ACORN Standards Applied to Practice (ASAP)
The count: Who can, who can't and who should?
So far in 2021, about a quarter of all clinical questions posed to ACORN relate to the surgical count. Most often questions are about who can be involved, who must be involved and what items should be included.
The primary purpose of ACORN's standard ‘Accountable items’ is to prevent unintentional retention of surgical instruments and equipment. Retained surgical items (RSI) is a serious and unresolved global preventable complication of surgery.
Domestically, this is a significant problem and Australia's 2012 to 2013 rate for a foreign body left in during procedure was 8.6 per 100 000 separations1. This was higher than the Organisation for Economic Co-operation and Development (OECD) average at the time which was 5.7 for the comparison year. Australian state and territory reports from 2012 to 20182 indicate that every year in Australian there are between 22 and 34 cases of instruments or other material retained after surgery requiring re-operation or further surgical procedure.
In 2019 Cockburn, Davis and Osborne published a seminal paper detailing how Australian cases of unintentionally retained surgical items have historically been dealt with legally3. Cockburn's work highlights the small proportion of RSIs that are resolved through the judicial system. The assertion being that most RSI cases are resolved prior to litigation. This accounts for the ‘disappearing’ nature of RSI outcomes. Most importantly the authors emphasise the current shared responsibility and accountability of the operating team, surgeons and nurses. They also highlight the current inadequacy of counting and documentation of accountable items in preventing RSIs3. This assertion is supported by another seminal Australian paper by Hibbert and colleagues4 in which the authors assert that count discrepancies are not fully protective with one study suggesting that counts only detected 77 per cent of RSIs4. Additionally, Hibbert reports that if a count is incorrect the risk of an RSI increases 20-fold4.
The count-related queries posed to ACORN in the last two years almost always seek clarification on who has responsibility for the count. Often the asker is also seeking ACORN's position on minor deviations from the process detailed in the current Accountable items standard, particularly alternative staffing requirements or possible exclusions of specific items from the count process. In every response ACORN reiterates the requirements of the standard. ACORN's responses are based on the premise that perioperative nurses should never make decisions that increases the risk of RSI or reduce the ability of any perioperative team member to provide safe, high quality care. Within ACORN's response and in the Accountable items standard ACORN notes that where contradictory recommendations exist in additional national or jurisdictional directives, including legislation, public policy or guidelines, those recommendations take precedence. ACORN’s responses routinely include the caveat ‘the ACORN Standards for Perioperative Nursing in Australia are voluntary documents that set out specifications, procedures and guidelines that aim to ensure products, services and systems used in perioperative nursing are safe, consistent and reliable’.
Given the ongoing risk of RSI in Australia ACORN's recommendation is that all perioperative nurses familiarise themselves with ACORN's Accountable items standard, participate in a gap-analysis to determine if local changes are needed and periodically monitor their own and their colleagues' practice in relation to accountable items and RSI prevention. We also recommend the papers published by Cockburn3 and Hibbert4.
More information is also available at Clinical FAQs under the Accountable items option.
- Australian institute of Health and Welfare (AIHW). OECD health-care quality indicators for Australia 2015: 6.1 Foreign body left in during procedure rate [Internet]. Canberra AIHW; 2016 [updated 2017 October 5, cited 2021 June 21]. Available from: https://www.aihw.gov.au/reports/international-comparisons/oecd-health-care-quality-indicators-2015/contents/table-of-contents.
- Australian Institute of Health and Welfare (AIHW). Health system: Safety, Sentinel events, Retained instruments or other material after surgery requiring re-operation or further surgical procedure [Internet]. Canberra AIHW; [updated 2021 March 25, cited 2021 June 21]. Available from: https://www.aihw.gov.au/reports-data/australias-health-performance/australias-health-performance-framework/national/all-australia/safety/safety/2_2_3?tab=2.2.3|Table&filter=2.2.3|2|Number&filter=2.2.3|4|2017–18&filter=2.2.3|1|Retained%20instruments%20or%20other%20material%20after%20surgery%20requiring%20re-operation%20or%20further%20surgical%20procedure.
- Cockburn T, Davis J, Osborne S. Retained surgical items: Lessons from Australian case law of items unintentionally left behind in patients after surgery. J Law Med 2019;26(4):841–848.
- Hibbert PD, Thomas MJW, Deakin A, Runciman WB, Carson-Stevens A, Braithwaite J. A qualitative content analysis of retained surgical items: Learning from root cause analysis investigations. Int J Qual Health Care 2020;32(3):184–199.
The Roadmap Project’s Clinical Workstream Team (WST) has extensively reviewed the contents of Volume 1 of the current 2020 ACORN Standards with the aim of making future ACORN clinical standards simple, easily located and narrowly focussed.
The Clinical WST members provide a broad base and after thorough consideration and robust discussion, ten topics were identified for inclusion:
- Accountable items
- Chlorhexidine and latex sensitivity
- Electrosurgical equipment
- Fire safety specific to the perioperative setting
- Infection prevention – this will include all of the following individual standards combined into a single standard
- Cleaning and maintaining the perioperative environment
- Disposal of surgically removed human tissue and explanted items
- Perioperative attire
- Preoperative patient skin antisepsis
- Sharps and preventing sharps-related injury
- Surgical hand antisepsis, gowning and gloving
- Laser safety
- Patient positioning and manual handling
- Specimen identification, collection and handling
- Surgical plume
- Surgical safety
In December 2020, the Clinical WST made its recommendations to the Roadmap Project’s National Leadership Group (NLG). The NLG carefully considered and discussed the WST's recommendations for clinical standard topics and how those standards relate to other primary safety and quality standards. In March 2021, the NLG accepted the ten topics outlined above to form the Standards for Safe and Quality Care in the Perioperative Environment (SSQCPE) in the 2022 ACORN Standards.
The Clinical WST have diligently met their intent that ACORN not duplicate, contradict or ignore higher-ordered public policy. In their review, the WST considered the current and future need for each existing clinical standard. They also identified what alternative pieces of public policy relate to the topics included in each existing 2020 clinical ACORN standard. Particularly, they took note of the authority and remit of the organisations and agencies authoring or promulgating these alternative directives. The WST's goal was to appropriately rationalise and substantiate the need for ACORN to retain, or not retain, specific clinical standards. The WST recognised that some clinical standards were now superfluous or redundant and have recommended ACORN retire those standards.
The standards, guidelines and position statements in Volume 1: Clinical Standards of the 16th edition of the ACORN Standards remain current until the release of the 2022 ACORN Standards. ACORN is reviewing the topics not carrying over to the 2022 edition, which will only contain standards, and will work with its leadership and members to determine which of those superfluous topics will be reviewed and republished separately as a guideline or position statement and which will be retired.
Redeveloping ACORN's clinical standards is a complex and fast-paced process. Please keep an eye on this page, the Roadmap Project webpage and ACORN social media accounts for updates and opportunities to review and contribute to these ten standards
Recently ACORN launched a public comment process to gain feedback on drafts of new and revised ACORN standards. The first standard open for review is the Professional Practice Standards for Perioperative Nurses (PPSPN) - Registered Nurse draft. Feedback can be submitted on this draft until midnight on 4 May 2021 after which ACORN will consider, review and respond to every piece of feedback. ACORN will use the feedback to produce a final draft which will then be progressed for approval and release.
ACORN developed this new public comment process in response to a report commissioned by the ACORN board in 2019. The report detailed de-identified stakeholder consultation responses about the pros and cons of ACORN’s standard-setting process as it was then. Some respondents expressed concern that the ACORN standard-setting process was not sufficiently transparent because it was largely conducted ‘in-house.’ The report also stated that
‘Several respondents said that the ACORN Standards would be more widely accepted if the College consulted more widely in their development. While the standard-setting process includes a “review draft” process for internal and external stakeholders, several respondents said that ACORN does not systematically expose its draft standards to members, related nursing and medical colleges or health care consumers. They say that feedback should be actively sought and incorporated into the Standards before they are published if they are to be accepted and observed by all operating theatre personnel.’
ACORN's overall response to the report included the establishment of the Roadmap Project (RMP) and major review, redesign and overhaul of the ACORN Standards and each aspect and process of their development and release.
Public comment on draft standards
As part of the RMP's priority work ACORN has recently launched an online review system whereby ACORN members, subscribers and stakeholders can access and provide feedback on pre-publication drafts of all future ACORN Standards.
ACORN's preferred method for receiving feedback on draft standards is by online survey. The survey for the draft currently open for comment is taking respondents around eight minutes to complete. The survey contains questions about the relevant consultation documents that are available to be downloaded on the ACORN website.
ACORN is unable to take written feedback into consideration as it is difficult to analyse and requires resources beyond those which ACORN has. If feedback includes a suggested change or alternate or additional recommendations ACORN requests that alternate phrasing is suggested and evidence cited to support each suggested change. A rationale for each suggestion is also welcomed. Suggestions that do not include alternate phrasing, a rationale or a full cited reference will not be considered. Comments received after the published closing date will not be considered in the final review.
ACORN looks forward to feedback on the feedback system and of course on each standard posted between now and the next scheduled release of the ACORN Standards in May 2022. We hope that this new system, along with the future initiatives from the RMP, will serve ACORN members and subscribers well and to their satisfaction.
Recently ACORN received an enquiry requesting additional insights regarding changes made by Standards Australia to AS/NZS 3825:1998 Procedures and devices for the removal and disposal of scalpel blades from scalpel handles. In late 2020, Standards Australia updated and republished AS/NZS 3825:1998 as AS 3825:2020 Procedures and devices for the removal, containment and disposal of scalpel blades from scalpel handles. The enquiry recognised that ACORN was a Nominating Organisation with a representative involved in reviewing the AS 3825 standard.
Standards Australia standards are developed and revised by Technical Committees (TCs) made up of representatives from organisations that represent the views of a particular interest group. Organisations that nominate a representative for a TC are referred to as Nominating Organisations (NOs). ACORN is a valued NO. It regularly provides representatives sourced from ACORN’s expert members to work with Standards Australia and representatives from other NOs as members of specific TCs. Under Standards Australia’s governance for standards development, all NO representatives are obligated to provide periodic updates to their respective NO. These updates ensure the NO representatives contribute from a broad base rather than from a personal or single facility perspective. This is important for ACORN as our members represent a diverse array of practice settings and perioperative roles.
Additionally, Standards Australia always has a period of public comment on every draft standard they develop. While ACORN acknowledges that its representative to a TC has an obligation to draw ACORN’s attention to pending changes, it is ultimately up to organisations such as ACORN and the local state and territory perioperative nursing associations (local associations or LAs) to keep abreast of Standards Australia’s work. Therefore, ACORN keeps a watching brief on publicly available information and updates published by Standards Australia. Further detail about Standards Australia’s public comments process and their governance structure around standards development is accessible on the Standards Australia website.
When considering new or updated standards from Standards Australia, one must also appreciate that ACORN is only one of many organisations represented on any TC. The Standards Australia drafting process always requires consensus before finalising any drafts. That consensus does not have to be unanimous; instead, it may be by majority. While the workings of committees are not in the public domain, it is not unreasonable to suppose that sometimes NOs hold minority views different to the majority of other stakeholders.
ACORN members seeking to understand and accept the recommendations included in various Standards Australia standards should find that the recommendations are generally consistent with the principles in other high-level public policies and directives e.g. the current Australian Guidelines for the Prevention and Control of Infection and the National Safety and Quality Health Service Standards. Standards Australia routinely seeks alignment with these and other equivalently powered directives.
Similarly, ACORN seeks to align ACORN standards with Australian and international standards. The two volumes of the current 16th edition of Standards for Perioperative Nursing in Australia (the ACORN Standards) both include a table of Australian and international standards cited within the respective volumes. ACORN included these tables for two reasons. Firstly, their inclusion reassures readers that ACORN has thoroughly interrogated public policy and directives related to each individual ACORN standard. Secondly, the details included in the table assist readers who are keen to review the existing Australian and international standards that have been cited.
ACORN is aware of only one downside of citing Australian and international standards – the need to review and revise ACORN standards in response to any changes or updates to the Australian and international standards in the period between each current and subsequent edition of the ACORN Standards. Such changes almost always require ACORN to make minor amendments to its standards and this is much more easily done on electronic, rather than hard copy, editions of the ACORN Standards.
It is hoped that this brief update clarifies how ACORN members are represented in Standards Australia standard-setting and how ACORN evaluates and incorporates specific Standards Australia standards into the ACORN Standards.
Volume 1 of the current 16th edition of Standards for Perioperative Nursing in Australia (the ACORN Standards) includes recommendations on a wide range of clinical practices. Historically each set of clinical practice recommendations was classified and structured as either a standard, guideline or position statement. Collectively those standards, guidelines and position statements formed approximately half of the entire suite of ACORN Standards. The next edition of the ACORN Standards will only include standards. Therefore an essential part of ACORN’s Roadmap Project currently being undertaken by the Clinical Workstream Team (WST) is making recommendations about which of the 16th edition's current clinical topics will remain as revised, updated standards.
ACORN will deal with the clinical topics not being retained in one of three ways. They may be reclassified as an ACORN guideline, reclassified as an ACORN position statement or rescinded. All reclassified topics will be subject to revision and updating before ACORN progressively republishes them. They will sit separate from the ACORN Standards and serve an entirely different purpose. ACORN will communicate that purpose as each guideline or position statement is published.
ACORN’s Roadmap Project has delegated responsibility for making recommendations about which clinical topics ACORN must include in the next edition of the ACORN Standards to the Clinical WST. To do this task well and thoroughly, team members have considered how they and their colleagues routinely use the ACORN Standards and, through a series of meetings, surveys, and email discussions the team has recommended improvements ACORN could make to increase the useability of future ACORN Standards.
The Clinical WST identified two key issues early in their discussion:
- the high degree of repetition, and possibly even contradiction, in the overall content of the Standards
- the absence of an index in the previous and current edition of the ACORN Standards.
To address the first issue the team has now provided a list of standards it recommends be revised and published in the next edition of the ACORN Standards. As well, the team has recommended the preferred future for the residual current standards, guidelines and position statements. Pending approval by the Roadmap Project’s National Leadership Group (NLG), some will be revised and retained as standards while others will be reclassified, revised and republished as guidelines or position statements. The team recognised that some topics, currently included in the ACORN Standards, are covered elsewhere as standards published by another reputable agency or organisation and has recommended that ACORN rescinds standards, guidelines and position statements about these topics.
In relation to the second issue, the team identified that perioperative staff may need to immediately know or confirm ACORN's recommendations contained in a specific standard; therefore, the team strongly recommended that ACORN consider developing an index for the next version of the ACORN Standards. As this brief report goes to press, ACORN is exploring possible options for integrating an index.
ACORN continues to seek ways to improve and simplify the ACORN Standards. ACORN remains committed to providing Australian perioperative nurses and organisations with standards that are clear, free from repetition or contradiction and reflective of their evolution over the last four decades. ACORN can only achieve these goals by the direct involvement of committed members and experts such as the members of the Clinical WST and the NLG. Together with the NLG, the Clinical WST and ACORN look forward to sharing more details about the next edition closer to its publication. In the interim, please keep up to date with the standards via ACORN's Standards webpage.
Recently, a member asked for ACORN's advice about the requirements for consent with paediatric patients. Specifically, when a child comes to theatre does the parent that signed the consent form have to be present? Or can it be the other parent who may not have consented for the surgery?
A great place to start to learn more about consent is ‘Informed consent in health care’ a fact sheet for clinicians published by the Australian Commission on Safety and Quality in Health care (ACSQHC). The fact sheet highlights:
- there is case law in Australia about informed consent
- each state and territory also has guardianship and/or medical treatment legislation about capacity and consent
- this legislation is different in each state and territory, and can be complex.
Fact sheet: Informed consent in health care, ACQSHC 2020, p.2
ACORN encourages all members practicing in Australia to refer to the Commission's fact sheet which is available at: https://www.safetyandquality.gov.au/publications-and-resources/resource-library/informed-consent-fact-sheet-clinicians.
The 2020 ACORN Standards stipulate that surgical hand scrub and alcohol-based surgical hand rub should not be used sequentially. Of all the recommendations included in the ACORN Clinical Standards this issue is one of the most commonly questioned. It's time we made it simpler to implement so please read on to learn more about this recommendation, where it comes from, what it means and how you can follow it clinically.
ACORN does not make recommendations regarding specific products as we appreciate that different jurisdictions and organisations have various procurement procedures in place including tenders with specific manufacturers and distributors. Important issues such as staff tolerance to the active ingredients in a solution used for surgical hand antisepsis should also influence what's used. Organisations should take care in selecting hand hygiene solutions as sensitivities may develop. Clinicians should also follow all manufacturer instructions for use (IFU) and only use the solution how and for what it was intended.
Both iodine and Chlorhexidine (CHG) are excellent antiseptics, the main benefit for CHG is its persistence. CHG should be in combination with alcohol so that both immediate kill is achieved (by the alcohol) and persistence is attained (by the CHG).
Members of the surgical team should perform a surgical hand scrub using an antiseptic surgical solution (surgical hand scrub) before the first and every subsequent surgical procedure of the day1.
Traditionally, surgical team members have performed a presurgical hand preparation (‘scrub’) using a surgical hand preparation and water. Recent formulations of waterless, alcohol-based antiseptic hand rub, when used according to IFUs, no longer require the preliminary scrub using a surgical hand preparation and water. The waterless, alcohol-based antiseptic hand rub alone should be sufficient to eliminate transient flora and reduce resident skin flora on the user's hands.
The 2020 ACORN Standards stipulate that surgical hand scrub and alcohol-based surgical hand rub should not be used sequentially as using surgical hand scrub and washing may result in moist hands and moisture may dilute the antimicrobial properties of the surgical hand rub. Surgical hand scrub may also enhance skin irritation and dryness. This recommendation is based on World Health Organization guidelines2 which cite a seminal paper by Kampf3.
Applying this recommendation requires a necessary change in long-held practice. Perioperative nursing often involves following highly ritualised behaviours and so ACORN appreciates this change may be difficult. ACORN also recognises that differences in recommendations, procurement and supply may exist and these need to be considered by perioperative staff at a local decision-making level. Also staff sensitivities; compatibility of hand hygiene solutions with other protections, such as surgical gloves; pricing; safety and IFUs also rightly influence purchasing decisions and practice.
ACORN encourages perioperative staff to engage with hand hygiene suppliers regarding IFUs, benefits, limitations and educational materials associated with their specific hand hygiene formulations. Also please refer to ACORN standard ‘Surgical hand antisepsis’, including its glossary of important terms.
- National Health and Medical Research Council (NHMRC). Australian guidelines for the prevention and control of infection in healthcare [Internet]. Canberra: NHMRC; 2019 [cited 2020 March 24]. Available from: https://www.nhmrc.gov.au/about-us/publications/australian-guidelines-prevention-and-control-infection-healthcare-2019.
- World Health Organization. Guidelines on hand hygiene in health care. First global patient safety challenge: Clean care is safe care. Geneva: WHO; 2009.
- G Kampf, H Löffler. Dermatological aspects of a successful introduction and continuation of alcohol-based hand rubs for hygienic hand disinfection. J Hosp Infect 2003;55(1):1–7. DOI: 10.1016/S0195-6701(03)00223-8.