Clinical Issues 1.5 CONTINUING EDUCATION SHARON A. VAN WICKLIN, MSN, RN, CNOR, CRNFA(E), CPSN-R, PLNC

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1 CONTINUING EDUCATION Clinical Issues SHARON A. VAN WICKLIN, MSN, RN, CNOR, CRNFA(E), CPSN-R, PLNC Continuing Education Contact Hours indicates that continuing education (CE) contact hours are available for this activity. Earn the CE contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Learner Evaluation at Each applicant who successfully completes this program can immediately print a certificate of completion. Event: #16518 Session: #0001 Fee: For current pricing, please go to: The CE contact hours for this article expire May 31, Pricing is subject to change. Purpose/Goal To provide the learner with knowledge of AORN s guidelines related to variations in documenting surgical wound classification, wearing long-sleeved jackets while preparing and packaging items for sterilization, endoscopic transmission of prions, and wearing gloves when handling flexible endoscopes. Objectives 1. Discuss practices that could jeopardize safety in the perioperative area. 2. Discuss common areas of concern that relate to perioperative best practices. 3. Describe implementation of evidence-based practice in relation to perioperative nursing care. Accreditation AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center s Commission on Accreditation. Approvals This program meets criteria for CNOR and CRNFA recertification, as well as other CE requirements. AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP Check with your state board of nursing for acceptance of this activity for relicensure. Conflict-of-Interest Disclosures Sharon A. Van Wicklin, MSN, RN, CNOR, CRNFA(E), CPSN-R, PLNC, has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. The behavioral objectives for this program were created by Helen Starbuck Pashley, MA, BSN, CNOR, clinical editor, with consultation from Susan Bakewell, MS, RN-BC, director, Perioperative Education. Ms Starbuck Pashley and Ms Bakewell have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article. Sponsorship or Commercial Support No sponsorship or commercial support was received for this article. Disclaimer AORN recognizes these activities as CE for RNs. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity. ª AORN, Inc, AORN Journal j 527

2 CLINICAL ISSUES THIS MONTH Variations in documenting surgical wound classification Key words: surgical wound classification, clean, clean-contaminated, contaminated, dirty. Wearing long-sleeved jackets while preparing and packaging items for sterilization Key words: long-sleeved jackets, organic material, sterile processing. Endoscopic transmission of prions Key words: prions, high-risk tissue, low-risk tissue, Creutzfeldt-Jakob disease (CJD), variant Creutzfeldt- Jakob disease (vcjd). Wearing gloves when handling flexible endoscopes Key words: gloves, low-protein, powder-free, natural rubber latex gloves, latex-free gloves. Variations in documenting surgical wound classification QUESTION: Recently, perioperative RNs at our facility were required to complete an educational program to help resolve variations in documenting surgical wound classification. Are there similar variations in other facilities, and if so, is the surgical wound classification a reliable method for predicting surgical site infection (SSI) following surgery? ANSWER: According to the Centers for Disease Control and Prevention (CDC), the surgical wound classification is a formula used for postoperatively grading the extent of intraoperative microbial contamination and the likelihood that a patient will develop a postoperative SSI. 1 The classification also allows for comparing wound infection rates associated with different surgical techniques, surgeons, and facilities. 1 The comparison 528 j AORN Journal

3 May 2016, Vol. 103, No. 5 Clinical Issues may be useful for research and also may serve to alert infection prevention personnel to patients at increased risk for SSIs, enabling health care providers to take appropriate surveillance and preventive measures. 1 The following are the CDC definitions for the four surgical wound classifications: [Class I] Clean wounds: These are uninfected operative wounds in which no inflammation is encountered and the respiratory, alimentary, genital, or uninfected urinary tracts are not entered. In addition, clean wounds are primarily closed, and if necessary, drained with closed drainage [eg, bulb drain]. Operative incisional wounds that follow nonpenetrating (blunt) trauma should be included in this category if they meet the criteria. [Class II] Clean-contaminated wounds: These are operative wounds in which the respiratory, alimentary, genital, or urinary tract is entered under controlled conditions and without unusual contamination. Specifically, operations involving the biliary tract, appendix, vagina, and oropharynx are included in this category, provided no evidence of infection or major break in technique is encountered [eg, spillage from gastrointestinal tract]. [Class III] Contaminated wounds: These include open, fresh, accidental wounds, operations with major breaks in sterile technique [eg, procedure performed with unsterile instruments] or gross spillage from the gastrointestinal tract, and incisions in which acute, nonpurulent inflammation is encountered. [Class IV] Dirty or infected wounds: These include old traumatic wounds with retained devitalized tissue and those that involve existing clinical infection or perforated viscera. This definition suggests that the organisms causing postoperative infection were present in the operative field before the operation. 1(p109) AORN developed the Surgical Wound Classification Decision Tree (Figure 1) as a tool to assist perioperative RNs in accurately classifying surgical wounds using the CDC surgical wound classification system. The decision tree is an algorithm that presents organized, directed wound classification questions. This tool is included in the 2016 Guideline for prevention of transmissible infections. 2 The literature reports variations in wound classification and the misclassification of surgical wounds by surgical team members. Levy et al 3 compared the wound classifications documented by RN circulators with the operative notes documented by surgeons for 2,034 procedures performed in 11 different pediatric institutions. The researchers found agreement in surgical wound classification between RNs and surgeons in 1,148 procedures (56%). The wound classifications differed by one class in 674 procedures (33%), by two classes in 175 procedures (9%), and by three classes in 36 procedures (2%). Of the procedures in which there was disagreement, the researchers found that when compared with the surgeons operative notes, the surgical wounds had been underclassified by the perioperative RNs in 741 procedures (84%). The researchers also found that 56 appendectomy, 93 gastrostomy tube placement, 110 cholecystectomy, and 16 ostomy closure wounds had been incorrectly classified by the RN circulators as Class 1, Clean, and that 103 incision and drainage procedures had been incorrectly classified as Class 1, Clean (n ¼ 18); Class 2, Clean-Contaminated (n ¼ 44); and Class 3, Contaminated (n ¼ 41). In all instances, the researchers found that the RN circulator had documented the surgical wound classification without consulting the surgeon and that the surgical wound classification was not included in the preoperative or postoperative briefing sessions in any of the institutions. The researchers concluded that the current surgical wound classification system was unreliable for comparing infection rates between patients and institutions and that it should not be used for benchmarking purposes. The researchers recommended developing and incorporating a more consistent process to increase the accuracy and consistency of surgical wound classification. In a study to measure the level of agreement in wound classification assignments among surgeons, RN circulators, and National Surgical Quality Improvement Program (NSQIP) reviewers, Snyder et al 4 collected data between July 21, 2010, and October 31, 2011, on 374 pediatric general surgery procedures selected for review by NSQIP random sampling methods. The researchers found an overall disagreement of 48% among the surgeons, RNs, and NSQIP reviewers. When comparing disagreement levels between the surgeons and NSQIP reviewers, the researchers found that there was disagreement about surgical wound classification in 23% of instances; however, they found 38% disagreement between the RN circulators and the surgeons and 40% disagreement between the RN circulators and the NSQIP reviewers. The highest rates of disagreement involved surgical wounds from fundoplication (73%), appendectomy (71%), cholecystectomy (60%), and incision and drainage (50%) procedures. Notably, the NSQIP reviewers more frequently classified surgical wounds as Class 3, Contaminated, or Class 4, Dirty or Infected, compared with either the surgeons or the RNs, and the RNs more frequently classified surgical wounds as Class 1, Clean, or Class 2, Clean- Contaminated, compared with the surgeons or NSQIP AORN Journal j 529

4 Van Wicklin May 2016, Vol. 103, No. 5 Figure 1. The AORN surgical wound classification decision tree. Reprinted with permission from AORN. Copyright ª 2014, AORN, Inc, 2170 S. Parker Road, Suite 400, Denver, CO All rights reserved. reviewers. The researchers concluded there was significant variation in assigning wound classification among perioperative RNs, surgeons, and NSQIP reviewers. They recommended providing educational interventions for all personnel involved in determining surgical wound classification and increasing communication between surgeons and perioperative RNs regarding wound classification assignments. Perioperative RNs should participate in educational activities to improve wound classification and use educational tools such as the AORN Surgical Wound Classification Decision Tree to assist in accurately identifying surgical wounds. The RN circulator and the surgeon should assign the surgical wound classification collaboratively at the conclusion of the procedure. 530 j AORN Journal

5 May 2016, Vol. 103, No. 5 Clinical Issues Sharon A. Van Wicklin, MSN, RN, CNOR, CRNFA(E), CPSN-R, PLNC, is a senior perioperative practice specialist in the Nursing Department at AORN, Inc, Denver, CO. References 1. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, Am J Infect Control. 1999;27(2): Guideline for prevention of transmissible infections. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2016: Levy SM, Lally KP, Blakely ML, et al. Surgical wound misclassification: a multicenter evaluation. J Am Coll Surg. 2015;220(3): Snyder RA, Johnson L, Tice J, et al. Wound classification in pediatric general surgery: significant variation exists among providers. J Am Coll Surg. 2013;217(5): Wearing long-sleeved jackets while preparing and packaging items for sterilization QUESTION: Why does AORN recommend that perioperative or sterile processing team members wear scrub attire that covers the arms while preparing and packaging items in the clean assembly section of the sterile processing area? ANSWER: Wearing long-sleeved scrub attire while preparing and packaging items in the clean assembly section of the sterile processing area helps contain skin squames and hair that may be shed from the perioperative or sterile processing team member s bare arms. 1 Not wearing a long-sleeved jacket while preparing and packaging items that will be used during these procedures may allow shed skin squames and hair from the team member s bare arms to drop onto the item that is being prepared or packaged. 2 If the hair is noticed when personnel subsequently open the tray or item in the OR, they would at a minimum consider the tray contaminated and have to return it to the sterile processing team for reprocessing. 3 More importantly, personnel may not notice the hair. This could potentially mean that the sterility of the instruments is questionable and could place the patient at risk of surgical site infection. Sterilization can only be achieved if all surfaces of an item have contacted the sterilizing agent under the correct conditions and for the correct amount of time. 4 Organic materials and other debris may act as barriers that interfere with sterilization or may combine with and deactivate the sterilant. 4-6 If organic material or other debris is found on an item or in an instrument tray that has been through a sterilization process, there is no way to ensure that the sterilant made contact with all surfaces of the item and with other items in the set. Even if the sterilization cycle does achieve a sterility assurance level of 10 6 (ie, there is less than or equal to one chance in a million that a single viable microorganism is present on a sterilized item), the presence of foreign material could lead to an inflammatory response that may affect the patient s response to infection from other sources. The hair also could be inadvertently transferred onto other areas of the sterile field or into the surgical wound. Personnel can reduce the patient s exposure to hair and squames shed from the arms by wearing long-sleeved cover jackets to help reduce the patient s risk of SSI. Sharon A. Van Wicklin, MSN, RN, CNOR, CRNFA(E), CPSN-R, PLNC, is a senior perioperative practice specialist in the Nursing Department at AORN, Inc, Denver, CO. References 1. Andersen BM, Solheim N. Occlusive scrub suits in operating theaters during cataract surgery: effect on airborne contamination. Infect Control Hosp Epidemiol. 2002;23(4): Guideline for surgical attire. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2016: AORN Journal j 531

6 Van Wicklin May 2016, Vol. 103, No Guideline for sterile technique. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2016: Guideline for sterilization. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2016: Rutala WA, Weber DJ; Healthcare Infection Control Practices Advisory Committee (HICPAC). Guideline for Disinfection and Sterilization in Healthcare Facilities, Atlanta, GA: Centers for Disease Control and Prevention; pdf/disinfection_sterilization/pages1_2disinfection_nov_2008.pdf. Accessed December 18, ANSI/AAMI ST79: Comprehensive guide to steam sterilization and sterility assurance in health care facilities. ANSI/AAMI; ItemNumber¼1382. Accessed December 18, Endoscopic transmission of prions QUESTION: We will be performing a gastrointestinal endoscopy procedure on a patient with a history of Creutzfeldt-Jakob disease (CJD). What is the potential for endoscopic transmission of prions? How should the flexible endoscope be processed? ANSWER: Prions are a unique class of infectious proteins that cause fatal neurologic diseases. 1 Examples of prion diseases are Gertsmann-Str aussler-scheinker syndrome, fatal familial insomnia syndrome, and CJD. 1 Creutzfeldt-Jakob disease is a rare and ultimately fatal degenerative disease that belongs to a group of neurologic disorders known as transmissible spongiform encephalopathies (TSEs). 2 Variant Creutzfeldt- Jakob disease (vcjd) may be transmitted to humans by consumption of contaminated beef from cattle with bovine spongiform encephalopathy, also known as mad cow disease. 1,3-5 The collective evidence shows there are concerns regarding the potential for the endoscopic transmission of prions and other TSEs, including CJD and vcjd. 4,6 For an endoscope to act as a vehicle for the transmission of prions, contact with infective tissue is required. 1,4 In patients with CJD, prions accumulate in the central nervous system and are transmitted by exposure to infectious brain, pituitary, or eye tissue. Because flexible endoscopes do not come into contact with brain, pituitary, or eye tissue, the endoscopic transmission of CJD or other TSEs is unlikely. 1,4 In patients with vcjd, however, prions accumulate in both central nervous system and lymphoid tissue. 3,5 In patients with vcjd, prions are detectable in the appendix, spleen, tonsils, thymus, and lymph nodes. 1-5,7 The prions responsible for vcjd are found in abundance in the Peyer patches located in the terminal ileum. 2,3 Aggregates of lymphoid prions are also found in the large intestine and the stomach. 3 In theory, the transmission of vcjd via a flexible gastrointestinal endoscope is therefore possible because of the lymphatic distribution of prions. The risk of transmission is greater during invasive interventional procedures (eg, biopsy, polypectomy, mucosal resection, sphincterotomy) than during noninterventional procedures; 2,5 however, there have been no reports of such transmission described in the literature. 3,5,7 Personnel should minimize the risk of transmission of prion diseases from flexible endoscopes and endoscope accessories by following the guidance provided in the AORN Guideline for cleaning and care of surgical instruments. 8 Prions are highly resistant to conventional physical and chemical disinfection and sterilization and can remain infectious for years. 1,3-5 Methods for processing instruments contaminated with prions are unsuitable for semicritical, heat-labile devices such as flexible endoscopes. 1,2 Current recommendations for processing instruments exposed to prions include decontamination with concentrated sodium hydroxide (ie, lye) or sodium hypochlorite (ie, bleach), which are corrosive to flexible endoscopes, followed by prolonged steam sterilization, which most flexible endoscopes cannot tolerate. 1,7 Dry heat, glutaraldehyde, and ethylene oxide are not effective disinfection or sterilization methods for flexible endoscopes contaminated with prions. 2,5,7 Aldehyde disinfectants (eg, glutaraldehyde, ortho-phthalaldehyde) may anchor prion proteins in endoscope channels and also render them more difficult to remove. 2,3,5 For this reason, aldehyde disinfectants are not recommended for high-level disinfection in some countries. 2,3,5 Additional research is warranted relative to the use of cleaning chemistries and low-temperature sterilization technologies for inactivating prions. 1 Flexible endoscopes and accessories used during endoscopy procedures on high-risk patients should be processed as shown in Table 1. Discarding the endoscope and accessories after their use on high-risk tissue from high-risk patients ensures the endoscope and accessories will not be used on 532 j AORN Journal

7 May 2016, Vol. 103, No. 5 Clinical Issues Table 1. Recommendations for Processing Flexible Endoscopes Used With High-Risk Patients 1,2 Type of Patient Type of Tissue Method of Processing High-risk patients include patients with Known prion disease Familial history of Creutzfeldt-Jakob, Gerstmann-Stra ussler-scheinker syndrome, or familial insomnia syndrome Known mutation in the PrP (prion protein gene involved in familial transmissible spongiform encephalopathies) History of dura matter transplantation Electroencephalograph findings or laboratory evidence suggestive of transmissible spongiform encephalopathies (eg, markers of neuronal injury such as protein) Known history of cadaver-derived hormone injection High risk: Brain (including dura matter) Spinal cord Posterior eye (including retina or optic nerve) Pituitary gland Low risk: Cerebrospinal fluid Kidney Liver Spleen Lung Placenta Olfactory epithelium Lymph nodes No risk: Peripheral nerves Intestine Bone marrow Blood Leukocytes Serum Thyroid gland Adrenal gland Heart Skeletal muscle Adipose tissue Gingiva Prostate Testis Tears Saliva Sputum Urine Feces Semen Vaginal secretions Milk Sweat Discard No recommendation (Unresolved issue) Conduct a risk assessment with a multidisciplinary team to determine whether to process or discard instruments Discard neurosurgical endoscopes with central nervous system contact Process in accordance with the AORN Guideline for cleaning and care of surgical instruments 2 References 1. Rutala WA, Weber DJ. Society for Healthcare Epidemiology of America. Guideline for disinfection and sterilization of prion contaminated medical instruments. Infect Control Hosp Epidemiol. 2010;31(2): Guideline for cleaning and care of surgical instruments. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2016: Adapted from Guideline for processing flexible endoscopes. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc: 2016: , with permission from AORN, Inc. subsequent patients and eliminates the risk of inadequate prion inactivation or patient-to-patient transmission of prion disease. There is no recommendation for processing critical or semicritical devices contaminated with low-risk tissue from high-risk patients. A multidisciplinary team that includes infection preventionists, endoscopists, perioperative and endoscopy RNs, sterile processing team members, and other involved personnel should conduct a risk assessment to consider the benefits compared with the potential harms of reprocessing a flexible endoscope contaminated with low-risk tissue from high-risk patients. Although low-risk tissue has been found to transmit CJD, this has been demonstrated AORN Journal j 533

8 Van Wicklin May 2016, Vol. 103, No. 5 only when low-risk tissue has been inoculated into the brain of a susceptible animal. 1 Flexible endoscopes contaminated with no-risk tissue do not present a risk for prion transmission. Sharon A. Van Wicklin, MSN, RN, CNOR, CRNFA(E), CPSN-R, PLNC, is a senior perioperative practice specialist in the Nursing Department at AORN, Inc, Denver, CO. References 1. Rutala WA, Weber DJ. Society for Healthcare Epidemiology of America. Guideline for disinfection and sterilization of prion-contaminated medical instruments. Infect Control Hosp Epidemiol. 2010;31(2): Guidance on decontamination of equipment for gastrointestinal endoscopy. British Society for Gastroenterology. -equipment-for-gastrointestinal-endoscopy.html. Published June Accessed December 18, Puzey A. Managing the risks of prion disease transmission through flexible endoscopy. Gastrointest Nurs. 2010;8(2): SGNA Practice Committee 2013e2014. Guideline for use of high-level disinfectants and sterilants for reprocessing flexible gastrointestinal endoscopes. Gastroenterol Nurs. 2015;38(1): Widmer A. Prions and endoscopy: an unresolved problem. Zentralsterilisation. 2004;12(suppl 1):S70-S Rey JF, Kruse A, Neumann C; ESGE (European Society of Gastrointestinal Endoscopy); ESGENA (European Society of Gastrointestinal Endoscopy Nurses and Associates). ESGE/ESGENA technical note on cleaning and disinfection. Endoscopy. 2003;35(10): Kovaleva J, Peters FT, van der Mei HC, Degener JE. Transmission of infection by flexible gastrointestinal endoscopy and bronchoscopy. Clin Microbiol Rev. 2013;26(2): Guideline for cleaning and care of surgical instruments. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2016: Wearing gloves when handling flexible endoscopes QUESTION: My colleague and I recently had a disagreement about the need to wear gloves when handling processed flexible endoscopes. What does AORN recommend? ANSWER: Personnel should wear clean, low-protein, powder-free, natural rubber latex gloves or latex-free gloves when handling processed flexible endoscopes and when transporting them to and from the storage cabinet. Sterile gloves are not required for handling processed flexible endoscopes unless the endoscope is intended to be placed on a sterile field. Wearing clean gloves may lessen the contamination of processed flexible endoscopes via the hands of personnel. 1 Using low-protein, powder-free, natural rubber latex gloves or latex-free gloves can minimize latex exposure and the risk of reactions in both health care workers and patients. 2 Studies related to the storage of flexible endoscopes have confirmed endoscope contamination from the hands of personnel and environmental surfaces. 3-9 Muscarella 10 described an instance in which a processed endoscope randomly selected from an endoscope storage cabinet for surveillance purposes yielded positive growth for both patient-borne and environmental bacteria. To investigate the potential for disease transmission, a second colonoscope was sampled immediately after use (ie, the positive control) and a third colonoscope that had been sterilized with ethylene oxide also was sampled (ie, the negative control). The investigator sampled environmental surfaces and the hands and fingernails of personnel who handled the endoscopes and found that the bacteria from the insertion tube of the negative control and contaminated colonoscope yielded Staphylococcus aureus identical to the strain cultured from the fingernails of a newly hired team member. These results suggested that the team member s hands and fingernails were the source of the bacteria and contamination of the colonoscope after processing. The investigator recommended that personnel wear clean gloves when handling processed endoscopes to prevent contaminating endoscopes before they are used on patients. Sharon A. Van Wicklin, MSN, RN, CNOR, CRNFA(E), CPSN-R, PLNC, is a senior perioperative practice specialist in the Nursing Department at AORN, Inc, Denver, CO. References 1. Choice of framework for local policies and procedures d decontamination of flexible endoscopes: operational management. UK Department of Health. system/uploads/attachment_data/file/192522/decontamination_ of_flexible_endoscopes.pdf. Published Accessed December 18, j AORN Journal

9 May 2016, Vol. 103, No. 5 Clinical Issues 2. Guideline for a safe environment of care, part 1. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2016: Osborne S, Reynolds S, George N, Lindemayer F, Gill A, Chalmers M. Challenging endoscopy reprocessing guidelines: a prospective study investigating the safe shelf life of flexible endoscopes in a tertiary gastroenterology unit. Endoscopy. 2007;39(9): Rejchrt S, Cermak P, Pavlatova L, McKova E, Bures J. Bacteriologic testing of endoscopes after high-level disinfection. Gastrointest Endosc. 2004;60(1): Riley R, Beanland C, Bos H. Establishing the shelf life of flexible colonoscopes. Gastroenterol Nurs. 2002;25(3): Vergis AS, Thomson D, Pieroni P, Dhalia S. Reprocessing flexible gastrointestinal endoscopes after a period of disuse: is it necessary? Endoscopy. 2007;39(8): Brock AS, Steed LL, Freeman J, Garry B, Malpas P, Cotton P. Endoscope storage time: assessment of microbial colonization up to 21 days after reprocessing. Gastrointest Endosc. 2015;81(5): Ingram J, Gaines P, Kite R, Morgan M, Spurling S, Winsett RP. Evaluation of medically significant bacteria in colonoscopes after 8 weeks of shelf life in open air storage. Gastroenterol Nurs. 2013; 36(2): Marino M, Grieco G, Moscato U, et al. Is reprocessing after disuse a safety procedure for bronchoscopy? A cross-sectional study in a teaching hospital in Rome. Gastroenterol Nurs. 2012;35(5): Muscarella LF. The study of a contaminated colonoscope. Clin Gastroenterol Hepatol. 2010;8(7): AORN Journal j 535

10 LEARNER EVALUATION Continuing Education: Clinical Issues This evaluation is used to determine the extent to which this continuing education program met your learning needs. The evaluation is printed here for your convenience. To receive continuing education credit, you must complete the online Learner Evaluation at Rate the items as described below. PURPOSE/GOAL To provide the learner with knowledge of AORN s guidelines related to variations in documenting surgical wound classification, wearing long-sleeved jackets while preparing and packaging items for sterilization, endoscopic transmission of prions, and wearing gloves when handling flexible endoscopes. OBJECTIVES To what extent were the following objectives of this continuing education program achieved? 1. Discuss practices that could jeopardize safety in the perioperative area. Low High 2. Discuss common areas of concern that relate to perioperative best practices. Low High 3. Describe implementation of evidence-based practice in relation to perioperative nursing care. Low High CONTENT 4. To what extent did this article increase your knowledge of the subject matter? Low High 5. To what extent were your individual objectives met? Low High 6. Will you be able to use the information from this article in your work setting? 1. Yes 2. No 7. Will you change your practice as a result of reading this article? (If yes, answer question #7A. If no, answer question #7B.) 7A. How will you change your practice? (Select all that apply) 1. I will provide education to my team regarding why change is needed. 2. I will work with management to change/implement a policy and procedure. 3. I will plan an informational meeting with physicians to seek their input and acceptance of the need for change. 4. I will implement change and evaluate the effect of the change at regular intervals until the change is incorporated as best practice. 5. Other: 7B. If you will not change your practice as a result of reading this article, why? (Select all that apply) 1. The content of the article is not relevant to my practice. 2. I do not have enough time to teach others about the purpose of the needed change. 3. I do not have management support to make a change. 4. Other: 8. Our accrediting body requires that we verify the time you needed to complete the 1.5 continuing education contact hour (90-minute) program: 536 j AORN Journal