Back to Basics: Flexible Endoscope Processing LISA SPRUCE, DNP, RN, CNS-CP, CNOR, ACNS, ACNP, FAAN

Transcription

1 CONTINUING EDUCATION Back to Basics: Flexible Endoscope Processing LISA SPRUCE, DNP, RN, CNS-CP, CNOR, ACNS, ACNP, FAAN 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 Examination and Learner Evaluation at A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answers. Each applicant who successfully completes this program can immediately print a certificate of completion. Event: #16516 Session: #0001 Fee: For current pricing, please go to: The contact hours for this article expire May 31, Pricing is subject to change. Purpose/Goal To provide the learner with knowledge of best practices related to flexible endoscope processing. Objectives 1. Discuss common areas of concern that relate to perioperative best practices. 2. Discuss best practices that could enhance safety in the perioperative area. 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 Lisa Spruce, DNP, RN, CNS-CP, CNOR, ACNS, ACNP, FAAN, 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 489

2 Back to Basics: Flexible Endoscope Processing LISA SPRUCE, DNP, RN, CNS-CP, CNOR, ACNS, ACNP, FAAN ABSTRACT Flexible endoscopes are important tools in patient care, yet recent outbreaks of infections in patients who have undergone endoscopic procedures have increased awareness of how the complex design of these instruments makes them difficult to clean. This Back to Basics article focuses on flexible endoscope processing and provides sterile processing, endoscopy, and perioperative team members with strategies for successful processing of these instruments. AORN J 103 (May 2016) ª AORN, Inc, Key words: flexible endoscopes, processing, infection, cleaning. In 2015, the Centers for Disease Control and Prevention joined forces with the Los Angeles County Health Department to investigate a cluster of patients infected with carbapenem-resistant Enterobacteriaceae (CRE) after exposure to contaminated duodenoscopes. 1 This is just one example of a recent investigation; previous investigations of CRE outbreaks related to duodenoscopes have revealed breaches of approved cleaning protocols, although some have not found breaches in duodenoscope reprocessing. 1 This emphasizes the risk that patients face when undergoing flexible endoscopic procedures. Some patients who have undergone these procedures have been infected with antibiotic-resistant organisms that have caused significant medical problems and, in some instances, death. 1 The US Food and Drug Administration (FDA) has identified critical lapses in endoscope processing and a failure to follow the manufacturer s instructions for use (IFU) as contributing factors to these infections. 2 Flexible endoscopes can become contaminated with tissue and body fluids, and the complex design of some flexible endoscopes does not allow for adequate cleaning of certain parts of the device. 3 When there is inadequate cleaning and processing of the endoscopes, transmissible infections can occur. AORN recently published its updated, evidence-rated Guideline for processing flexible endoscopes 4 that provides guidance to endoscopy, perioperative, and sterile processing personnel for processing flexible endoscopes and their accessories. The guideline discusses the complex design of flexible endoscopes and provides guidance on how personnel can clean and process them effectively. This Back to Basics article highlights the flexible endoscope processing cycle (Figure 1). For a complete, in-depth look at this topic, readers should refer to the guideline in its entirety. HOW-TO GUIDE It is imperative that personnel who process flexible endoscopes follow the manufacturer s IFU and the steps in the endoscope processing cycle listed as follows: precleaning at the point of use; transporting, leak testing, cleaning, and inspecting; using high-level disinfection or liquid chemical sterilization, or packaging and sterilizing the endoscope; and storing the endoscope correctly. 4 Additionally, because of the complexity of these devices and the difficulty in cleaning them, it is imperative that all personnel responsible for processing endoscopes undergo specific education and competency verification related to best practices for processing flexible endoscopes. 4 ª AORN, Inc, j AORN Journal

3 May 2016, Vol. 103, No. 5 Back to Basics: Flexible Endoscope Processing precleaning the endoscope s water,air,and other channels by alternately flushing them with the cleaning solution and air; inspecting the endoscope visually for damage; and discarding the cleaning solution and used cloths or sponges. 4 Transporting Endoscopes should be safely transported from the procedure room to the endoscopy processing room as soon as possible after use. 4 To accomplish this, transport personnel should keep the endoscopes and accessories wet or damp but not submerged in liquid during transport. Personnel must transport the endoscopes in a closed container or closed transport cart that is leakproof, puncture resistant, and large enough to contain all contents. 5 In addition, transport personnel Figure 1. The flexible endoscope processing cycle. All instruments, whether purchased, loaned, or returned from repair, are leak tested first. The Roman numerals indicate the recommendation number in the guideline where detailed guidance and discussion of the evidence is provided. Reprinted with permission from Guideline for processing flexible endoscopes. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; Precleaning Precleaning the endoscope (ie, cleaning it at the point of use, immediately after the procedure and before it is transported to the endoscopy processing room) helps to moisten, dilute, soften, and remove debris that accumulates during the procedure and reduces the formation of biofilm; this, in turn, helps to improve the final cleaning process. The perioperative RN, scrub person, or endoscopy technician should begin cleaning as soon as the endoscopist completes the procedure and before organic material has dried in the channels or on the surface of the endoscope. 5 The team member responsible for precleaning at the point of use should perform this in accordance with the manufacturer s IFU. 4 Precleaning steps may include preparing a fresh solution of the cleaning product recommended by the manufacturer; washing the exterior surfaces of the endoscope with a soft, lint-free cloth or sponge that has been saturated with the cleaning solution; suctioning the cleaning solution through the biopsy and suction channels; placing the distal end of the endoscope into the cleaning solution and suctioning the solution through the scope; must label the transport cart with an orange or orange-red biohazard label, 5 should transport the endoscope horizontally rather than suspended, 4 and should transport accessories with the endoscope but in a separate container. 4 When delivered to the decontamination area, personnel should process the endoscope and accessories as soon as possible after arrival in the endoscopy processing room. 4 If there is a delay in initiating processing, personnel should follow the manufacturer s IFU for delayed processing. 4 Endoscopy and sterile processing personnel should collaborate to develop and implement a procedure for recording the times when the procedure is completed and when the cleaning is initiated. 4 Leak Testing Not every endoscope requires leak testing. Leak testing is a procedure that detects openings in the internal channels or surfaces of the endoscope that could permit chemicals, water, or organic matter to enter a portion of the endoscope not intended for fluids. 4 Leak testing helps to decrease patients risk of infection or injury as a result of using an endoscope that is not completely sealed and may also reduce repair costs by preventing damage that might occur during the cleaning process if the endoscope has been compromised. 4 Sterile processing personnel should perform leak testing according to the endoscope manufacturer s IFU and should also perform leak testing before placing the endoscope into the cleaning solution and before manually cleaning it. 4 Steps for leak testing may vary between manufacturers but should include pressurizing the endoscope to the recommended pressure; placing the endoscope in a loose configuration (eg, not kinked or coiled tightly); AORN Journal j 491

4 Spruce May 2016, Vol. 103, No. 5 manipulating all moveable parts, angulating the bending section of the distal end, and actuating video switches; and maintaining pressure and inspection for a minimum of 30 seconds. 4 When an endoscope fails a leak test, it should be removed from service and replaced or repaired. 4 Cleaning Perhaps the most important step in the processing cycle is for personnel to manually clean the endoscope. 5 Some flexible endoscopes contain several ports and channels that can acquire high levels of microbial contamination. 4 Effective cleaning helps to reduce the bioburden to a level that does not pose a sterilization or high-level disinfection challenge in the subsequent processing steps. 4 Personnel should follow these manual cleaning steps: Clean the endoscope as soon as possible after leak testing and in accordance with the endoscope manufacturer s IFU. 4 Use the type of water and cleaning solution recommended by the endoscope manufacturer. 4 Use a freshly prepared cleaning solution, and use a clean solution for every new cleaning process to help prevent crosscontamination. 4 Do not add additional products to the cleaning solution unless recommended by the manufacturer. 4 Follow the cleaning solution manufacturer s IFU for o water quality, hardness, and ph; o solution concentration and dilution; o water temperature; o contact time; o conditions of storage; o the defined period for the safe use of a cleaning product after opening the container (ie, use life); and o the period of time during which a stored cleaning product remains effective, useful, or suitable for use (ie, shelf life). 4 An automated titration unit may be used to concentrate cleaning chemicals at a consistent ratio. Personnel should change cleaning solutions when the temperature of the solution does not meet the temperature specified in the manufacturer s IFU. 4 Personnel should completely submerge the endoscope in the cleaning solution during the cleaning process and clean all exterior surfaces of the endoscope (Figure 2) with a soft, lint-free sponge or cloth saturated with the cleaning solution. 4 This helps to remove any material left after precleaning. In addition, personnel should brush all accessible channels and the distal end of the endoscope with a cleaning brush of the width, length, and material recommended by the endoscope manufacturer (Figure 3); 4 manually actuate the endoscope s valves while cleaning; 4 clean and brush the elevator mechanism and the recesses surrounding it with a cleaning brush of the width, length, and material recommended by the manufacturer; 4 raise and lower the moveable elevator at the distal end of the endoscope, if present (Figure 4), throughout the manual cleaning process to help ensure no organic debris is lodged in the moving part and to allow for more effective cleaning; 4 use a clean brush for each endoscope cleaning; 4 visually inspect the brush and do not use it if the integrity of the brush is in question; 4 brush the accessible channels of the endoscope several times until there is no debris present on the brush; 4 use new lumen cleaning technologies, if compatible with the endoscope, because they may be less damaging to the internal lumens; 4 flush the endoscope channels with the cleaning solution; 4 flush and rinse the external surfaces and internal channels with utility water (ie, tap water) until all cleaning solution and residual debris are removed; 4 dry the exterior surface of the endoscope with a lint-free cloth and purge all channels with instrument air 4 (ie, a medical gas that is not respired, is filtered to 0.01 micron, is free of liquids and hydrocarbon vapors, and is dry to a dew point of e40 F[e40 C]); 6 clean, brush, rinse, and process reusable parts such as water bottles, tubing, port covers, and accessories such as forceps and cleaning brushes; 4 sterilize or high-level disinfect water bottles at least daily, using sterile water to fill the bottle; 4 and use single-use components and accessories if compatible with the scope and discard all single-use components after use. 4 Inspecting An inspection of the scope helps to identify any residual organic residue that may remain on the endoscope or any damage that may need to be repaired. 4 Personnel should visually inspect all new, used, refurbished, repaired, and loaned endoscopes, accessories, and other equipment according to the manufacturer s IFU and evaluate them for cleanliness, clarity of lenses, missing parts, moisture, integrity of seals and gaskets, 492 j AORN Journal

5 May 2016, Vol. 103, No. 5 Back to Basics: Flexible Endoscope Processing Figure 2. All exterior surfaces of the endoscope should be cleaned with a soft, lint-free sponge or cloth saturated with the cleaning solution. Reprinted with permission from Guideline for processing flexible endoscopes. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; correct functioning, and defects. 4 Personnel should use lighted magnification for the inspection and inspect internal channels using an endoscopic camera or borescope (ie, a device used to inspect the inside of an instrument through a small opening or lumen of the instrument). 4 Personnel should replace or repair any defective scopes, equipment, or accessories. 4 High-Level Disinfection or Liquid Chemical Sterilization Following the manufacturer s IFU for manual cleaning, personnel should either mechanically clean and mechanically process endoscopes by exposure to a high-level disinfectant or liquid chemical sterilant, or mechanically clean and sterilize endoscopes and accessories. 5 Mechanical processing should be performed in accordance with the endoscope and mechanical AORN Journal j 493

6 Spruce May 2016, Vol. 103, No. 5 Figure 3. All accessible channels and the distal end of the endoscope should be brushed with a cleaning brush of the width, length, and material recommended by the endoscope manufacturer. Reprinted with permission from Guideline for processing flexible endoscopes. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; processor manufacturers IFU. 4 Processing personnel should verify that the endoscope and the processor are compatible before use and position the endoscope and its accessories in the mechanical processor so that the processing solutions come into contact with all surfaces of the endoscope. 4 In addition, all connectors between the endoscope and the processor should be connected correctly. 4 Processing personnel should monitor mechanical processing cycles to verify that they are completed as programmed. 4 When using mechanical processing, it should be performed using water that is extensively treated to remove microorganisms and other materials (ie, critical water). 4 Cleaning, sterilant, and disinfectant solutions and chemicals recommended by the endoscope manufacturer and the mechanical processor manufacturer should be used. 4 Do not use the following for processing endoscopes: skin antiseptics, hypochlorites, phenolics, or quaternary ammonium compounds. 4 Solutions and chemicals should be used at the volume, concentration, temperature, and contact time recommended by the mechanical processor manufacturer. 4 After high-level disinfection or liquid chemical sterilization, personnel should mechanically rinse and flush the endoscope and its channels with sterile or critical water; they should rinse and dry all removable parts and may mechanically or manually flush lumens with 70% to 90% ethyl or isopropyl alcohol. 4 Alcohol facilitates drying by binding the residual water and enhancing its evaporation. It also prevents the colonization and transmission of waterborne bacteria. 4 However, flushing endoscope lumens with alcohol may not be necessary if the endoscope is effectively dried. This practice is not recommended in some countries because of the fixative properties of alcohol. 4 The exterior surfaces of the scope should be dried with a soft, lint-free sponge or cloth, and the channels should be dried by purging with instrument air or mechanically dried with a mechanical processor drying system j AORN Journal

7 May 2016, Vol. 103, No. 5 Back to Basics: Flexible Endoscope Processing available, personnel should store the endoscope in a closed cabinet with high-efficiency particulate arrestanceefiltered air that provides positive pressure and allows air circulation. 4 Endoscopes should not be stored in the original shipment case. 4 They should either be stored in a cabinet that is of sufficient height, depth, and width to allow the endoscope to hang vertically without coiling or touching the bottom of the cabinet or be stored in a cabinet designed and intended for the horizontal storage of flexible endoscopes. 4 Flexible endoscopes should be stored with all valves open and removable parts detached and stored with the endoscope. 4 The endoscope should be clearly identifiable as processed and ready for use with a distinct visual cue. 4 Personnel should wear clean gloves when transporting scopes to and from the cabinet and visually inspect endoscopes and storage cabinets for cleanliness before endoscopes are placed into or removed from storage. 4 Figure 4. Some duodenoscopes have a moveable elevator channel at the distal end that allows accessory instruments to access the biliary and pancreatic ducts. Reprinted with permission from Guideline for processing flexible endoscopes. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; Packaging and Sterilization Endoscope accessories that enter sterile tissue or the vascular system should be packaged and sterilized. 4 Sterilization procedures for flexible endoscopes should be performed in accordance with AORN s Guideline for selection and use of packaging systems for sterilization 7 and Guideline for sterilization. 8 Storage Flexible endoscopes should be stored in a manner that minimizes their contamination and protects them from damage. 4 Personnel should store endoscopes in accordance with endoscope and cabinet manufacturers IFU. Storage cabinets should have doors and be located at least three feet from any sink. 4 Personnel should store flexible endoscopes in a drying cabinet. 4 Drying cabinets include a drying system that circulates high-efficiency particulate arrestanceefiltered air through the cabinet while filtered air under pressure is forced through the endoscope channels. 4 If no drying cabinet is A multidisciplinary team should establish a policy to determine the maximum storage time that endoscopes are considered safe to use without reprocessing. 4 The evidence regarding the maximum safe storage time for processed flexible endoscopes is inconclusive. 4 Professional organizations recommended storage times range from three hours to 30 days. 4 More detailed information on the evidence regarding the maximum safe storage times for processed endoscopes can be found in the AORN Guideline for processing flexible endoscopes. 4 BENEFIT Endoscopes are used in identifying and treating diseases and are highly beneficial to patients. Meticulous adherence to evidence-based clinical practice guidelines benefits patients by helping to decrease the risk of exposure to potentially dangerous pathogenic microorganisms transmitted via flexible endoscopes. Understanding the complexity of these instruments and how to clean, process, and store flexible endoscopes in compliance with manufacturers IFU and guidelines from professional organizations benefits patients and perioperative, endoscopy, and sterile processing team members by providing clean, safe endoscopes for use. STRATEGIES FOR SUCCESS To help ensure that patients are receiving care in a clean, safe, environment, it is critical that professionals follow evidencebased practices consistently every time they use, clean, or process flexible endoscopes. To do this, AORN s Guideline for processing flexible endoscopes 4 recommends the following practices. AORN Journal j 495

8 Spruce May 2016, Vol. 103, No. 5 Personnel should process flexible endoscopes in an area constructed and designed for that purpose. 4 After precleaning at the point of use, cleaning and processing should occur in a room that is not used for any other purpose and is physically separated from locations where patient care is being performed. 4 Endoscope reprocessing may occur in a single room or two separate rooms. 4 o In a one-room design, a minimum of three feet should separate the decontamination area and clean work area. 4 There should be a door that provides access to and from the decontamination area and a separate door that provides access to and from the clean area. 4 There should be a unidirectional workflow from the decontamination area to the clean area and to clean storage in a separate location. 4 Heating, ventilation, and air conditioning systems for endoscopy suites should be designed according to state and local building codes and guidelines set forth by the Facility Guidelines Institute 9 and the American Society of Heating, Refrigerating, and Air-Conditioning Engineers. 10 Hand hygiene stations should be provided, and a minimum of two decontamination sinks (or one sink with two divisions) should be provided in the decontamination area of the endoscopy processing room. 4 Sinks should be deep enough to allow the complete submersion of the endoscope and large enough to allow the endoscope to be positioned in the sink without tight coiling. 4 Instrument air should be provided in the endoscopy processing room. 4 Team members who are processing flexible endoscopes should receive initial and ongoing education and complete competency verification activities that address protocols for controlling and maintaining a safe environment, precleaning at the point of use, transporting, leak testing, manual cleaning, inspecting, high-level disinfection or liquid chemical sterilization, packaging and sterilization, maintaining records of processing and procedures for traceability, and quality assurance measures. 4 WRAP-UP The FDA has issued a safety communication and alert to all health care providers regarding endoscopes and their potential to infect patients with pathogenic, drug-resistant organisms. 11 It is a call to action to all health care providers to follow manufacturers IFU and evidence-based guidelines to help decrease risk to patients and protect them from potential harm. References 1. Healthcare-associated infections (HAIs): CDC Statement Los Angeles County/UCLA investigation of CRE transmission and duodenoscopes. Centers for Disease Control and Prevention. Updated November 16, Accessed December 21, Infections associated with reprocessed flexible bronchoscopes: FDA safety communication. US Food and Drug Administration htm. Accessed December 9, Design of endoscopic retrograde cholangiopancreatography (ERCP) duodenoscopes may impede effective cleaning: FDA safety communication. US Food and Drug Administration. Published February 19, Updated March 4, Accessed December 21, Guideline for processing flexible endoscopes. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2016: CFR x : bloodborne pathogens. Occupational Safety and Health Administration. owadisp.show_document?p_table¼standards&p_id¼ Accessed December 9, NFPA 99: Health Care Facilities Code Handbook. Quincy, MA: National Fire Protection Association; Guideline for selection and use of packaging systems for sterilization. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2016: Guideline for sterilization. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2016: Guidelines for Design and Construction of Hospitals and Outpatient Facilities. Chicago, IL: Facility Guidelines Institute; Overview of health care HVAC systems. In: HVAC Design Manual for Hospitals and Clinics. 2nd ed. Atlanta, GA: American Society of Heating, Refrigerating and Air-Conditioning Engineers; Medical devices: factors affecting quality of reprocessing. US Food and Drug Administration. ProductsandMedicalProcedures/ReprocessingofReusableMedical Devices/ucm htm. Updated August 4, Accessed December 21, Lisa Spruce, DNP, RN, CNS-CP, CNOR, ACNS, ACNP, FAAN, is the director, Evidence-based Perioperative Practice, at AORN, Inc, Denver, CO. Dr Spruce has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. 496 j AORN Journal

9 EXAMINATION Continuing Education: Back to Basics: Flexible Endoscope Processing PURPOSE/GOAL To provide the learner with knowledge of best practices related to flexible endoscope processing. OBJECTIVES 1. Discuss common areas of concern that relate to perioperative best practices. 2. Discuss best practices that could enhance safety in the perioperative area. 3. Describe implementation of evidence-based practice in relation to perioperative nursing care. The Examination and Learner Evaluation are printed here for your convenience. To receive continuing education credit, you must complete the online Examination and Learner Evaluation at QUESTIONS 1. Undergoing flexible endoscopic procedures decreases the risk that patients may become infected with antibioticresistant organisms. a. true b. false 2. The issues that have been identified as contributing to endoscope-related health careeassociated infections include 1. critical lapses in endoscope reprocessing. 2. failure to follow manufacturer s written instructions for use (IFU). 3. endoscope design that prevents adequate cleaning of some parts of the device. 4. lack of processing equipment. 5. lack of adequate time for processing. a. 4 and 5 b. 1, 2, and 3 c. 1, 2, 3, and 4 d. 1, 2, 3, 4, and 5 3. To improve endoscope processing, perioperative personnel can 1. follow the manufacturer s IFU for cleaning and processing. 2. clean the endoscope at the point of use. 3. follow guidelines for transporting, leak testing, cleaning, and inspecting endoscopes. 4. appropriately store clean endoscopes. a. 1 and 3 b. 2 and 4 c. 1, 2, and 4 d. 1, 2, 3, and 4 4. The most important part of endoscope processing is a. visual inspection. b. mechanical decontamination. c. manual cleaning. d. sterilization. 5. Some of the recommended ways to clean an endoscope include 1. cleaning the exterior surfaces of the endoscope with a soft, lint-free sponge or cloth saturated with the cleaning solution. 2. moving the valves while cleaning. 3. cleaning and brushing the elevator mechanism and the recesses surrounding it with a cleaning brush of the width, length, and material recommended by the manufacturer. AORN Journal j 497

10 Spruce May 2016, Vol. 103, No raising and lowering the elevator, which helps to ensure there is no organic debris lodged in the moving part. 5. using a clean brush for each endoscope cleaning. 6. using a cleaning solution of sodium hypochlorite. a. 2, 4, and 6 b. 2, 3, 5, and 6 c. 1, 2, 3, 4, and 5 d. 1, 2, 3, 4, 5, and j AORN Journal

11 LEARNER EVALUATION Continuing Education: Back to Basics: Flexible Endoscope Processing 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 Examination and Learner Evaluation at Rate the items as described below. PURPOSE/GOAL To provide the learner with knowledge of best practices related to flexible endoscope processing. OBJECTIVES To what extent were the following objectives of this continuing education program achieved? 1. Discuss common areas of concern that relate to perioperative best practices. Low High 2. Discuss best practices that could enhance safety in the perioperative area. 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 1.6 continuing education contact hour (96-minute) program: AORN Journal j 499