This usually occurs when
there is compression at the nerve site, unequal pressure of the tourniquet or ischemia distal to the tourniquet. Patient
injury results in short term or long term paralysis of the affected limb.
Liquid: A substance that flows readily in its natural state; neither solid nor gaseous.
LOP: Limb occlusion pressure.
LSO: Laser safety officer.
Lumen: The cavity within a tubular structure.
Low level disinfection: Level of disinfection required when processing noncritical items or some environmental
surfaces. Low level disinfectants kill most vegetative bacteria and some fungi as well as enveloped (lipid) viruses
(e.g. Hepatitis B, C, Hantavirus and HIV). Low level disinfectants do not kill mycobacterium or bacterial spores.
Low level disinfectants- detergents are used to clean environmental surfaces.
M
Malignant Hyperthermia (MH): A severe form of pyrexia that usually occurs with the use of muscle relaxants
&/or inhalation agent. Common triggers succinylcholine and halothane. This inherited condition progresses very
rapidly and if untreated may be fatal. May be referred to as Malignant Hyperpyrexia.
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LCD: Liquid crystal display.
Materials: Specific operating room equipment, supplies and instruments.

ME: Mistaken entry, as in documentation.
MEC: Minimum Effective Concentration lowest level of concentration of an active ingredient required to meet the
label claim of a reusable HLD/sterilant.
Medical device: Any instrument, apparatus, appliance, material or other article, whether used alone or in
combination, including the software necessary for its proper application intended by the manufacturer to be used for
human beings for the purpose of:
diagnosis, prevention, monitoring, treatment or alleviation of disease;
diagnosis, monitoring, treatment, alleviation of or compensation for an injury or handicap;
investigation, replacement or modification of the anatomy or of a physiological process; or
control or conception,
and which does not achieve its principal intended action in or on the human body by pharmacological,
immunological or metabolic means, but which may be assisted in its function by such means. Note: For the
purposes of this Standard, this term also encompasses medical device sets.
Medical error: An error made when something planned as part of medical care does not occur, or when a wrong
plan is implemented. The four types of medical errors include:
diagnostic - failures or delays in diagnoses or in ordering diagnostic tests;
treatment - technical errors in performing a procedure or administering a treatment;
preventive - failure to provide preventive treatments; or
other (e.g., improper medical staff behavior, laboratory errors, equipment failures, communication).
Medication error: An error in the processing, ordering, delivery, or administration of a medication.
Memory: Tendency of a textile or single use product to retain the shape and folds it had in the sterilized package.
Note: High memory will cause an opened textile or single use product to spring back to its original package shape,
and this may allow contamination of the sterile field.
Mentor: A trusted counselor or teacher to another person.
MHAUS: Malignant Hyperthermia Association of United States. www.mhaus.org
Microorganisms: Living organisms of microscopic size. The term is generally used in this Standard to refer to
bacteria, fungi, viruses, and bacterial spores.
Microprocessor: A very small silicon chip used in computers; the central processing unit.
Mini-laparotomy: a surgical procedure typically using laparoscopic instruments in conjunction with a small
abdominal inscision. Often refered to as a mini-lap.
Minimum effective pressure: The minimum pressure needed in a tourniquet cuff to stop blood flow past the cuff
for a time period suitably long for the performance of a surgical procedure. For each usage of a tourniquet system,
the Minimum Effective Pressure is typically determined by first measuring the Limb Occlusion Pressure (see
definition) and then adding to it a safety margin of between 70-90 mmHg to account for intraoperative variations
which may occur over the time period.
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Management: A process of leadership within the broad framework of administration, which executes policies,
advises and supports administration, and facilitates collaboration.
Miscellaneous items: Includes, but not limited to: delicate instrument tip protectors; clip cartridges; ligaclip bars;
vessel loops, clamps, inserts; umbilical and hernia tapes; ESU (cautery ) pencils, blades, and scraper/scratch pads;
wing nuts; screws; small endodscopic parts (i.e. trocar sealing caps, washers, O-rings, springs, caps); and any other
small items in a surgical count that have the potential for being retained in a surgical wound.
Monitoring: Clinical observation that is individualized to patient needs and based on data obtained from preprocedure patient assessments. The objective of monitoring patients who receive conscious sedation/analgesia is to
improve patient outcomes. Monitoring includes the use of mechanical devices and direct observation.
Morbidly Obese: Body mass index (BMI) greater than 30 (Schneider, 2008).
MORNA: Manitoba Operating Room Nurses Association.
MRSA: Methicillin Resistant Staphylococcus Aureus, which is resistant to methicillain, penicillin, and as well as
other antibiotics.
N
N95 Mask: N95 refers to the rating given by NIOSH to a mask. The N notes the mask is not oil resistant. The mask
filters 95% of non-oil particles of 0.3 microns.
N & LORNA: Newfoundland and Labrador Operating Room Nurses Association.
N.A.T.N.: National Association of Theatre Nurses, now known as the Association for Perioperative
Practice (AfPP).
NBORN: New Brunswick Operating Room Nurses.
NDD: Neurological Determination of Death
Near miss: An occurrence that could have resulted in an accident, injury, or illness but did not by chance, skillful
management, or timely intervention.
Necrotizing Fasciitis: A rapid progressive, inflammatory, bacterial infection often located in the deep fascia which
is usually caused by Streptococcus A. Commonly called Flesh Eating Disease.
Needs: Those physical, emotional, spiritual, and intellectual needs required and common to all human beings
regardless of their culture, race, sex, or age (patient, personnel, physician, student). Basic human needs must be
either supplied or relieved.
Nerve injury: A tourniquet-related complication ranging from complete nerve loss to mild transient neuroproxia;
caused by pressure at the edge of the tourniquet cuff, ischemia distal to or under the tourniquet cuff, or compression
of a nerve segment resulting in nerve lesions.
NIAID: National Institute of Allergy ad Infectious Diseases. Falls under the Institute of Health of United States
government. http://www3.niaid.nih.gov/
NIOSH: National Institute for Occupational Safety and Health in the United States of America.
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Minimally Invasive Surgery (MIS): Surgery performed through cannulas using telescopes, cameras, and video
monitoring devices.
Non-critical item: Those that either touch only intact skin, but not mucous membrane or do not directly touch the
patient. Reprocessing of noncritical items involves cleaning and/or low-level disinfection.
Non-porous: not permeable by air, steam, water
Nosocomial: Hospital acquired infections.
Nurse Practitioner: A registered nurse with additional educational preparation and experience who possesses and
demonstrates the competencies to autonomously diagnose, order and interpret diagnostic tests, prescribe
pharmaceuticals and perform specific procedures within the legislated scope of practice (CNA, 2006).
Nursing: Art and science in the application of the nursing process, performed with a caring attitude while assisting
patients to meet their needs in health, sickness, and for a dignified death.
Nursing actions: Professional activities which include leading, facilitating, teaching, supporting, counseling,
informing, and providing physical and supportive care (comfort measures, maintenance, prevention, diagnostic, and
therapeutic).
Nursing intervention: Those activities performed by the nurse to meet expected patient outcomes.
Nursing process: A systematic approach to nursing practice utilizing problem solving techniques. The major
components of the nursing process are assessment, planning, implementation, and evaluation which are continuous
throughout the perioperative phases.
ASSESSMENT:
The initial phase of the nursing process which identifies the patient's existing needs and problems.
These steps include:
- collection of data;
- analysis of data; and
- nursing diagnosis - a concise statement which is a product of the assessment phase identifying the
individual's existing and/or potential health needs within the scope of nursing practice.
PLANNING:
The phase of the nursing process which involves setting goals, judging priorities,designing
methods to resolve problems, and confirming the plans with the patient.
Nursing Care Plan (NCP) - a written document indicating the requirements, resources, and nursing
interventions, which will meet the unique needs of patients psychologically and physically, from admission
through to discharge from the operating room.
IMPLEMENTATION:
The phase of the nursing process in which the Registered Nurse initiates and completes patient care actions
necessary to accomplish defined goals and resolve problems in cooperation with other health care team
activities.
EVALUATION:
The phase of the nursing process in which the Registered Nurse determines in a progressive, ongoing
manner, the patient's responses and outcomes to activities of health care team members.
O
Obese: BMI 30-35 (Schneider, 2008).
OPA: ortho-phthalaldehyde - a high level disinfectant.
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Noise: Sound energy in the workplace.
Operating room theatre: A room within the operating room suite designed and equipped for the purpose of
performing surgical operations. This term may be reduced to "Operating Room", "Theatre" or "OR".
Organization: A business, company, or facility that is involved in manufacturing, distributing, transporting,
processing, or using a medical device (e.g. health care facility, manufacturer, distributor).
ORNAA: Operating Room Nurses Association of Alberta.
ORNAC: Operating Room Nurses Association of Canada. www.ornac.ca
ORNANS: Operating Room Nurses Association of Nova Scotia.
ORNAO: PeriOperative Registered Nurses Association of Ontario.
ORNPEI: Operating Room Nurses Prince Edward Island.
Out count: The final surgical count performed at the end of the procedure by the perioperative scrub and registered
circulating perioperative nurse concurrently. The results of this count are reported to the surgeon.
Over weight: BMI 25-30 (Schneider, 2008).
P
PACS: picture archiving and communication systems (PACS) used in medical imaging. These are computers or
networks that store, retrieve, distribute and display medical images.
PACU: Post-Anesthetic Care Unit (Recovery Room).
Particulate: A formed element or discrete body within a surrounding liquid or semi-liquid material.
Passive communication: Occurs when there is no response to a question. There is an assumption on the part of
communicator that their statement has been accepted.
Patient: Person requiring care in the surgical suite.
Peak sound level: The maximum instantaneous sound level.
Perioperative: Surrounding the operative and other invasive experience (i.e., before, during, and after).
Perioperative nursing care: The nursing activities that address the needs of patients, their families, and significant
others that occur preoperatively, intraoperatively, and postoperatively.
Perioperative Nurses College of New Zealand (NZNO): is special interest group under the New Zealand nurses
Organization. http://www.nzno.org.nz/Groups/Colleges/PerioperativeNursesCollege.aspx
Perioperative Registered Nurse: A Registered Nurse whose primary professional focus is patient care during the
perioperative phase of surgical intervention until admission to the post anesthetic care unit:
- a Registered Nurse who provides administration of the surgical suite;
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Open-gloving method: A method of donning sterile gloves in which the everted cuff of each glove allows the
gowned person to touch the inner side of the glove with ungloved fingers and the outer side of the glove with gloved
fingers.
Perioperative registered nursing practice: Those nursing activities performed by the professional nurse in the
preoperative, intraoperative, and postoperative phases of the patient's surgical experience.
Perioperative nursing services: Services extended to a variety of other groups to enhance the care ultimately
provided to the patient. These groups include, but are not limited to hospitals, clinics, schools and colleges of
nursing, physicians, other nurses, insurers, and medical device and pharmaceutical manufacturers.
Perioperative Period: Time commencing with the decision for surgical intervention and ending with a follow-up
home/ clinic evaluation. This period includes the preoperative, intraoperative, and postoperative phases.
Personal protective equipment (PPE): Specialized equipment or clothing used by health care workers to protect
themselves from direct exposure to patients' blood, tissue, or body fluids. Personal protective equipment may
include gloves, gowns, fluid-resistant aprons, head and foot coverings, face shields or masks, eye protection, and
ventilation devices (e.g., mouth pieces, respirator bags, pocket masks).
PIDAC: refers to the best practices document developed by the Ontario Provincial Infectious Disease Advisory
Committee. http://www.health.gov.on.ca/english/providers/program/infectious/pidac/pidac_fs.html
Pneumatic: Pertaining to gas or air; filled with compressed gas (or air).
Policy: A specified requirement developed by the healthcare facility. Personnel and physicians shall follow facility
policies.
Porous: permeable by air, steam, water.
Positioning device: Any device or piece of equipment used for positioning the patient and/or providing maximum
anatomic exposure. Devices include, but are not limited:
- support devices for head, arms, chest, iliac crests, and lumbar areas;
- pads in a variety of sizes and shapes for pressure points (e.g., head, elbows, knees, ankles, heels, sacral
areas);
- securing devices (e.g., safety belts, tapes, kidney rests, vacuum pack positioning devices);
- procedure bed equipment (e.g., headrest/holders, overhead arm supports, stirrups, foot boards); and
- specialty surgical beds (e.g., fracture tables, ophthalmology carts/stretcher chairs).
Postoperative: Begins with admission to the postanaesthesia care area and ends with a resolution of surgical
sequelae.
Post Tourniquet Syndrome (PTS): This tourniquet complication is a result of postoperative swelling in the
extremity. It is caused by a combination of hyperemia and reactive hyperemia; edema, hematomas, and excessive
wound bleeding contribute to further swelling. This occurs most often in patients whose tourniquet cuff pressure is
insufficient to prevent arterial inflow while preventing venous outflow.
Potentially infectious material: Blood; all body fluids, secretions, and excretions except sweat, regardless of
whether they contain visible blood; non-intact skin; mucous membranes; and airborne, droplet, and contacttransmitted epidemiologically important pathogens.
PPM: parts per million.
Precautions: Interventions implemented to reduce the risk of transmission of microorganisms from patient to
patient, patient to Health Care Worker (HCW) and HCW to patient.
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- a Registered Nurse who teaches theory and skills to student nurses and/or staff in the perioperative
setting; and
- a Registered Nurse who supports, participates in, and initiates research.
Professional Nurse: A formally educated nurse licensed/registered to perform within a define scope of practice by
a recognized regulatory body. i.e. a Registered Nurse; Licensed Practical Nurse; Registered Practical Nurse.
Each provincial or territorial nursing regulatory body in Canada is responsible for ensuring that the individuals it
registers as nurses meet an acceptable level of competence before beginning to practise. (CNA, 2009 retrieved April
5, 2009 from www.can-aiic.ca
Preoperative: Begins when the decision for surgical intervention is made and ends with the transfer of the patient to
the operating room bed.
Prion: Protienaceous infectious particle which is able to initiate infections without the traditional inflammatory
response. Incubation ranges from months 40 years. They are smaller than viruses and contain no nucleic acid.
Prion protein: A protein that is present in many organs and tissues including the brain, spinal cord and eye of
healthy humans and animals. The TSE agent is believed to be an abnormal form of a prion protein which causes
surrounding prion proteins to change their configuration.
Procedure: A specific mode or way of performing tasks in a sequential manner. Procedures are often developed as a
guideline to implement policies.
Process: Activities of the nurse or the process of nursing. Meeting the needs of the patient in a caring manner and
conforming to established standards of nursing practice. Includes those functions carried out by practitioners, such as
assessment, planning, treatments, indications for procedures/treatments, technical aspects of performing treatment,
and management of complications.
Pyrogen: A waste product of bacterial metabolism and growth which produces a fever, is toxic to patients and is not
destroyed in the sterilization process.
R
Rapid Read Out Incubator: at the time of printing this is the only incubator system from 3M which provides a
reading of a Biological Indicator after 1 hour (gravity cycle) and 3 hours (vacuum cycle).
Recall: Voluntary process of corrective action or removal of items from the market.
Receiving: The activities that take place once the device arrives at the health care facility, including examination and
inventory, and preparations for the processing, storage or disposal of the device.
Reference: Sources used in the research and preparation of a document. Direct quotes include page number.
Summarized information includes author and date. (APA, 2001).
Reflectance: The ratio of the light reflected from a surface to that falling on the surface, expressed as a percentage.
Regulated Medical Waste: Waste that is generated by human or animal health care facilities; medical research and
medical teaching establishments; clinical testing; or research laboratories. Includes anatomical waste; microbiology
laboratory waste; blood and body fluids; and sharps waste. (Code of Practice for Management of Biomedical Waste
in Canada, 1992).
Reprocessing: The steps performed to prepare a used medical device for reuse.
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Preceptor: A nurse who gives personal instruction, training, support, and supervision to a nursing student or a nurse
who is new to the area.
Reusable: Any product or piece of equipment intended by the manufacturer for multiple uses. The manufacturer is to
provide instructions for reprocessing, care and maintenance as appropriate to each item.
R.H.P.A.: Regulated Health Professions Act. Legislation in the Province of Ontario that defines the scope of
practice and regulations for practice of twenty-four health disciplines, including nursing.
Rigid sterilization container: A box or tray made of a rigid material that is designed to contain items for
sterilization. Specific containers are developed for regular steam sterilization and another specific for emergency
(flash) sterilization.
RMW: Regulated Medical Waste.
RNFA: Registered Nurse First Assist of Canada Network. Refer to Section 1 for more information.
Roentgen equivalent man (rem): A unit equivalent dose derived by multiplying rads by quality factors for the
relative biologic effects of a type of radiation. Rem is a measurement used in occupational monitoring: 1 rem = 1
R = 1 rad; 1 milliroentgen (mR) = 1/1000 rem.
Role: Expected behavior patterns.
Root cause analysis: A process performed after an adverse event already has occurred to identify basic and
contributing causal factors underlying variations in performance associated with near misses, adverse events, and
sentinel events. Root cause analysis seeks to find common causes to improve performance.
Routine Precautions (RP): A set of procedures and protocols for consistently treating all body substances from
every patient as potentially infectious.
RSV: respiratory syncytial virus.
S
Safe Surgery Checklist: Is part of the WHO World Alliance Challenge to improve surgery globally. The 3 part
checklist is a result of the work to improve the safety of surgery. WHO has declared surgery can cause harm!
http://www.who.int/patientsafety/safesurgery/ss_checklist/en/index.html
Safer Heathcare Now! (SHN): Is a campaign aimed at improving the safety of Canadian patient care, sharing the
knowledge, implementing & learning. Campaign was launched by CPSI. http://www.saferhealthcarenow.ca
SARS: Sudden Acute Respiratory Syndrome. A viral respiratory illness first reported in 2003.
SATS: South African Theatre Nurses, at the time of printing a founding member of IFPN, www.theatresisters.co.za
Scatter radiation: Radiation is scattered when an X-ray beam strikes a patient's body, as it passes through the
patient's body, and as it strikes surrounding structures (e.g., walls, OR furniture).
Scope of Nursing Practice: The activities that nurses are educated and authorized to perform, as established
through legislated definitions of nursing practice, complemented by standards, guidelines and policy positions issued
by professional nursing bodies (CNA, 2008, p. 41)
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Responsibility: Being depended on for completion of an activity or group of activities including those delegated to
other persons.
Semi-critical items: Devices that come in contact with non-intact skin or mucous membrane but ordinarily do not
penetrate them. Reprocessing semi-critical items involves meticulous cleaning followed by high-level disinfection.
Depending on the type of item and the intended use, intermediate level disinfection may be acceptable.
SENS: Safety engineered needles.
Sensitization: The development of immunological memory in response to exposure to an antigen.
Sentinel event: Unexpected occurrences involving death or serious physical or psychological injury or risk. May
include loss of limb or function (i.e., sensory, motor, physiologic, intellectual impairment) not previously present
which requires continued treatment or lifestyle change.
Sequential compression device (SCD): also known as pneumatic compression devices (PCD). Placed on lower
extremities to facilitate deep vein thrombosis prevention by reducing the pooling of blood and aiding in flow.
Sequentially compress sections of the lower extremities.
SGNA: Society for Gastroenterology Nurses and Associates of the United States of America. www.sgna.org
Sharps: Items containing a sharp point(s) or edge(s) such as suture needles, hypodermic needles, scalpel blades,
electrosurgical tips/blades, safety pins and instruments with sharp edges or points.
SHEA: Society for Healthcare Epidemiology of America
Shelf life: The length of time that a sterilized item will remain sterile. Factors affecting the maintenance of sterility
include the quality of the wrap, packaging material, or rigid container, the sealing method, the handling, and the
storage and transport practices. The shelf life of a chemical is the length of time after production or after mixing, that
the chemical is expected to be effective.
Shield or Shielding: Radiation absorbing material or materials used to reduce the absorbed dose, or absorbed dose
rate imparted to an object.
Sodium Hypochlorite: Common name is bleach. A caustic agent frequently used for cleaning/disinfecting.
Sodium Hydroxide: NaOH is soda lye, another caustic agent which may be used as a cleaning/disinfecting.
SORNG: Saskatchewan Operating Room Nurses Group.
Spaulding classification: Dr. Spaulding devised classification system for medical devices. It has 3 levels, critical,
semi-critical & no critical. It is recognized as the internationally accepted norm or practice when employing the use
of disinfection or sterilization.
Specialized Practice: Practice that concentrates on a particular aspect of nursing, related to the clients age (e.g.,
paediatrics, gerontology), the clients problem (e.g., pain management, bereavement), the diagnostic group (e.g.,
orthopaedics, vascular surgery), the practice setting (e.g., home care, emergency) or the type of care (e.g., primary
health care, palliative care, critical care) (CNA, 2008, p. 41).
Sponges: Includes all sizes and shapes of absorbent dissecting material (i.e., pledgettes, peanuts, etc). All sponges
must have radiopaque markers and/or tab.
SSI: Surgical Site Infection.
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Scrub Nurse: A Perioperative Registered Nurse who performs a surgical scrub, gowns, gloves, uses anticipatory
skills, and manages the sterile field and equipment in assisting the surgical team to perform the surgical procedure
and to meet individual patient needs.
Standard: An established norm determined by opinion, general agreement, authority, research, and/or theory that are
measurable by established criteria. An agreed upon level of excellence.
Standard Precautions: The primary strategy for successful prevention or control of nosocomial infection; reduction
of worker exposure to infection; precautions used for care of all patients regardless of their diagnosis or presumed
infectious status. Refer to Routine Practices. Previously called Universal precautions.
Sterile: Free from viable microorganisms.
Sterile field: An area immediately around a patient that has been prepared for a surgical procedure, including the
scrubbed team members, the furniture, and fixtures.
Sterile medical device: A device that is free from viable microorganisms.
Sterile storage area: A controlled storage area used to store clean and sterile medical devices.
Sterilization: A validated process used to render a product free from viable microorganisms. Note: In a
sterilization process, the nature of microbial death is described by a mathematical function. Therefore, the presence
of microorganisms on any individual device can be expressed in terms of probability. While this probability may be
reduced to a very low number, it can never be reduced to zero.
Sterilization: The chemical process: Chemical sterilization processes are used when items are not compatible with
heat or steam. Chemical sterilization is achieved by EO, hydrogen peroxide plasma/vapor, or by gas (peracetic acid)
vapor/plasma processes.
Sterilization: The physical process: Saturated steam under pressure shall be used for instruments compatible with
heat and moisture.
Sterilizer: A processing unit that cleans by a spray-force action known as impingement. This machine combines a
vigorous agitation bath with jet-stream air to create under-water turbulence. A sterilization cycle follows the
washing cycle.
Strike-through: An event whereby sterile drapes or packages become contaminated with microorganisms due to
soaking through or forcing through of moisture or air.
Subungual: Under the nail (e.g., finger).
SUMeDs: Single Use Medical Devices. May also be referred to as SUDs
Superficial:
Superheating: Uncontrolled, and possibly damaging, heat rise in a package that is being steam-sterilized, usually as
a result of insufficient moisture in the package materials or contents. Note: In addition to damaging materials,
superheating can result in the failure of sterilization, as effective sterilization relies on the presence of moisture.
Surgical attire: Surgical apparel worn within the semirestricted and restricted areas of the Surgical Suite which
includes the two-piece pantsuit, cover jackets, head coverings, shoes, masks, protective eyewear, and other protective
barriers.
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SSSL: Safe Surgery Saves Lives, campaign from WHO challenging the world to make global surgery safer.
http://www.who.int/patientsafety/safesurgery/
Surgical gown: A sterile textile gown that is worn by health care providers who are performing sterile procedures.
Note: Surgical gowns are recognized as Class 1 medical devices, according to the Medical Device Regulations of
the Canada Health Act.
Surgical hand scrub: The process of removing as many microorganisms as possible from the hands and forearms by
mechanical washing and chemical antisepsis before participating in a surgical procedure.
Surgical plume: Smoke produced by combustion of human tissue which is a health hazard containing organisms,
body fluids and carcinogens. i.e. Electrosurgery, Laser Surgery.
Surgical Suite: An area including the operating rooms, post anesthetic recovery room and support facilities.
Systems approach: A method to assess the structural and functional ways in which an organization operates and
how the people interact.
T
Tamper-evident device: A seal or disposable "lock" designed so that it cannot be resealed after opening, which is
used to indicate whether a container has been intentionally or accidentally opened and therefore exposed to potential
contamination prior to use. The device is generally secured on the container latching mechanism.
TB: Tuberculosis. A disease caused by bacteria usually attacking the lungs, which is spread via the airborne route
from person to person.
Telerobotic surgery: Minimally invasive surgery technique that utilizes advanced information technology to offer
treatments and procedures over long distances.
Terminal cleaning: Cleaning that is performed at the completion of surgical practice settings' daily surgery
schedules. Terminal cleaning is performed in surgical procedure rooms and scrub/utility areas, which include, but
are not limited to, surgical lights and external tracks, fixed and ceiling-mounted equipment, all furniture (including
wheels and casters), equipment, handles of cabinets and push plates, ventilation faceplates, horizontal surfaces (e.g.,
tops of counters, autoclaves, fixed shelving), the entire floor, kick buckets, and scrub sinks.
Third party reprocessor: A facility licensed by Health Canada or the US Food and Drug Administration (FDA) to
reprocess single-use medical devices to the same quality system requirements as the original manufacturer.
Toxic reaction: A reaction which may occurs in intravenous regional anesthesia (i.e., Bier block) procedures. The
major danger is an inadvertent bolus of local anesthetic entering the general circulation. This condition results from
accidental or sudden deflation of the tourniquet, from deflation soon after injection of local anesthetic, or if the bolus
is released too rapidly at the end of the procedure. During the procedure, minor toxicity symptoms could indicate
leakage due to under inflation of the tourniquet cuff.
Transfer: The process of preparing and moving a clean device from one organization to another. It includes
sending, transporting, and receiving.
Transmission based precautions: Second tier of precautions designed to be used with patients known or suspected
to be infected or colonized with highly transmissible or epidemiologically important pathogens for which additional
precautions are needed to prevent transmission in the practice setting.
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Surgical Conscience: professional behavior in the surgical setting that demonstrates an understanding consistent
application of the principles of asepsis; being unable to note a break in technique and not ignore it.
Transportation: Movement of medical devices between an off-site facility and a health care facility. Note: This
includes movement of medical devices between health care facilities.
TURP: Transurethral resection of prostate.
U
ULPA filter: An ultra low penetration air filter, used for the capture of submicronic particles. The Institute of
Environmental Sciences (IES) for ULPA filters specifies an efficiency of 99.9999% for particle diameters of 0.12
um; one particle out of every 100,000 passes through. Research has shown that pathogens such as HIV, HPV, and
HBV particles are found attached to droplet nuclei, and that the total size of the particle is significantly larger than
the 0.1um particles that an ULPA filter is designed to capture.
Ultrasonic technology: Ultrasonic technology allows for the cutting and coagulation via the use of sound waves.
Ultrasonic energy begins with an electrical current that generates a signal that is sent to a handpiece. A transducer
converts the energy to a mechanical motion in the handpiece. The tip of the handpiece when in contact with tissue
coagulates vessels. No tissue plume is generated and damage to adjacent tissue is limited. Examples of ultrasonic
systems are the Harmonic Scalpel, Ultrasonix.
Universal Precautions: Refer to Routine Practices.
Unlicensed Assistive Personnel (UAP): Individuals trained to assist registered nurses in providing patient care
activities as delegated by registered nurses. Assistive personnel include, but are not limited to, aides/assistants,
orderlies, technicians and technologists.
Unregulated support staff: Staff members who are not regulated in their role by Provincial/National legislation,
who work under the supervision of a healthcare professional. The public has no recourse for lodging complaints
except directly to the employer.
Used items: Items that are opened for surgical procedures that may or may not have come in contact with the
patients blood, tissue or body fluids.
User-centered design: A system designed to devise methods to avoid errors. Strategies are directed at the design of
individual devices so they can be used reliably and safely.
UV: Ultraviolet.
V
Validation: Documented procedure for obtaining, recording, and interpreting the results required to establish that a
process will consistently yield product complying with predetermined specifications.
Valve: A mechanical component of a rigid sterilization container system that opens during sterilization to allow air
evacuation and sterilant penetration and closes after sterilization to prevent contamination.
Glossary
Page 329 of 334

Transmissible Spongiform Encephalopathy (TSE): Also known as prion diseases are fatal degenerative brain
diseases. The TSE agents are hardy, remain infectious for years in a dried state, and resist all routine sterilization
and disinfection procedures commonly used in health care facilities. Examples of human TSE are: GSS, FFI, Kuru,
and CJD.
VRE: Vancomycin Resistant Enterococcus which is resistant to Vancomycin and other microbial agents.
W
Weight: A measurement used for textiles, expressed in grams per square meter.
WHMIS: Workers' Hazardous Material Information System. A federal program administered by Health Canada,
Environmental & Workplace Health, http://www.hc-gc.ca/ewh-semt/occup-travel/whmis-simdut/index-eng.php
WHO: World Health Organization is the United Nations specialized agency for health. www.who.int
Wrap: To enclose and fasten securely as a package.
Wrong level/part surgery: A surgical procedure that is performed on the correct site, but at the wrong level or part
of the operative field. For example, performing a lumbar laminectomy on an unintended intervertebral level with
identified pathology. In this type of error, the correct part of the body is prepped and draped, but the surgical
procedure is performed on the wrong level of the patients anatomy.
Wrong patient surgery: An error includes procedures that are performed on the wrong patient; a patient not
correctly identified prior to surgery.
Wrong side surgery: A surgical procedure that involves operating on the wrong extremity or wrong side of the
body.
Wrong site surgery: A broad term that encompasses all surgical procedures that are performed on the wrong body
part or the wrong patient.
X
X-rays: Electronically generated electromagnetic radiation of maximum photon energy not less than 5,000 electron
volts.
X-ray machine: Electrically powered device, the principal purpose of which is the production of x-rays.
X-ray source: Any device or that portion of any device that emits x-rays, whether or not the device is an x-ray
machine.
Glossary
Page 330 of 334

vCJD: Variant Creutzfeldt-Jakob Disease. A new prion disease in humans linked to eating beef products from cattle
infected with BSE. First reported case in Canada was 2002. It is a progressive fatal disease affecting the central
nervous system.
American Psychological Association (APA) (2001). Publication Manual (5th. Ed.). Washington: Author.
Canadian Nurses Association (2008). Advanced Nursing Practice A national Framework. Ottawa: Author.
Canadian Nurses Association (2006). Practice Framework for Nurse practitioners. Ottawa: Author.
Canadian Association of Bariatric Physicians & surgeon (CABPS). http://www.cabps.ca
Schneider, M. (2008). Anesthesia safeguards for the obese. Out Patient Surgery. March 2008, p. 5.
Tabers Cyclopedic Medical dictionary (2005). Philadelphia: F A Davis Co.
Glossary
Page 331 of 334

REFERENCES
Standards, Guidelines and Position Statements for

Perioperative Registered Nursing Practice
The ORNAC Standards Committee would like your feedback on this edition of the Standards.
Please complete this form and send it to the ORNAC president
Thank you in advance for your participation.
1.
Comments on the revised, bound, format.
2.
Is information presented in logical order? (if not, give example of where information
should be moved).
3.
Areas requiring correction (including typo errors).
4.
Material/information you wish to see added in future editions/revisions.
Comments: please use other side of page.
The name and address of the current President is available at the ORNAC web site
www.ornac.ca
Standards, Guidelines and Position Statements for Perioperative Registered Nursing Practice
Evaluation Form 9th Edition

Page 332 of 334

Evaluation Form
General standards and guides for all facilities

Number
Title
Intended for
Z314.8
Decontamination of Reusable Medical

Devices
Z314.10
(2009)
Selection, Use, Maintenance & Laundering

of Reusable Textile Wrappers, Surgical
Gowns and Drapes for Health Care
Facilities
Selection and Use of Rigid Sterilization
Containers
Sterile processing departments; clinical

areas and ORs (covers all activities
from point-of-use to cleaning,
disinfection and preparation for
sterilization)
Laundries and purchasing departments
in facilities that use or process reusable
textiles.
Z314.14
Z314.15
Warehousing, Storage and Transportation

of Clean and Sterile Medical Devices
Z314.22
Management of Loaned, Shared and

Leased Medical Devices
PLUS 1112
Handbook on Infection Prevention and

Control in Office-Based Health Care and
Allied Services
Sterilization of Health Care Products Biological Indicators - Guidance for the
Selection, Use and Interpretation of Results
Sterilization of Health Care Products Chemical Indicators - Guidance for
Selection, Use and Interpretation of Results
Infection Control During Construction or
Renovation and Maintenance of Health
Care Facilities
Z14161
Z15882
Z317.13
Sterile processing departments and

other area where rigid sterilization
containers, organizing trays, etc. are
used.
Material managers, sterile processing
departments and infection prevention
and control personnel in facilities that
store and pick medical devices outside
of controlled sterile supply areas.
Sterile processing departments and
operating rooms (Standard outlines
requirements and responsibilities for the
safe and effective use of loaners).
Smaller health care facilities that want
guidance consistent with the hospital
sterilization standards.
Health care facility departments and
staff that purchase or use biological
indicators.
Health care facility departments and
staff that purchase or use chemical
indicators.
Hospital engineers, architects,
contractors and infection prevention and
control personnel in facilities
undergoing construction or renovation.
Page 333 of 334

Canadian Standards Association - Standards for Sterilization and

Infection Control in Health Care Facilities
Number
Title
Intended for
Z314.3
Effective Sterilization in Health Care

Facilities by the Steam Process
Steam Sterilizers for Health Care Facilities
Sterile processing departments that

perform steam sterilization
Hospital engineering departments
Z314.7
Additional standards for ethylene oxide (EtO) sterilization

Number
Title
Intended for
Z314.1
Ethylene Oxide Sterilizers for Health Care

Facilities
Effective Sterilization in Health Care
Facilities by the Ethylene Oxide Process
Installation, Ventilation and Safe Use of
Ethylene Oxide Sterilizers in Health Care
Facilities
Hospital engineering departments
Z314.2
Z314.9
Sterile processing departments that

perform EtO sterilization
Hospital engineering and sterile
processing departments in facilities that
perform EtO sterilization
For an entire listing of health care standards and to ordered, contact a CSA sales
representative at 1-800-463-6727 or by visit the Online Store at www.shopcsa.ca
Page 334 of 334

Additional standards for steam sterilization

Periop Standards

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Promoting Excellence

OPERATING ROOM NURSES ASSOCIATION OF CANADA (ORNAC)

Licensed for Michelle Kent. Sold by CSA on September 8, 2011.

Standards, Guidelines and

Licensed for Michelle Kent. Sold by CSA on September 8, 2011.

Routine Practices and Additional Precautions ..................................................................................................89

Licensed for Michelle Kent. Sold by CSA on September 8, 2011.

Section 2 Infection Prevention and Control

Single Use Medical Devices (SUMeDs) ........................................................................................................142

Section 3 Safety/Risk Prevention and Management

Introduction to Risk Management ..................................................................................................................155

Licensed for Michelle Kent. Sold by CSA on September 8, 2011.

Specialized Instruments and Equipment .........................................................................................................140

Specialized Surgical Equipment ......................................................................................................226

Section 4 Environmental Hazards and Responsibilities

Section 5 Nursing Care of the Anesthetised Patient

Licensed for Michelle Kent. Sold by CSA on September 8, 2011.

Regional Anesthesia-Spinal, Epidural, Peripheral Nerve Blocks ...................................................................290

Licensed for Michelle Kent. Sold by CSA on September 8, 2011.

Intravenous Regional Anesthesia (Bier Block) .............................................................................................288

Licensed for Michelle Kent. Sold by CSA on September 8, 2011.

Licensed for Michelle Kent. Sold by CSA on September 8, 2011.

Kathy Radcliffe RN, BSN, CPN(C) Chair, Standards Committee, Ontario

10th edition committee members

Licensed for Michelle Kent. Sold by CSA on September 8, 2011.

A MESSAGE FROM THE PRESIDENT. . .

A MESSAGE FROM THE PRESIDENT

Bonnie McLeod, RN, BScN, MN, CPN(C)

Licensed for Michelle Kent. Sold by CSA on September 8, 2011.

Licensed for Michelle Kent. Sold by CSA on September 8, 2011.

Section 1 ORNAC Beliefs, Professional Standards and Competencies

Licensed for Michelle Kent. Sold by CSA on September 8, 2011.

ORNAC'S FUNDAMENTAL PRINCIPLES

Perioperative nursing is a dynamic process guided by theoretical knowledge, ethical principles,

Standards of nursing practice, as well as collegial and interdisciplinary collaboration, enhance

Approved by Board and Executive: April 1994

Licensed for Michelle Kent. Sold by CSA on September 8, 2011.

Licensed for Michelle Kent. Sold by CSA on September 8, 2011.

We promote and continually develop our unique specialized body of knowledge.

We strive to achieve excellence in perioperative practice, and the activities

We are role models who communicate a vision and who empower

We promote the perioperative patients right to be informed and to

We strive to be fiscally and environmentally responsible while optimizing patient

National Standards for Perioperative Registered Nursing Practice

Licensed for Michelle Kent. Sold by CSA on September 8, 2011.

Licensed for Michelle Kent. Sold by CSA on September 8, 2011.

CONCEPTUAL MODEL FOR

The perioperative Registered Nurse precepts and mentors colleagues.

Scope of Practice for Expanded Perioperative Nursing Practice

Licensed for Michelle Kent. Sold by CSA on September 8, 2011.

ORNAC Scope of Practice for Perioperative Registered Nurses

Registered Nurse First Assistant - RNFA

Scope of Practice for Advanced Perioperative Nursing Practice

Licensed for Michelle Kent. Sold by CSA on September 8, 2011.

STAFFING THE SURGICAL SUITE

Meet individual patient's needs and surgical complexity.

Maintain acceptable levels of safety for patients, personnel and physicians.

Function within legal limitations of the provincial scope of practice.

Facilitate appropriate initial and specialty orientation, and continuing education.

Attain and maintain perioperative Registered Nurse competency.

The surgical theatre shall be managed by an experienced perioperative Registered Nurse.

Licensed for Michelle Kent. Sold by CSA on September 8, 2011.

ORNAC POSITION STATEMENTS

Licensed for Michelle Kent. Sold by CSA on September 8, 2011.