Standards FAQs

What is the difference between the Standards for Individuals and Organisations?

The Standards for Individuals are a quick reference guide for clinical perioperative nurses. Like the standards for organisations, they set out the standardised processes perioperative nurses must follow during their clinical practice to comply with the ACORN standards but in a format that is easy to read and enables the user to quickly scroll to the relevant section within each standard.

 The Standards for Organisations are designed to be used by perioperative managers and hospital administration more than perioperative nurses but are still useful for clinical personnel, especially those who undertake auditing within their perioperative units. The standards for organisations:

• Outline the standardised processes for perioperative nurses to follow to ensure they provide the best evidence-based safe perioperative care
• Set out the quality and safety processes health service organisations need to have in place to support perioperative staff in the provision of safe perioperative care
• Outline the policy requirements which health service organisations need to meet
• Includes a comprehensive evidence section. This does not speak to the evidence used to develop the standards, rather it clearly sets out the evidence that health service organisations need to gather to show compliance against The New ACORN Standards. The information within the evidence section can be used by health service organisations in their quality and safety processes to audit the organisation and perioperative personnel. The results of audits based on the evidence will enable health service organisations to demonstrate compliance with the SSQCPE and PPSPN thereby showing not only that the organisation complies with National Safety and Quality Health Service Standards but that it has exceeded them.
• Include a guidance section providing expanded information for hospital administrators to assist their understanding of the needs of the perioperative unit, as some administrators may not be from a perioperative or even a nursing background.

 

Can I still use versions of the ACORN Standards released before The New ACORN Standards?

The New ACORN Standards will supersede any previous versions of the ACORN Standards.

The only exceptions are the standards listed below, which are yet to be updated and included in The New ACORN Standards.

• Anaesthetic gas pollution
• Loan sets and trial re-usable medical devices
• New equipment and instrumentation
• Perioperative nurse surgeon’s assistant (PNSA)
• Planning and design of the perioperative environment
• Reprocessing re-usable medical devices
• Staffing for safety
• Visitors to the perioperative environment

The standards above, which are still valid from the 16^th edition, can be found at https://www.acorn.org.au/acorn-standards-16th-edition and, for ACORN members, fellows and affiliate members, in the Member Jungle app.

 

Who determines what goes in the ACORN Standards?

The ACORN Standards content is determined by the ACORN Board of Directors, ACORN staff and volunteer experts in the field of perioperative nursing. The Editor-in-Chief and Managing Editor review all content before it is published.

How do I access the Standards for Organisations?

The Standards for Organisations can be accessed in the same way as you accessed the 16th edition of the ACORN Standards.

As an online resource, the ACORN Standards are not designed to be read standard by standard, volume by volume as a book. The best way to use the ACORN Standards is to search for the topic you are interested in.

To search, click on the small eyeglass icon and enter keywords (e.g. 'gloves') in the search bar. The eyeglass and search bar are located on the top left-hand side of every page. You may choose to limit your search by case or by page.

You can also browse individual ACORN Standards by opening the sidebar in the upper left, selecting and clicking on the individual standard according to the alphabetical list of standards shown for each volume. However, for the best results, we encourage you to search by topic using the search bar. Our optimised search tool combs through the standards in an instant and shows you all the pages related to your area of interest, so you don’t miss anything.

 

How do I access the Standards for Individuals?

You need to be a financial member of your local state or territory association, a fellow or an affiliate member of ACORN to access the Standards for Individuals as a member benefit.

All financial members of the Australian state and territory perioperative nursing associations are full members of ACORN.

Become a member now

 

The Standards for Individuals are accessed through the Member Jungle app only.

With your preferred device, whether Android or iOS, search for 'Member Jungle' and install the app. Open the Member Jungle app, type 'ACORN' to find your club/group. Click 'login' when the ACORN group appears. To access the Standards for Individuals, type in your ACORN username and password, then click 'sign in'.

     

 

Please see the video below for instructions on how to access and navigate the standards for individuals in the Member Jungle app.

   Watch video instructions

 

How do I purchase The New ACORN Standards?

Access to The New ACORN Standards for individuals is included in the local state or territory association membership fee, or the affiliate membership fee.

Individual subscription: The Standards for Individuals is a member benefit to all members of ACORN. To access the Standards for Individuals, all you need to do is become a financial member of your local state or territory association, become a fellow, or become an affiliate member of ACORN.

Become a member now

 Access to The New ACORN Standards for organisations is available through a 12-month subscription.

Organisation subscription: Pricing for multiple users is available. Visit the Standards store to purchase the Standards for Organisations subscription.

Purchase an Organisation subscription now

Government organisations and universities: Please email contact@acorn.org.au  for pricing and to organise your subscription to the standards.

 

I can’t remember my username or password. What should I do?

The ACORN members login page information provides details to reset your ACORN username and/or password. Please follow the steps exactly as written.

Click the 'Forgot your password' or 'Forgot your username' link, whichever applies. You will be prompted to provide additional unique information including the email address associated with your ACORN membership account. You will receive an email containing instructions on resetting your password or username.

 

Help! I’m still having trouble logging in

First, we recommend clearing your browser’s cookies, saved passwords, and data from automatically filled forms, then trying to log in again.

If you still have login issues, please email  contact@acorn.org.au

 

My subscription is about to expire. How do I renew it?

One month prior to when your subscription is set to expire, you should receive a renewal notice by email from ACORN. Please respond to renew your subscription. If you have not renewed, ACORN will send a further reminder one week prior to your subscription's expiration date.

If you have questions about renewal, please email contact@acorn.org.au

 

Recommended technical requirements to read the ACORN Standards?

The New ACORN Standards require an internet connection and one of the following web browsers:

• Microsoft Internet Explorer 8.0 or higher
• Mozilla Firefox
• Google Chrome
• Apple Safari

The New ACORN Standards are also compatible with Android and iOS smartphones and mobile devices.

 

Can I share my ACORN Standards subscription?

ACORN Standards subscriptions are intended only for the use of the individual or organisation subscriber. Any sharing of ACORN Standards log in information or content is a violation of ACORN's licence with you or your organisation. 

 

Can I print the ACORN Standards content?

Only the Standards for Individuals may be downloaded and printed.

Please note: The re-use or distribution of the ACORN Standards or content without the express written permission of ACORN is a violation of Australian copyright law. Sharing of the ACORN Standards e-subscriptions is not authorised.

 

Can I re-use content from the ACORN Standards?

All content in the ACORN Standards is protected by Australian copyright law, and re-use of any material (including text, tables and figures) requires express written permission from ACORN. Permission is granted on a case-by-case basis.

To request permission, please complete the Standards feedback form and explain how you would like to use the material.

 

How to reference ACORN Standard publications.

Refer to the document link below for guidance on how to reference:

• The New ACORN Standards
• 16th Edition ACORN Standards (still valid)
• Clinical guidelines
• Position statements
• Practice audit tools

How to reference ACORN publications

I think I’ve found an error in the ACORN Standards. What should I do?

If you notice an inaccuracy in the ACORN Standards, we would be grateful if you would share it with us.

Submit your standards feedback

 

I have ideas for improving the ACORN Standards. Whom do I contact?

We would love to hear your ideas and innovations! 

Submit your standards idea

 

I want to provide feedback about the ASIP tool.

To provide feedback on the new ACORN Standards Implementation Planner (ASIP) tool, please click on the button below.

ASIP tool feedback

 

I want to provide feedback about the new ‘guidance’ section in the Standards for organisations.

To provide feedback on the new guidance section of the SSQCPEs (Standards for Organisations) volume, please click on the button below.

Guidance section feedback

 Can ENs work as an anaesthesia nurse?

Yes, provided they meet the requirements of both the standards set out by the Nursing and Midwifery Board of Australia Standards, ACORN (PPSPNs) and ANZCA PS08 Assistant to the anaesthetist's core competencies.

“This role is suitable for both registered nurses (RNs) and enrolled nurses (ENs). ENs need to be able to administer medicines in this role which they can do unless they have the notation ‘Does not hold Board-approved qualification in administration of medicines’ or ‘May only practise in the area of mothercraft nursing’ on their registration. ENs administering medications shall have the competence and confidence to administer medications safely, regardless of when the initial education occurred. ENs administering medication shall be supervised by an appropriately qualified RN, in accordance with the NMBA Enrolled nurse standards for practice. In addition, an EN undertaking the anaesthesia nurse role shall have access at all times to a named and accessible RN for assistance and support.8 This RN shall be a suitably qualified and experienced anaesthesia nurse.” (ACORN, 2024)

Further information can be found on pages 57 to 64 of the PPSPNs regarding governance, overview of activities, knowledge and skills, education and professional development, delegation and supervision, and professional accountability.

It is important to consult the HSO policies and procedures around the enrolled nurse’s scope of practice and medication handling and administration for local variances, requirements or limitations.

 

Anaesthesia nurses and the surgical count

(See accountable items section of FAQ page)

ACORN received no inquiries regarding this standard during 2024.

Can instrument nurses assist with fundal pressure during a caesarean section?

This appears to be above the role of the instrument nurse’s standard practice and would therefore require additional education and training in surgical assistance. Within the intraoperative technique section of the RANZCOG Clinical Guidance Statement attached (page 7) it states that the pressure exerted is to be done by the surgical assistant or, accoucheur.

Please refer to the following guidelines, standards, and position statements for more detail:

• Clinical guidance statement (RANZCOG) Clinical Guidance Statement
• Standard (ACORN) 16th Edition Standard (still valid): PNSA
• Position statement (ACORN): Perioperative Nurses as Surgical Assistants
• Position paper (RACS): Surgical assistants

 

Can ENs work in PACU?

Yes, provided they meet the requirements of both the standards set out by the Nursing and Midwifery Board of Australia Standards and ACORN (PPSPNs).

“This role is suitable for both registered nurses (RNs) and enrolled nurses (ENs). ENs need to be able to administer medicines in this role which they can do unless they have the notation ‘Does not hold Board-approved qualification in administration of medicines’ or ‘May only practise in the area of mothercraft nursing’ on their registration. ENs administering medications shall have the competence and confidence to administer medications safely, regardless of when the initial education occurred. ENs administering medication shall be supervised by an appropriately qualified RN in accordance with the NMBA Enrolled nurse standards for practice.”

Further information can be found on pages 92 to 99 of the PPSPNs regarding governance, overview of activities, knowledge and skills, education and professional development, delegation and supervision, and professional accountability.

It is important to consult the HSO policies and procedures around the enrolled nurse’s scope of practice and medication handling and administration for local variances, requirements or limitations.

Do you need a post graduate degree to be a perioperative nurse educator?

While holding a postgraduate degree is not a mandatory requirement for a perioperative nurse educator in Australia, it is strongly recommended to pursue postgraduate studies in both perioperative nursing and education to enhance effectiveness in the educator role. Several tertiary education institutions offer postgraduate programs in these fields, and it is advisable for perioperative nurse educators to undertake such qualifications. It is also important to note that, in certain health service organisations, the position description for a perioperative nurse educator may specify the requirement of postgraduate qualifications to meet the role's responsibilities.

ACORN received no inquiries regarding this standard during 2024.

ACORN received no inquiries regarding this standard during 2024.

Surgical count – who is involved and why?

The accountable items standard is one that ACORN receives the most enquiries annually. A common query is around who is/can be involved in the surgical count.

“There shall be a clear delineation of roles and responsibilities in the perioperative management of accountable items, with the circulating nurse and instrument nurse (one of whom must be a registered nurse (RN) taking responsibility for the management of accountable items and being involved in the surgical counting process” (ACORN SSQCPE Accountable items)

 

It is important to have at least one registered nurse involved in the surgical count to ensure proper clinical oversight, as well as to meet the necessary requirements for delegated responsibility and accountability (IFPN 2019, ACORN 2024c). The practice of having two individuals conduct the count, with consistent involvement throughout the procedure, is supported by guidelines from the WHO "Safe Surgery Saves Lives" (2009) and AORN "Retained Surgical Items" (2022) and is in alignment with the NMBA standards for supervision and practice. Together, these measures help maintain the integrity of the surgical count process and protect patient safety.

So, can the Anaesthetic RN be the ‘supervising RN’?

The allocation of the anaesthesia nurse to supervise the surgical count may not be appropriate due to several professional and operational considerations. Firstly, the anaesthesia nurse’s primary responsibility is to remain immediately available to manage anaesthesia, as outlined by the Australian and New Zealand College of Anaesthetists (ANZCA) PS08(A). This guideline emphasises that the anaesthesia nurse must be present and fully available during the anaesthetic process to ensure patient safety and effective management of anaesthesia.

Furthermore, as per the ACORN PPSPN for anaesthesia nurses, anaesthesia nurses are required to practice within their scope of practice, aligned with their level of education, knowledge, skills, and capability. The supervision of surgical counts, which involves the precise tracking and documentation of accountable items, requires expertise specific to the circulating nurse role. As such, the ACORN PPSPN for circulating nurses stipulates that those performing surgical counts must possess in-depth, current knowledge and skills relevant to this task.

While perioperative nurses undertaking the role of anaesthesia nurse may have some knowledge of surgical counts, it is important to recognise that their primary responsibility is focused on anaesthesia management. Although anaesthesia nurses may possess the necessary clinical skills for this role, supervising the surgical count falls outside their designated scope of practice and may affect their ability to fully manage their anaesthesia responsibilities. As such, the anaesthesia nurse may not be the most suitable individual to serve as the registered nurse supervisor for the surgical count in this context.

References:

• Australian and New Zealand College of Anaesthetists. PS08(A) Position statement on the assistant for the anaesthetist. 2016. ANZCA; Melbourne, VIC
• Association of periOperative Registered Nurses (AORN). Guidelines for perioperative practice: Retained surgical items [Internet]. Denver: AORN; 2022 ]. Available from: www.aorn.org/guidelines/about-aorn-guidelines
• Australian College of Perioperative Nurses Ltd (ACORN). Anaesthesia nurse. In The new ACORN standards: Volume 4 – 2023 professional practice standards for perioperative nurses (PPSPN) for Organisations. Adelaide, South Australia: ACORN; 2024a.
• Australian College of Perioperative Nurses Ltd (ACORN). Circulating nurse. In The new ACORN standards: Volume 4 – 2023 professional practice standards for perioperative nurses (PPSPN) for Organisations. Adelaide, South Australia: ACORN; 2024b.
• Australian College of Perioperative Nurses Ltd (ACORN). Enrolled nurse. In The new ACORN standards: Volume 4 – 2023 professional practice standards for perioperative nurses (PPSPN) for Organisations. Adelaide, South Australia: ACORN; 2024c.
• Australian College of Perioperative Nurses Ltd (ACORN). Accountable items. In The new ACORN standards: Volume 3 –2023 standards for safe and quality care in the perioperative environment (SSQCPE) for organisations. Adelaide, South Australia: ACORN; 2023.
• International Federation of Perioperative Nurses [IFPN]. (2019). IFPN Guideline for Surgical Counts. Retrieved from: https://www.ifpn.world/application/files/1715/7951/7011/1002__Surgical__Count__.pdf
• Weston, M., & Chiodo, C. (2022). Preventing Retained Surgical Items. AORN Journal, 115(6), 569–575. https://doi.org/10.1002/aorn.13697
• World Health Organization. WHO Guidelines for Safe Surgery 2009: Safe surgery saves lives. 2009. WHO. Geneva

 

Do I have to conduct a mandatory count if accountable items cannot be retained due to the nature of the surgical procedure?

The clauses outlined in the accountable items allow for local variations to policies and procedures while also allowing perioperative personnel and HSOs to comply with standards. If consumable and absorbent items and instruments are identified as accountable items which are subject to a mandatory count, then unless stated in the local policy, they will need to be counted. However, exceptions can be made for particular procedures, and HSOs may clearly define in their policies which procedures are subject to mandatory counts. For example, the policy may require a minimum of four mandatory counts of all accountable items to be conducted for a caesarean section while stating that accountable items used during cataract surgery are not subject to a mandatory count.

The primary objective of managing accountable items through the use of a count sheet is to prevent the unintended retention of surgical items within the patient. However, the count sheet serves several additional purposes, which may vary depending on the healthcare organisation's policies. These include:

• Documentation of the completed timeout process and identification of the personnel involved.
• Recording of perioperative staff participation, including attendance times and accountability signatures.
• Management of operating room session times for theatre utilisation.
• Documentation of medications administered, such as local anaesthetics.
• Tracking of implantable items inserted or removed, such as infiltration catheters.
• Management of rebate and consignment codes, including reordering procedures.

The use of a count sheet may still be required even in cases where no accountable items are utilised during the procedure, to address the above-listed purposes. In such instances, the count sheet would indicate "No Count Required." The specific requirements for count sheet usage are typically determined at the local level, often through explicit guidelines outlined in the institution's Accountable Items Policy.

Bringing in baskets/trolleys of unopened stock for cases 'just in case'

Whilst ACORN does not have a specific standard for this enquiry; however, some points of consideration when considering bringing in a consumables' basket ‘just in case’ to an operating room:

• Is the basket being cleaned between cases? Refer to ACORN Standard ‘Cleaning and maintaining the perioperative environment’ standard for the expectations around this.
• Where is the basket being kept within the theatre? On an open bench or trolley within the theatre, or enclosed within a trolley that has covering to prevent contamination?
• Is there a chance of contamination of the contents of the basket? 
• Is the basket being used for multiple cases/patients or just brought in for that one case/patient?
• What type of procedure is being undertaken? One that generates environmental microbial movement? E.g., ortho joint replacements

There is a certain level of clinical judgement required regarding what is appropriate given the case and the consumables stock being brought in, e.g., are you taking in a couple of extra dressings, sutures, and towel clips that are likely to be used? Or a full shopping basket of things that are unlikely to be used? 

It is reasonable to bring in a few extra items that are likely to be used for a single patient/case (this is often listed on the surgeon preference card to have available but not opened), particularly if these items will be required quickly; however bringing in excessive consumables for the sake of it (or for use on multiple patients) is not ideal practice from an infection control perspective (risk of contamination) and may be best to store outside the immediate operating room.

 

Moments of hand hygiene in the perioperative environment

Since November 2019, the Australian Commission on Safety and Quality in Health Care has had responsibility for the National Hand Hygiene imitative  in Australian health service organisations. There are specific obligations that health service organisations have including assessment of local hand hygiene compliance. These obligations may differ between jurisdictions and so ACORN recommends you review materials specific to your state or territory. For example, on the NSW Clinical Excellence Commission’s website specifically at http://cec.health.nsw.gov.au/keep-patients-safe/infection-prevention-and-control/healthcare-associated-infections/hand-hygiene 

ACSQHC’s resources for hand hygiene can be accessed free of charge at https://www.safetyandquality.gov.au/our-work/infection-prevention-and-control/national-hand-hygiene-initiative-nhhi/what-hand-hygiene

ACORN has produced a series of 12 Practice audit tools (PATs) specific to the perioperative environment. PAT 3 is for Surgical hand antisepsis, gowning and gloving. The ACORN PATs are available for purchase as a set of 12.

More information is available at https://www.acorn.org.au/practiceaudittools.

Food and beverages in the operating theatres

This is a highly contentious issue and one that ACORN receives many enquiries about. Food and drink should not be permitted in the operating suite or other restricted perioperative areas due to the risk of contamination and the potential for compromising patient safety. Surgical site infections (SSIs) and hospital-acquired infections (HAIs) are significant concerns in the perioperative environment, as food and beverages can introduce bacteria, pathogens, or foreign particles into critical aseptic areas, potentially increasing the risk of infection. The operating room must maintain its critical aseptic environment, and the presence of food could jeopardise the sterility of the area by contributing airborne particles or contaminating surfaces.

In addition to the infection risks, allowing food and beverages in restricted areas may also cause distractions amongst perioperative personnel, compromising their concentration and focus during critical surgical procedures. The removal of personal protective equipment (PPE), such as masks, for eating or drinking further undermines the integrity of sterile conditions and exposes both staff and patients to potential allergens or sensitivities. Furthermore, food and drink remnants can attract vermin and insects, creating additional hazards in the sterile environment.

ACORN continues working with RACS and ANZCA to develop a united position on this based on patient safety and infection control principles, emphasising the need to restrict food and beverage consumption in operating suites and other restricted areas. Health service organisations are encouraged to implement clear policies regarding the storage and consumption of food in these environments, ensuring that designated areas outside the operating room are available for personnel to access hydration and nutrition. By maintaining these standards, healthcare providers can ensure optimal care while minimising the risks associated with contamination, distractions, and the potential for equipment damage.

 

Perfume in the perioperative environment

ACORN's standards are silent on this issue as the decision should be organisation-wide rather than perioperative-specific. There are multiple confined areas within health service organisations where staff and patients are in close proximity. Any policy should address aftershave as well as perfume. ACORN keeps a watching brief on emerging evidence or research, but in this case for now ACORN advises you to take it up with your organisation’s OH&S management, as it is a governance issue. If you or any others in your workforce are truly sensitive, then I suspect there could be good grounds from an occupational health perspective to discourage and/or ban staff from wearing perfume while at work.

What is the difference between a laser operator, a laser user, and a laser safety officer?

Please refer to the Glossary section on page 88 of the Laser safety standard.

Is it safe for perioperative personnel to manually lift or reposition patients during surgery, and what are the best practices for patient handling in the operating suite in Australia?

The safety of manually lifting or repositioning patients during surgery is a controversial issue in the Australian healthcare context, as it poses potential risks for both the patient and perioperative staff. Manual handling in the operating suite is often necessary when adjusting patients’ positions, but it can lead to musculoskeletal injuries for healthcare workers if proper techniques are not followed. Moreover, improper patient positioning can affect surgical outcomes or patient safety, especially during critical stages of the procedure.

Best practice guidelines in Australia, such as those provided by Safe Work Australia and health service organisations, recommend that mechanical aids—such as patient lifts, transfer boards, and slide sheets—be used whenever possible to reduce the need for manual lifting. These devices are designed to help staff safely reposition patients with minimal physical strain, reducing the risk of injury to both workers and patients.

When manual handling is unavoidable, it is essential that perioperative personnel receive training on safe lifting techniques and proper body mechanics. Healthcare workers should also work closely as a team, using coordinated movements to ensure patient safety and minimise strain. Australian healthcare institutions must ensure that policies are in place to support safe patient handling, following local workplace health and safety regulations. The debate around this issue often centres on whether manual handling can ever be fully eliminated from the operating suite, with many advocating for a greater reliance on mechanical aids to safeguard both patient and staff well-being.

Is it necessary to remove hair from the surgical site before surgery, and if so, what is the safest method?

The question of whether to remove hair from the surgical site before surgery remains controversial, particularly regarding the safest method of hair removal. Historically, shaving was widely used; however, it has been shown to increase the risk of surgical site infections (SSIs) due to the potential for micro-abrasions and the introduction of bacteria into the skin. As a result, contemporary guidelines recommend avoiding shaving and instead, using clippers or chemical depilatories when hair removal is necessary.

The safest method for hair removal is using electric clippers with a single-use head or a disposable razor to minimise the risk of skin trauma. This is supported by the Australian Commission on Safety and Quality in Health Care (ACSQHC) and other infection control organisations. Clipping should be done just before the surgical procedure to minimise the length of time the area is exposed to potential contamination. If clippers are not available, depilatory creams may be used, but these should be applied with caution due to potential allergic reactions or skin irritation.

The controversy surrounding hair removal stems from the balance between the desire for a clean surgical site and the need to prevent SSIs. While some argue that hair removal is essential for ensuring sterile conditions, others emphasise that non-removal of hair can be equally safe, provided the surgical site is properly prepped and draped. Ultimately, the decision to remove hair and the method used should be based on institutional policies and best practices that prioritise patient safety and minimise the risk of infection.

Cloth hats - the ongoing debate

The use of cloth hats as part of perioperative attire remains a subject of ongoing debate, particularly in relation to infection control and sustainability in the operating room. While older Australian Standards (AS 3789.3-1994 and AS/NZS 1957:1998) are still technically current, they are outdated and are currently under review for potential updates. In the past, the Association of periOperative Registered Nurses (AORN) issued a statement against the use of cloth hats to reduce the risk of surgical site infections (SSIs), but this position was retracted due to insufficient evidence supporting this claim. Currently, there is no strong consensus within global guidelines, including EORNA Best Practice and AORN, specifically on whether cloth hats contribute to reducing SSIs.

In addition to concerns about infection control, there is a growing emphasis on the environmental impact of single-use items, driving initiatives to encourage the use of reusable cloth hats. These hats are also seen as beneficial for personnel identification within the surgical team. However, concerns persist regarding the potential for contamination, particularly if cloth hats are laundered at home, where domestic laundry settings are not equipped to ensure the complete removal of microorganisms. Studies have shown that home laundering is generally ineffective at removing microbial contamination, posing risks not only to healthcare workers but also to patients, household members, and the wider community.

An alternative approach to mitigating these risks involves the use of commercial laundering facilities, which adhere to strict hygiene protocols to ensure the proper cleaning of surgical attire. The Association of Surgical Technologists (AST) recommends professional laundering facilities due to their higher standards of microbial removal. Additionally, technologies such as Radio Frequency Identification (RFID) tags for monitoring laundering practices and strict auditing could further enhance compliance and safety. This could be an avenue for exploration in perioperative environments where staff insist on home laundering, ensuring that proper cleaning processes are followed to protect both healthcare workers and patients.

 

Jewellery in the perioperative areas (specifically rings)

Please refer to the Perioperative Attire Standard, which advises that "perioperative personnel shall ensure all wristwatches, bracelets, and rings have been removed". The ACORN rationale for this recommendation is based on evidence indicating that microorganisms can be harboured under and within rings, as well as the risk of accidental traction causing avulsion injuries to the soft tissues, ranging from simple contusions to traumatic amputation.

In 2019, the National Health and Medical Research Council (NHMRC) published revised Australian Guidelines for the Prevention and Control of Infection in Healthcare. These guidelines, which are incorporated into the mandatory National Safety and Quality Health Service (NSQHS) Standards for Australian health service organisations, state that "if jewellery must be worn in clinical areas, it should be limited to a plain band (e.g., a wedding ring), and this should be moved about on the finger during hand hygiene practices." However, in high-risk areas such as operating suites or rooms, any jewellery, including plain bands, should not be worn.

ACORN's recommendation is that no jewellery, including wedding rings, should be worn in the perioperative environment. While there is less evidence linking jewellery directly to the effectiveness of hand hygiene, wearing rings can interfere with the proper technique, potentially leading to higher bacterial counts. Although no studies have linked this practice to healthcare worker-to-patient transmission, the consensus is to strongly discourage the wearing of rings, watches, or other jewellery in healthcare settings. If jewellery must be worn, it should be limited to a plain band and moved during hand hygiene practices.

Handling of Sharps Bins in the Operating Theatre

A common concern in perioperative settings revolves around the placement and management of sharps bins within the operating theatre. Specifically, questions arise about the potential risks of relocating regular and laparoscopic sharps bins into the theatre, particularly in situations where these bins may contain accountable items from previous patients. This raises concerns about cross-contamination, the exposure of contaminated materials, and the risk of infection, especially given that these bins may contain decomposing tissue and other biohazardous substances.

ACORN's standards for sharps disposal, as outlined in the SSQCPE Sharps and Preventing Sharps-Related Injury Standard (page 132), align with the NHMRC Australian Guidelines for the Prevention and Control of Infection in Healthcare. These guidelines stress the importance of the safe management and immediate disposal of single-use sharps, such as needles and scalpel blades, in puncture- and leak-proof containers that comply with standards like AS 4031: 1992, AS/NZS 4261: 1994, or ISO 23907: 2019. While the guidelines do not mandate that sharps bins be permanently stationed inside the operating room, they must be positioned close to the point of use to ensure safe and immediate disposal.

In response to concerns about contamination and cross-contamination, ACORN recognises that sharps bins should ideally have features that prevent re-access to disposed items. Smaller sharps bins used in anaesthesia, for example, often incorporate a revolving lid or inner barrier to minimise exposure to contaminated materials. For laparoscopic procedures, which involve specific challenges due to the design and size of the bins, ACORN recommends using a portable sharps bin placed near the point of use at the end of a procedure. These bins should include features such as a foot pedal for closure to minimize the risk of sharps injuries and prevent the spread of odour or particles.

Ultimately, the decision to permanently relocate sharps bins into the operating theatre should be guided by local policies, ensuring the bins are designed for safe handling, easy mobility, and proper disposal practices. Proper training and adherence to these standards help reduce the risks associated with cross-contamination while maintaining a safe environment for both staff and patients.

Formalin handling

The safe handling of formaldehyde (formalin) in the perioperative environment is crucial due to its hazardous nature. The ACORN Standard most relevant to this issue is the Specimen Identification, Collection, and Handling (SICH) Standard, specifically the subsection on ‘Safe Handling of Fixative Solutions’ found on page 143 of the SSQCPEs. This section provides guidance on precautions when handling fixative solutions like formalin, with further details on page 145 and evidence for implementation outlined on page 148.

It is recommended to follow engineering controls, such as using a fume cabinet, as outlined by SafeWork NSW, to minimise exposure. If a fume cabinet is unavailable, a risk assessment should be conducted within your health service organisation to measure airborne particles during the decanting process, including both when formalin is decanted onto specimens and when specimens are placed into formalin. This assessment can help ensure the practice aligns with safety standards and provides a more specific evaluation of the local environment. Additionally, the alternative method of placing specimens in prefilled buckets may raise safety concerns regarding spills and splashes, which should also be addressed in the risk assessment.

Why shouldn't hand scrub and alcohol-based surgical hand rub be used sequentially?

Since 2020, ACORN Standards stipulate that surgical hand scrub and alcohol-based surgical hand rub should not be used sequentially.

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 of 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 of CHG is its persistence. CHG should be in combination with alcohol so that both immediate killing is achieved (by alcohol) and persistence is attained (by 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 2023 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 protection, 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's standard ‘Surgical hand antisepsis, gowning and gloving’, including its glossary of important terms.

References:

1. 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.
2. World Health Organization. Guidelines on hand hygiene in health care. First global patient safety challenge: Clean care is safe care. Geneva: WHO; 2009.
3. 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.

Digitally signed consent forms

ACORN is not within the scope to comment on the legal validity of specific documentation. However, for further guidance, I direct you to the Australian Government (Attorney-General’s Department) website, which provides detailed information on electronic signatures: Australian Government - Electronic Signatures. Although this page does not specifically address medical or procedural consent forms, it highlights that the Electronic Transactions Act 1999 (ETA) states that electronic signatures (often referred to as e-signatures) are legally equivalent to traditional paper or 'wet ink' signatures for most Commonwealth processes.

Additionally, the Royal Australasian College of Surgeons (RACS) position statement provides detailed information on the elements required for informed consent, beyond the signature itself: RACS Informed Consent Position Statement.

As you appear to be based in Queensland, I recommend reviewing the relevant Queensland Government resources, including:

• Electronic Transactions (QLD) Act 2001: Legislation Link
• Electronic Signatures Guideline: Queensland Government Guidelines
• Authentication Framework: See attached document
• Crown Law – Please Sign Electronically 2.0: Crown Law Guide
• Australian Government – Electronic Transactions Regulations 2000: Regulations Link

These resources should assist in clarifying the legal aspects regarding electronically signed documents in Queensland and the broader Australian context.

 

Acronyms and abbreviations on consent forms

Regarding the use of acronyms and abbreviations on surgical consent forms, it’s important to refer to your local policies and procedures, as many healthcare services have guidelines on approved abbreviations for clinical communication, often as part of their NSQHS National Standards accreditation. If no policy exists, it would be advisable to create one to reduce confusion, especially around procedure identification. For reference, I’ve attached the NSW Health Clinical Abbreviations list (Nov 2020), and Vic Health’s glossary of acronyms: Vic Health Glossary.

The ACORN SSQCPEs highlights the importance of clear communication in ensuring patient safety and correct procedure matching, emphasising the risks of using unknown abbreviations. Position statements from RACS and ANZCA on consent and documentation are also recommended for guidance.

Regarding informed consent documentation, the NSQHS National Standards provide detailed requirements, particularly in the 'Partnering with Consumers' and 'Communicating for Safety' Standards. These standards stress the use of standardised language and approved abbreviations to ensure clarity and reduce the risk of errors: Informed Consent Standard, Correct Identification & Procedure Matching.

Additionally, the Queensland Clinical Excellence Commission's guide advises against using abbreviations in consent forms to avoid misinterpretation. For example, fingers should be named (e.g., thumb, index) rather than numbered, and procedures should be written out fully (e.g., "Right" instead of "R" or "Rt").

Further resources:

• Queensland Clinical Excellence Commission's ‘Guide to informed decision making in healthcare.’
• NSW Health Clinical Abbreviations List.
• Australian Commission on Safety and Quality in Healthcare’s guidelines on terminology, abbreviations, and symbols used in medical documentation.

Readers will have noticed that the Staffing for safety standard in the current edition of Standards for Perioperative Nursing in Australia (the ACORN Standards) makes no mention of or recommendations about staffing numbers, ratios or mix. The 16^th Edition ACORN Standards does, however, include a note in the Staffing for safety standard that reads as follows.

Historically, ACORN has set minimum numbers of perioperative staff according to specific perioperative care settings and the specific phase of perioperative care. Nevertheless, ACORN receives constant enquiries regarding local variation in perioperative staffing. Because of different industrial awards, employment contracts and various local issues, it is generally not possible to determine, based on evidence, an exact figure for the number of perioperative nursing staff required. Rather, ACORN recommends that at every stage of perioperative care the number and skills of the nurses attending the patient shall be appropriate for the acuity of the patient and sufficient to ensure quality care is delivered with minimal risk to patients and staff.

During the Roadmap Project, the National Leadership Group (NLG) undertook healthy and informed discussion regarding perioperative staffing. They instructed ACORN not to include a Staffing standard in the 2023 Professional Practice Standards for Perioperative Nurses (PPSPNs). The NLG reminded ACORN that inclusion of a Staffing standard will, as it has done previously, detract from widespread jurisdictional adoption of the broader ACORN standards. The NLG also recognised that in some jurisdictions, such as Queensland, the ACORN Staffing for safety standard is relied on as a primary piece of perioperative governance.

The NLG instructed ACORN to begin, from mid-2023 onwards, exploring options for including a perioperative staffing recommendation in relevant industrial instruments. The NLG recognised that it would be desirable for ACORN to continue to produce a Staffing guideline as a stand-alone document that would then support easier adoption into industrial instruments. NLG members agreed that one of the challenges is the limited evidence that is available to support a staffing standard.

Readers of the 2023 ACORN Standards should not be surprised to find that the PPSPNs contain no recommendations specifying staffing numbers, ratios or mix. Instead, they can be reassured that, as instructed, ACORN’s leadership and Board of Directors will be giving further consideration to how to best engage with relevant national industrial and professional bodies to define and address shortages in perioperative nurse staffing.

Best practices for reprocessing medical devices

It is important to always ensure the medical device IFU and manufacturer guidelines are received and understood prior to use. ACORN does not recommend specific reprocessing equipment products but advocates for best practice principles to be followed. These include but are not limited to:

• Following manufacturer guidelines for cleaning, disinfecting, and sterilising each device.

• Using validated equipment that meets the standards for sterilisation.

• Training staff regularly on proper reprocessing techniques and infection control protocols.

• Documenting each reprocessing cycle to maintain traceability and accountability.

• Inspecting devices for damage before and after each reprocessing cycle to ensure their integrity.

• Ensuring proper storage of sterilised devices in a clean and dry environment.

 

How do you know if a medical device has been properly sterilised?

To ensure that a medical device has been properly sterilised:

• Use of biological indicators: These are vials containing spores that are exposed to the sterilisation process. A negative result confirms that the sterilisation cycle was effective.
• Chemical indicators: These are applied to the devices or sterilisation pack to confirm that the correct temperature, pressure, or chemical concentration was reached.
• Regular monitoring and validation of sterilisation equipment, including routine maintenance and testing, to ensure its proper function.

Cardboard boxes in the perioperative environment

The use of corrugated or unsealed cardboard boxes is not recommended within the perioperative suite due to the high risk of contamination from external microbes, which can compromise sterile stock and instrumentation. It is unclear whether you are referring specifically to the operating room or other areas within the perioperative suite, such as sterile stockrooms or the Post-Anaesthetic Care Unit (PACU). As a general guideline, restricted areas like the operating room or sterile stock areas should be kept free from external contaminants to maintain sterility. This is why appropriate perioperative attire is required in these areas.

Cardboard boxes used for transporting stock or instruments from external environments are porous and can carry a variety of microbes. Therefore, they should be decanted or unpacked before entering restricted perioperative areas, as they cannot be adequately cleaned for such settings.

For further guidance, the following resources may be helpful:

• ACORN Standard - Planning and Design of the Perioperative Environment, specifically the section on ‘Delivery, Storage, and Support – Sterile and Unsterile’: ACORN Standards
• Australian Health Facility Guidelines - B.0520 Operating Unit: Health Facility Guidelines
• NSQHS National Standard 3 - Preventing and Controlling Infections: NSQHS Standards

For ACORN's stance related to PNSA, please refer to the position statement located on the ACORN website: https://www.acorn.org.au/position-statements

To be an auditor you will need to be an experienced perioperative nurse, ideally with three or more years’ nursing experience in a perioperative setting. You will also need to be familiar with the specific ACORN standard being audited, including the specific principles, rationales for practice and the individual performance criteria. Experience or training with other audit programs will be very helpful, i.e. Infection Control audits, Hand Hygiene Australia, WH&S audits, ACHS etc.

You do not need to be an experienced Excel user for conducting the audit. It is essential however, that an experienced Excel user is responsible for entering the data, analysing the results and ongoing management of the audit program.

The time taken to audit one standard will depend upon many things and will change over time as you become more experienced and efficient. At the beginning, you should schedule one hour to conduct an audit, including time to return to the PAT if there are some practices you did not observe at the time. You will get faster and more efficient with experience. For example, you may feel skilled enough to audit more than one standard during an observation period. Eventually, you may feel skilled enough to conduct audits while doing your other work.

Practice audits are designed to take a random snapshot of many nurses' practice within your workplace at many varied times and situations. The result of the audit will tell you whether there are many nurses who are practising according to the standards at a variety of times and in various situations. Audits are the measurement tools in quality improvement.

Competency assessments are designed to focus on a single nurse's practice at an agreed point in time. The result of the competency assessment will tell you whether this nurse knows how to practise according to the standards when asked to do so. Assessments are measurement tools in training and education.

All staff, including the nurses, medical officers and ancillary staff, should be aware that practice audits are being conducted. We recommend that you display reminder posters as part of your audit program. These posters should inform the staff of the period of time, i.e. dates of the month, when the nursing practice audits will be conducted.

At the beginning, the nurses may notice when you are observing their practice. Aim to be discrete when using the audit tool – carrying a piece of paper is more discrete than a clipboard. Eventually, your colleagues will become used to this and you will be able to observe without being noticed as much.

Remember, the audit is designed to be a random snapshot of many nurses' practice within your workplace, so you should try to observe more than two or three nurses whenever that is possible. This will be more of a challenge for small departments with only one or two rooms.

Avoid audits that observe only new nurses or only experienced nurses.

With each audit, consider whether you are observing a range of nursing experience and consider whether this reflects the usual mix of nursing experience in your workplace. Your set of ten audits should be representative of the diversity of your workplace.

Some standards include practices which must be performed in the correct sequence of procedural steps. In these instances, you should focus on one nurse when observing these practices: for example, complete stages of surgical hand antisepsis technique from the sink to the gown trolley, and/or from the gown trolley to the instrument table.

It is very important to observe different nurses for each of the ten audits with this standard so your results are representative of your workplace.

Non-routine or emergency procedures are not appropriate times to conduct the practice audit. Observe more than two or three nurses whenever possible. Avoid audits that observe only new nurses or only experienced nurses. With each audit, consider whether you are observing a range of nursing experience and consider whether this reflects the usual mix of nursing experience in your workplace.

Your set of ten audits should be representative of the diversity of your workplace. An exception is when standards include practices which must be performed in the correct sequence of procedural steps: for example, complete stages of surgical hand antisepsis technique from the sink to the gown trolley, and/or from the gown trolley to the instrument table (see FAQ 7). In these instances, you should focus on one nurse. It is very important to observe different nurses for each of the ten audits with this standard to ensure that your results are representative of the diversity of your workplace.

Each standard should be audited on ten separate and diverse occasions. You should try to provide a wide snapshot of nurses' practice within your workplace in many different surgical lists, clinical situations and teams.

Consider the results you get when you conduct ten audits in one week, compared with ten audits in one month – the first example will provide you with a narrow snapshot of practices (not representative and potentially biased), while the second example will provide you with a wider snapshot of practices and is likely to represent more of the diversity in your workplace.

Score practices as non-compliant as and when you observe them.

Patient and staff safety are paramount at all times and practice audits are no different in this respect. You should be prepared to speak up if you observe practices that compromise patient or staff safety. Consider whether non-compliant practices are likely to compromise patient or staff safety. It may require immediate intervention or it may require corrective instruction. For example, you may observe a nurse at the scrub sink without protective eyewear. You could observe until the nurse approaches the instrument trolley and prepares for direct patient care. If the nurse has not yet corrected their practice and the circulating nurse has not noticed and provided assistance, you should intervene. You would then score the practice as non-compliant.

A general rule of observational audits is that you cannot audit practices that you do not observe. In most instances, it is preferable for you to leave the practice unscored and wait to observe the practice again – in this way you will score it based on the nurse's practice (i.e. what the nurse does – their real practice), not the nurse's knowledge (i.e. what the nurse knows – their ideal practice).

In some instances, you might be able to ask the nurses what they did when you were not looking, for example: – if you did not see the nurse pour the prep solution into the bowl you might ask them how they did it – you might read a specimen label yourself and check if the nurse has completed it correctly – to audit whether the nurse has been compliant with scrub duration and consistent with the use of agents you might ask the nurse about the scrub techniques and agents they used. However, it would NOT be acceptable to ask the nurse what they did before you arrived in the room for the audit.

When a nurse's practice deviates from the accepted standard it is considered non-compliant and scored zero. Generally, this score is not influenced by the reason for the nurse's non-compliance. As auditor, you could make a note of the reason so that the manager can take action. For example, 'plastic aprons not available'. This may explain to the manager why the nurses were non-compliant for the month that the equipment was out of stock.

The Excel formula will ignore the NAs when it calculates the compliance rate. The first edition of the PATs required the NAs to be manually subtracted but that is no longer necessary unless you wish to check the Excel calculations.

Whenever the nurse performs surgical hand antisepsis (SHA), they will use either the traditional surgical hand scrub (SHS) with running water or they will use the waterless technique with alcohol-based hand rub (ABHR). Both of these techniques are acceptable and, when performed correctly, they are considered compliant practice. Therefore, the criteria for the observed technique should be scored '1' when the nurse's practice is compliant. The criteria for the other technique (the technique you did not observe) are not applicable and should all be scored 'NA'. The Excel formula will ignore the NAs when it calculates the compliance rate.

The intention of the ACORN PAT Project is to look for evidence of Australian perioperative nurses’ compliance with their national standards, as in ACORN Standards for Perioperative Nursing in Australia. While individual standards might refer to the multidisciplinary team and might describe what members of the multidisciplinary team should be doing, the focus of the ACORN standards is the nurses’ roles. So, the ACORN PATs are specifically designed as audit tools for perioperative nursing staff only. The PATs have not been validated for use as audit tools for other professions.