AORN writes agency refuting techs’ arguments

AORN has written the federal Health Care Financing Administration (HCFA), responding to arguments presented by the Association of Surgical Technologists (AST) in their meeting with HCFA officials March 1 1. AST, which rep- resents operating room technicians, had re- quested the meeting as part of its fight against the proposed federal Medicare rule that would continue to require registered nurses to per- form circulating duties in the operating room.

The technicians are seeking reinstatement of a HCFA proposal issued in 1980 that would have permitted OR technicians to circulate without RN supervision. When HCFA issued a new set of proposed Medicare rules in January, it had restored the language requiring the circulator to be an RN. (That is also the current rule.) Public comments were accepted until March 7.

AST strongly protested the government’s action. Attorneys for the group petitioned for an extension of the comment deadline, which was not granted. They also asked for an oral hear- ing with HCFA and for the disqualification of HCFA Administrator Carolyne Davis, RN, on the grounds that she is biased in favor of regis- tered nurses.

HCFA officials agreed to meet with the group but noted they would not comment or negotiate on the rule at that time because they had not finished evaluating more than 30,000 public comments received on all the Medicare rules. Public minutes of the meeting show AST presented these six arguments to support its position:

1. The registered nurse curriculum “pro- vides only minimal operating room experi- ence,” while the technician’s curriculum “pro- vides extensive onsite training.”

2. OR technicians “often furnish on-the-job

training for RNs without OR experience.” 3. OR technicians “are considerably less

costly to a hospital than RNs without a lessen- ing of quality care.”

4. Circulating requires no evaluation of pa- tient symptoms “because the circulating nurse is not scrubbed and seldom gets close to the patient.” AST added that “the surgeon and anesthetist or anesthesiologist are responsi- ble for monitoring the patient.”

5. Hospitals would have to have “an RN on standby to ‘fill in”’ during breaks for the RN supervising a technician. If HCFA does not intend for a hospital to provide RN coverage during breaks, why is RN supervision needed at other times? AST asked.

6. AST alleged that use of technicians with- out RN supervision has become widespread since the 1980 proposal was issued. They said failure to adopt that proposal would be a “hardship” for hospitals, adding that “while there are 28,000 certified STs (surgical technologists) there are only 3,000 certified operating room RNs.”

In its letter to HCFA, AORN responded to each point. Regarding RN education, AORN pointed out that “registered nurses receive a two- to four-year postsecondary education that provides a sound scientific foundation” allow- ing them to “function effectively in any area of the hospital, including the operating room, with a minimum amount of orientation.”

On the second point, AORN said that orien- tation for registered nurses in the operating room is conducted “by RNs who are educa- tional specialists.” The Association added that “if technicians are participating in orientation of RNs, they are teaching specific technical tasks under the supervision of a registered nurse.”

The cost of OR technicians and RNs “can-

18 AORN Journal, July 1983, Vol38, No 1

not be directly compared because they func- tion at different levels-professional and tech- nical,” AORN argued. “Since they have a pro- fessional education and a scope of practice defined by law, registered nurses are more versatile employees than technicians.”

ASTs third argument about evaluation and monitoring “shows a lack of understanding of nursing and the circulating role,” AORN said. Because the circulator acts as a coordinator during surgery, “it is important that he or she not be in the sterile field,” AORN pointed out. “Only the circulating nurse has an overview of the entire procedure.” Nursing care “is differ- ent from care given by the surgeon and anes- thesiologist,” AORN continued, using position- ing as an example.

“Positioning is done by the circulating nurse,” AORN said. “Improper positioning of anesthetized patients, who may be paralyzed for several hours, can lead to serious and sometimes irreversible nerve, muscle, and cir- culatory damage. Proper positioning requires a thorough knowledge of anatomy and physiol- ogy as well as the patient’s individual prob- lems, such as arthritis or diabetes.”

Contributing to the importance of circulating are the need for quick action in emergencies and the monitoring needed for local anes- thesia cases. AORN said it does not believe OR technicians are prepared for this responsi- bility, adding that the Joint Commission on Ac- creditation of Hospitals (JCAH) requires the circulator to be a registered nurse. (The Medi- care rules apply only to hospitals not accred- ited by JCAH.)

Hospitals would have to provide RNs to fill in during breaks, as they do under the current regulation, AORN said. The Association does not believe this to be a problem.

If hospitals are using technicians without RN supervision, they are in violation of the current regulations, the Association stated in re- sponse to the sixth argument.

“Hospitals should have no trouble hiring RNs for the OR because any RN with the proper experience and orientation can work in the operating room,” AORN maintained. There are approximately 1.4 million RNs in the coun- try today.

The Association told HCFA that AST had drawn a misleading comparison between cer- tification of OR nurses and OR technicians.

ASTs certification for technicians is for mini- mal competency; RNs do not need certification for minimal competency because they already have a professional license. AORN’s certifica- tion of OR nurses is for professional achieve- ment.

Patricia Patterson Associate editor

JCAH column The JCAH question and answer column is usually published every other month in the Journal. It does not appear in the July issue, but will be in the September Journal.

New contraceptive to be available soon The US Food and Drug Administration has approved a sponge containing a spermicide as a contraceptive. It will be sold without a prescription and was expected to be for sale by the middle of the year.

The disposable sponge is made of polyurethane and contains 1 g of spermicide. The device does not have to be fitted by a physician and is as effective as a diaphragm. It protects against fertilization by inactivating the sperm with nonoxynol-9, by blocking the cervix so sperm cannot enter, and by trapping and absorbing semen. The clinical trials indicate the sponge is effective for 48 hours, but this has not been sufficiently proven, according to a report in American Medical News.

The sponge was tested on 1,000 women over a three-year period and was 85% effective. The effectiveness rate would be higher if the cases where the woman either inserted the device improperly or removed it too soon after intercourse were excluded. The clinical tests did not show if the device increased the risk of toxic shock syndrome.

20 AORN Journal, July 1983, Vol38, No 1