Jewelry in the OR - MisInformation

[sandiegojames]

Having just finished reading a prior post about jewerly in the operating room on patients I found there was a bit of mis information and lack of understanding regarding jewelry on patients in the OR and bovies in general.

First off lets say from the beginning. Patients coming to the operating room should take off their jewelry prior to surgery for a variety of reasons which we will explore.

However, this is not because of the possibility of burns from stray current or alternate pathways from the modern bovie.

Reasons jewelry should be removed.

-the possibility of swelling

-loss of the jewelry

-can get caught on things ie, peircings or necklace getting snagged while transfering the patient

The AORN 2007 standard pg 520.

"Although there may be other reasons for removal of all patient jewelry (eg, risk of swelling, theft), the risk of an alternative site injury from stray current is negligible."

In writing the current policy regarding bovies for our department I personally contacted valley lab and spoke with their clinical expert. When asking about alternate site burns I was told. "There have not been any alternative site burns reported to us and we are not aware of any documentation of any alternative site burns in the literature when a return electrode contact quality monitored bovie is in use."

Alternate site burns have historically occurred during the use of ground reference ESUs, which is and old technology and should not be in use in a modern OR.

Pad site burns were possible prior to electrode contact quality monitoring. This technology was developed in 1981.

After a number of years of practice in the operating room and in nursing, I have found that some nurses want a definite rule to follow eg, all jewely should be removed, so all jewelry is taken off regardless of circumstance. The problem with this type of thinking from my perspective is that one really isn't taking the best care of the patient, taking into consideration the total patient.

If you have a patient with a ring or body peircing easily removable or which causes a safety hazzard by all means remove it. Tongue rings are coming out no matter what in my book, and a patient having a CABG has to have their rings off becuase of swelling likelyhood/risk.

But consider the patient I had last year. She was 75 years old and had just lost her husband last year. She had her wedding ring on of 50 years which had never come off and was extremely important to her. It wasn't tight on her finger at all but couldn't be removed because of an arthritic knuckle.

The preop nurse was saying it needed to be cut off becuase our old policy stated it was a burn risk. And this was the rational she was giving the patient. This was unfortunately completely false. As stated above, our bovies are patient monitored systems so there was no burn risk, the ring was loose on her actual finger, and to cut someones ring off for the rational of it getting stolen or lost was simply ludicrous. And yet because of the inflexible wording of our now former bovie policy, she was left with little discression as to best take care of our patient. Not to mention significantly increasing the stress level and blood pressure of an acute patient immediately prior to anesthesia induction which understandably was making the anesthesiologist very angry.

I can't stress enough the importance of using critical thinking skills to take care of the total patient. Often times we do not live in a black and white world with rules that fit every patient.

We use bovies every day in our practice in the OR, as professionals it is important to understand the tools of our trade, not simply ground the patient and turn the cut and coag up to 35 35. If you don't know what type of bovie you have or don't fully understand how it works. Valley lab has a good online resource.

http://www.valleylabeducation.org/esself-2a/pages/esself2-01.html

[PtWRing]

I know this thread is old, but I wanted to leave a note just in case someone else found it like I did while researching this issue. I am a patient/patient's spouse and am appalled at the attitude taken by some nurses in this thread. My research so far suggests that while there is some risk here (burns, virtually nonexistant; swelling, real but rare; loss, real but both minor and controllable through taping) that on the whole the risk to the patient is very slight, indeed. The patient is already giving informed consent to being cut upon and having large foreign objects inserted where the sun never shines and that consent is frequently being given in situations which are entirely elective. Is there any reason why informed consent through a signed specific waiver is not sufficient for this very minor risk as well? I find the comments to the effect that this shouldn't be allowed because it might complicate a nurse's job or because the nurse is responsible for patient safety to be exceptionally arrogant in this case. Should surgery (for unrelated reasons) be refused to patients with self-inflicted medical or physical conditions because those conditions may make the nurse's job more complicated? As for patient safety, I've always been under the impression that it was the patient's primary right to decide on the basis of informed consent what was and was not going to be done to him. Sure there are things which are so risky or inappropriate that a caregiver should have the right to decide not to give care even if the patient is willing to give informed consent to them, but this simply isn't one of them in light of the fact that the only real risk is swelling and that the informed consent can certainly provide for a cut-off if that occurs. Fortunately the hospitals and outpatient surgery centers where I and my spouse usually get surgery don't care about this: they ask us to remove our wedding rings but are immediately willing to just tape them down if we decline (and I do not recall ever having to sign a waiver on that point, but perhaps I have). It has only been in the last few days when we have encountered, for the first time in our lives (both over 60 yoa), a surgery center which is outright refusing to allow surgery if we do not have my spouse's wedding ring cut off in advance (it's loose on the finger, but cannot be removed otherwise due to arthritic increase in the size of the finger joint). Since the physician involved does not do surgery anywhere else (and will not step up to the plate to get the center to change its policy even though he's an owner of the center), we'll be taking our business elsewhere. Though in this case it's a matter of not being able to remove the ring, if it were me it would be an — admittedly sentimental — refusal to remove the ring that's been on my finger without being removed even a single time since my spouse put it there 25 years ago. Before someone says, "But isn't the clear-thinking thing to do to set aside your sentimentality or minor inconvenience in order for your safety?" let me say that neither my spouse nor I would have any objection to our ring being cut off during surgery if swelling develops, at that point necessity must overcome sentimentality or inconvenience, but it should be _our_ choice whether or not to take the minor risk that that necessity might arise.

[TXJDRN]

As a former OR nurse and current med-malpractice defense attorney, I offer the following observations and opinions: jewelry and other valuables should be left at home. Reasons: 1. Safety. PtWRing does not realize that finger swelling can occur after the patient is under surgical drapes and the hands are no longer visible. Sorry, but OR nurses and anesthesia providers are not going to monitor a patient's fingers throughout surgery. Also, by the time swelling occurs, it may be too late to cut the ring to prevent damage. And the risk of burns is minimal but so long as we can prevent burns, we will. 2. Risk. Why bring a valuable to the OR or hospital and risk it getting lost, stolen, etc. I am reminded of a claim where the patient left a laptop unsecured in his room when he was transported to another facility for a procedure, notwithstanding that he was cautioned by the hospital not to leave valuables in his room. When his laptop disappeared, he wanted the hospital to pay for it. Sorry, no dice. And yes, it is an "inconvenience" for OR nurses to keep up with patient valuables. The OR staff is under tremendous pressure to be safe and efficient. The OR nurse's focus is on maintaining safety and sterility in the OR, not on securing jewelry that can be left at home. While I sympathize with PtWRing's situation vis-a-vis her husband's wedding ring, I hope she will keep an open mind regarding why patients are asked to remove rings before going to the OR.