Safety lecture part 2

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Patient and Provider Safety in Anesthesia:

Professor: Maribeth Massie, CRNA, MS, Ph.D.(c) ANE 507: Basic P rinciples of Anesthesia I Patient and Provider Safety in Anesthesia

Environmental factors:

Environmental factors Temperature: surgeons/staff want it very cold in OR (down to 60*F); must think of patient before allowing heat to be turned down Multiple warming measures Warmer room for pediatrics/burn patients Noise Ceilings, floors and other surfaces are smooth, nonporous, and constructed of fire proof materials. Prevents trapping of potentially contaminating materials and withstands frequent harsh cleanings

Environmental factors:

Environmental factors Ventilation High flow decreases contamination of surgical site Blends recirculated air with fresh air If working with orthopedic prosthesis implants, must not break air seal on outer door; must enter through inner laminar flow door Pressure in room is POSITIVE Air flow is from ceiling to floor: air inlet near ceiling and exhaust near floor Minimum of 20 air exchanges/hr with a minimum of 4 which must be fresh Air derived directly from outside to avoid air contaminated from other parts of hospital

Humidity:

Humidity Usually maintained between 50-65% The ideal humidity level to achieve minimal static and also reduce microbial growth is 50% to 53%. No longer as strict with adherence because of abandonment of explosive anesthetics Humidity too high: Damp or moist supplies; inc. incidence of contamination Humidity too low: Excessive bacteria carrying dust in environment. Incr. incidence of static discharges  microshock Grounded strips on OR floors to prevent static shocks and fire

Lighting:

Lighting Overhead fluorescent lights Halogenated surgical spot lights Emits pale bluish cast that is less fatiguing on eyes Bluish cast is indication of immense energy which is given off as brightness rather than heat and is therefore safer to use near delicate tissues

Occupational hazards in the O.R.:

Occupational hazards in the O.R. Physical hazards: Anesthetic gases Radiation Methylmethacrylate Headaches, n/v, congenital defects, contact problems Infectious hazards: Resp viruses Herpes Rubella/ measles Cytomegaly HIV/ Aids Hepatitis MRSA/VRE

Occupational hazards cont’d:

Occupational hazards cont’d Stress Miscarriage Substance abuse #1 occupational hazard in anesthesia Suicide 3-4x’s than predicted in socio-economic group Exceeds most other specialties

Miscellaneous safety::

Miscellaneous safety: No eating or drinking of any kind in the O.R. Find out where the following items are in your O.R.: Pre-op, post-op, special procedure areas “The Board” Code cart Difficult airway cart MH cart Fire extinguishers Oxygen shut off Anesthesia work room

Regulation of gases and equipment:

Regulation of gases and equipment Compressed gases Pharmocopeia of the United States or National Formulary Regulates purity of cylinders U.S. Department of Transportation Regulates storage and transportation of compressed gases Cylinders inspected every 10 years

Fire safety:

Fire safety National Fire Prevention Association Publishes standards for use of only nonflammable agents in OR NFPA 99: standard for health care facilities for pipeline gas sources and electrical supply to OR Voluntary but enforceable by law Compressed Gas Association Standards for manufacture and delivery of compressed gases

Misc. safety:

Misc. safety Safe Medical Devices Act of 1990 Notify FDA if death or injury occurs with equipment CDC Offers broad recommendation for infection transmission and prevention Does NOT regulate only makes recommendations

Voluntary standards:

Voluntary standards American National Standards Institute (ANSI) Private organization that publishes minimum safety and performance standards for anesthesia machine American Society for Testing and Materials (ASTM) Publishes standards for anesthesia machine Tracheal tubes Has no role in requiring or enforcing compliance with its standards, but in many instances its standards are mandatory

Voluntary standards:

Voluntary standards Joint Council on Accreditation of Hospital Organizations (JCAHO) Monitors outcomes, analyzes problems and offers solutions Requires safety program

Who is OSHA?:

Who is OSHA ? The Occupational Safety & Health Administration Congress created in 1970 as a result of the Occupational Safety and Health Act Part of the U.S. Department of Labor Mission: “To assure the safety and health of America’s workers by setting and enforcing standards; providing training, outreach, and education; establishing partnerships; and encouraging continual improvement in workplace safety and health.” Write Standards and conduct Inspections Can enforce the acts with fines

NIOSH:

NIOSH The National Institute for Occupational Safety and Health Also created as a result of the National Safety and Health Act of 1970 Part of the U.S. Department of Health and Human Services Helps assure safe and healthful working conditions for working men and women by providing research, information, education, and training in the field of occupational safety and health.

What is NIOSH authorized to do?:

What is NIOSH authorized to do? Develop recommendations for occupational safety and health standards; Perform all functions of the Secretary of Health and Human Services under Sections 20 and 21 of the Act •   Conduct Research on Worker Safety and Health (Section 20) Conduct Training and Employee Education (Section 21) Develop information on safe levels of exposure to toxic materials and harmful physical agents and substances; Conduct research on new safety and health problems; Conduct on-site investigations (Health Hazard Evaluations) to determine the toxicity of materials used in workplaces (42 CFR Parts 85 and 85a); and Fund research by other agencies or private organizations through grants, contracts, and other arrangements.

Air safety:

Air safety Gas Pollution Excess Anesthetic gases Effects Trace exposures can be harmful Increase in spontaneous abortions Increased involuntary sterility Increased birth defects Increased cancer rates Increased kidney/liver failure

Harmful effects of trace gases cont’d:

Harmful effects of trace gases cont’d Impaired performance ability Decreased B12 synthesis Impaired bone marrow DNA Factors influencing waste gas concentration Length of anesthetic Equipment used for measurement Cuff vs uncuffed ETT Ambu bag vs anesthesia machine circuit Effectiveness/proper fx of scavenging system Technique

Trace gas measurements:

Trace gas measurements Measured in parts per million: 1 ppm= 1% of 1,000,000 = 1000parts Allowable standards: N2O: 25ppm Halogenated agents alone: 2ppm N2O with halogenated agent: 0.5 ppm  Advent of scavenging systems Hospital biomed dept or external contractors sample air every 3-6 months

How do we control gas levels?:

How do we control gas levels? Scavenging system Assure proper functioning Work practices Proper mask fit/technique Check N2O briefly 100% O2 Administered at end of case to wash out anesthetic (prevent diffusion hypoxia) Avoid liquid spills

Control of gas levels cont’d:

Control of gas levels cont’d Low flow technique lower the flow the less pollution Control leaks Daily machine checks O.R. ventilation system Air exchanges Soda lime Protects pt from CO2 inhalation Rebreathing of exhaled gases

Electrical safety:

Electrical safety Heart most susceptible to 40-150 Hz (# of cycles per second) AC: alternating current; electrons flow back and forth; impedance only applies to AC Impedance: sum of forces that oppose electron movement when AC is used DC: direct current; nonoscillating; electrons only flow in one direction (i.e: battery); resistance applies only to DC

Electrical Safety:

Electrical Safety Body contact with two conductive materials at different voltage potentials may complete a circuit and result in an electrical shock IE: a provider (grounded) touches the metal OR table that has developed a fault in the plug wiring after being run over repeatedly

Electrical safety:

Electrical safety Use of explosive anesthetics was abandoned in the 1970’s Conductive flooring Static fields would be safely discharged to ground instead of dangerously discharged as a spark that could ignite an explosion Older O.R.’s had electrical outlets placed 5 ft. above ground level due to settling of cyclopropane vapor

Ohm’s law:

Ohm’s law E = I X R (like BP = CO X SVR) E is voltage (volts); unit of electromotive force that propels electrons thru circuit I is current (amps); unit of electron flow R is resistance (ohms); force that opposes electron flow; everything provides some resistance to electron flow W is electrical power (watts); electromotive force Joules (watts per second) W= E x I

Electrical safety:

Electrical safety Conductor: any substance that permits the flow of electrons (AC or DC) Inductance: ability of electrons flowing in a wire or wire coil to create a magnetic field around the wire which can induce an opposing electromotive force in adjacent conductors As AC frequency increases, there is greater electron movement, inductance increases, and impedance increases

Electrical safety:

Electrical safety Capacitance: ability to store an electrical charge IE: Defibrillator Capacitor: consists of two parallel conductors separated by an insulator DC: since no circuit loop current does not flow unless plates are connected; this occurs when the capacitor is discharged Charged by voltage source (battery) Safer than AC circuits since battery operated devices use 1/10 th voltage an no leakage current is possible

Electrical safety:

Electrical safety AC circuits continually reverse itself so they will permit current to flow even when a circuit is not completed This can occur when the equipment is just plugged in but not turned on Results in presence of leakage current from “stray capacitance”

Leakage current:

Leakage current Present in all electrical equipment as a result of capacitance coupling, induction between internal electrical components or defective insulation

Macroshock :

Macroshock Occurs when electricity enters and exists thru skin (lightening bolt); gross amount of current applied to dry intact skin that can cause harm or death First sense at 1 milliamp (mamp- mA) Pain sensed at > 5 mA (maximal harmless current) Current of 10-20 mA produces “let go” condition; unable to let go of source Loss of consciousness at 50 mA 100-300 mA can induce Vfib but respiratory center remains intact >6000 mA, threat to heart and respiratory centers

Microshock :

Microshock Applies to electrically susceptible patient and electrical current applied directly to the myocardium Current enters thru portal into patient (pacing wires, central line, etc) Vfib can be induced with 100 microamps (0.1 mA) Requires much less current because bypasses skins’ high resistance 10 microamps (0.01 mA) recommended maximal 60 Hz leakage current

Electrosurgical units (ESU):

Electrosurgical units (ESU) Also called cautery units Bovie Provides hemostasis during surgery Cauterize, cut, destroy tissue Current passes from tip of cautery thru tissue and back to machine via grounding pad and wire Usually 300-3000 KHz This is too low or too high of frequencies of current to disturb heart rhythm

Electrosurgical units:

Electrosurgical units Never place grounding pad between heart and surgical area Most common source of thermal injury to patient Burns may occur when grounding pad does not have good contact with skin Bipolar cautery is preferred in patients with pacemakers Current flows from each tip of cautery so doesn’t flow thru body Place grounding pad at site distant from heart and in a location where the current will not pass through the heart

Safety features in OR:

Safety features in OR All outlets and equipment grounded Since current follows path of least resistance, all extra current will be diverted to ground and not to patient/staff Grounding means there is a connection between the electrical circuit and earth ground Circuit consists of hot wire (120 v) and neutral ground wire When a faulty piece of equipment containing a ground wire is properly connected to an electrical outlet with a grounding connection, the current will preferentially flow down the low resistance ground wire; an individual touching the equipment standing on the ground will still complete the circuit; however, only a small part of the current will go through the individual Isolation transformer

Isolation transformer:

Isolation transformer Transformer used to isolate the electrical system in the OR Safety feature to protect against macroshock Uses electromagnetic induction to induce a current in a secondary ungrounded system; there is voltage potential between live and neutral lines but no voltage difference between two working lines and ground; when working properly, a circuit cannot be completed, reducing risk of shock If a short circuit develops b/t two working lines, potential develops b/t the lines and ground, creating a potential for shock  first fault

Line isolation monitor :

Line isolation monitor This monitor detects current leakage caused by first fault and sounds an alarm When this occurs, the fault must be found; equipment should be unplugged in reverse order that it was plugged in If the fault is not found and someone touches the faulty equipment, the circuit may be completed causing a second fault and shock may more readily occur Set to alarm at 2-5 mA for a potential leak Newer system alarms at 5 mA though accounting for normal leakage Results from cumulative effect of minor leakages of many pieces of properly functioning equipment

Line isolation monitor:

Line isolation monitor

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