neatness/jcaho

[tweekin19]

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One of my attendings who was previously in private practice told me that according to jcaho we aren't supposed to open packaged things before the patient is in the room and that my academic institution wasn't really following protocol (i.e. you can't test the ETT cuff by opening it before patient rolls back). At the same time, if the surgery techs are opening sterile equipment that are going to be in contact with the patient's body before patient is in the room, then why is this against jcaho guidelines?

Do you all change gloves immediately after intubating a patient before touching the machines to adjust the settings, turn up the gases?
Do you gel everytime you change gloves?

I feel like if I started doing these in front of other attendings, I'd get criticized for not prioritizing correctly or not properly checking equipment before patient comes back. At the same time, I don't want to get into bad habits if what I'm doing so far is wrong.

 

[tweekin19]

One of my attendings who was previously in private practice told me that according to jcaho we aren't supposed to open packaged things before the patient is in the room and that my academic institution wasn't really following protocol (i.e. you can't test the ETT cuff by opening it before patient rolls back). At the same time, if the surgery techs are opening sterile equipment that are going to be in contact with the patient's body before patient is in the room, then why is this against jcaho guidelines?

Do you all change gloves immediately after intubating a patient before touching the machines to adjust the settings, turn up the gases?
Do you gel everytime you change gloves?

I feel like if I started doing these in front of other attendings, I'd get criticized for not prioritizing correctly or not properly checking equipment before patient comes back. At the same time, I don't want to get into bad habits if what I'm doing so far is wrong.

sorry I didn't realize the thread entitled "thoughts?" was basically addressing the same thing. please feel free to delete

 

[anbuitachi]

With the changing gloves after intubation yes i do. I dont alcohol everytime b/c otherwise i can't put on the gloves due to the resistance. And with the opening packaged things, that is dumb and makes no sense. I would not just blindly follow dumb rules like that

As a resident/student just do whatever your attending wants. Annoying about being a resident is different attendings have different habits, and they all think their own is the best way to do things, so you might get yelled/criticized at for doing something they don't like.

 

[urge]

(i.e. you can't test the ETT cuff by opening it before patient rolls back)

When was the first time anyone found a malfunctioning ett cuff on a sealed tube?

Never for me.

 

[Orin]

I used to carry around a ETT/package where the tubing that runs to the balloon had gotten sealed into the packaging, making it unable to inflate/hold a seal.

Someone did a study in the last 4 years or so, which I can't find right now, where they counted the number of times you would have to change gloves/rub down your hands/swab the stopcock or hub/etc and multiplied it by the time required to do each event properly, finding that there wasn't enough time to do that in the manner the guidelines recommend in the time they observed.

Regardless, it helps to be aware of the problem and attempt to address it, even if the guidelines/solutions aren't realistic.

The key part of this is to do whatever your attending wants until you're senior enough to ask wtf...

 

[Psai]

I've found that doing things the opposite way that jhacho tells you to do is most likely the right way. I don't understand why people obsess about the "rules" that come from nonphysicians. Everyone does what they want for the week they come by and then it's back to business as usual.

 

[2Fast2Des]

Because the air in the OR is so sacredly sterile... I do try to unglove immediately after intubating though because I'd really rather not touch the machine with my bare hands after patient slobber is on everything if I don't take off. Also if we want to keep things so sanitary, why does the patient get to roll in to the OR without any face mask while "contaminating" the air while god forbid we breathe without a mask on once the OR nurse loses their stuff. I asked this to a couple of nurses and they said oh it's the patients bacteria so its ok if their air contaminates equipment.

 

[Psai]

Because the air in the OR is so sacredly sterile... I do try to unglove immediately after intubating though because I'd really rather not touch the machine with my bare hands after patient slobber is on everything if I don't take off. Also if we want to keep things so sanitary, why does the patient get to roll in to the OR without any face mask while "contaminating" the air while god forbid we breathe without a mask on once the OR nurse loses their stuff. I asked this to a couple of nurses and they said oh it's the patients bacteria so its ok if their air contaminates equipment.

Then they laugh at you when you try to explain to them that the most likely source of bacterial infection is the patient themselves. It's mindbogglingly impossible to explain basic scientific concepts to nonphysicians.

 

[narcusprince]

I unglove after intubating. And change gloves after I touch the ET or OG tube, I do change gloves when I enter the pyxsis. I think better in a sterile neat environment.

 

[dhb]

Gloves are for *******

 

[urge]

I run through a box of gloves in 1 day. Healthcare is not good for the environment.

 

[narcusprince]

Gloves are for *******

I fine using a drop of water based lubricant helps tactile sensation before gloving in. Also having a partner assist with gloving helps too.

 

[Ronin786]

One of my attendings who was previously in private practice told me that according to jcaho we aren't supposed to open packaged things before the patient is in the room and that my academic institution wasn't really following protocol (i.e. you can't test the ETT cuff by opening it before patient rolls back). At the same time, if the surgery techs are opening sterile equipment that are going to be in contact with the patient's body before patient is in the room, then why is this against jcaho guidelines?

Do you all change gloves immediately after intubating a patient before touching the machines to adjust the settings, turn up the gases?
Do you gel everytime you change gloves?

I feel like if I started doing these in front of other attendings, I'd get criticized for not prioritizing correctly or not properly checking equipment before patient comes back. At the same time, I don't want to get into bad habits if what I'm doing so far is wrong.

Never confuse what JCAHO guidelines say and good habits. They're different ends of the spectrum.

 

[epidural man]

The thing you should remember is JC (previously JCAHO - but they needed a name that corresponded to the GOD complex since they think of themselves as the literal JC) - is that they are a private company trying to make as much money as possible and they don't make any rules.

They come and tell the hospital what to do because they think they can - and like a dog to it's vomit, the hospital then says they should do what this ridiculous company says because they haven't figured out a way to get medicare dollars without the JC blessing.

If you think of JC in this way, it changes your feelings about being in "compliance" with their ridiculous statements.

Have they ever apologized for killing patients from instituting the 5th vital sign? Nope. IN fact, they have recently written a large statement saying they aren't to blame for all the deaths. What an evil company. If the FDA and JC where somehow killed, medicine would instantly improve by about 200%.

 

[dhb]

I run throug a box of gloves in 1 day. Healthcare is not good for the environment.

It would be better if people didn't use a box of gloves a day.

 

[rakotomazoto]

We were swapping stories in the OR about this yesterday, Filipino nurse was saying they would routinely wash gloves with soap and water and use the same pair all day. People who did medical missions in the Dominican Republic were talking about washing off and reusing all sorts of metal surgical equipment and things like syringes, etc. I am not exactly sure where I would draw the line, probably somewhere in between the two extremes of reusing gloves and creating expensive plastic covers to routinely drape over everything in sight.

 

[anbuitachi]

We were swapping stories in the OR about this yesterday, Filipino nurse was saying they would routinely wash gloves with soap and water and use the same pair all day. People who did medical missions in the Dominican Republic were talking about washing off and reusing all sorts of metal surgical equipment and things like syringes, etc. I am not exactly sure where I would draw the line, probably somewhere in between the two extremes of reusing gloves and creating expensive plastic covers to routinely drape over everything in sight.

what they need are studies.. to get some evidence

 

[Lurch]

The thing you should remember is JC (previously JCAHO - but they needed a name that corresponded to the GOD complex since they think of themselves as the literal JC) - is that they are a private company trying to make as much money as possible and they don't make any rules.

They come and tell the hospital what to do because they think they can - and like a dog to it's vomit, the hospital then says they should do what this ridiculous company says because they haven't figured out a way to get medicare dollars without the JC blessing.

If you think of JC in this way, it changes your feelings about being in "compliance" with their ridiculous statements.

Have they ever apologized for killing patients from instituting the 5th vital sign? Nope. IN fact, they have recently written a large statement saying they aren't to blame for all the deaths. What an evil company. If the FDA and JC where somehow killed, medicine would instantly improve by about 200%.

I just read the background to this. Fascinating but obviously intensely frustrating. The lack of accountability by this company is disturbing. Physicians are in an impossible position caught between hard evidence and patients/groups dictating our practice by curbing our reimbursements.

 

[osumd]

I'll often put on 2 pair of gloves. Intubate, shed the outer pair, then continue what you need. Same with extubating- pull the tube, shed the outer pair. I guess it sounds more cumbersome than it is.

 

[pjl]

Our last JC visit was a breeze after hospital across the street stopped using them. They know enough to play nice when threatened.


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[dhb]

I'll often put on 2 pair of gloves. Intubate, shed the outer pair, then continue what you need. Same with extubating- pull the tube, shed the outer pair. I guess it sounds more cumbersome than it is.

 

[d9sccr]

what they need are studies.. to get some evidence

Even that's put to the wayside when it doesn't meet the narrative. Go read the AORN guidelines regarding surgical attire. Much of it has no research but one item that does are beard covers and masks.

Several studies show as long as you're not over the field, wearing a mask or not is irrelevant. Probably bc I've always worn one, but this doesn't bother me too much. The beard cover one annoys me to no end though. There's only one study with an n=20, but it showed no difference among surgeons over the field.

EBM is how we should practice, except when it conflicts with nursing initiatives

 

[InfinitiPSI]

Even that's put to the wayside when it doesn't meet the narrative. Go read the AORN guidelines regarding surgical attire. Much of it has no research but one item that does are beard covers and masks.

Several studies show as long as you're not over the field, wearing a mask or not is irrelevant. Probably bc I've always worn one, but this doesn't bother me too much. The beard cover one annoys me to no end though. There's only one study with an n=20, but it showed no difference among surgeons over the field.

EBM is how we should practice, except when it conflicts with nursing initiatives

Pretty much what I was saying in another thread the other day. I agree with you.

 

[Orin]

Comparison of Sterile vs Nonsterile Gloves in Cutaneous Surgery and Common Outpatient Dental Procedures: A Systematic Review and Meta-analysis. - PubMed - NCBI

JAMA Dermatol. 2016 Sep 1;152(9):1008-14. doi: 10.1001/jamadermatol.2016.1965.
Comparison of Sterile vs Nonsterile Gloves in Cutaneous Surgery and Common Outpatient Dental Procedures: A Systematic Review and Meta-analysis.
CONCLUSIONS AND RELEVANCE:
No difference was found in the rate of postoperative SSI between outpatient surgical procedures performed with sterile vs nonsterile gloves

 

[Orin]

The issue is that the cost matrix looks simple for adding random stuff or interventions to reduce a dreaded SSI until you account for all the time and cost in aggregate that it takes up.

Administrative and "safety" is where a lot of $s are lost

 

[Noyac]

I rarely use gloves and I touch pts even more rarely.

I'm not joking either. I can intubte most of my pts without touch them directly. I grab the top of their head which has bonnet on it and gently tilt te he'd back enough to enter the mouth with the blade or LMA.

 

[deleted162650]

While I'm not quite as "hands-off" as Noy, I rarely even have my hands in their mouth to intubate. Thumb under the nose and index finger on the mentum to open the mouth in conjunction with the head tilt.

LMA's are another story. We've got those sh*tty green Ambu LMA's that always fold on themselves if you don't reach in and redirect the tip.

 

[Noyac]

LMA's are another story. We've got those sh*tty green Ambu LMA's that always fold on themselves if you don't reach in and redirect the tip.

I had an attending that taught me how he would insert an LMA without putting my fingers in the mouth. He had some pretty derogatory terms for anesthesiologists who put their fingers in pts mouths but I won't go that far.
Just try inserting the LMA one of two ways, completely upside down until the mask part is entirely in the mouth and then flip it over as you push it further down. Or you can try my variation of the technique were I insert the LMA with a quarter turn and slightly lateral to midline of the tongue. Then I flip it. I have not put my fingers in a pts mouth in so many years that I have lost count.

 

[GravelRider]

The purpose of the joint commission or any other clipboard organization is to create submissive doctors. The physicians used to be the most important group in any healthcare system. That is no longer the case. These organizations only serve to remind physicians that they no longer hold the power.

 

[d9sccr]

At our institution, there are a few "admins" whose job it is to ensure that everyone is following a bunch of nursing initiatives pertaining to surgical attire. Beard covers, bouffants over surgical caps, hand washing, etc. We recently had someone written up during a trauma call after 3 GSW came in at the same time. This person went from room to room assessing and securing airways in 2 EMERGENT patients. Unfortunately, the same gown was worn into these rooms. It would be one thing if it was visibly soiled with blood or whatever, but visibly it was fine. I understand infection CAN travel, but hypoxemia WILL kill.

Can't see the forest through the trees

 

[deleted162650]

I had an attending that taught me how he would insert an LMA without putting my fingers in the mouth. He had some pretty derogatory terms for anesthesiologists who put their fingers in pts mouths but I won't go that far.
Just try inserting the LMA one of two ways, completely upside down until the mask part is entirely in the mouth and then flip it over as you push it further down. Or you can try my variation of the technique were I insert the LMA with a quarter turn and slightly lateral to midline of the tongue. Then I flip it. I have not put my fingers in a pts mouth in so many years that I have lost count.

The insert 180* thing has only ever worked for me with pediatric size LMA's. I don't have issues with the nice LMA brand ones, just the crappy green Ambu brand, and this is a common complaint among my partners. I'll give your slight twist off midline approach a go and see how it works.