Clinical Issues JANUARY 2005, VOL 81, NO 1

I
C L I N I C A L I S S U E S I

Anesthesia awareness;
formalin handling; standing orders;
witnessing consents I
I
BymnL

Budingame, RN
For answers to

Q
UESTION: We have been told that mented to occur more frequently dur- your questions
we need to address patient aware- ing cesarean sections, surgery resulting contact the
ness during general anesthesia i n from trauma, and cardiac surgery.' Center for
response to the O d 6, 2004, Joint When interviewing patients preoper-
Commission on Accreditation of Health- atively, perioperative nurses should Practice at
care Organizations (JCAHO) sentinel assess patients for previous incidents of (800) 755-
event alert. This seems like an issue for anesthesia awareness. If a history of 2676 x 265
anesthesia care providers and not some- awareness is discovered, the preopera- or send an
thing that penoperative nurses can or
should address. What can penoperative
tive nurse should notify the anesthesia
care provider and all other periopera-
, e-moj[ to

staff members do to help prevent aware- tive team members immediately of the .erg. AORN's
ness in patients under anesthesia? potential risk for anesthesia awareness.' 2o04
Intraoperatively, conversation Standards,

A
NSWER: Perioperative RNs can should be kept to a minimum6and Recommended
assist in preventing awareness should relate to the care of the patient practices,and
in patients under anesthesia by as much as possible. All OR team Guidelines are
becoming informed about the issue, members should refrain from making now
implementing appropriate interven- inappropriate comments or jokes or
tions throughout the perioperative peri- discussing other patients or unrelated
od, and helping increase other staff topics because patients may recall all
members' sensitivities to the issue. or parts of the conversation.' The circu-
Anesthesia awareness is the postopera- lating nurse should monitor traffic
tive recollection of noises; conversation; entering and leaving the room and
pain; feelings, such as those experi- keep it to a minimum. Conversations
enced during the intubation process or and other environmental noises should
by cold instruments being inserted into be reduced whenever possible.
the surgical site; or other events that If a patient mentions a recall situa-
occurred during the time the patient tion postoperatively, the RN caring for
was under anesthesia.' v (w')Although that patient should notify the anesthe-
patients are unable to communicate sia care provider as soon as possible.
their level of awareness because of The nurse should support the patient
induced paralysis or intubation, they by taking the time to listen to and
may be aware of their surroundings.' understand the patient's concerns. The
The rate of awareness is approximately anesthesia care provider should explain
0.1% to 0.2%' (ie, 20,000 to 40,000 cases what has happened and answer the
per year).' Awareness can be caused by patient's or family members' questions.
four basic situations: During the discharge process, the
0 a light level of anesthesia, patient should be instructed to inform
0 patient-related factors creating the all future anesthesia care providers
need for an unusually high dose of about his or her potential for anesthesia
anesthetic agents, awareness.'
0 mechanical problems with anesthe- The surgeon also should be
sia equipment, or informed of the event. The surgeon or
0 anesthesia care provider error
resulting in an inadequate dose of
anesthetic agent being delivered.'
Anesthesia awareness has been docu-

AORN JOURNAL 2 13
JANUARY 2005, VOL 81, NO 3 Clinical Issues

Perioperative nurses
should listen to and
believe any patient
who states he or she
stress disorder? A health care handling formalin should
facility risk management staff had an anesthesia wear pmper protection,
member also should be made including face and eye
aware of the event. A facility awareness event. shields, gloves, and other
representative, such as the appropriate clothing neces-
anesthesia care provider, risk They should take all sary to prevent skin
manager, nursing staff mem-
ber, or other designated pro- possible measures to Prefilled specimen con-
fessional, should follow up tainers are acceptable but
with the patient daily during make the experience should be used with care.
the period of hospitalization Prefilled specimen containers
and for a period of time after less frightening. may create a staff exposure
the patient is discharged. The risk because formalin may
length of time for follow-up splash as the specimen is
will vary with the response of to prefill specimen contain- dropped into the container. If
individual patients.' ers? If not, i s it acceptable to the container is filled after
Facility policies and proce- store the formalin i n the clean the specimen has been
dures should be developed to core area i n a larger receptacle placed into it, care still must
address care of patients who containing a large quantity of be exercised to minimize
experience anesthesia aware- formalin? splashing as the formalin is
ness. The facility policy and dispensed into the container.

A
procedure should include staff NSWER: Caution Formalin should be dis-
member education to recog- should be used when pensed and stored in an area
nize and manage patients who .dispensing and using other than the OR. The room
experience anesthesia aware- formalin in the surgical suite. should have a negative pres-
ness. The organizationalquali- Formalin can be absorbed sure ventilation system (eg,
ty improvement process through the skin and nasal an exhaust hood).'" This helps -
should include reviewing anes- passages, splashed in the remove aerosolized formalin
thesia awareness incidents. eyes, and ingested.' Formalin from the air during the filling
Brain activity monitoring is a potential carcinogen that process, reducing the risk of
devices should be considered may be fatal if inhaled or inhalation exposure. The
and evaluated for purchase by absorbed through the skin. storage location should be a
the facility.This consideration Irritation or burns to areas separate area, such as a dirty
should be documented for such as skin, eyes, mucous utility room or a special labo-
accrediting agency review. membranes, upper respirato- ratory room, not the clean
Perioperative nurses ry tract; allergic reactions; core or other restricted areas
should listen to and believe coughing; chest pain; or pul- of the surgical suite. To
any patient who states he or monary edema may result decrease the potential for
she had an anesthesia aware- from exposure.8 spilling large amounts of for-
ness event. Perioperative Storage and use of forma- malin, OSHA recommends
nurses should be involved lin is regulated by the formalin be purchased in
actively in patient care and Occupational Safety and small containers.'"
take all possible measures to Health Administration Formalin is a dangerous
make the experience less (OSHA)and other state toxic chemical that should be
frightening. health regulatory agencies. handled with caution. Health
All formalin in the OR care facilities should review

Q
UESTION: How should should be stored in one loca- the safe storage, dispensing,
formalin be handled in tion along with a material and handling of formalin.
the OR? Is it acceptable safety data sheet. People Policies and procedures for the

2 14 AORN JOURNAL
Clinical Issues JANUARY 2005, VOL 81, NO 1

Preference cards or
pick lists are
considered standing
physician order
safe storage and dispensing of even if physicians’ order
formalin in the surgical envi- sheets if they meet sheets are used, medications
ronment should be document- still must be documented on
ed and periodically reviewed. the same criteria as the perioperative record.
Staff members should be edu- Physician‘s preference cards
cated during orientation and standing orders and can be considered standing
when changes are made. orders if regular review by
are reviewed by the physicians is described in the

Q
UESTION: Should medica- facility policy and adhered to
tions used i n the OR be ordering physician by physicians.
documented on a physi-
periodically
Q
cian‘s order sheet? We docu- UESTION: Who i s allowed
ment all medications on the to witness the patient‘s
perioperative record, but is according to the signature on the consent
this enough? At Congress last form? Is witnessing the signa-
year, I reviewed a poster dis- facility’s process. ture the same as obtaining
play that included a physi- informed consent?
cian‘s order sheet for medica-

A
tions administered i n the OR, Preference cards or pick NSWER: The facility
but the general consensus here lists are considered standing consent policy should
i s that this i s not necessary as (ie, preprinted) physician be followed regarding
long as we continue our estab- order sheets if they meet the who can witness the signa-
lished documentation. same criteria as standing ture of a patient or patient’s
orders. Standing orders representative on a consent

A
NSWER: All medica- should be reviewed by the form. The person who signs
tions should be docu- ordering physician periodi- the consent form as a witness
mented on the peri- cally according to the facili- is only witnessing that the
operative nursing record ty’s process.II A master copy patient or patient’s represen-
regardless of whether a sepa- of the order form signed by tative signed the form. This
rate physician’s order form is the physician should be is not the same as obtaining
used. Physician’s order retained. If there are changes informed consent. Obtaining
forms can be used as a tool made to the master copy, it informed consent is the
to reduce medication errors. should be resigned and dated responsibility of the physi-
Using this form may provide and the original should be cian involved in the patient’s
an opportunity to write retained for the period of care and not the responsibili-
down and read back oral time specified by facility poli- ty of nursing staff members
orders.”,’*In some organiza- cy. Outdated order forms or other facility personnel.
tions, the order sheet may be should be removed from The patient must be
used by billing departments inventory in all locations to informed of the benefits,
to validate the physician’s prevent their accidental use. risks, and alternatives to the
order for reimbursement Preprinted order forms surgical procedure to meet
purposes. Other nonmedica- should be individualized for the requirements of informed
tion orders may be included, each patient and signed at the consent. If the patient has
such as urinary catheter time they are used by the questions, signing the con-
insertion; sequential com- physician. sent form should be delayed
pression device application; Using physicians’ order until the patient has had an
and use of irrigation solu- sheets may help decrease opportunity to speak with
tions, especially those con- medication errors related to the physician to have all
taining medications. oral orders. Nevertheless, questions answered.”

AORN JOURNAL 2 15
JANUARY 2005, VOL 81, NO 1 Clinical Issues

Legally, anyone can witness designated witness can telephone or by having the
the signature of a patient or acknowledge the second sig- consenting person repeat the
patient's representative on a nature accordingly.' information to each person
consent form. The facility's A patient who is a minor who will be signing as a wit-
policy and procedure for (ie, 15 to 18 years of age) may ness. The witnesses should
obtaining consents may define sign the consent form for his obtain and document the con-
who can witness the signature or her own procedure if he or senting person's name and
and other responsibilities she is emancipated as deter- relationship to the patient.
associated with preparation of mined by state regulation, Both staff members should
the medical record. Some facil- which includes sign the witness area of the
ities require that consents be 0 living away from parents, consent form. Patients with
witnessed by someone other 0 being in the military, communication barriers (eg,
than OR staff members 0 being financially inde: language, hearing, speech)
involved with the surgical pendent, or should be provided with an
procedure. The physician 0 being married or divorced. interpreter. The witness is not
should not witness the signa- witnessing the accuracy of
ture on the consent form as the information provided but
this may be considered coer- is witnessing the signature of
cion by someone expected to
The person the ~ e r s o n . ' ~
realize financial gain as a witnessing the Any person can witness
result of the surgery." the signature on the consent
A person who witnesses patient's form, but individual facility
the signature of a legal repre- policy and procedure should
sentative for the patient is signature should be followed. Witnessing a
responsible for confirming signature on the consent
that the individual is the actually observe form is not the same thing as
legal representative of the obtaining informed consent,
patient. For instance, in the the individual which is the responsibility of
case of a single parent, does the physician performing the
the parent signing for the signing the form. procedure. 0
child have legal custody of
the child? BYRON L. BURLINGAME
The person witnessing the RN, BSN, MS, CNOR
patient's signature should This also may apply to a PERIOPERATIVENURSING SPECIALIST
actually observe the individ- minor female who is having CENTER FOR NURSING PRACTICE
ual signing the form. If the a sexually oriented proce-
document is already signed dure, such as a pregnancy- NOTES
by the patient but the person related procedure. These 1. M M Ghoneim, "Awareness
who witnessed the signature rules differ from one state to during anesthesia," Atzestlzesio-
did not sign it and is not another, so be sure to check logy 92 (February 2000) 597-602.
available to do so, a new the applicable laws in your 2. P S Myles et al, "Bispectral
index monitoring to prevent
consent form should be com- state." awareness during anesthesia:
pleted, and the patient When it is necessary to The B-aware randomized con-
should sign the new form in obtain informed consent via trolled trial," Lancet 363 (May
the presence of a witness. As telephone, two people who 29,2004) 1757-1763.
an alternative, the patient or will sign as witnesses should 3. C Lennmarken, R Sandin,
"Neuromonitoring for aware-
representative can initial or hear the consenting person ness during surgery," Lancet 363
sign again in the area of the verbalize consent. This can be (May 29,2004) 1747-1748.
original signature and the accomplished via a speaker 4. N Phillips, Berry 6 Kolztz's

2 16 AORN JOURNAL
JANUARY 2005, VOL 81, NO 1 Clinical Issues

Operating Rooni Techniqiie, 10th formaldehyde," in Code of A t various times tlzroughout the
ed (Philadelphia: Mosby, Inc, Federnl Regulntioiis (CFR) 29: year, the Rmommended
2004). Occirpationd Snfety arid Health Practices Committee seeks
5. Joint Commission on Accre- Stnndards (Washington, DC: US
ditation of Healthcare Organiza- Government Printing Office, reuiezo and comments on pro-
tions, "Preventing and managing 2004). Also available at /Jttp:// posed reconimended pmctices
the impact of anesthesia aware- iu~i~zu.oshn.gov/pls/oshnzoeb/ozund is froin members and other inter-
ness," Sentinel Event Alert 32 (Oct p.slioiu-dociinieii t ?p-table= ested individuals. When avail-
6,2004). Also available at /Jftp:// STANDARDS&p_id=l0076 able, these proposed recommend-
iuziw.jcnlio.org/aboiit +iis/naus (accessed 21 October 2004).
+letters/seiitiiiel+event+nlert/sea 10. "Recommended uidelines ed practices appear on A O R N
-32.htin (accessed 16 Nov 2004). for controlling noninfectious Online at http://www
6. "Recommended practices for health hazards in hos itals," .aorn.org. Interested individu-
traffic patterns in the periopera-
tive practice setting," in S t m -
8
National Institute of ccupa-
tional Safety and Health, http://
als who do not have access to
dards, Reconinieiided Prflctices, niid 7iizuzi7.cdc. pov/i J ios/~/lzciuo~d5a.
htW d
the Internet may obtain copies
Guidelines (Denver: AORN, Inc, (accessed 21 Oct 2004). of the proposed dociinzents by
2004) 398. 11.Joint Commission on calling the Center for Nursing
7. "Medical surveillance- Accreditation of Healthcare Practice at (800) 755-2676 x
formaldehyde," in Code of Organizations, "Medication 334. Proposed reconiinended
Federnl Regirlations (CFR) 29: management," in 2004
Occiipntional Safety mid Henlth Comprehensive Mnnunl for practice documents are available
Standards (Washington, DC: US Hospitals: Tlie Oficial Hniidbook for review and comment for a
Government Printing Office, (Oakbrook Terrace, 111: Joint 30-day period after they are
2004). Also available at littp:// Commission on Accreditation of posted. A deadlinefor coinments
zu~uzu.oshn.gov/pls/oshnzueb/oiun Healthcare Organizations, 2004) is indicated with each docu-
disy.shozi,-docuiiieizt ?p-tnble= MM-12.
STAN D ARDS&p-id= 10078 12.H Cohen, J Smetzer, "Safe ment. H e m e check these soiirces
(accessed 21 October 2004). medication practices in the OR: frequently to locate proposed
8. "Material safety data sheet: A systems approach," Surgicnl recommended practices. All
Formalin solution 5%," Science Services Mnizngemeii t 5 (July comments received are consid-
Stuff, Inc, litt //luzozu.science 1999) 22-28. ered as the document isfinal-
stuflcom/rrisd!/C~ 776.html 13. N J Brent, Nurses arid the
(accessed 16 Nov 2004). Lnzu, second ed (Philadelphia: W ized. Thank you for your
9. "Medical surveillance- B Saunders, 2001). participation.

Common Anesthetic May Relieve Severe Pain

novel treatment using a common anesthetic med- than three months, and 31% were free of pain for
A ication has shown success i n reducing the severe
pain caused by complex regional pain syndrome
more than six months. Although the pain relief did
not last indefinitely, a second treatment given t o
(CRPS), according t o an Oct 1, 2004, news release 12 of the patients improved outcomes. I n the
from Blackwell Publishing, Malden, Mass, publishers of retreated group, 58% of patients remained pain free
Pain Medicine. Complex regional pain syndrome, also for more than a year, and almost 33% experienced
known as reflex sympathetic dystrophy, can be associ- relief for more than three years.
ated with chronic pain resistant t o conventional ther- The most frequent side effect of the medication
apies. The disorder affects between 1.5 million and was a feeling of inebriation. Less frequent side effects
seven million people i n the United States. were hallucinations, dizziness, light-headedness, and
Thirty-three patients with unrelenting CRPS nausea.
were treated with a low-dose infusion of ketamine.
After only one treatment, 25 members (76%) of the Severe Pain Relief May Be Possible With a Common
group experienced complete relief. Fifty-four per- Anesthetic Drug (news release, Malden, Mass: Blackwell
cent of the patients remained free of pain for more Publishing, Oct I, 2004).

218 AORN JOURNAL