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AORN is committed to promoting excellence in perioperative nursing practice, advancing the profession, and supporting the professional perioperative registered nurse (RN). AORN promotes safe care for patients undergoing operative and other invasive procedures by creating this collection of evidence-based and evidence-rated perioperative guidelines. The descriptive and comprehensive documents in this publication reflect the perioperative RN’s scope of professional responsibility. The guidelines are intended to be achievable and represent what is believed to be an optimal level of patient care and workplace safety. Each guideline contains recommendations that are broad statements to be used to guide the development of policies, procedures, and criteria for measuring individual competency in a variety of practice settings. These guidelines represent AORN’s official position on questions regarding perioperative practice, and they have been approved by the AORN Guidelines Advisory Board.

Evidence-based practice is essential to improving patient care by promoting decisions based on evidence rather than on the opinion of an individual health care provider. The Institute of Medicine defines clinical practice guidelines as “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.”1(p38) AORN’s guidelines meet this definition. The AORN guidelines are based on a comprehensive, systematic review of research and non-research evidence; the individual references are appraised and scored, and the recommendations are rated according to the strength and quality of the evidence supporting each recommendation.

The guidelines are authored by perioperative practice specialists in the AORN Nursing Department with assistance from members of the AORN Guidelines Advisory Board and in collaboration with liaisons representing the American Association of Nurse Anesthetists, the American College of Surgeons, the American Society of Anesthesiologists, the Association for Professionals in Infection Control and Epidemiology, the International Association of Healthcare Central Service Materiel Management, and the Society for Healthcare Epidemiology of America.

Each guideline is reviewed and updated on a 5-year cycle. This approach enables AORN to meet the submission criteria for acceptance by the National Guideline Clearinghouse as nationally recognized guidelines for perioperative practice. When adhering to the AORN Guidelines for Perioperative Practice, perioperative clinicians can be confident that they are following trustworthy guidelines developed in accordance with the principles set forth by the Institute of Medicine.

Because only a portion of the guidelines are updated for publication in any given year, differences in format, content organization, and design may occur. The titles of previously released recommended practices documents have been changed to “Guideline.” However, the name “Recommended Practices” will continue to appear within the text and references of some of the documents until these documents are fully reviewed and revised.

As used within the context of the guidelines, the word “should” indicates that a certain course of action is recommended. “Must” is used only to describe requirements mandated by government regulation. Use of “may” indicates that a course of action is permissible within the limits of the guideline, and “can” indicates possibility and capability.

Evidence Review

Evidence-based guidelines provide a sound foundation that perioperative RNs can use to provide the highest quality patient care possible. Perioperative practices based on science and the professional literature instead of tradition or personal preference are of the utmost importance for protecting patients and health care personnel from harm.

AORN began writing the guidelines using a systematic review of the evidence in 2012. The Johns Hopkins Nursing Evidence-Based Practice Model and Guidelines2 and the Oncology Nursing Society Putting Evidence Into Practice (ONS PEP®)3 schema initially served as the foundation for the evidence review process. After gaining experience in the evidence review process, AORN created the Evidence Appraisal tools and AORN Evidence Rating Model in 2013 to better meet the unique needs of the perioperative practice guidelines. The AORN Model was further refined in 2015 (See  Appendix A).

Evidence Rating

Each guideline focuses on a specific question or topic. A clinical research librarian employed by AORN conducts a systematic literature search using the MEDLINE®, CINAHL®, and Scopus® databases and the Cochrane Database of Systematic Reviews to identify meta-analyses, randomized and nonrandomized trials and studies, systematic and nonsystematic reviews, and opinion documents and letters related to the topic. The hierarchy of evidence (Figure 1) is a visual depiction of the types of evidence used in the AORN Guidelines and demonstrates the weakest to the strongest types of evidence.

Figure 1.
Hierarchy of Evidence

Hierarchy of Evidence

Figure 1.
Hierarchy of Evidence

Hierarchy of Evidence

As relevant research and other evidence is located, it is independently evaluated and critically appraised according to the strength and quality of the evidence using the AORN Evidence Appraisal Tools (See  Appendices B, C, and D). The reviewers participate in conference calls to discuss their individual appraisal scores and to establish consensus. Each article or study is assigned an appraisal score as agreed upon by the reviewers. Each appraisal score includes a Roman numeral (ie, I, II, III, IV, or V) and an alphabetical character (ie, A, B, or C). The Roman numeral represents the level of strength, and the alphabetical character represents the level of quality. The appraisal scores of individual references are noted in brackets after each citation in the references section of the guideline as applicable.

After the evidence is individually appraised, the collective evidence supporting each intervention within a specific recommendation is rated using the AORN Evidence Rating Model. Factors considered when applying the evidence-rating model to the collective body of evidence are the quality of research, the quantity of similar studies on a given topic, and the consistency of results supporting a recommendation. The recommendations in each guideline are given one of the following ratings:

  • 1: Strong Evidence

  • 1: Regulatory Requirement

  • 2: High Evidence

  • 3: Moderate Evidence

  • 4: Limited Evidence

  • 5: Benefits Balanced with Harms

The evidence ratings are noted in brackets after each recommended intervention and activity statement within the guideline (See  Appendix E).

Document Structure

Each evidence-rated guideline is composed of eight elements.

  1. Introduction: a general introductory statement.

  2. Purpose: a description of the intent and scope of the document.

  3. Evidence Review: a description of the systematic literature search and review of the evidence and the processes used to evaluate and rate the evidence.

  4. Recommendations: broad recommendations for optimal practice. The recommendation statements are in a bold font and identified by a Roman numeral (eg, I). Each recommendation statement is followed by a rationale.

  5. Interventions: specific recommendations for treatment or action. Interventions are identified by an alphabetic character after the recommendation Roman numeral (eg, I.a.). The intervention statement is followed by a rationale detailing the evidence that supports the recommendation. The level of each intervention is rated using the AORN Evidence Rating Model. The evidence rating is noted in brackets after the intervention statement (eg, [1: Strong Evidence]).

  6. Activities: statements that describe the actions necessary to implement the intervention. Activities are noted by a number following the recommendation Roman numeral and the intervention alphabetic character (eg, I.a.1.). The level of each activity may be rated using the AORN Evidence Rating Model. If so, the evidence rating is noted in brackets after the activity statement (eg, [1: Strong Evidence]).

  7. Glossary: a list of definitions for terms used in the document with which the reader may be unfamiliar.

  8. References: a list of all references used within the document and the assigned appraisal scores. The appraisal score is noted in brackets after each citation (eg, [IA], [IVA]).

Ambulatory Supplements

Each document is reviewed and vetted for applicability to ambulatory surgery centers, and supplemental information is provided related to recommendations that may have additional considerations for these perioperative practice settings. The Ambulatory Supplements are intended to be used as additional information for the perioperative RN practicing in a free-standing ambulatory surgery center or a physician office-based surgery center.

The symbol in the text of a guideline indicates that there is additional information in the Ambulatory Supplement following the document. Relevant text from the guideline is repeated in the Supplement for easy reference and to give context to the ambulatory considerations. New text is denoted with the symbol in the Supplement (See  Appendix F). Where applicable, the Ambulatory Supplements include text from the Centers for Medicare & Medicaid Services State Operation Manual Appendix L—Guidance for Surveyors: Ambulatory Surgical Centers.

The Ambulatory Supplement is an adjunct to the guideline on which it is based and is not intended to be a replacement for that document. Perioperative personnel who are developing and updating organizational policies and procedures should review and cite the full guideline.

AORN Guidelines and the PNDS

The Perioperative Nursing Data Set (PNDS) is the standardized nursing language developed and refined by AORN and recognized by the American Nurses Association to describe the nursing care, from preadmission to discharge, of patients undergoing operative or other invasive procedures.4 The PNDS enables nursing care to be documented in a standardized manner and allows the collection of reliable and valid comparable clinical data to evaluate the effectiveness of nurse-sensitive interventions and the relationship between these interventions and patient outcomes.

The Guidelines for Perioperative Practice is the foundation of clinical knowledge from which the PNDS is derived. This standardized language consists of a collection of unique concepts that reflect the nursing process as described in the Guidelines for Perioperative Practice. The perioperative patient and his or her family members are at the core of the Perioperative Patient Focused Model (Figure 2), the conceptual framework for the PNDS. The model depicts perioperative nursing in four domains and illustrates the relationship among the patient, his or her family members, and the care provided by the professional perioperative RN. Within the PNDS, the Safety, Physiological Responses, and Behavioral Responses domains contain actual or potential nursing problems, interventions, and patient outcomes representing patient care concerns. The Health System domain focuses on standardized data elements that describe the environment in which care is provided. Each uniquely identified concept in the PNDS is clearly defined, is common to all procedures, relates to the delivery of care, and is appropriate for use in any surgical setting.

Figure 2.
Perioperative Patient Focused Model

Perioperative Patient Focused Model

Figure 2.
Perioperative Patient Focused Model

Perioperative Patient Focused Model

The Guidelines for Perioperative Practice and the PNDS concepts are mapped to the clinical content within the AORN Syntegrity® perioperative documentation solution for the electronic health record. The AORN Syntegrity solution provides standardized content for electronic perioperative nursing documentation. The PNDS is distributed only through an AORN Syntegrity license. To learn more about the AORN Syntegrity solution and implementation of the PNDS within the electronic health record, contact the AORN Syntegrity team via e-mail at or visit

Implementation in Practice

Individual commitment, professional conscience, and the setting in which perioperative nursing is practiced should guide the RN in implementing these guidelines. Implementation of the guidelines in perioperative settings requires close examination of existing policies and procedures. This review may indicate that new or revised policies and procedures are needed. Although the guidelines are considered to represent the optimal level of practice, variations in practice settings and clinical situations may limit the degree to which each guideline can be implemented. AORN has created a comprehensive set of implementation tools to help health care organizations implement the guidelines. For more information, visit

New in this Edition

The 2018 edition of this book includes six new evidence-rated guidelines:

  • Manual Chemical High-Level Disinfection

  • Medical Device and Product Evaluation

  • Medication Safety

  • Positioning the Patient

  • Prevention of Venous Thromboembolism

  • Team Communication


Editor’s note: ONS PEP is a registered trademark of the Oncology Nursing Society, Pittsburgh, PA. MEDLINE is a registered trademark of the US National Library of Medicine’s Medical Literature Analysis and Retrieval System, Bethesda, MD. CINAHL, Cumulative Index to Nursing and Allied Health Literature is a registered trademark of EBSCO Industries, Birmingham, AL. Scopus is a registered trademark of Elsevier B.V., Amsterdam, Netherlands. Syntegrity is a registered trademark of AORN, Inc, Denver, CO.


  • 1. 
  • Institute of Medicine. Field  MJ, Lohr  KN, eds. Clinical Practice Guidelines: Directions for a New Program. Washington, DC: National Academy Press; 1990:38.
  • 2. 
  • Newhouse  RP, Dearholt  SL, Poe  SS, Pugh  LC, White  KM. Johns Hopkins Nursing Evidence-Based Practice Model and Guidelines. Indianapolis, IN: Sigma Theta Tau International; 2007.
  • 4. 
  • Petersen  C, ed. Perioperative Nursing Data Set. 3rd ed. Denver, CO: AORN, Inc; 2011.

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