[laughnsmile]

I work in a small hospital where we do a little bit of everything, but have been increasing the number of total joint cases that we do. When I was trained to the OR, I had to spend 3 of my many months training at a level 1 trauma center OR that had a large number of OR's and specific ortho teams and rooms. I was told there that they had the cleaning crews come in at night to wash everything down really good (walls, etc) so things would be clean as possible with the beginning of every day. My supervisor tells me this is a sacred cow. Any thoughts? Also the new orthoped's are bringing in these total cases that start after office hours (12pm and on). Is there any information regarding avoiding dirty (vag/I&D's, etc) cases in the same room to be used for the late total case? This may be a stupid question, but as I thought it was second nature to do these things, my supervisor now says that we can't provide a standard of care to these total patients that we cannot provide to any other patient in the OR. But we still only use the small rear door as opposed to the large main OR door after the total case has been opened to minimize traffic, and she requires us to wear those blue alien hats if we're to be in the room (even circulator). It sounds like she's contradicting herself, but wanted to provide some good hard evidence with my common sense explanation when she talks to me about this next. (She thinks I'm questioning her authority, but really I'm only worried about the safety of the patient.)

[SFCardiacRN]

Be careful about challenging your supervisor. Follow protocol as set by your hospital. There is always room for improvement in any given situation but (unfortunatley) policy is driven and set by the surgeons and administration. All it will take is a couple of infections and you will see changes. Larger hospitals tend to be stricter because they have allready been through the problems. In the mean time, protect your patient as best you can and use diplomacy when suggesting changes.

[mcmike55]

I tend to agree with SFcardiac...watch butting heads the administration.
In the long run it sounds that it is going to be counter productive, you all need to find some middle ground, and work from there.
Have you checked with AORN or other ortho nursing groups?? They may have some insight.
Many hospitals have laminar flow, and other special things for total rooms.
Ours does not, we are a small rural hospital, and one doc uses the space helmets, the other not. As far as I know, their infection rates are both unremarkable.
We use a dedicated room, total joints are first in the room. We have done back to backs, but always in the same room
We have had the best success by minding the pre op antibiotics (1 hr before, etc), keeping the traffic out of the room, etc.
I'm not sure having different levels of care for different types of pts applies.
Once you talk with AORN, etc you may find that what you are trying to do is the proper care for totals. I guess I never thought about it, but standards of care are somewhat different, depend on the type of case you are doing. Yes there are basics that apply to all OR pt's, but I would think the type of surgery you are performing, would dictate differences. Does that make sense??
My suggestion is to check with national organizations and see what they say. You may also want to talk with other hospitals, in your area, your own size and see where they stand on these issues. Try to compair apples to apples you see.
I love total joint procedures, I've scrubbed some but mostly circulate. I'm not totally sure about financial issues, but it's really great to see someone start walking normally again with less pain!
hope this helps mike

[P_RN]

Naon has a forum for various ortho problems and questions.
http://www.orthonurse.org/Forum/view/index.cfm
It's been a long time since I circulated, but I'm with you dirty cases last was still my impression.

[Marie_LPN, RN]

Clean to dirty, just like washing.

Our hospital has 2 rooms specifically for orthopedics.

[Marie_LPN, RN]

But we still only use the small rear door as opposed to the large main OR door after the total case has been opened to minimize traffic, and she requires us to wear those blue alien hats if we're to be in the room (even circulator).

Wow. We're only allowed to go in and out any door if it's a dire emergency (like vomiting or diarrhea) or to scrub. If we forgot to bring something in, we call out to the coordinator, who has to pass it through the door.

Our circulator only wears the space helmet, if the surgeon requests they do it. And it's typically requested if the pt. has Hep B, Hep C or HIV.

[shodobe]

Got rid of laminar flow a few years ago because it was proven, according to a number of orthopods, that it wasn't beneficial. None wear "hoods" at all. We just restrict our movements in and out of the rooms. As far as I know our infection rate for totals are near zero. Mike

[DNRme]

I wonder what the surgeons would think if they knew that the total was following a pilonidal cyst. The MD's I work with would go ballistic. We all know about air exchanges and universal precautions but they still want what they want (the customer, ya know).

We wear hoods for our own protection. Circ. never wears one.