top 10 most read aorn journal articles

107 Pages·2015·11.85 MB·English

TOP 10
MOST READ
AORN JOURNAL ARTICLES
AORN JOURNAL - THE OFFICIAL VOICE OF PERIOPERATIVE NURSING
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As a thank you for renewing, we are excited to provide this unique assortment of the top 10 most read AORN
Journal articles. From guideline implementation to perioperative safe practice, catch up on articles you may
have missed that other AORN members have found quite popular over the last year.
As a member, your monthly AORN Journal provides evidence-based guidelines, peer-reviewed articles, and other
best practices that convey the standard of excellence in perioperative nursing, and helps you stay up-to-date and
improve your own practice every day.
Enjoy.
Top 10 Most Read AORN Journal Articles:
Guideline Implementation: Surgical Instrument Cleaning (May 2015) .........................................................Page 3
Safety Culture and Care: A Program to Prevent Surgical Errors (April 2015) ..............................................Page 11
Guideline Implementation: Surgical Attire (Feb. 2015) ...............................................................................Page 20
Surgical Team Mapping: Implications for Staff Allocation and Coordination (Feb. 2015) ............................Page 27
Back to Basics: Implementing Evidence-Based Practice (Jan. 2015) ........................................................Page 38
Nursing Shortages in the OR: Solutions for New Models of Education (Jan. 2015) ....................................Page 49
The Role of the OR Environment in Preventing Surgical Site Infections (Dec. 2014) ..................................Page 71
Back to Basics: Implementing the Surgical Checklist (Nov. 2014) .............................................................Page 77
Developing Strategies for On-Call Staffing: A Working Guideline for Safe Practices (Oct. 2014) .................Page 86
Hemostatic Agents: A Guide to Safe Practice for Perioperative Nurses (Aug. 2014) ...................................Page 93
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CONTINUING EDUCATION
Guideline Implementation:
Surgical Instrument Cleaning
1.3
www.aorn.org/CE
LIZ COWPERTHWAITE, REBECCA L. HOLM,
BA; MSN, RN, CNOR
Continuing Education Contact Hours Accreditation
indicates that continuing education (CE) contact hours are AORN is accredited as a provider of continuing nursing
available for this activity. Earn the CE contact hours by education by the American Nurses Credentialing Center’s
reading this article, reviewing the purpose/goal and objectives, Commission on Accreditation.
and completing the online Examination and Learner Evalua-
tion at http://www.aorn.org/CE. A score of 70% correct on the Approvals
examination is required for credit. Participants receive feed-
This program meets criteria for CNOR and CRNFA recerti-
back on incorrect answers. Each applicant who successfully fication, as well as other CE requirements.
completes this program can immediately print a certificate of
completion. AORN is provider-approved by the California Board of Regis-
tered Nursing, Provider Number CEP 13019. Check with your
Event: #15517
stateboardofnursingforacceptanceofthisactivityforrelicensure.
Session: #0001
Fee: Members $10.40, Nonmembers $20.80 fl
Con ict of Interest Disclosures
MsCowperthwaiteandMsHolmhavenodeclaredaffiliations
ThecontacthoursforthisarticleexpireMay31,2018.Pricing
thatcouldbeperceivedasposingpotentialconflictsofinterest
is subject to change.
in the publication of this article.
The behavioral objectives for this program were created by
Purpose/Goal
Rebecca Holm, MSN, RN, CNOR, clinical editor, with
To provide the learner with knowledge specific to imple-
consultation from Susan Bakewell, MS, RN-BC, director,
mentingthe updated AORN “Guideline for cleaning and care
Perioperative Education. Ms Holm and Ms Bakewell have no
of surgical instruments.”
declaredaffiliationsthatcouldbeperceivedasposingpotential
conflicts of interest in the publication of this article.
Objectives
Sponsorship or Commercial Support
1. Explain the importance of processing surgical instruments
No sponsorship or commercial support was received for this
correctly.
article.
2. Describesteps thatshouldbeperformedintraoperativelyto
prepare instruments for disinfection.
3. Describe the steps in the decontamination process. Disclaimer
4. Identify heating, ventilation, and air conditioning parame- AORN recognizes these activities as CE for RNs. This
ters (HVAC) specific to the decontamination area. recognition does not imply that AORN or the American
5. Identify special precautions to observe during instrument Nurses Credentialing Center approves or endorses products
processing. mentioned in the activity.
http://dx.doi.org/10.1016/j.aorn.2015.03.005
ªAORN,Inc,2015
j
542 AORN Journal www.aornjournal.org
Guideline Implementation:
Surgical Instrument Cleaning
1.3
www.aorn.org/CE
LIZ COWPERTHWAITE, ; REBECCA L. HOLM,
BA MSN, RN, CNOR
ABSTRACT
Cleaning,decontaminating,andhandlinginstructionsforinstrumentsvarywidelybasedonthetypeof
instrument and the manufacturer. Processing instruments in accordance with the manufacturer’s in-
structions can help prevent damage and keep devices in good working order. Most importantly,
proper cleaning and disinfection may prevent transmission of pathogenic organisms from a contam-
inateddevicetoapatientorhealthcareworker.TheupdatedAORN“Guidelineforcleaningandcare
of surgical instruments” provides guidance on cleaning, decontaminating, transporting, inspecting,
and storing instruments. This article focuses on key points of the guideline to help perioperative
personnel implement appropriate instrument care protocols in their practice settings. The key points
address timely cleaning and decontamination of instruments after use; appropriate heating, ventila-
tion, and air conditioning parameters for the decontamination area; processing of ophthalmic in-
struments and laryngoscopes; and precautions to take with instruments used in cases of suspected
prion disease. Perioperative RNs should review the complete guideline for additional information
andforguidancewhenwritingandupdatingpoliciesandprocedures.AORNJ101(May2015)543-549.
ª AORN, Inc, 2015. http://dx.doi.org/10.1016/j.aorn.2015.03.005
Key words: cleaning, decontamination, HVAC, ophthalmic instruments, laryngoscopes, prion diseases.
http://dx.doi.org/10.1016/j.aorn.2015.03.005
ªAORN,Inc,2015
j
www.aornjournal.org AORN Journal 543
CowperthwaitedHolm May 2015, Volume 101, No. 5
I
nstruments used in surgery should be properly cleaned SCENARIO
and decontaminated and in good working order. Items Nurse M is the scrub person for a cataract procedure. During
that are soiled or working incorrectly could compromise the procedure, Nurse M removes gross soil from the in-
patient care.1-5 Perioperative personnel should process in- struments by wiping the instruments with a sterile, lint-free
strumentsaccordingtothemanufacturer’swritteninstructions sponge that has been moistened with sterile water. She also
for use (IFU). Proper cleaning and disinfection may prevent periodically irrigates the lumens of instruments with sterile
transmission of pathogenic organisms from a contaminated water to remove gross soil, immediately after use if possible.
device to a patient or health care worker.1,3,4,6-10
Whentheprocedureiscompleted,NurseMsegregatesthesharp
The AORN “Guideline for cleaning and care of surgical in- instruments from the others and puts them into a puncture-
struments”11 (formerly titled “Recommended practices for resistant container. She removes the disposable sharp items
cleaning and care of surgical instruments”) was updated in and putsthem in a puncture-resistant,leakproof container with
September 2014. AORN guideline documents provide a biohazard label. Nurse M opens the hinged instruments (eg,
guidance based on an evaluation of the strength and quality tenotomy scissors) and disassembles the irrigation/aspiration
of the available evidence for a specific subject. The handpiece according to the manufacturer’s written IFU. She
guidelines apply to inpatient and ambulatory settings and are separates delicate instruments and heavy instruments into
adaptable to all areas where operative and other invasive different containers so that the delicate instruments will not be
procedures may be performed. damagedduringtransporttothedecontaminationarea.Tokeep
the instrumentsmoist,she placesa towelmoistenedwithsterile
Topicsaddressedintheupdatedinstrumentcleaningguideline
waterovertheinstruments.Shesendsalloftheinstrumentsthat
include care of new, repaired, refurbished, and loaned in-
have been opened on the sterile field to be processed in the
struments and devices; requirements for the sterile processing
sterile processing area, whether or not they have been used.
areas; cleaning products and equipment; instrument inspec-
tion; and special precautions to observe during instrument
Technician G arrives at work, changes into scrub attire, and
processing.11Thisarticleelaboratesonkeytakeawaysfromthe reportstothesterileprocessingarea.Ashisfirsttaskoftheday,
guideline document; however, perioperative RNs should
he checks and documents the HVAC parameters in this area,
review the complete guideline for additional information and
which are maintained at
for guidance when writing and updating policies and
procedures. (cid:1) two outdoor air changes per hour,
(cid:1) six total air changes per hour,
Key takeaways from the AORN “Guideline for cleaning and (cid:1) negative air pressure, and
care of surgical instruments” include the following: (cid:1) temperature between 72(cid:3) F and 78(cid:3) F (22(cid:3) C and 26(cid:3) C).
(cid:1) Instruments should be cleaned and decontaminated as soon
Technician G puts on personal protective equipment so that
as possible after use.
his skin will be protected from splashes and splatters from
(cid:1) The heating, ventilation, and air conditioning (HVAC)
contaminated instruments and his hands will be protected
system in the decontamination area should be maintained
from a potential sharps injury. The personal protective
within the HVAC design parameters at the rate that was equipmentincludesafluid-resistantgownwithsleeves,general
applicableatthetimeofdesignormostrecentrenovationof
purpose utility gloves with a cuff that extends beyond the cuff
the HVAC system.
of the gown, a mask with a full face shield, and shoe covers.
(cid:1) Special precautions should be taken when processing intra-
ocular ophthalmic instruments. Nurse M brings a closed instrument and supply transport cart
(cid:1) Laryngoscope blades and their handles should be cleaned, from the cataract procedure to the sterile processing area.
decontaminated, dried, and stored in a manner that reduces Technician G receives the cart and takes it to a designated
patient and personnel risk of exposure to potentially patho- cleaning area away from the area for cleaning general surgical
genic microorganisms. instruments. He uses cleaning products that are compatible
(cid:1) Special precautions should be taken to minimize the risk of with the instruments in accordance with the manufacturers’
transmission of prion diseases from contaminated in- IFU.Aftercleaning,herinsestheinstrumentsthoroughlywith
struments (Figure 1). copious amounts of water and performs a final rinse with
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544 AORN Journal www.aornjournal.org
May 2015, Volume 101, No. 5 Guideline Implementation: Instrument Cleaning
Figure 1. Key takeaways from the AORN “Guideline for cleaning and care of surgical instruments.”
sterile deionized water. He cleans the lumen of the irrigation/ Technician G then receives a laryngoscope handle and blade
aspiration handpiece with a brush of the appropriate diameter from the emergency department. After cleaning and decon-
andlengthtocleantheentirelumenandexitatthedistalend. taminating the handle and blade according to the manufac-
The bristles are soft enough to prevent damage to the interior turer’s written IFU, he sends them to the packaging and
ofthelumen.Herinsesthelumenwithsteriledeionizedwater sterilization area. Although laryngoscope handles are classified
and expels the water into a drain. He then dries the lumen as noncritical items that only require low-level disinfection,12
with medical-grade compressed air. at this facility, both the handle and blade are considered
semicritical items, which require high-level disinfection or
In accordance with the manufacturers’ IFU, Technician G sterilization.12 Technician K wraps the blade in an individual
disinfects the instruments by wiping the outside of the in-
package for storage and sterilizes both the handle and blade
struments with 70% alcohol. He inspects the instruments according to the manufacturer’s written IFU.
under magnification to make sure there is no residual
ophthalmic viscoelastic material present. He records the Technician G is now processing neurosurgical instruments.
cleaning method, cleaning solution, and lot number of the Duringapreoperativescreening,thepatientwhounderwentthe
cleaning solution for the ophthalmic instruments. Technician procedure was determined to be at high risk for having a prion
G then sends the instrument set to the packaging and sterili- disease (ie, variant Creutzfeldt-Jakob disease). The preoperative
zation area, where Technician K will wrap and sterilize the set nursecommunicatedthisinformationtotheentireperioperative
according to the manufacturers’ IFU. team, including the sterile processing personnel, so that they
j
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CowperthwaitedHolm May 2015, Volume 101, No. 5
could follow the recommended precautions. Many of the in- that forms in a lumen can be difficult to see and remove.21
struments used in the procedure were designated for single use She keeps the instruments moist by placing a towel
only, so the scrub person discarded them in a contaminated moistened with sterile water over the instruments. She does
trashreceptacleintheOR.Thescrubpersonsentonlyreusable not use saline, which could cause pitting of the
instruments that are easy to clean and can tolerate extended- instruments.16,17 She sends all the instruments that have
cyclesteamsterilizationforsterileprocessingaftertheprocedure. been opened on the sterile field to the sterile processing area
for cleaning and decontamination because contamination of
Technician G decontaminates the instruments that may have unused instruments can occur without being noticed.17
been exposed to variant Creutzfeldt-Jakob disease in a me-
chanical washer, which helps ensure cleaning consistency that
HVAC Parameters
may not be achieved with manual cleaning. He uses cleaning
The HVAC system controls the room air quality, humidity,
chemicals that have shown evidence of prionicidal activity and
temperature, and air pressure. The system is designed to
are compatible with the instruments. After decontamination,
reduce environmental contaminants as well as to provide a
Technician G sends the instruments to the packaging and
comfortable environment for those working in the sterile
sterilization area. He then cleans and disinfects the noncritical
processing area. In the scenario, the HVAC parameters are set
environmentalsurfacesinthedecontaminationareathatcamein
contactwiththecontaminatedinstrumentsusedonthepatient’s according to recommendations from the American Society of
Heating, Refrigerating and Air-Conditioning Engineers22 and
high-risktissue.Heusesa1:5dilutionofhypochloritesolution,
the Facility Guidelines Institute.23
ensuring that the solution remains in contact with the envi-
ronmental surfaces for 15 minutes.13,14 Meanwhile, Technician
TheHVACparametersinthedecontaminationareashouldbe
K steam sterilizes the instruments in a prevacuum sterilizer at
thosethatareapplicableatthetimeofthedesignoftheHVAC
(cid:3) (cid:3)
273 F (134 C) for 18 minutes, which is one of the methods
system or the most recent renovation of the system.24 If
recommended for use when steam sterilizing instruments that
personnel detect a variance in the HVAC parameters, they
have been exposed to high-risk tissue.13,15
should report the variance according to the facility’s policy
and procedure. Designated personnel should correct the
KEY TAKEAWAYS DISCUSSION variance and then perform a risk assessment to determine
The key takeaways from the AORN “Guideline for cleaning whether any measures need to be taken to restore the
and care of surgical instruments” address timely cleaning and decontamination area to full functionality.24
decontamination of instruments after use, appropriate HVAC
parameters for the decontamination area, processing of Ophthalmic Instruments
ophthalmicinstrumentsandlaryngoscopes,andprecautionsto Inadequate cleaning and rinsing of intraocular ophthalmic
takewithinstrumentsusedinsuspectedcasesofpriondisease. instruments have been implicated in outbreaks of toxic ante-
These takeaways do not cover the entire guideline. Rather, rior segment syndrome (TASS), an acute inflammation of the
they help the reader focus on important or new information anterior segment of the eye, which is most commonly associ-
that should be implemented into perioperative practice. atedwithcataractsurgery.25Amongotherfactors,incidentsof
TASS have been associated with various facets of instrument
processing,5,26-35 including
Immediate Cleaning and Decontamination
(cid:1) detergent residues remaining on instruments,
“Cleaninginstrumentsassoonaspossibleafterusecanhelpto (cid:1) insufficient rinsing of instruments,
prevent formation of biofilm.”11(p619) In the scenario, Nurse (cid:1) dried debris and residues of ophthalmic viscoelastic material
M begins the process of preparing instruments for
remaining on instruments, and
decontamination by removing the gross soil at the point of (cid:1) insufficiently dried lumens.
use.16-18 She understands that dried blood and other organic
material could be corrosive to the instrument In the scenario, Technician G cleans the intraocular in-
surfaces.16,17,19,20 Allowing blood or other bioburden to dry struments in an area separate from the general surgery in-
on instruments could make it more difficult to remove and struments to help prevent cross-contamination from heavily
could compromise the effectiveness of the subsequent soiled nonophthalmic instruments.16 He uses cleaning
disinfection or sterilization.8,16,18,19 Likewise, Nurse M products recommended by the instrument manufacturers16,36
periodically irrigates the instruments with lumens to remove and rinses the instruments thoroughly to help remove
gross soil and reduce the risk of biofilm formation. A biofilm residual cleaning product.36 When rinsing the lumens,
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546 AORN Journal www.aornjournal.org
May 2015, Volume 101, No. 5 Guideline Implementation: Instrument Cleaning
Resources for Implementation What Else Is in the Guideline?
(cid:1) Guidelines Implementation: Cleaning and Care of Read the AORN “Guideline for cleaning and care of
Instruments and Powered Equipment web page. surgical instruments”1 to learn what the evidence says
AORN, Inc. https://www.aorn.org/Topics_of_Interest/ about the following:
Sterilization_and_Disinfection/Cleaning_and_Care_of_ (cid:1) What items should be evaluated to determine whether
Instruments_and_Powered_Equipment/. a facility has the capability to comply with manufac-
(cid:1) AORN Syntegrity(cid:2) Framework. AORN, Inc. http:// turers’ instructions for instrument processing?
www.aorn.org/syntegrity. (Recommendation I.b.)
(cid:1) ORNurseLinkTM. http://www.ornurselink.org/home. (cid:1) Whatshouldbeincludedinpoliciesandproceduresfor
(cid:1) Perioperative Competency Verification Tools and Job managing loaned instruments? (Recommendation
Descriptions [CD-ROM]. Denver, CO: AORN, Inc; II.e.)
2014. http://www.aorn.org/CompetencyTools. (cid:1) Whataccessoriesandsuppliesshouldbestockedinthe
(cid:1) Policy and Procedure Templates [CD-ROM]. 4th ed. decontamination area? (Recommendation V.e.)
Denver, CO: AORN, Inc; 2015. http://www.aorn.org/ (cid:1) When should water quality assessments be conducted?
Books_and_Publications/AORN_Publications/Policy_and_ (Recommendation VII.b.)
Procedure_Templates.aspx. (cid:1) What types of detergents should be used for instru-
(cid:1) TheRoadmaptoASCCompliance[CD-ROM].Denver, ment cleaning? (Recommendation VIII.a.1.)
CO: AORN, Inc; 2012. https://www.aornbookstore.org// (cid:1) Why should only instruments made of similar metals
Product/product.asp?sku¼MAN543&dept_id¼1. be combined in the ultrasonic cleaner? (Recommen-
dation IX.e.4)
Syntegrity is a registered trademark and ORNurseLink is a
1. Guideline for cleaning and care of surgical instruments. In:
trademark of AORN, Inc, Denver, CO.
GuidelinesforPerioperativePractice.Denver,CO:AORN,Inc;
Web site access verified March 17, 2015. 2015:615-650.
TechnicianGexpelsthefluidfromthelumenintothedrainto handle should be classified as semicritical. The rough surface
prevent recontamination of the rinse water with debris from of the laryngoscope handle can accumulate bioburden,41,42
inside the lumen. He uses sterile deionized water to rinse the which could be transferred to the laryngoscope blade when
instruments because untreated water may contain the blade is folded closed.41-44
endotoxins16,37 or may cause stains, deposits, or corrosion of
the instrument surface.38,39 He dries the lumens with Technician K packages the blade to prevent recontamina-
compressed air29,36 to eliminate moisture that could foster tion.12 Storing the blade in the individual package minimizes
the chance that the blade will become contaminated, which
microbial growth.
could happen if a contaminated blade was placed into a
package containing multiple uncontaminated blades.45
Laryngoscope Blades and Handles
As a potential source of contamination, laryngoscope blades
should be cleaned and high-level disinfected or sterilized after Prion Disease Precautions
each use according to the manufacturer’s written IFU. A Aprionisasmallinfectiousproteinthatcancauseneurological
laryngoscopebladeisconsideredasemicriticaldevicebecauseit diseases known as transmissible spongiform encephalopathies,
comes in contact with mucus membranes; therefore, at a such as Creutzfeldt-Jakob disease.13 Instruments that have
minimum, it should undergo high-level disinfection.12,40 A contacted high-risk tissue in patients at risk for a prion
laryngoscope handle is classified as a noncritical device and disease require adequate decontamination to reduce the risk
thus requires only cleaning and low-level disinfection12 unless for patients who subsequently are treated using these
the manufacturer’s IFU specify high-level disinfection or instruments. Neurosurgical instruments are of particular
sterilization. In a comprehensive integrative review of concern because typically there are large concentrations of
laryngoscope blades and handles as sources of cross- prions in the brain and spinal cord.46 Prions are known to
infection,41 however, the authors recommended that because be resistant to conventional physical and chemical
they are used concurrently, both the laryngoscope blade and sterilization techniques.13 Because the preoperative nurse
j
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CowperthwaitedHolm May 2015, Volume 101, No. 5
notifiedsterileprocessingpersonnelinadvanceofthepatient’s 5. CutlerPeckCM,BrubakerJ,ClouserS,DanfordC,EdelhauserHE,
prion status, Technicians G and K were prepared to Mamalis N. Toxic anterior segment syndrome: common causes.
J Cataract Refract Surg. 2010;36(7):1073-1080.
implement special precautions and protocols, which are
6. Rutala WA, Weber DJ. Disinfection and sterilization: an overview.
required to inactivate prions. Technician G processes the
Am J Infect Control. 2013;41(5):S2-S5.
instruments according to the 2010 Society for Healthcare
7. HerculesPA.Instrumentreadiness:apatientsafetyissue.Perioper
Epidemiology of America “Guideline for disinfection and
Nurs Clin. 2010;5(1):15-25.
sterilization of prion-contaminated medical instruments”13 8. Goldberg JL. What the perioperative nurse needs to know about
and the facility’s policies. cleaning, disinfection, and sterilization. Perioper Nurs Clin. 2010;
5(3):263-272.
9. Shimono N, Takuma T, Tsuchimochi N, et al. An outbreak of
CONCLUSION
Pseudomonas aeruginosa infections following thoracic surgeries
As the patients’ advocates, perioperative nurses help ensure occurring via the contamination of bronchoscopes and an auto-
that actions are performed to promote patient safety. This matic endoscope reprocessor. J Infect Chemother. 2008;14(6):
418-423.
includes making sure instruments are in good working order
10. Saito Y, Kobayashi H, Uetera Y, Yasuhara H, Kajiura T, Okubo T.
and have been correctly processed according to the manufac-
Microbial contamination of surgical instruments used for laparot-
turers’ written IFU to reduce the chance of transmitting
omy. Am J Infect Control. 2014;42(1):43-47.
pathogenic microorganisms to patients or personnel. Periop-
11. Guideline for cleaning and care of surgical instruments. In:
erative RNs and sterile processing team members who have Guidelines for Perioperative Practice. Denver, CO: AORN, Inc;
responsibilities related to care and cleaning of surgical in- 2015:615-650.
struments should receive education and complete competency 12. Guideline for Disinfection and Sterilization in Healthcare Facilities,
verification on instrument care and cleaning activities. In 2008. Atlanta, GA: Centers for Disease Control and Prevention;
2008.
addition, perioperative RNs should participate in multidisci-
13. RutalaWA,WeberDJ.Guidelinefordisinfectionandsterilizationof
plinary teams that include infection preventionists, surgeons,
prion-contaminated medical instruments. Infect Control Hosp
sterile processing personnel, and other stakeholders to
Epidemiol. 2010;31(2):107-117.
(cid:1) develop mechanisms for evaluating and selecting cleaning 14. Lehmann S, Pastore M, Rogez-Kreuz C, et al. New hospital
and decontamination equipment and associated cleaning disinfection processes for both conventional and prion infectious
agents compatible with thermosensitive medical equipment.
products,
J Hosp Infect. 2009;72(4):342-350.
(cid:1) implement systematic processes for monitoring HVAC pa-
15. McDonnell G, Dehen C, Perrin A, et al. Cleaning, disinfection and
rameters in the sterile processing areas and addressing vari-
sterilization of surface prion contamination. J Hosp Infect. 2013;
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(cid:1) establishevidence-basedpoliciesandprocedurestominimize 16. ANSI/AAMIST79:ComprehensiveGuidetoSteamSterilizationand
the risk of prion disease transmission. Sterility Assurance in Health Care Facilities. Arlington, VA: Asso-
ciation for the Advancement of Medical Instrumentation; 2013.
The AORN “Guideline for cleaning and care of surgical in-
17. Spry CC, Brooks Tighe SM. Care and handling of surgical in-
struments” is an evidence-based resource that perioperative struments. In: Brooks Tighe S, ed. Instrumentation for the Oper-
RNs and sterile processing team m(cid:1)embers can use to help ating Room: a Photographic Manual. 8th ed. St Louis, MO:
influence safe perioperative practice. Elsevier/Mosby; 2012:1-2.
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