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MAY 1988, VOL. 47, NO 5 AORN JOURNAL Perioperative Nurses Talk About AIDS cquired immune deficiency syndrome A (AIDS). This complex and devastating disease with the deceptively short acronym is causing radical changes in the current health care system. It is forcing health care workers and hospital administratorsto view patients differently; it is forcing the public to view the scientific community differently. The ramifications of AIDS-clinical, emotional, and financial-may someday cause health care workers to view patient care in terms of before AIDS and after AIDS. The Journal conducted a roundtable discussion at the 35th AORN Congress to discuss AIDS and its impact on perioperative nursing. The six participants generously shared both their ideas and their concerns on topics ranging from educational programs to skyrocketing costs. The Journal appreciates their participation and candor. Participants in the AIDS discussion included: David Bachman, RN, MS, CNOR, oper- ating room instructor The Union Memorial Hospital Baltimore (Bachman was employed at Johns Hopkins Hospital,Baltimore, when thk dkcussion was held) Nan Hemphill, RN, MEd, CNOR, CNA, associate director, department of surgical suites Howard University Hospital, Washington, DC Jane E. Kuhn, RN, CNOR, specialty supervisor Children’s Hospital of San Francisco Noreen McHugh, RN, MS, CNOR, clinical director, perioperative nursing Hospital of the University of Pennsylvania, Philadelphia Brenda J. McKonly, RN, MS, operating room nurse manager Beth Israel Hospital, Boston of surgical services Margery M. Sawyer, RN, CNOR, director Humana Hospital-Gwinnett, Snellville, Ga In-Service Education Journal: What type of education program regarding AIDS is available for employees at your hospital? McKonly We have included infection control education in our nursing orientation program, and we have a two-page guideline based on the Centers for Disease Control (CDC) guidelines. I’m fortunate to have a very supportive nursing service department that supports educational opportun- ities for nurses. I am able to send staff to programs outside the hospital. Hemphill. We have an ongoing program that has the infection control nurse or the physician in charge of infectious diseases available to come to units as requested. We are going to have an AIDS team that will be responsible for the entire hospital-right now it [education] is kind of fragmented. I don’t know that we have a real problem with people not wanting to take care of AIDS patients, but the administration feels that getting a team together would be a positive thing for the whole hospital. MeHugh: We, of course, have the mandatory annual in-service program on infectious diseases required by the Joint Commission on Accred- itation of Healthcare Organizations (Joint Commission). What I have noticed though, to my delight, is the medical staff, not nursing as much as medical staff, has really turned around and are very interested in all the information and all the resources that are available. I have never seen such a positive reaction in trying to get more and more education on any subject like this before, and I have been in the OR for 20 years. It is great to see a nursing staff, medical staff, and ancillary staff that want to get all the information possible. It is not something you can force. Bachman. One of the big thrusts that we had 1171

Perioperative Nurses Talk About AIDS

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MAY 1988, VOL. 47, NO 5 AORN J O U R N A L

Perioperative Nurses Talk About AIDS

cquired immune deficiency syndrome A (AIDS). This complex and devastating disease with the deceptively short acronym is causing radical changes in the current health care system. It is forcing health care workers and hospital administrators to view patients differently; it is forcing the public to view the scientific community differently. The ramifications of AIDS-clinical, emotional, and financial-may someday cause health care workers to view patient care in terms of before AIDS and after AIDS.

The Journal conducted a roundtable discussion at the 35th AORN Congress to discuss AIDS and its impact on perioperative nursing. The six participants generously shared both their ideas and their concerns on topics ranging from educational programs to skyrocketing costs. The Journal appreciates their participation and candor.

Participants in the AIDS discussion included: David Bachman, RN, MS, CNOR, oper- ating room instructor The Union Memorial Hospital Baltimore (Bachman was employed at Johns Hopkins Hospital, Baltimore, when thk dkcussion was held) Nan Hemphill, RN, MEd, CNOR, CNA, associate director, department of surgical suites Howard University Hospital, Washington, DC Jane E. Kuhn, RN, CNOR, specialty supervisor Children’s Hospital of San Francisco Noreen McHugh, RN, MS, CNOR, clinical director, perioperative nursing Hospital of the University of Pennsylvania, Philadelphia Brenda J. McKonly, RN, MS, operating room nurse manager Beth Israel Hospital, Boston

of surgical services Margery M. Sawyer, RN, CNOR, director

Humana Hospital-Gwinnett, Snellville, Ga

In-Service Education

Journal: What type of education program regarding AIDS is available for employees at your hospital?

McKonly We have included infection control education in our nursing orientation program, and we have a two-page guideline based on the Centers for Disease Control (CDC) guidelines. I’m fortunate to have a very supportive nursing service department that supports educational opportun- ities for nurses. I am able to send staff to programs outside the hospital.

Hemphill. We have an ongoing program that has the infection control nurse or the physician in charge of infectious diseases available to come to units as requested. We are going to have an AIDS team that will be responsible for the entire hospital-right now it [education] is kind of fragmented. I don’t know that we have a real problem with people not wanting to take care of AIDS patients, but the administration feels that getting a team together would be a positive thing for the whole hospital.

MeHugh: We, of course, have the mandatory annual in-service program on infectious diseases required by the Joint Commission on Accred- itation of Healthcare Organizations (Joint Commission). What I have noticed though, to my delight, is the medical staff, not nursing as much as medical staff, has really turned around and are very interested in all the information and all the resources that are available. I have never seen such a positive reaction in trying to get more and more education on any subject like this before, and I have been in the OR for 20 years. It is great to see a nursing staff, medical staff, and ancillary staff that want to get all the information possible. It is not something you can force.

Bachman. One of the big thrusts that we had

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was a program presented by the physician in charge of the AIDS unit, the physician in charge of infection control, and the infection control nurse. They videotaped the presentation, and it became the mandatory program for 1987. The videotape was distributed to all the departments.

K u h ~ I work in a community hospital, and the OR in-service program isn’t what you will find in the university setting. We do meet the Joint Commission requirements and have one in- service a year on infection and AIDS is the topic that is currently discussed. In the hospital, we have gone to body substance isolation precautions. (Editor? note: Body substance isolation is a relatively new technique that treats the waste products from all patients as potentially infectious.) In the department, I find that the nurses still have a lot of questions, and rely heavily on what is written in the AORN Journal and published CDC guidelines. In our community, there is a lot of research being done on AIDS and a high population of AIDS patients. We are fortunate that the local television stations have lots of current information about AIDS, and the nurses use the media as a resource.

Sawyer: I’m from a community hospital as well, and we don’t have one designated individual within the OR who handles infection control, so the hospitalwide person does that. We have our required yearly in-service program, and as staff members go to different programs, they come back and share the information with the other staff members. There was a lot of discussion in our patient care committee about universal precautions versus body substance isolation technique; however, we opted to stay with the universal standards that we have focused on all along where each disease process has its own isolation process. It’s interesting that operating room n u m have been essentially doing body substance isolation all along and now other areas are just catching on to it.

“Operating room nurses have been doing body substance isolation all along and now other areas are

catching on to it.” Sawyer

Nursing Program Curriculum

Journak Let’s move to the topic of what skills you would like to see in nurses graduating from nursing programs.

Sawyer: I think the emphasis on putting

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perioperative nursing back in the school curric- ulum is the best thing that could be done for students. Within the operating room setting, students could learn aseptic technique and isolation technique to deal with anything they would have to deal with in the hospital. It is more important than ever to put the emphasis on operating room curriculum for nursing students. JournaE Does the curriculum usually include virology and immunology?

McHugh: I may be putting myself out on a limb with this, but I think the theory may be there, but I don’t think there is a practical application of that theory. I don’t see that in the programs, and I would have to agree with Marg (Sawyer), I think that this is where we can put our foot in the door right now. I think ambulatory surgery was one giant step forward when it came within the realm of perioperative nursing. I think that this particular disease [AIDS] and other infectious diseases may present another step toward reinforcing the fact that penoperative curriculum should be in nursing programs.

Testing Guidelines

Journd Has your hospital decided on the ethical guidelines for testing patients? What kind of sensitivities toward patients, employees, and the hospital does your institution advocate?

Sawyer: In our patient care committee, at least half of every meeting for the last year and a half has been devoted to how to deal with the worker and the patient with regard to AIDS. Many of the medical staff members were really opposed to documenting the diagnosis of AIDS on the patient’s chart because they felt that once the diagnosis was on the chart the insurance company would refuse the patient’s insurance and then there would be a lot of ramifications from that standpoint. But as nurses we felt that the worker needed to be protected. We came up with a policy that states that if there is exposure-a needlestick, direct splash, or whatever-then the physician would have to tell the patient what happened and request that the patient be tested. And the physician would have to be emphatic that the patient would be tested. The results would then go on the patient’s

“I think AIDS may present another step toward reinforcing

the fact that perioperative curriculum should be in nursing programs.”

McHugh

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chart, and the staff member would be fully informed.

McKonly: We have spent a tremendous amount of time trying to draw up a consent form for testing that we are comfortable with. We have done that and are now moving into ethical issues and confidentiality issues-how to deal with patients coming to the hospital and how to deal with testing. We happen to have a public health clinic in one of our outpatient clinics, so people who want confidential human immunodeficiency virus (HIV) testing could have it done there and it would not be a part of their records. As far as any incidents, we offer screening to an individual who has had a needlestick at the time of the incident and then a follow-up three months, six months and a year later. I certainly encourage everyone to go, but not everyone chooses to have it done. Some people would just as soon not know.

Hemphilk That is basically what we do at our hospital, If an employee is stuck with a needle, then they go to the employee health unit. The staff of the employee health unit is responsible for following through on the employee with testing at three months, six months, and one year, and it is responsible for checking the patient’s chart to see if anything on it might affect the employee.

Sawyer: But you don’t make it mandatory for the patient to be tested for AIDS?

Hemphilk No, we don’t. Sawyer: You just rely on the information on

the chart? Hemphill: Right. We don’t test for AlDS

hospitalwide. We only test to make a medical diagnosis or at the request of the patient. There is no blanket testing of patients.

McHugh: If there is a needlestick and we don’t know if the patient has AIDS, it is mandatory that we get a screening of the patient. We have blanket testing under discussion right now. I t is getting a lot of support from the medical staff members. They really would like to see it.

HemphilL A columnist in the Washington Post reported that she visited San Francisco General and talked with a female orthopedic surgeon who dressed for surgery in full protective gear. The surgeon’s concern was that the people who give the care do not have the right to know the status

“We offer screening to an individual who has had a needlestick. I encourage

everyone to go, but not everyone chooses to have it done.”

McKoniv

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of the patient. I think that is an issue. I think we need that information to do what we are suppose to do.

Sawyer: I strongly agree with what you are saying, but I also agree that we need to put emphasis with our staff on the techniques that they use. It is the unkown that gets you more than the known.

Treating the AIDS Patient

Journal: David (Bachman) had a nurse refuse to take care of an AIDS patient. Tell us a little bit about how the hospital administration reacted and particularly the rest of the nursing staff.

Bachman. The nurse was assigned to scrub, and when the patient amved and the nurse learned of the patient’s AIDS status, the nurse refused to scrub on the case. The nurse received a two- day suspension and has come back to work. The next administrative step will be suspension pending discharge. Journal: What were the ‘feelings of the other nurses?

Bachman. Among the nurse’s peers I heard comments such as we are here to take care of patients, the nurse could have possibly circulated, or the nurse could have switched cases.

McKont’y: There has been a lot of anxiety, and sometimes what is in the media is beneficial and sometimes it is not. I’ve had people work in an on-call position and I’ve found that those individuals have a lot of questions when they come back because they are not receiving the informa- tion that we receive within our organization. They are only hearing what is on the television and are sometimes confused. They think they shouldn’t be working in the OR because they think it is an extremely high risk area.

The OR ap a High Rkk Area

“The nurse was assigned to scrub and when the nurse learned of the

patient’s AIDS status, the nurse refused to scrub on the case.”

Bachman

McHugh: If you look at the statistics, the incidences of needlesticks and cuts in the OR are very low. Most of the needlesticks are happening in housekeeping because people are careless. In the OR, I think we are really a lot more protected.

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It is like second nature to us. McKonly: I think it [AIDS] is helping us

because people have become a little lax with techniques. I think we are in a better area because it is not uncomfortable for us to wear goggles and gloves.

Hemphill. I heard you mention goggles. We make goggles available for everybody on the staff. Some surgeons wear them all the time.

Sawyer: With the new Occupational Safety and Health Administration (OSHA) guidelines [adapted from the CDC guidelines], are you going to be able to just make them [goggles] available to everyone or are you going to have to make policies state that they will be mandatory?

McHugh: Actually, the OSHA guidelines are probably good because hospitals are going to have to develop protocols for different levels-different protocols for how we treat different patients.

Sawyer: It [OSHA guidelines] is not a blanket thing. It tells you when it is appropriate to wear goggles and when you can get by without them.

Hemphill. Some people are going to wear them all the time. The appropriateness is out. They are interested in protecting themselves. (Editors note: OSHA is working on a new rule that will threaten hospitals with tines of up to $10,OOO if they do not take the necessary steps to curb blood-borne diseases such as AIDS and Hepatitis B.)

The High Cost of AIDS “Some people are going to

wear them (goggles) all the time. Appropriateness is out. They

McHugh: We are seriously studying the whole aspect of disposable gowns. To look at that, we have to look at one side of the coin which is

are interested in protecting themselves.”

Hemphill

the laundry and sterilization, and the other side, which is waste disposal. I am delighted if this is the one [AIDS] that pushes the use of disposables over the hill. My biggest concern is not an education or ethical issue, but a dollar issue. Isolating waste is very expensive. It has become more of an issue than education.

McKonly: I think all of us have seen an inability to get gloves, and the amount we spend on them has probably doubled. Since the last health care worker incident, you can’t get work gloves, you can’t get surgeon’s gloves. People are now wearing

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double gloves. There is a certain anxiety just around having the appropriate things to provide protection.

Sawyer: Nurses on the floor are wearing surgeon’s gloves because they have a better feel than the exam gloves, and that drives up the costs and increases the shortage.

Hemphill: I think there is an indiscriminate use of gloves, You can go anywhere in the hospital and see a person in gloves, where you would not have seen this six months or one year ago. It might provide a false sense of protection. 1 think education in regard to gloves needs to be stressed.

McKonly: At least the use of gloves is a step forward, but it still makes me anxious.

Are Hospital Education Policies Working?

Journal: Do you find that the education policies your hospital has implemented are working to allay the fears of nurses, or are you having problems with this?

Kuhn: I think there is a lack of trust on the part of the nurses of the exact transmission of the AIDS virus. I think the anxiety of the staff was pretty well under control with the in-service that we had done and everyone was willing to care for the patient. With the most recent incident about the three health care workers being infected, I saw a renewal of concern. In addition to education, I would like to see nurses practice body substance isolation techniques on their own initiative and not because it is a standard.

McKonly: There is always a sense of anxiety whenever there is a known patient. There is always encouragement to treat everyone the same, but when it comes out that the patient has AIDS, the anxiety is thrown out all over again. That’s when we go through the education process and give an update again. There is still distress.

Sawyer: 1 find that anxiety i s not so prevalent in the OR. In the other areas of the hospital, the emergency room or on the units for example, they still have a real fear of what to do, and they wonder if what they are doing the correct thing.

Kuhn: I think it is important to stay current on the research and always try to present the

“In addition to education, I would like to see nurses practice

body substance isolation techniques on their own initiative and not

because it is a standard.” Kuhn

AORN J O U R N A L MAY 1988, VOL. 47, NO 5

information to the staff on that level.

The Nursing Role

Journak Do you think the nursing profession can have an impact on AIDS education and the public’s view not only of AIDS as a disease, but of nurses as care givers?

McKonly: I think some already have. We have had support within the clinics from nurses who go to the home to give transfusions to AIDS patients. They go out and do some teaching. I think that nursing is the best for this.

Kuhn: I would agree with that. I have seen nurses receiving positive attention [in the media] as primary care givers to AIDS patients. It is the nurses who work on the AIDS floor at San Francisco General Hospital who have been highlighted in newspaper articles and documen- taries for their roles in providing care.

McHugh: As an Association [AORN], we could take the guidelines that are being developed and just reinforce those standards. AORN does have a policy that could put us in the forefront.

Sawyer: We need to reemphasize the practices that we do all the time, that are second nature to us.

McKonly: I think we could send AORN’s recommended practices to the hospital infection control people and encourage them to use them along with CDC universal guidelines.

Sawyer: It’s interesting to read articles about AIDS and the research that is being done with the units that do treat AIDS. Essentially, though. workers have been exposed over long periods [to AIDS] and maybe precautions are not as good as they should be, but they do not come down with the virus or associated complexes. You wonder if that’s because they are better educated or if it’s just a fact of life.

PEGGY S. LEHR ASSOCIATE EDITOR

Suggested reading lki brief compilation of suggested reading touches on rhe clinical social, political, and emotional facers of AIDS. It is nor intended as a comprehensive overview of the topic. Centers for Disease Control. “Recommendations for

preventing transmission of infection with human T- lymphotropic virus type IIl/lymphadenopathy- associated virus in the workplaces.” AORN Journal 46 (August 1987) 332.

Centers for Disease Control. “Recommendations for preventing transmission of infection with human T- lymphotropic virus type III/lymphadenopathy- associated virus during invasive procedures.” AORN Journal 46 (August 1987) 348.

Centers for Disease Control. “Recommendations for prevention of HIV transmission in health-care settings.” AORN Journal 47 (March 1988).

Farrell, B. “AIDS patients: Values in conflict.” Crifical Care Nursing Quarterly 10 (September 1987) 74.

Kubler-Ross, E. On Death and Dying New York: Macmillan Publishing Go, 1969.

Salisbury, DM. “AIDS psychosocial implications.” Journal of Psychosocial Nursing. 24 (December 1986) 13.

Shilts, R. And the Band Played On. New York St Martin’s Press. 1987.

“Statement on perioperative nursing care of the patient with acquired immune deficiency syndrome,” in AORNJournal46 (September 1987) 396.

Wells, R J. “AIDS-A perspective of care.” Interna- tional Nursing Review 34 (May/June 1987) 64.

Drug Instantly Reverses Effects of Drug Overdose A new drug that can potentially reverse the symptoms of a drug overdose within seconds is being tested at Vanderbilt University (VU) Medi- cal Center, Nashville, Tenn. The drug, fluma- zenil, is given intravenously, and may reverse a benzodiazepine-induced coma.

Benzodiazepines are a group of minor tranquil- izing drugs that include alprazolam (Xanax@) and diazepam (Valium@). An overdose results in low blood pressure, a decreased respiratory rate, and possible coma.

According to a report in the VU Medical News, flumazenil acts by binding to benzodiaze- pine receptors in the brain, preventing them from acting. Preliminary studies indicate that fluma- zenil r e v e m the patient’s low blood pressure, increases the respiratory rate, and changes the men- tal status, if these conditions are secondary to ben- zodiazepine toxicity. It has proved most effective in patients with isolated singledrug overdoses.