"Shocked" Could There Be Electrical Strays in Your Trays?

Authors:
Cheron M Rojo, AA, CRCST, CIS, CER, CFER, CHL, Clinical Education Coordinator, Healthmark Industries
Stephen Kovach, BS, Director of Education, Healthmark Industries
Alisha Lowe, Marketing , Healthmark Industries

Abstract: In November of 2018 the FDA issued a Safety Communication on the Dangers of Monopolar Laparoscopic Surgery. Could this warning letter have been prevented if real quality management programs were in place? Could some of these injuries (burns to patients while undergoing surgery) have been prevented?

This poster will examine the present state of insulation testing buy sharing a survey of medical device reprocessing professionals concerning testing of all type of insulated instruments.
The authors will also give solutions to help prevent any future burns to patients and stress the importance of following these solutions including addressing the Performance Qualification (PQ) part of a departments quality management system.

A Healthcare System's Journey to Go Smoke Free

Authors:
Deborah Hedrick, BSN, MA, RN, CSSM, NEA-BC, Director Perioperative Services, Lutheran Medical Center
Lesia Hatlestad, MSN, RN, CNOR, Perioperative Clinical Practice Specialist, Lutheran Medical Center

Abstract: Purpose: The purpose of this poster is to enable the learner to review how a healthcare system was able to work toward becoming  surgical smoke free.

Content:
This poster will describe the steps that were taken to move  an eight facility healthcare system towards a smoke free environment through the development of a system wide policy .  This work involved obtaining a system Safety Grant allowing for hiring an industrial hygienist to conduct an air quality study in one of the system’s facilities.  The poster will share the results of the study that were shared at the  organization’s system level Perioperative Safety Collaborative.  The presenters will share how the system evaluated products to support smoke evacuation and collaboratively came to consensus on standard equipment and disposable smoke evacuation devices.

Strategies of implementation:
System Supply Chain developed smoke evacuation trials at each hospital for vendor selection.

The system policy was approved and presented at each hospital’s  Operating Room committee.

The selected vendor supported the  implementation of the evacuation supplies and devices.

Outcomes:
All 8 hospitals now are equipped with smoke evacuation equipment and supplies.

System policy has been revised to include any procedural area that may produce surgical smoke.

Surgical packs have previous non evacuation cautery pencils removed and evacuation cautery pencils are placed on case carts.

Go Clear Award application in process for the system hospitals

A Patient Condition Can Change in The Blink of an Eye: How Comfortable are You in Responding and What Do You Do when Death Occurs in the Operating Room?

Authors:
Karen Edwards, MBA, BSN, RN, CNOR, Nurse Education Specialist II Perioperative, Center for Nursing Research, Education and Practice, Houston Methodist Hospital
Joanne Muyco, Manager Walter Tower CVOR, Houston Methodist Hospital

Abstract: Houston Methodist Hospital provides a Perioperative Change in Patient Conditions seminar annually. The seminar is geared toward increasing the comfort level of the operating room nurse, when caring for a patient whose condition changes, or when unexpected death occurs. Prior to the seminar a pre-screening survey was sent to the registered participants.

The survey questionnaire was developed to measure the comfort level of the registered nurse caring for a patient who would possibly experience a change in their condition during surgery. The same survey was sent post-seminar at thirty days, sixty days, and ninety days. The comfort level of the nurse when death occurs in the operating room was also measured with the same group of nurses post-seminar.

The topics presented were selected based on conditions that could have an adverse impact on the intraoperative and postoperative outcome of the patient. The expectations were to increase comfort level of the perioperative nurse caring for a patient that experiences changes in their condition during surgery. The results showed awareness of potential changes in the patient condition and increased the comfort level of the nurse.

All Aboard the Biliary Track: Preparing for a New Service Line

Authors:
Victoria Hamary, BSN, RN, CNOR, Nurse Educator, Cleveland Clinic
Elizabeth Maltese , BSN, RN, CNOR, Assistant Nurse Manager, Cleveland Clinic

Abstract: Clinical Issue

• Preparing for an addition of a service line in the perioperative department at a community hospital required a collaborative approach

Description of Team

An intraprofessional team of key stake holders from the department of surgery included:

• Surgical processing


• Nursing


• Education


• Leadership


• Physicians

Preparation and Planning

A general surgeon specializing in hepatic-biliary disease was assigned to a community hospital. A team was developed to address all practice and equipment needs within this specialty service line.

• Multiple meetings held within this team to complete a needs assessment


• Plans then devised to meet the identified needs, such as equipment cost and ordering, surgeon preferences, and the specific needs of the patient pre operatively and post operatively


• Educational plans developed to ensure competency of caregivers to provide safe quality patient care

Assessment

No current process was in place to onboard new specialties. A process was developed, implemented  and will be used routinely with the addition of any specialty service line in the future:

• Hepatic service new to site


• Service specific education needed


• No process in place to on-board service line


• Lack of equipment/supplies

Implementation

Educational sessions were held in the months leading up to the first scheduled case. These included:

• In-service by the provider on the pre/intra/ and post-operative care of the hepatic patient to perioperative caregivers


• Hands-on equipment training provided by vendors


• Additional training given to perianesthsia caregivers regarding the pre/ post-operative care of the hepatic patient


• Equipment strategically located to provide optimal accessibility to allow for efficiency in the operating room

Outcomes

Since the inception of the program approximately 200 surgical cases have been performed by this provider. The program continues to grow and patient outcome data is continually collected to improve quality outcomes and optimal patient experiences, current outcomes include:

• Liver team developed


• Consolidated supplies


• Equipment obtained, education completed


• Service specific education/ competency successfully completed

Implications for Perioperative Practice

Successful implementation of a specialty service line required a collaborative approach by a multidisciplinary team. Following a systematic plan assures a world class patient and caregiver experience.

Applying Visualization Makes Knee Arthroplasty Easy

Author:
Huamei Deng, RN, Director of the Operating Room and Central Sterile Processing, Guangdong Provincial Hospital of Chinese Medicine

Abstract: Clinical Issue:
Knee Arthroplasty, including Total Knee Arthroplasty (TKA) and Unicompartmental Knee Arthroplasty (UKA), are more complex procedures in which you need to prepare many instruments. Because these instruments are provided by a manufacturer's representative, standard package is often unavailable. As such, it is very difficult for the nurses to manage the instruments during the operation, requiring many facilities to depend on the manufacturer's representative to support the surgeon during the procedure.

Description of Team:
In order to improve the quality of nursing cooperation, we set up a specialist care group consisting of 6 senior nurses.

Preparation and planning:
(1) Provide Nurses Knee Arthroplasty training  (the same as the Orthopedist received).
(2) The nurses who completed the training classified and sorted the instruments of the manufacturers.
(3) Nurses made visualized instrument atlas and standard modules.

Assessment: The day before the operation, nurses assessed the patient's condition, determined the device's left and right, estimated model size, and the type of instrument that may be required.

Outcome: Visualizations Significantly reduced the number of instruments needed during Knee Arthroplasty (Table 1). The procedure transformed from being very complex to being quite simple. The quality of perioperative care also greatly improved.

Implications for perioperative Nursing:
The application of Visualization helps nurses find out the methods to solve quality problems faced during the Knee Arthroplasty. We must constantly improve the perioperative nursing quality and professional technical level. This study improved the professional confidence of perioperative nurses and gained the respect from our orthopedist.

Avoiding Pressure Injury in the Operating Room with Root Cause Analysis & Action

Authors:
Susan M. Scott, MSN, RN, WOC Nurse, Medical Educator, UTHSC-GME
Linda Minnich, BSN, RN CPAN, PACU Nurse, John Muir Health, Concord CA
Jason Bennett, MSN, MBA, RN, Short Stay Charge Nurse, John Muir Health, Concord CA
Jennifer A. Mercer, RN, ADN, OR Charge Nurse, John Muir Health, Concord CA

Abstract: Pressure ulcer/injuries have always been a concern in healthcare but have become a greater priority since the Centers for Medicare & Medicaid services introduced prospective bundled payment programs for surgical episodes of care which requires elimination of hospital acquired conditions (HACs) to achieve maximum reimbursement. The surgical population is aging and becoming more obese increasing risk. The incidence of perioperative pressure injuries (PPI) over the past 5 years has NOT decreased but increased. According to a 2014 publication from the National Pressure Ulcer Advisory Panel, the incident rate for pressure injury attributed to the operating room ranges from 5% to 53.4%. High-reliability health care organizations (HCOs) create a safety culture where potential problems are anticipated, detected early, and timely response and action eliminate patient harm. Successful PPI prevention in vulnerable surgical patients includes: Risk assessment, standardization of equipment and devices, and implementation of bundles utilizing AORN guidelines. Ongoing real-time Root Cause Analysis (RCA) in conjunction with a PPI gap assessment and incident reports are used to create a (SWOT) analysis i.e. strengths, weaknesses, opportunities, and threats. Using the Root Cause Analysis and Action (RCA2) model we advance lessons learned by investigating system failures. The interprofessional team of PeriAnesthesia nurses, perioperative nurses, anesthesia providers, wound, ostomy and continence nurses (WOCN), and surgeons must collaborate to identify gaps in knowledge, skills, and attitudes. The goal of process improvement is to integrate innovative practices, clear communication, and seamless teamwork into daily routines. By addressing gaps in the current state with the evidence an ongoing action plan is created to provide continuous improvement. Achieving high-reliability and zero errors will require active engagement of leadership and support for the investigation and improvement process. By utilizing tools such as RCA2 model one facility reported zero PPI for 4 years.

Building a Sustainable Sterile Processing Workforce through Partnerships

Authors:
Miranda Woods, DNP, MS, BSN, RN, NE-BC, System Director, Patient Care Services, Norton Healthcare
Betty McGee, Sterile Processing Instructor; PRN operating RN, New Albany Floyd Count Schools; Norton Healthcare

Abstract: Currently, there are limited options for local or regional training programs for sterile processing or materials management technicians. This health system identified a lack of qualified applicants and had been hiring individuals into these positions with little to no healthcare background and without an educational background in the field of sterile processing. Most of the training for these positions is on the job training. A local vocational branch of a nearby school system with a robust Certified Nursing Assistant (CNA) and pharmacy technician program wanted to expand their health careers path. This successful partnership has allowed the school system to partner with a healthcare system to offer students another health careers pathway and offer dual college credit hours, as well as clinical hours that count toward the national sterile processing certification exam. Poster presenters will identify creative ways to partner with local high schools or career centers with healthcare systems to establish a better qualified and trained pool of applicants for sterile processing careers.

Burning Issues: Joint Commission Patient Fire Safety Guideline

Author:
G. Barnes Clark, II, BSN, RN, CNOR, Registered Nurse II, Central Arkansas Veterans Healthcare System

Abstract: Clinical Issue:
Joint Commission Patient Safety Goal to prevent fire in the OR.

Purpose:
Maintaining as safe an environment for our patients and staff as is possible is of utmost importance. Meeting and adapting to new challenges and ideas is a continuous process. Fire prevention is an achievable object that is everyone’s concern.

Content:
I began by reviewing the Joint Commission Patient Safety Goals, and the recommendations of the National Fire Prevention Association. The Goals and Recommendations required that flammable or explosive germicidal solutions used in preparation of a patient’s skin for surgery must be allowed to dry after application, pooling of solutions wicked away, and applicators and remaining unused solution removed from the OR room.

Implementation:
Our solution to meet this goal was as simple as we could make it; after application of a flammable germicide (one that contains alcohol) the unused solutions or prep sticks would be placed in a clear plastic bag and placed in the outer core for housekeeping personnel to dispose of correctly. Most OR personnel are indoctrinated to not let trash leave an OR until all counts are correct, and/or the patient has left the OR first. So, it was a challenge, albeit one that was met, to get that one clear trash bag out of the OR.

As part of our new protocol, our Time Out was also changed slightly. During our Time Out we began to mention whether or not a flammable germicide was used and how it was disposed of properly. We also added a section in our documentation that specified what sort of skin preparation solution was used, and how it was disposed.

Outcome:
Our OR now has implemented this new practice protocol, with documentation that meets Joint Commission and National Fire Prevention Association goals and recommendations.

Can I See My Surgical Site: Process Review to Improve Patient Safety and Reduce Cost

Authors:
Raymund M. Avenido, MSN, RN, CNOR, Robotics Surgery Specialist, Cedars-Sinai Medical Center
Alfonso Chicas, MSN, RN, CNOR, NE-BC, Executive Director, Cedars-Sinai Medical Center
Elaine Suris, MSN, MBA, RN, Associate Director, Cedars-Sinai Medical Center

Abstract: Purpose: Reduce the number of damaged robotic endoscopes by reviewing the process from sterilization to patient usage.

Content: A key instrument for robotic procedures in the operating room (OR), endoscopes, function as an extension of the surgeon’s eyes, and must perform at a constant optimum. From October 2017 to April 2018 (six months), 14 damaged endoscopes were sent to the manufacturer, costing the organization $104,000.

Strategy and Implementation: Damaged endoscopes are identified through visual inspection by: 1) sterile processing technician prior to sterilization, 2) scrub personnel before, during and after use, 3) surgeon and team immediately upon insertion of the endoscope through the trocar. Unfortunately, in the 14 cases, damaged endoscopes were discovered following their insertion into the trocar, with condensation and poor visibility being the most common malfunctions reported. The manufacturer’s representative, Sterile Processing Department (SPD), and nursing OR leadership reviewed the current process and observed several deficiencies: 1) SPD technicians verbalized their need for comprehensive training on the handling of robotic endoscopes, 2) endoscopes were improperly stored after use and sterilization (non-rigid containers), 3) improper placement of endoscopes (stacking) after decontamination. Implementation of new process included: 1) SPD technicians trained on the approved decontamination, assembly, sterilization and storage of robotic endoscopes, 2) education for nursing and scrub personnel on correct placement and storage in rigid containers, 3) nurses invited SPD staff to observe live robotic procedures to understand how endoscopes are utilized during a case.

Outcomes: Following implementation of the new process, there was a 60% reduction in the number of damaged endoscopes (14 to 6) from May to November 2018 (six months). This was a cost savings of $76,200 (decreasing from $104,000 to $27,800). Both OR and SPD staff verbalized confidence in the proper handling, sterilizing and storage of robotic endoscopes, and attested to an improved process.

Charge RN Handoff Communication - Standardized Approach

Authors:
Andrey Ibragimov, MSN, RN, CNOR, Assistant Director , University of Chicago Medicine
Erin Chabot, MBA, RN, CNOR, Director, Surgical Services, RUSH Medicine
Lauren Rubio, RN, Lurie Children's Hospital
Lauren Malfeo, RN, Lurie Children's Hospital

Abstract: The effect of communication failures in healthcare is well documented and studied.

Researchers found that communication breakdown is the leading cause of healthcare errors, which may result in patient harm. In our Operating Room (OR), the communication between the OR Charge RNs was not standardized, and we have noticed that the type of information that was passed between the charge RNs varied in content and quality. A standardized handoff tool, using either a checklist or a mnemonic, has been shown to decrease medical errors and is highly recommended by regulatory bodies and professional organizations.

The aim of this project was to address variability in Charge RN inter-shift communication (handoff) by developing a standardized handoff tool. We have reached out to the pool of weekday and weekend Charge RNs and assembled a team. Each member of the team had experience giving and receiving shift handoff report.

Our team developed an 8 step process for this pilot project.

To assess the current handoff process, a 7 question survey was developed using a 5 point Likert-type scale.

The survey was distributed via Survey Monkey. The survey was conducted to validate the team’s perception that the processes of communication between incoming and outgoing charge RNs were not standardized. The information collected included:the timeliness of hand-off, compliance with a comprehensive hand-off, awareness of staffing resources, and the perception of the effect of the handoff process on the nursing process and patient safety.

Results confirmed the need for a standardized method of communication that is concise, clear, and accurate. Our main goal was to develop Night to Morning Charge RN handoff.Our team identified the content of the checklist and debated each datapoint. After the checklist was developed by the team, it became evident that we would need three checklists:Night to Morning,Morning to Afternoon and Afternoon to Overnight. The reason being that different data points are important at different times of the day.

A single document with 3 section Night-AM, AM-PM and PM-Nights was developed. The pilot was conducted, and handoff checklist was finalized. We have developed the Charge RN standard work document – a six-step process that provides instructions on how to conduct a comprehensive handoff using a new checklist. In addition, we developed a compliance sheet to document the integration of the new process into our daily routine.

After six months, we repeated the same survey with our charge nurses.

Improvements: Timeliness of the handoff from 18% to 50%

Awareness of resources and changes from 50% to 75%

Staff perception of consistently receiving a comprehensive report from 50% to 70%Our pilot project indicates that there is a need to apply established handoff techniques developed for bedside nursing to the handoff communication of the Charge RNs.

Overall, the process improved perceptions of the Charge nurses about the handoff process and provided structure and reliability.

Chasing Turnover and Winning

Authors:
Elaine Martin, MSN, RN, CNOR, Implementation Director, Sullivan Healthcare
Monique Ross, MA, BSN, NE-BC, Director Surgical Services, Abbott Northwestern Hospital/Allina Health
Gerald Biala, MSN, BSN, CNOR, CSSM, Senior Vice President, Sullivan Healthcare

Abstract: Calculating, understanding and improving surgical case turnover times continues to be a KPI (key performance indicator) for OR Leaders. We call it chasing, because that’s how it feels: elusive, unpredictable, and never good enough! The perception created on the side of nursing, anesthesia, and surgeons are all different and generally self- serving.

Objectives: 1.) Understand a new methodology for turnover calculation. 2.) Understand how to build accountability by daily metric reporting and role clarity. 3) Understand and develop physician engagement and collaboration. 4) Understand a turnover recovery communication escalation tool. 4) Describe practical tips that can implemented with immediate results.

Developing a time segment analysis tool proved to be a much more effective way to analyze and understand the breakdown in the turnover process. Daily AM huddles with metrics reported on a grease board provides for real time dialogue about what went well and do different with those responsible for the turnover leading the discussion. Development of a highly functioning perioperative executive committee (PEC) that gets weekly updates and provides constant feedback as to the challenges and successes provides physicians the involvement they desire. Turnover recovery escalation is a communication tool that provides the nursing staff escalation steps to follow, so that situations are handled in the moment and it doesn’t become an “oh well” we didn’t achieve our goal today. Developing a sense of urgency is key.

At Abbott Northwestern, the poster authors have been on the journey for over two years, and have seen a decrease in turnover from 42 to 26 minutes with wheels out to room ready now averaging 8 minutes. They attribute the success to daily metric reporting, role clarity and team engagement in the successes and the identification of ongoing opportunities with a very active and interested PEC.

 

Circle of Safety: It's All in the Wristband

Authors:
Julie McDonald, RN, CNOR, Clinical Nurse Educator- Surgery, Silver Cross Hospital
Patricia Kroesch, MSN, BSN, RN, CNOR, OR Manager, Silver Cross Hospital

Abstract: As part of our hospital’s safety and COEMIG committee, Silver Cross Hospital has a commitment to patient and employee safety as one of the initiatives that we strive for here. A patient safety concern and potential risk exists that any type of packing could be left in the body without proper identification that packing was in place. Silver Cross Hospital did not have a structured method for identifying that packing was in place.

With a foremost focus on patient safety, our Center of Excellence Minimally Invasive Gynecology (COEMIG) committee began discussions about ways to help staff focus on Obstetric and Gynecological patients and identify which select patients had vaginal packing inserted post-delivery or post operatively.

We began to discuss ways to help staff begin to recognize a way to alert staff that the patient had vaginal packing inserted. We wanted a visual cue to help alert staff as well as the patient that packing had been used. Having a visual reminder would help staff, the patient, and the patient’s physician recognize that packing was still in place. Colored wristbands are utilized in our facility as identifying markers worn by patients to alert staff to allergies, fall risks, and DNR to name a few. Having an identifying wristband seemed like a likely choice as a visual cue. Staff is already attune to colored wristbands and it was decided that one would utilized for this purpose of identification. A vibrant orange color with the word “PACKING” on the band would be applied for each vaginal packing placed. The nurse will enter the corresponding documentation related to the packing alert band placement into the appropriate area of the medical record. The identification band would be removed when the vaginal packing is removed per physician’s order and marked off complete in the electronic medical record.   For patients being discharged home or to another facility, the bands are left intact as a safety alert during transfer. Instructions are given to the patient prior to discharge about follow up with the physician for removal. It is very important to verify the patient’s banding during all handoff communications.

I had consulted with my staff and they were very receptive of the ideas of having a visual alert as a reminder that vaginal packing was in place. Safety comes first with our patients, and staff thought that the banding was a perfect idea and reminder to all that something had been placed in the vagina. I searched around and could not find a company that makes wristbands that say the word “PACKING” on it so I had ordered some vibrant orange colored ones and had a staff member use label maker tags and place on the band. She is responsible for the supply that we currently keep on the gynecology specialty cart.  You could also use a permanent marker for marking the tags as well. Staff were  in –serviced on this new addition and also on the new policy that had been created to help guide staff through his new  process. It really did not take them any time to adjust to this new work flow. I also made sure in our committee meeting that the other floors involved with patient care were aware of the new banding process as they have a role in this safety initiative as well. Nurse Managers had the information and the newly created policy that they shared with their staff. Reception from the floor staff has been very positive. The physicians are also onboard with this positive communication addition as they can visually see the clearly marked bands if the patient should need removal in the office. All positive feedback from everyone involved.

We really did not have any challenges or barriers with this project. It was a very easy choice for us to go forward with the proposed implementation of the banding process. A very thorough education had been given to staff before launching the program.

Since the beginning of the discussion in our committee in 2016, we rolled out the project in 2017 and for FY 2017 there were 16 cases in which vaginal packing had been placed with no deviations and in FY 2018 13 cases with no deviations noted.

Staff is doing an excellent job in making sure all bandings were done properly.

Cleaning Personal Mobile Devices Prior to Use in the Operating Room

Author:
Lynn Radzinski, MSN, RN, CNOR, OR Charge Nurse, UC Health

Abstract: Introduction: With the evolution of technology, personal mobile device use has increased significantly in health care. These personal mobile devices (PMD) include cell phones, tablets, and laptops and can harbor high percentages of bacteria that can be transmitted to patients when used in the operating room (OR).  As the OR charge RN, observation of vendors, surgeons, anesthesia and nurses using PMD brought the question to my mind: “Where has that been, is it clean”? After literature review, numerous studies report a very high percentage of microorganisms on cell phones and other mobile devices. Multiple efforts go into ensuring infection prevention is forefront, including cleaning the OR environment prior to use, after procedures and terminal clean at the end of the day. We perform surgical hand scrub prior to entering the surgical field and maintain that sterile field throughout the length of the procedure. The number of people in the OR and those using mobile devices brought in from the outside undermines efforts to keep patients safe from infection risks.

Preparation/Planning: Infection prevention is a high priority in healthcare, especially in the OR. Proper preparation of the surgical suite helps ensure patient and personnel safety by minimizing the number of microorganisms and unpredictable environmental hazards in the area. We follow strict policy/procedures of aseptic techniques to maintain a safe environment for our patients, however none exists for the cleaning of PMD prior to entering the OR. An opportunity arose to gain more knowledge around the cleanliness of PMD brought to our OR’s. To assess the situation, I first collected random observations of PMD usage in the OR during one procedure/patient, noting by whom and how often. Using a Rapid Adenosine Triphosphate (ATP) swab and luminometer borrowed from our cleaning company, I then swabbed multiple PMD’s to assess surface hygiene. Far superior to visual inspection, this simple to use, portable and lightweight device provided immediate readings. This testing device measures ATP in residual organic matter (blood, saliva, bacteria) that may remain on a surface, device or piece of equipment after it is cleaned. This enzyme can be present in any organic matter, living or not.  The process included swabbing various PMD and insert into the luminometer, of which the unit of cleanliness as an RLU (relative unit of light) was revealed in a range from Ultra clean (0-10 RLU) to Filthy (>1000 RLU). Then, I randomly tested PMD’s of all personnel in the OR on one day. These same individuals’ has their PMD retested on a different day and after cleaning with a Sani-cloth or Phone Kleen wipe.

Assessments: 1) Observations - Randomly observed who used and how many times their devices were used during one procedure/patient. The individuals observed were the Nurses, CST, CRNA, Anesthesiologist, Surgeon, PA, Resident, Medical student and Vendors. 2). ATP testing - Obtained  ATP swabs and luminometer from our cleaning company to randomly test the PMD of those present the day of testing. I did obtain permission or testing. 3). Retesting after cleaning – Retested the same individuals’ PMDs on a different day and after cleaning with a Sani-Cloth or Phone Kleen wipe.

Results:  After testing the devices the range of Levels of Clean (RLU) was from Ultra Clean to Filthy. Levels obtained were lowest at 2 RLU, and the highest at 1503 RLU. The vendor (who often use a tablet for documentation of implanted items requested per surgeon for the procedure) had the highest incidence of Filthy. After cleaning and retesting all PMD’s, the RLU significantly improved on all devices. The RLU of 2 after cleaning went to 0 RLU, the 1503 RLU after cleaning went to 68 RLU. As expected, vendors had the highest incidence of “filthy” as they often use a tablet for documentation of implanted items and travel to many hospital and surgery centers in a day. Additionally, they may have calls and texts during their time in the OR.

Implementation: Implemented a new guideline titled: “Perioperative and OB Department Guideline for Cleaning Mobile Devices/Cell Phones Prior to Use in the Operating Room” based on findings of testing and cleaning.  An informational memo was sent to all staff, providers and vendors on the guideline with details and direction for cleaning PMD before use in the OR. We now stock the hospital approved cleaning products/wipes for use on touch screen equipment for cleaning of PMD prior to entering the OR, and keep readily available in locker rooms, nurse desk and outside the OR’s. Additional signage placed strategically to remind all to clean PMD regularly with approved wipes.

Outcome:   Regular disinfection of PMD’s is now happening due to implementation of the guideline. However, as a result of the evidence and findings presented, recommendations to standardize a disinfection policy system wide for UCHealth for all PMD used in the OR as well as all hospital environments is necessary.  A good start would be focus on the vendors/visitors as they travel form other facilities and use the devices in the OR and further educate staff and vendors/visitors throughout the entire hospital.  To sustain the gain, random ATP testing of PMD should be completed every quarter. Additional continual hand washing /hand hygiene campaigning with the inclusion of cleaning PMD to really decrease the possible transmission of pathogens to patients will be crucial.  Stretching incorporation of cleaning PMD’s to patient and family members also could significantly reduce possible transmission of pathogens throughout hospital /facility.

Implications for perioperative nursing: Infection risk is a top priority for all perioperative environments. While environmental cleaning has improved significantly over the years, we have missed the risk of bringing personal devices into the OR uncleansed. These devices travel far and wide, are vectors for multiple types of microorganisms, and can put patients at substantial risk for infection. We currently clean and sterilize all outside equipment and instrumentation, and PMD’s should be no different.

Clear the Air: Effective Methods of Surgical Smoke Evacuation

Authors:
Santina Mazzola, MSN, RN, CNOR, CPPS, OR Service Line Coordinator, Hospital of the University of PA
Colleen Mattioni, DNP, RN, CNOR, Interim Chief Nursing Officer, UPHS

Abstract: Perioperative personnel are routinely exposed to surgical smoke generated when tissue is cauterized using heat-producing equipment. The composition of smoke is similar to unfiltered cigarettes. Conservative appraisals estimate over 500,000 anesthesiologists, nurses, and surgeons are exposed to surgical smoke each year. The purpose of this study was to evaluate the effectiveness of surgical smoke evacuation devices on air particulate concentration. Forty-eight participants were randomly assigned to four study groups. An ultrafine particle counter was used to measure the concentration of particles less than 0.1 μm in diameter in four specific locations in an operating room during breast reconstruction surgery. Data was analyzed using an initial Kruskal-Wallis test and post hoc Mann-Whitney tests. All of the smoke evacuation methods had a statistically significant reduction in air particulate concentration at the surgical field (p=.0182, p=.0261, p=.0447). There was a significant difference between the means of the evacuation methods from two of the four testing locations (p=.0409, p=.0040, p=.1420, p=.0645). All types of surgical smoke evacuators effectively lowered the amount of smoke in the air. More research is needed to quantify the efficiency of each kind. Personnel workspaces in the operating room should be strategically placed to lessen exposure to air particulates. These factors should be taken into consideration when designing an operating room to create a safe work environment for healthcare personnel.

CNS Collaboration: New Business Model for Electroconvulsive Therapy (ECT)

Authors:
Ted Walker, Perioperative Clinical Nurse Specialist, APRN, Providence Alaska Medical Center
Nan Magrath, Psychiatric Clinical Nurse Specialist, Providence Alaska Medical Center

Abstract: Given direction from administration, two Providence Clinical Nurse Specialists, one from Mental Health and one from Perioperative, both APRNs, were asked to partner with mangers to develop a new program. This project involved the Behavioral Health outpatient/inpatient programs, Anesthesia and Behavioral Health (both private groups) and the Perioperative/PeriAnesthesia areas all part of the service delivery team at Providence Alaska.

This population has a disease process that can be treated using medically based neuroscience. Electroconvulsive therapy must be delivered in a safe manner to achieve desired effects. The onset of an EEG/Organic brain-based seizure requires the interdependence of a small electrical stimulus and general anesthesia. The medications of anesthesia interface with time/strength of a stimulus to allow individualized therapy.

Two CNSs observed other programs, completed literature reviews, initiated business case analysis on both local and lower 48 care, finally formed multidisciplinary teams. The CNS led teams brought together information, developed plans, vetted information, gave expert clinical consultation and project management. The final business and medical models developed a new delivery system in the OR.

Patient selection, insurance authorization, outpatient visits, preanesthesia testing, admitting, ambulatory surgery, anesthesia, intraprocedural, postprocedural and patient education were key components to the new care delivery model.

Improvement cycles continue. There is a need to further work. The business model utilizing perioperative nurses in a procedural based model was not efficient. The specialized resource of the perioperative nurse was needed in OR cases. The CNS team further developed a program allowing for behavioral health nurses to expand their knowledge of anesthesia and procedures. This complete package allowed these nurses to practice within the new core competency set of a proceduralist. The process has allowed another team to open a first start open booking room in the OR, allowing for increased trauma and urgent care delivery.

CO2 Quality Improvement Study

Author:
Beth Hogan, Clinical Director of Nursing, Northern GI Endoscopy Center

Abstract: Define: A CO2 insufflation trial to assess patient comfort and recovery time. Patients with CO2 insufflation were compared to patients with air.

Measure: Data was collected from 6/28/ -7/26/2017. Of the 272 patients, 91 had CO2 and 163 utilized air insufflation. The average recovery time with CO2 was 47.9 and air was 54.6 minutes. The difference was 6.7 minutes.

Analyze: The study revealed a 6.9% decrease in patients requiring medication with CO2 use. The difference of 6.7 minutes in recovery time from the CO2 to the air insufflation patient resulted in a savings of 10.16 recovery room hours during the three week trial. If this savings persisted with an average of 4000 colonoscopy patients, NGIEC would see a reduction in recovery room time of 446 hours over a year.

Improve: The board in September 2017 decided to implement CO2 insufflation on all colonoscopy patients.

Control: Recovery time and post procedure medication percentage was remeasured in late January of 2018 running form 1/22 - 2/09/18. Recovery time for the 315 patients averaged 39.8 minutes.

Average recovery time for the CO2 patient in 2017 was 47.9 minutes. This was a difference of 8.1 minutes. In reviewing any potential for why there were variations, it was noted there was a transition in September of 2017 from a recovery room nurse for the facility to a primary care nursing model. This may account for part of the variation with a more patient focused process.

Reference:

Lord, A. C., & Riss, S. (2014). Is the type of insufflation a key issue in gastrointestinal endoscopy? World Journal of Gastroenterology : WJG, 20(9), 2193–2199. https://doi.org/10.3748/wjg.v20.i9.2193

Communication of Surgical Delays

Authors:
Renee Ziomek, BSN, RN, CNOR, OR Service Coordinator Transplant Surgery, Northwestern Medicine
Rowena Martinez, BSN, RN, CNOR, OR Service Coordinator General Surgery/ Surgical Oncology/ Trauma, Northwestern Medicine

Abstract: Purpose/ Objectives: At this level 1 trauma, academic medical center, consisting of sixty operating rooms across three pavilions, communication of surgical delays was found to be inconsistent. These delays impact surgical case start times, patient and family member’s expectation of on time starts, and patient satisfaction. The goal of this project was to increase communication of surgical delays by standardizing the process for surgical delay notification and increasing utilization of a delay page protocol.
Content: Three months of baseline data were collected from four OR service lines: General surgery, Urology, Neuro surgery and Transplant surgery. Baseline utilization of a delay page was 13%. A survey in overall understanding of the delay page use and OR delay protocol was sent electronically to 113 nurses. The response rate was 59%. Survey responses revealed: (1) lack of education on importance of delay page utilization; (2) difficulty locating the delay page name in web page directory; (3) staff forgetting to utilize the delay page.

Strategies for implementation: Survey questionnaire revealed the need for staff re-education on the importance of communicating surgical delays. A standardized process for surgical delay notification was developed that included a single web paging name, a structured message that includes OR room number, case number, and duration of delay. As a visual reminder, bright orange labels were placed on each OR nursing computer to remind staff to utilize the delay page. Additionally, count sheet documentation was changed to include delay page utilization and time page was sent.

Outcomes: Delay pager utilization increased from 13% to 36% as a result of standardizing the delay page name, utilizing visual cues, and re-education of staff.

Communication, Collaboration and Trust Lead to a Major Savings in Power Sets

Authors:
Brenda Nack, MSN, RN, CNOR, CSSM, CRCST, Director, Central Sterile Processing , The Johns Hopkins Hospital
Carol Gentry , MSN, RN, CNOR, Nurse Manager, Pediatric Operating Room , The Johns Hopkins Hospital
Nick Breslin, CRCST, Manager, Central Sterile Processing, The Johns Hopkins Hospital
Keith Wiley, RN, Staff Nurse , The Johns Hopkins Hospital
Graham Mazur, ST, Surgical Technician , The Johns Hopkins Hospital

Abstract: An Instrument Committee made of Operating Room staff (OR), Registered Nurse (RN), Surgical Techs (ST), Instrument Processors (IP), and leadership meet collaboratively to focus on the care and handling of instruments, drills, cameras and scopes. One of the major successes from this collaborative meeting has been with the power sets. This success was a result of communication, collaboration and trust between Central Sterile Department (CSD), and Nursing teams utilizing the methodology of Plan, Do, Study, Act.

The power sets were coming to the OR or arriving back to the CSD with missing or broken parts. Each team blamed the other for the incomplete sets. The cost for replacements was adding up to significant dollars each month. There was a time delay for replacement that included approval of funds for replacements, reordering-companies not always having the replacement part available for shipping-so one missing item could delay the set up to several months. These delays was costly to everyone.

Together the OR and CSD staff in their Instrument Committee collaborated on a plan to improve the power situation. Audits were performed on the power sets in the decontamination area and if instruments were missing the OR was called right away. The CSD team worked to create consistent organization of the power sets. CSD created trays that were organized and labeled for each power piece. The CSD team also created photos of all the power parts and provided these in books to the OR team for reference.

The OR front line staff determined the best way to prevent the loss of items at the end of the case would be to count the power sets before and after use.
The loss of parts dropped from $20,000 month up to $150,000 annually to a loss of only 3 items @ $5000 in 6 months.

Consolidation of Instrument Sets Based on Usage

Author:
Jessica Havens, BAN, RN, Charge of service ENT/OPTH, Seattle Childrens

Abstract: Purpose: The purpose of this quality improvement project was to reduce the number of instruments in a set based on frequency of use, thus reducing associated waste and cost.
Description of Team: The core team consisted of the Nurse and Surgical technologist (ST) Otolaryngology (OTO) Service Lead, the OTO Surgical chief, a project and a data input manager.
Preparation and Planning: First steps included developing criteria for set selection and a data collection method. Then, a staff and provider communication and education plan were developed about the project process and expectations.

Assessment: The Tonsillectomy and Adenoidectomy (T&A) set was selected for initial set review based upon the following criteria: high case volumes, time since last set evaluation and variable surgeon needs. Instruments in the sets that are never used can be a waste of resources in the Sterile Processing department. By identifying unused instruments and removing them it reduces waste through time and money.

Implementation: The instrument count sheet in each set was used to identify instruments used. The ST indicated the instruments used by highlighting the count sheet, noting the quantity of each instrument used, and documenting additional instruments opened for the procedure. The data sheets were labeled with a patient sticker, date, and the surgeon performing the procedure. The data input manager compiled the data and sorted it based on surgeon.

Outcome: Conclusive data collected identified various instruments in the set that were not being used. From this data, we recommended that those instruments be removed from the T&A set. This change reduced the number of instruments in the set by seven out of twenty seven.

Implications on perioperative nursing: Through the reduction of unused instruments in the set, we are able to reduce cost in the perioperative setting. Through the collection of this data, we can repeat this investigation with other sets used in the OR to identify unused instrumentation and reduce waste.

Decreasing Musculoskeletal Injuries Among Operating Room Personnel through the use of Anti-fatigue Mats

Authors:
Pam Raake, MS, BSN, RN-BC, Director of Surgical Services, Baptist Health Floyd
Hannah C. Raake , DNP, APRN, University of Louisville
Barbara Polivka, PhD, RN, Professor & Associate Dean of Research, University of Kansas
Becky J Christian, PhD, MSN, RN, FNAP, PhD Program Director, University of Louisville

Abstract: Statement of Problem: Work-related musculoskeletal disorders (WRMDs) are a common occurrence among operating room (OR) personnel due to certain job requirements including standing in a static position for long periods of time. Consequences of WRMDs include pain, spinal compression, venous insufficiencies, decreased productivity, and days missed from work. The American Association of Operating Room Nurses (AORN) ergonomic guidelines support interventions (anti-fatigue mats, shoe in-soles, etc.) aimed at decreasing the rates of WRMDs among OR personnel.

Methodology: A 3-month pre- and post-intervention trial was established at one Southern Indiana hospital to assess the efficacy of anti-fatigue mats in the OR theatre. Two anti-fatigue mats were placed in each OR, cardiovascular operating room (CVOR), and endoscopy room for use with each case. Prior to implementation, an education session was provided to staff regarding use and care for the mats. Measures assessed include demographic data, height, weight, pain (utilizing a modified Nordic Musculoskeletal questionnaire), weekly observations on the use of the mats, and overall satisfaction with mat usage, availability, and continued use. Data was collected before mat implementation (T1) and 3-months after continued mat usage (T2). Sample sizes were 48 for T1 and 30 for T2. SPSS data analysis included descriptive statistics and chi-squared statistics comparing pre- and post-intervention data. Significance was set at an α < 0.05.

Implications: While results failed to show statistical significance between pre- and post-pain levels, the T2 cohort did show decreases in overall pain levels impacting normal work when compared to the T1 cohort. Satisfaction results found that 86% of OR, CVOR, and endoscopy staff reported continued use of anti-fatigue mats after the completion of T2.

Support for research: Future studies should include larger sample sizes, longer intervention time frames, and should occur in areas that currently do not utilize anti-fatigue mats as to assess their full efficacy.

Decreasing Variability and Waste: Management of Surgeon Preferences in the Operating Room

Authors:
Adonica Dugger, DNP, RN, CNOR, Administrator of Surgical Services, University Medical Center
Cassidi Linnenkugel, BSN, RN, CNOR, Assistant Business Manager Surgical Services, University Medical Center

Abstract: Purpose/Objectives: Rising costs of surgical supplies and reduction in reimbursement from third party payers caused a reduction in the profit margin for a teaching hospital in West Texas. The surgical services management was tasked with finding ways to decrease costs while maintaining and/or improving the quality of surgical care. The surgeons were also challenged to find ways to help decrease supply and implant costs while still providing high quality care. In reviewing the cases performed in the previous twelve months, a large amount of variation was found in supplies used in the most common cases between surgeons in the same practice group. Standardizing supplies in the most common surgeries was identified as a process that could be improved through teamwork with the surgeons.

Preparation and Planning: The procedures performed most by this surgical team were determined to be laparoscopic appendectomy and laparoscopic cholecystectomy. Data was obtained for the cases performed by the surgeons on the team including the items used in each case and the cost of each item. The items were gathered and prices for each item were tagged to the item. The participants collaborated about items needed to perform a safe surgery, and the surgeons agreed to use a standard preference card with like items for all their laparoscopic appendectomies and laparoscopic cholecystectomies.

Implementation: The preference cards were updated with the requested changes and the operating room staff and surgical residents were educated about the new process and reasoning.
Outcome: There was a significant decrease in the average cost per surgical procedure for laparoscopic appendectomy from $1,023.70 down to $582.53 and for laparoscopic cholecystectomy from $572.34 down to $458.22. The approximate annualized savings (based on case totals from the previous twelve months) is $62,204.97 for the laparoscopic appendectomy and $23,280.48 for the laparoscopic cholecystectomy. The approximate total savings is $85,485.

Development and Implementation of an Active Shooter Plan

Author:
Bryan Mehalick, BS, RN, Registered Nurse, St. Luke's University Hospital

Abstract: Due to the prevalence of active shooter situations in the United States, emergency preparedness is essential. Healthcare facilities must have plans in place to meet the challenge of an active shooter situation. Although our operating rooms are in a locked unit, this only provides us with a false sense of security. Preparing for an active shooter should follow the same rigorous training as other life threatening events such as fires or weather emergencies.. Recent events, both locally and nationally, led for the formation of a committee to tackle this unique problem. Despite much literature on active shooter protocols in public areas as well as the main parts of the hospital, literature on how to respond to active shooter in an operating room or surgery center was lacking. The committee teamed up with security officials from the hospital network as well as consulting active shooter protocols put forth by federal agencies when designing the OR specific guideline. The active shooter guideline was tediously reviewed before the OR staff was given the information. The information presented in the guideline will be drilled alongside other safety drills such as fire drills and malignant hyperthermia emergencies. The committee’s goal for implementation of this guideline is that it could be used as a model for other ORs seeking to implement active shooter protocols.

EBP Smoke Plume Evacuation

Author:
Dawn Brue, MSN RN, Staff Nurse, Universitiy of Iowa Hospital

Abstract: The purpose is to implement and evaluate evidence-based smoke plume evacuation in the pediatric OR (operating room) to reduce exposure to carcinogens. Surgical smoke plume is a product released when cautery, laser, or energy generating devices are used on tissues in the body. “During the procedure (cut, coagulate, vaporize or ablate tissue), the target cells are heated to the point of boiling, causing the membranes to rupture and disperse fine particles into the air or pneumoperitoneum” When the tissues burn, the plume released contains smoke, formaldehyde, acetaldehyde, and toluene. Inhalation of one gram of tissue being cauterized is equivalent to a person smoking six unfiltered cigarettes (Alp, et al., 2006; McCormik, 2008)

The practice change was bringing in the new equipment to evacuate smoke plumes at the site of cauterization. Implementation has included sharing key evidence about the dangers of smoke plume, education during a morning meeting, perioperative hospital meeting presentation regarding smoke plume, troubleshooting at the point of care, academic detailing, clinician input, inform organizational leaders, report within organizational infrastructure, just in time eduction, change protocol and equipment access, preincision safety and quality scripting for every case requiring cautery. Future implementation will expand smoke plume pens availability as a standard part of the packs, and discussing barriers and successes for rollout.

Evaluation of the project has included feedback from nurses and surgeons, extent of use of the smoke plume evacuators, and integration of the smoke plume evacuators into the packs. Clinicians indicate in an open ended questionnaire they like having smoke removed (n=4/9), noise remains problematic (n=2/9), bulk of equipment is a challenge (n=4/9), and one said “Let’s do it!” Trends of use show a 36% increase. Efforts are targeting where there is greatest opportunity.

Exposure to smoke plume is an occupational and patient safety prioirty. There are promising results indicated in current literature. Troubleshooting use of new equipment is key. With the support from leadership, the OR staff are encouraging doctors to increase use of smoke evacuators for all indicated procedures. Nursing can make a difference in leading healthcare changes that benefit all stakeholders to reduce occupational exposure and children’s exposure in the OR.

Efficient Care - How can Zimmer Biomet Help You with the Delivery of Care?

Authors:
Jason Reese, Senior Product Manager, Zimmer Biomet
Tyler Bell, Product Management Associate Director, Zimmer Biomet
James Grimm, Project Associate Director, Zimmer Biomet

Abstract: Traditionally, total joint replacement surgeries involve numerous trays that contain numerous surgical instruments. This necessitates significant time and costs for hospitals with cleaning and sterilization. Large amounts of instruments on the back table create delays when locating the appropriate instruments, thus reduce surgical efficiency.

Zimmer Biomet’s Efficient Care team has developed a joint replacement surgical pre-planning service using standard patient x-rays. Case pre-planning aids in determining the patient implant sizes, reducing the number of instruments. Zimmer Biomet sales representatives also work closely with the surgeon to further reduce instrumentation based on their individual preferences.
Zimmer Biomet partnered with Accelero Health Partners to help quantify the hospital benefits. Based on two hospital time studies, one in the Detroit, MI area and one in the Indianapolis, IN area, Efficient Care resulted in 55% and 25% savings, respectively. These time savings add up to significant estimated annual cost savings for these hospitals of more than $400,000. Efficient Care is currently being offered by Zimmer Biomet and further studies are ongoing.

Eliminating the Uncertainty of Managing Vendors and Their Inventory

Authors:
Shonyasha Forston , MBA, CST, CRCST , Sterile Processing Supervisor, Orlando Health Dr. P. Phillips Hospital
Tracie Craddock, BSN, RN, CNOR, Assistant Nurse Manager, Orlando Health Dr. P. Phillips Hospital
Constance Tasker, MSN, RN, CNOR, Learning Specialist, Orlando Health Dr. P. Phillips Hospital
Amy Perkins, CST, Surgical Services Clincal Resource Coordinator, Orlando Health Dr. P. Phillips Hospital

Abstract: This abstract documents implementation of a vendor management tracking system to improve arrival times of vendor managed trays for timely sterilization and to electronically trace trays from arrival through pickup.

Vendor owned trays frequently arrive late delaying cases causing conflict between vendors and hospital teams.  Previously, a room was available to vendors for tray storage prior to and after procedures.  A Borrow Loan Coordinator daily phoned vendors, scanned the environment, arranged tray arrival, timely sterilization, and accounted missing items.  The process from scheduling to use included (15) manual steps. A web based app vendor management system was chosen to notify the vendor, register the tray upon arrival, take pictures of contents, and label the tray for scanning at each location of sterile processing flow from washing, sterilizing, sterile supply, patient cart, back through decontamination to improve tray tracking.

A flow chart was created mapping out the current process of tray management.  Key stakeholders identified.  Current inventory levels were taken of trays in the storage room and vendors asked to remove trays not for a scheduled case. Policy review and new process was communicated internally and to all vendors.  The app was downloaded to all necessary computers and phones and a registration computer for incoming trays set up in the storage room.  Program representatives were available for support through the transition.

Steps required for tray availability replaced by electronic tracking decreased manual labor. There is a perceived decrease in management time and in conflict with vendors about location of trays with data available to hold vendors accountable to expectations.  Knowledge of which trays are needed for cases versus vendors storing trays not being used has opened up working space, and lastly, there has been no cost incurred for lost instrumentation since implementation versus > $33,000 the year prior to implementation.

Emotional Intelligence: How to Develop it as a Person and Use it as a Leader to Build Resiliency and Strong Teams

Author:
Gail Avigne, MSN, BA, CNOR, Senior Associate, Press Ganey Associates, Inc.

Abstract: This poster will share the concepts of emotional intelligence, including how to develop it and use it as a leader to build strong teams and resiliency. The author has dentifed the tool-set nurse leaders need to develop emotional intelligence and facilitate a more resilient, team-spirited work environment.

Employee Engagement: It’s Everyone’s Responsibility

Author:
Ebony Mitchell, MSN, BSH, RN, Charge Nurse/RN IV, Memorial Hermann Hospital

Abstract: Creation and cultivation of a sustained and nurturing, flourishing culture of retention, requires that managerial focus is more than ensuring training and competitive pay is evident.

Joy must illuminate in the areas of people, workload, achievement/accomplishment, and recognition. Preparation of protégé requires a combined effort between preceptors, mentors, and management to identify, develop, and continuously evaluate strategies employed to determine if those strategies that have previously been successful in the past, truly set the stage for increasing retention rates and futuristically enhancing organizational performance financially for years to come.

Engagement champions employed within Memorial Hermann, a newly designated Magnet facility, were charged with the task of tackling the issue of improving employee involvement and retention within perioperative services among the weekend day and night trauma teams. Brainstorming and divulgence of ideas/suggestions occurred during formal meetings and champions were provided the opportunity to present, solicit more ideas, and follow through with ideas with approval from management. Working closely with engagement champions from both teams, workable strategies were developed that enabled us to continue to remain one of the top and least likely units in the entire organization to have decreased turnover and improved retention rates.

Implementation of an ”I am engaged” pledge, ceremony, and celebratory dinner, huddle, the customary graduation, bridal showers, retirement celebrations, and holiday parties, in addition to “just because” celebrations for a job well done were discussed. Presentation occurred in the form of power-point to all staff to solicit buy-in as well as suggestions and questions. The information was then discussed with management and once approval was obtained each item that was approved was presented to staff in a second power-point presentation.

The outcome of this project is that the day and night weekend trauma teams have increased staff retention and continue to be less turnover then has been experienced in prior years within Memorial Hermann Texas Medical Center. Efforts to ensure that the perioperative nursing shortage is kept at a minimum nationally and internationally require leaders, preceptors, and mentors to engage in meaningful conversations with staff that enable divulgence of pertinent and realistic strategies to improve joy in the workplace, retention of staff while decreasing unwarranted feelings, increased turnover, and a continual nursing shortage of perioperative nurses.

Engaging the Patient and Family in the Surgical Safety Process Utilizing SafeStart

Authors:
Richard M Vazquez, MD, FACS, CMO, SafeStart Medical, Inc
Richard H Pearl, MD , Chief Safety Officer and Chief of Pediatric Surgery Emeritus, OSF
Breanna Elger, Medical Student, Research Coordinator, Creighton School of Medicine
Joseph Esperaz, MD, Surgical Resident , UI College of Medicine
Robert Jennetten, MS, Director of Innovation Partnerships, Jump Trading Simulation Center OSF Healthcare

Abstract: Background: Owing to the vulnerable nature of children, parental/caregiver engagement in surgical safety is a crucial aspect of care. Historically, the surgical safety process has been isolated from parent involvement. The digital, tablet-based surgical safety application, SafeStart, requires parent participation and provides multiple instances of verification of patient safety information from preoperative clinic visit, to perioperative care, and into the operating room.

Method: The SafeStart application was utilized for 100 pediatric general surgery patients in an IRB approved prospective study. Parent assessments of the surgical consent and safety processes were collected in pre- and postoperative surveys with a 100% response rate. Standard consent forms were used and compared as a control.

Results: Only 31% of parents had knowledge of the surgical safety checklist process prior to their exposure to the study. 96% of the parents reported that the SafeStart patient portal was easy to use. A majority would prefer SafeStart to the standard consent process.

Conclusion: The SafeStart program connected the surgical safety process from the preoperative clinic visit through postoperative care. Parent's preferred SafeStart to the standard surgical safety checklist and consent process, felt that they were instrumental in protecting their child's safety, and would recommend SafeStart for the surgical care of others.

Level of evidence: II

Enhanced Surgical Recovery: Improving the Patient Experience Through Patient Education and Best Practice Implementation

Author:
Kathleen Ranne, MSN/Ed, CNOR, CSSM, Core Measure Analyst, St. Lucie Medical Center

Abstract: Purpose/Objectives
Enhanced surgical recovery (ESR) is the protocol designated for implementation in Hospital Corporation of America (HCA) hospitals in the East Florida Division (EFD) but stems from the enhanced recovery after surgery (ERAS) protocol studied abroad for many years. The ERAS protocol consists of some 20 components (Sofin & YaDeau, 2016), but HCA has selected only 5 for implementation thus far. They are: 1) multimodal anesthesia care, 2) fluid volume maintenance, 3) carbohydrate drink preop loading and early return to regular diet, 4) early mobilization postoperatively and 5) patient satisfaction. The purpose of the ESR protocol is for improved surgical outcomes including decreased length of stay, improved patient satisfaction, and reduction in the use of opioids postoperatively.

Content
Interdisciplinary planning meetings were scheduled throughout the summer and included members from surgery, nursing, anesthesiology, dietary, physical therapy, pharmacy, and informational technology (IT).

Strategies for Implementation
Patients undergoing total knee and total hip arthroplasty have the opportunity to attend a preoperative teaching session including two sessions, the first being an interview assessment with a perioperative nurse, lab blood draw, and the introduction to the ESR protocol, and the second being a class on the orthopedic unit where a nurse continues the introduction and review of the ESR protocol, the postoperative phase including physical therapy, dietary, nursing, pain management and discharge planning. This class session is a multi-disciplinary team approach to patient education for the surgical patient.

Outcomes
Patient experiences are reported via the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, analyzed by Press Ganey, and provided for the hospital to improve the patient experience. Patient satisfaction scores, overall rating, improved (70.11% to 81.5%) by the end of the fourth quarter 2018, along with a reduction in the opioid requirements postoperatively (19.4% to 15.17%) for ESR patients at St. Lucie Medical Center.

Enhancing Intraoperative Communication Utilizing Technology

Author:
Lori Fuehrer, BSN, CNOR, Patient Care Manager, Lehigh Valley Health Network

Abstract: Purpose: Lehigh Valley Health Network (LVHN) sought a way to enhance communication to the patients' family during their surgery. LVHN partnered with a company that sent HIPAA compliant text message updates to the family members who were waiting during their loved one’s surgery.

Content: A multidisciplinary team was developed of perioperative leadership, information services, and staff to research and launch a communication system. The team participated in site visits to gain a boarder understanding of an electronic communication application system Electronic Access to Surgical Events also called EASE. Standard work was then developed. Clinical inclusion criteria were set to identify cases applicable to the use of the EASE application.

Strategies for Implementation: The team used a phased approach to roll out utilization by surgical specialties. Physician champions were identified, workflows were created for staff, and education was presented to nursing, physicians, anesthesia, and non-clinical staff. The process is voluntary and controlled by the patient. Once the patient agrees to use the application, they are required to sign a consent, the patient will download the EASE application, and choose from their phones contacts people to receive the text messages. During their operative procedure updates are provided to anyone the patient has consented to receive messages. Guide sheets with phrases and tips for timed messages were provided to staff. At the conclusion of the procedure an optional five question survey is provided.

Outcomes: As of June 2019 over 4,000 surveys have been received, family members have been reached in all 50 states and multiple countries. Through examining comments and survey data, it can be concluded there will be a positive effect in our patient satisfaction scores. Communication from the OR is often varied, using this technology institutions can be transparent providing critical information during the patient’s most vulnerable time.

Evolution of PACU Nursing Residency Program over Five Years to Meet the Unique Needs of the Unit and Nurse Residents

Authors:
Ayumi Fielden, MSN, RN, CCRN-K, CPAN, Clinical Nurse Expert, Houston Methodist Hospital
Hong Tran, MBA, BSN, RN, NE-BC, Director of Perioperative Services, Houston Methodist Hospital

Abstract: Purpose/objectives
The goal of the Post Anesthesia Care Unit (PACU) Nursing Residency Program is to transition Registered Nurses (RNs) to meet the unique needs of PACUs to alleviate the nursing shortage in this specialized unit within prescribed time frame while maintaining low turnover.

Introduction/Content
The PACU Nursing Residency was developed five years ago to alleviate nursing shortages in the recovery rooms. The PACU Nursing Residency Program is a five-month long formal program, which offers Graduate Nurses (GNs) to transition to a unique role of PACU RN in a large academic medical center. The feedback from the residents included the need for additional exposure to critical care patients, critical care medications such as vasoactive drips, emergency situations, and recovery of complex cases.

Strategies for implementation
Additional opportunities for past residents were offered to increase their confidence and competence in the care of critically ill patients in the PACU setting. Addition of critical care concept classes to include didactic and high-fidelity simulation to enhance learning of these concepts, as well as rotations through Intensive Care Units (ICUs) to build upon their current skill sets. Their feedback prompted restructuring of the program and evaluation of target audience. The core fundamentals of the program, such as didactic contents from ASPAN Competency Based Orientation and Essentials of Critical Care Orientation remained while high-fidelity simulation of each topic and critical care concept classes were added. The target audience of this program shifted to experienced med-surg RNs with no prior critical care experiences. GNs needed time to master basic nursing skills such as medication administration and physical assessment, thus additional time and training were needed in order to master critical care nursing; whereas med-surg experienced nurses were ready to learn the skills needed to meet the unique challenges of PACU due to varying acuity of patient population.

Outcomes
The recent feedback of residents who had prior med-surg experience indicated that they have received more than an adequate amount of critical care training and voiced confidence in the care of critically ill patients in the PACU as well as complex cases.

Fellowship, Nurse Residency, Clinical Mentor: Cohesive Periop Orientation

Authors:
Madeleine Ly, BSN, RN, CNOR, Clinical Mentor, Inova Fairfax Medical Campus
Elaine Feyder, MS, RN, CNOR, Director, Bethesa Chevy Chase Surgery Center

Abstract: Purpose/Objective: The American Association of Colleges of Nursing predicts that 1.09 million nursing jobs will open between 2014-2024 due to employment growth and replacement of nurses leaving the bedside. The Institute of Medicine in 2010 released the Future of Nursing Report recommending implementation of nurse residency programs. Literature has shown that new registered nurses (RNs) who participate in a nurse residency program (NRP) express improved confidence with leadership, organization, prioritization, communication, and ability to handle stress.

Content: The Inova Fairfax Medical Campus (IFMC) is a level 1 trauma center with 20 Operating Rooms (ORs). New OR nurses (Fellows) are rotated through the different surgical services over 9 months. The Clinical Mentor’s role is to support the Fellows and to collaborate with preceptors, creating a positive learning environment at orientation and beyond.

Strategies for Implementation: Clinical Mentors at IFMC work on skill building, collaborative feedback, facilitate critical thinking, and provide linkage between experiential, didactic and peer cohort learning. IFMC began the first residency cohort in 2017, with over 180 new graduates, 11 of whom had selected Periop nursing. The NRP focuses on quality outcomes, leadership behaviors, personal accountability, and evidence-based practice (EBP). OR Fellows complete Periop 101 (including a final exam), a rigorous nine months of orientation, and an NRP EBP project. Clinical Mentors tailor the NRP topics to OR practices and AORN standards to maximize relevancy.

Outcomes: The first year’s cohort data showed a hospital-wide turnover rate decrease by 5.1%. EBP education encourages new RNs to take ownership of their practice and contribute to the profession. Integrating the OR fellowship with the general hospital wide NRP program allows the periop cohort to feel connected to each other as well as the hospital at large; benefitting relationship building, retention and patient outcomes.

Geriatric Hip Fracture Program: The ThunderCat Protocol

Authors:
Johanna Powers, MSN, RN, CNOR, Clinincal Nurse 3, UCSF Medical Center
Stephanie Rogers, MD, UCSF Medical Center
Lee-lynn Chen, MD, UCSF Medical Center
Derek Ward, MD, UCSF Medical Center
Jahan Fahimi, MD, UCSF Medical Center

Abstract: Hip fractures are common among the elderly and those with limited/challenged mobility issues. Hip fractures typically require surgical intervention, and the timeliness of such is crucial to ideal outcomes. Many of these patients are elderly and suffer from comorbidities which may deem them a suboptimal candidate to withstand an operation, and may push their surgery timeframe back. These patients waiting for surgery are also in pain which can lead to heavy narcotic doses, and ultimately post-operative delirium which can prolong their hospital stay. In short, the progression of the hip fracture patient through our system left much room for improvement.

In fall 2017, I joined a multidisciplinary group made up of representatives from gerontology, orthopaedic surgery, emergency department (ED), anesthesia, and perioperative nursing formed a Lean Team to optimize the management of our hip fracture patients seen at UCSF.

The four main areas of focus in the protocol are 1) geriatric co-management – daily rounding with geriatric-specific care and rapid OR-optimization to get them cleared for the operating room (OR), 2) evidence-based treatment protocol from admission to follow-up, 3) ED flow and pain control – rapid assessment and referral to orthopaedic team and fascia iliaca blocks and non-opioid pain control, and 4) rapid surgical intervention which includes the specific OR process, equipment and staffing.

I was asked to represent the OR through this process of brainstorming, reviewing and revising protocol ideas and implementation. We identified areas in need of improvement throughout the patient's stay: from the ED to discharge.

We provided education to physicians and nursing staff highlighting our concept of simplifying the hip fracture process, from learning block techniques to OR set-up.
The past year we have seen changes to our ‘mean hours to OR,’ ‘average length of stay (LOS)’ and ‘average LOS index.’ The mean hours to OR at baseline was 52, and when last measured (September 2018) was 25.48 – a difference of 49%! The baseline average LOS was 8.96 days and improved to 4.85 – a difference of 44%! The average LOS index is a comparison of our data to other hospitals in which anything less than 1 indicates we are leading amongst our peers; the baseline was 1.44 and is now 0.85 – a difference of 41%! The numbers indicate the new “ThunderCat protocol” is making a positive impact on our hip fracture patients!

Getting Engaged! Say Yes to Staff Engagement in PAT Process Innovation

Authors:
Robin Kaufman, DNP, APRN, FNP-C, Nurse Director, Perioperative Services, Brigham and Women's Faulkner Hospital
Jeffrey Blackwell, MHA, Director of Surgical and Procedural Services, Brigham and Women's Faulkner Hospital

Abstract: Enhancing Pre-Anesthesia Testing (PAT) processes to keep up with growing surgical volume while containing cost and preserving quality is a challenge for many healthcare organizations. Engaged staff can support innovation needed to successfully meet these goals. Nurse engagement is positively associated with quality and patient satisfaction as well as lowered cost of care. However, rapid and unrelenting change as well as pressure to do more without increasing resources can threaten their level of engagement. How can leaders engage staff while meeting volume growth needs? The presenters will share how they lead their department at Brigham and Women’s Faulkner Hospital through process improvement to increase PAT capacity by >15%. Using case-based analysis their work will provide today’s perioperative leader with strategies and tools to increase nurse engagement while optimizing PAT systems to support volume growth.

Go Get Your CNOR

Author:
Chante Logan, MSN, RN, CNOR, Charge Nurse, McGuire VAMC

Abstract: This poster presentation was created to highlight the importance of professional nursing certification, and how the staff at the Hunter Holmes McGuire Veterans Hospital have made nursing certification an integral part of the culture of the Operating Room. The highly unique patient population for which the nurses in this unit serve greatly benefit from the high standards and dedication from the professional nursing staff with superior outcomes of nursing care. This poster demonstrates how this journey was tackled and strategies they used to overcome many obstacles to reach their goal. These nurses were faced with fear of failure, test anxiety, preventative cost of review courses, and testing fees. The team members at the McGuire VAMC foster a culture of professionalism. They also encourage nurses to pursue professional certification at their own pace, voluntarily. During the journey, the nurses were assisted by a multitude of supporters outside
of the operating room. These supporters included a local hospital network that generously sponsored a dynamic review course for six nurses to complete.

The instructors for the review course provided encouragement and support along the successful journey. The backbone of support ultimately resided with the McGuire OR team who provided daily
encouragement to those seeking to test and embraced each new CNOR as a valued and motivated member of the team who “voluntarily” demonstrated a desire to rise to the standard of professional nursing that the team represents.

The McGuire VAMC operating room team obtained CNOR Strong recognition in 2016. The operating room continues to grow and add professional nurses to the team. These new staff members are encouraged to obtain certification, if they do not already hold certification. Every opportunity is given to prepare for testing to relieve anxiety.

Demonstration of dedication and commitment to exceptional patient care is the expectation, and successful completion of the CNOR certification was the key to belonging to this phenomenal group. The team includes approximately 50 Operating Room (OR) nurses. This percentage of CNOR nurses is approximately 90%! The additional credibility that comes with successfully passing a national standardized examination improved patient care. The benefit of CNOR certification includes elevating the nursing profession, demonstrating specific and detailed knowledge, increased patient safety, and opportunities for con for continuing education. Having a certified nurse at the bedside decreases the chance of negative outcomes and ensures a highly confident and committed nurse provides high quality care for our veteran patients. They deserve only the best!

Going for Gold with the Perioperative Olympics

Author:
Kristen Sohaney, BSN, RN, CNOR, Patient Care Manager, Operating Room, Lehigh Valley Health Network

Abstract: Leadership within the Perioperative Division of a Community Based Health Network with 9 campuses were tasked with finding an innovative solution to expense management.  Understanding front line staff often see waste through a different lens than leadership, the team wanted to implore the staff to provide ideas on expense savings.  Through this lens, the Perioperative Olympic competition was realized.

Staff from multiple campuses throughout the Perioperative Division, including preoperative staging, PACU, and OR, were invited to meet with "judges", who were members of our Perioperative Business Services Department and Value Analysis Program.  Ideas were judged and scored on their creativity, feasibility, and financial impacts.  The program was presented by site leadership at each campus to generate healthy competition.  The judges visited each site and met with each "Olympian" with an idea.  After the idea was presented, financial data was captured and tallied.

The Perioperative Olympics generated 78 individual ideas on cost-saving or efficiency enhancements.  These 78 ideas generated a potential annual savings of over $1M.  52 of these ideas were implemented immediately.  Ideas ranged from changing preference cards to procedure cards to implementing water conservation on our scrub sinks.  Gold and Silver medalists from each category were awarded to staff.  Engaging the front line staff was key to the initiative.  In the first quarter, over $125,000 in actual savings was captured.  Savings have continued, along with implementing the ideas front line staff have suggested.  A total of over $700,000 of savings was captured in FY19.

Graduating to the OR: Ensuring Success of the Novice Nurse in Surgery

Authors:
Natasha Luster, MSN, CNOR, Nurse Manager of Surgical Services, Miami Valley Hospital
Beth Heyse, MSN, RN, CNOR, Director of Surgical Services, Miami Valley Hospital

Abstract: During this time of challenging recruitment and retention, it is imperative that the operating room (OR) has programs accepting of the novice nurse. Considering the national turnover rate for the OR is greater than 20%, it is important to cultivate an orientation that fosters mentorship and empowerment of all nurses. The graduate nurse faces known challenges that can be compounded by the unique environment of the OR. We have created a successful internship program that integrates the novice nurse into the OR culture.

Our OR internship comprises of 9-10 months of specific OR training. The intention is that the novice nurse will circulate independently, in one specialty, within 16 weeks. Once independent in their chosen specialty they will alternate between weeks of independence and weeks of orientation in a new service. They will continue building knowledge and gaining independence after each specialty rotation. The length of each service rotation is dependent on the complexity of cases within the service.

During the first 4 weeks of orientation the nurse is in the classroom setting with the educator. They will learn, study, and practice skills exclusive to the OR. They will position, prep, count, and bond with their cohorts. They will spend time reading AORN guidelines and learning best practices. They will have OR observation time, and purposeful one on one time with OR leadership. The first month serves as an opportunity for pep talks and critical expectation setting.
During the classroom time, the new nurse is assigned a service line and specific preceptor(s). This is mapped out, in advance, so that the expectations are clear and concise. Once the classroom time is complete, the nurse knows the next steps and can anticipate goals and challenges specific to their service. Their first three weeks in the OR are spent learning the basics of circulating. They are non-specific in regards to service, and focus on basic patient care, advocacy, and safety. After this initial orientation, the nurse can expect to learn service specific equipment, preferences, and anticipation of surgeon/procedure specific needs.

Throughout orientation the nurses meet with educators and members of the leadership team. The educators asses gaps in education and experiences, while the leadership team ensures empowerment in regards to policy and procedure guidelines. Every new team member is invited and encouraged to participate in our Mentor Committee. This team, made of dedicated and seasoned team members, meet with the orientees and newer team members to discuss challenges and concerns in the OR. This committee affords a safe space to provide feedback and coaching related to expectations and navigating challenging situations. This committee has been incredibly successful.

Historically, novice nurses have not been welcomed into the OR. This program challenges the status quo. Our new nurses are learning how to apply specific critical thinking to the OR. Not only have we improved in many key performance indicators, our turnover rate in 2017 was less than 2%. Having a well-organized, intentional internship can improve quality of care, employee engagement, and patient satisfaction in the operating room.

Healthcare Utilization and Payer Cost Analysis of Robotic Assisted Total Knee Arthroplasty at 30-, 60-, and 90-Days

Authors:
Andrea Coppolecchia, MPH, Sr. Manager, Health Economic Research, Stryker
Christina Cool, MPH, Baker Tilly
David Jacofsky, MD, The Core Institute
David Gregory, MPA, FACHE, Baker Tilly
Nipun Sodhi, MD, Lenox Hill Hospital, Northwell Health

Abstract: Introduction
Robotic assisted total knee arthroplasty (rTKA) has shown the potential to help improve clinical, radiographic, and patient-reported outcomes 1-3. The purpose of this study was to compare healthcare utilization and costs between robotic assisted and manual TKA (rTKA, mTKA). Specifically: (1) index costs; (2) discharge dispositions; and (3) 30-; (4) 60-; and (5) 90-day: a) total episode-of-care (EOC) costs, b) post-operative healthcare utilization, and c) readmissions.

Methods
The Medicare 100% Standard Analytical Files were queried for rTKA and mTKA between January 1, 2016 and March 31, 2017. After inclusion and exclusion criteria, and 1:5 propensity score matching based on age, sex, race, geography, and comorbidities, 519 rTKA and 2,595 mTKA cases were analyzed. Total episode costs, healthcare utilization, and readmissions, at 30-, 60-, and 90-day time points were compared between cohorts with a generalized Linear Model, Binomial Regression, log link, Mann-Whitney, and Pearson's Chi Squared tests with p<0.05 for statistical significance.

Results
The robotic vs. manual cohort average total episode payment was $17,768 vs. $19,899 (p<0.0001) at 30-days; $18,174 vs. $20,492 (p<0.0001) at 60-days; and $18,568 vs. $20,960 (p<0.0001) at 90-days. At 30 days, 47% fewer rTKA patients utilized SNF services (13.5 vs. 25.4%, p<0.0001) and had lower SNF costs at 30- ($6,416 vs. $7,732; p = 0.0040), 60- ($6,678 vs. $7,901, p=0.0072), and 90-days ($7,201 vs. $7,947, p=0.0230). rTKA patients also utilized fewer home-health visits and costs at each time point (p<0.05). Additionally, 31.3% fewer rTKA patients utilized emergency room services at 30-days postoperatively and had significantly fewer 90-day readmissions (5.20 vs. 7.75%; p=0.0423).

Conclusion
Robotic assisted TKA was associated with lower 30-, 60-, and 90-day post-operative EOC costs and reduced 90-day readmissions. These lower costs can likely be associated with shorter lengths-of-stay, higher rates of discharge to home, reduced post-operative resource utilization, and fewer readmissions.

Improved Cleaning with Enzymes

Authors:
John Howell, Technical Service Scientist, Novozymes North America
Mike Palazzo, Account Manager, Novozymes North America
Andressa Bisol, Business Analyst, Novozymes North America

Abstract: Inadequate cleaning of medical instruments can cause serious problems in hte operating room, leading to increased costs. Enzymatic detergents, designed specifically for cleaning reusable medical devices, have been used for several decades and are supported by indsutry studies demonstrating improved performance over non-enzymatic detergents. However, current medical device cleaners, meeting today's cleaning guidelines, may not showe effective performance on clinical soils. In this study, we evaluated the impact of using multiple enzymes under various dosages to determine the impact on the cleaning process and, ultimately..patient outcomes in the OR.

Increasing Competence of PACU RNs Responding to Code Blue

Authors:
Ayumi Fielden, Critical Care Clinical Nurse Expert, Houston Methodist Hospital
Laura Ortiz, MSN, BBA, RN, CCRN, OB Perioperative Coordinator & Educator, Houston Methodist Hospital
Pamela Northrop, MSN, RN, CPAN, CAPA, Nurse Education Specialist, Houston Methodist Hospital
Xavia Holmes-Fuller, MSN, RN, CCRN, Neuroscience Service Line Nurse Educator, Houston Methodist Hospital

Abstract: Background:
Cardiopulmonary arrest (Code Blue) remains a high risk, low frequency event in Post-Anesthesia Care Units (PACUs). Literature denotes that healthcare facilities should implement Code Blue refresher programs to bridge the gap amid initial and recertification of Advanced Cardiac Life Support (ACLS) and Basic Life Support (BLS) skills due to the loss of knowledge in as little as two weeks after certification. A gap analysis revealed that PACU RN’s compliance to the American Heart Association (AHA)’s ACLS and BLS guidelines during mock Code Blues were suboptimal.

Purpose of the study:
The purpose of this project was to increase PACU RN’s compliance and competence in ACLS and BLS skills while responding to Code Blues.

Strategies for implementation:
Baseline assessment of PACU RN Code Blue response was completed during mock Code Blue drills using a forty-six item standardized observation tool. Areas of opportunity led to the creation of monthly ACLS refresher workshops focusing on teamwork, ACLS algorithms, medication management, BLS skills, and in-situ Code Blue drills. Participant performances were re-evaluated using the same tool following the workshops during mock Code Blue drills several weeks after the last workshop.

Outcomes/Results:
Initial assessment revealed a 33.4% Code Blue management compliance, whereas the post-intervention score increased to 92.2%. Tachycardia and bradycardia algorithm adherence increased from 28% to 91.2% and 21.4% to 81%; BLS adherence increased from 40.6% to 96%. Furthermore, 64.3% of participants initially met AHA’s guidelines for initiating chest compression; however, after intervention 100% of the participants initiated chest compression post-intervention appropriately.

Discussion:
The AHA emphasizes the importance of ACLS and BLS skills in the chain of survival. BLS components such as: quality and timing of chest compression, and ventilation skills improved significantly as did the adherence to ACLS guidelines. The PACU RN’s response to cardiac arrest and deteriorating patient conditions using ACLS standards indicate that reinforcing ACLS skills leads to increase in knowledge.

Conclusion:
ACLS refresher programs should be implemented in PACUs to bridge knowledge gaps between certification and recertification. Reinforcement of AHA guidelines lead to an increase in competence in Code Blue management, in-hospital cardiac survival rates, and improved patient outcomes.

Increasing First Case On Time Starts in an Ambulatory Surgery Center

Authors:
Diane Fecteau, MSA, RN, CASC, NE-BC, Executive Director, Maine Medical Center Scarborough Surgery Center
Shannan Reid, BSN, RN, CNOR, OR Director, Maine Medical Center Scarborough Surgery Center
Sydney Green, BS, Operational Excellence Intern, Maine Medical Center
Ruth Hanselman, BA, LSSBB, Program Manager Operational Excellence, Maine Medical Center

Abstract: The purpose of this Operational Excellence performance improvement project was to increase the percent of first cases of the day that start on time to 70% or greater in a ten room ambulatory surgery center.” On-time” was defined as starting on or before the scheduled surgery patient in the room time (no “grace period”). Improving on-time first case starts within Maine Medical Center (MMC) Scarborough Surgery Center (SSC) is important as it directly affects the patient experience as well as the respect between members of the operating room team. Patients expect to have a procedure started within a reasonable time after their arrival. When delayed, this causes patient and family anxiety and delays subsequent patients in a cascading impact. Through this initiative, MMC SSC will be positively impacted by improved patient satisfaction, as well as an increase in care team well-being with improved respect, efficiency, and accountability from all team members.
A multidisciplinary First Case On-Time Starts Workgroup was formed and case delay data was collected. A root cause analysis of the causes for late first case starts revealed surgeon late arrival (42%), patient late arrival (16%), and medication issues (8%) accounted for 66% of the late starts. Actions were taken to address these issues, including 1:1 conversations with late surgeons followed by posting names of late surgeons, adjusting patient arrival times for specific patient populations, calling all first case patients the day before to remind of arrival time, and staffing an onsite pharmacist.

Outcomes improved and on time first case starts, averaging 50.2% in October 2018, improved to 76% and 69% in May and June, 2019, respectively.

Inpatient Pre-op RN to RN Handoff

Authors:
Juli Edge , BSN, RN, CPN, Clinical Nurse Manager , Phoenix Childrens Hospital
Tracy Herbert, MSN, RN, CPN, Clinical Director, Phoenix Childrens Hospital
Amber Senetza, MSN, RN, CPN , Clinical Educator , Phoenix Childrens Hospital

Abstract: Background: Standardizing the process of Inpatient Pre-Op addresses patient safety concerns that arise from a lack of RN to RN report, multiple hand-offs in care, and delays in patient surgery. Previously there was no RN to RN verbal handoff, as the OR unit coordinator would call the Inpatient RN to bring the patient to Pre-Op. The lack of RN to RN verbal handoff resulted in incomplete transfer of care elements. No verbal handoff has the potential for patient errors and incomplete patient preparation prior to surgery.

Objectives: The primary goal was to improve consistency with RN to RN verbal handoff for all Inpatients going to the OR. The integration of verbal handoff allows the Inpatient Pre-Op RN to effectively collaborate with the Acute Care RN on the patient’s condition, and address concerns prior to surgery. The outcome of this quality improvement initiative was to improve patient readiness for surgery, prevent delays, and enhance the patient and family experience.

Process of Implementation: An Acute Care and Perioperative Services taskforce was established to develop a consistent practice for all patients going to the OR. An 18-month internal audit was performed to identify missing elements in preparing the patient prior to surgery. The audit supported a need to create a new role for an assigned Inpatient Pre-Op RN. Staff participated in developing a standardized patient history questionnaire to obtain a thorough and complete handoff from the Inpatient RN. Obtaining a complete patient history prior to surgery decreases errors, increases unit efficiency, and standardizes the organizational process.

Successful Practice: The integration of verbal handoff between Pre-Op and Acute Care eliminated inconsistencies in practice, and improved patient readiness for surgery. The results showed how consistent RN to RN handoff helped to improve nurses’ performance in terms of patient safety, continuity of care, and improving quality outcomes.

Latex Allergy - Who is at Risk?

Authors:
Era V Burgos, BSN, RN, CNOR, Clinical Nurse III, Cedars Sinai Medical Center
Beverly Hall, BSN, RN, CNOR, Clinical Nurse III, Cedars Sinai Medical Center
Demerius Miller, BSN, RN, CNOR, Clinical Nurse IV, Cedars Sinai Medical Center
Ann Gilligan-Maruca, MSN, RN, CNML, Assistant Nurse Manager, Cedars Sinai Medical Center

Abstract: Quality Initiative
Latex allergies affect about 3 million people in the United States. Continuous exposure to latex products may sensitize the human body by causing mild to fatal reactions. All patients should be screened for latex allergy and sensitivity. This project aims to identify the value of asking additional screening questions during preoperative allergy screening and increase latex sensitivity awareness in the operating room of a large medical center.

Description of Team
A team was formed consisting of:

• 
  
  
  
  • Operating Room RNs
  
  
  • Nursing Administration
  
  
  • Anesthesia Pre-Procedure Evaluation Center (APEC) RNs
  
  
  
  

Preparation and Planning
A latex allergy questionnaire was created and used on preoperative patients undergoing elective surgery to determine: (1) the prevalence of a latex allergy or sensitivity, and (2) reactions to possible sources of latex allergen exposure and food cross sensitivities. An in-service was given to APEC RNs on the purpose of the project and to elicit their cooperation.

Assessment
Preoperative histories often do not obtain the information needed to determine a patient’s allergy or sensitivity to latex. With thorough questioning, patients may report reactions to balloons or gloves, even though they had not associated their reactions with latex in the product. The team wanted to establish the value of asking additional latex allergy and sensitivity questions to determine: (1) if a positive latex allergy was identified, were there associated reactions and risk factors noted, (2) if a negative latex allergy was reported, was there a correlated sensitivity with a positive response to one or more questions.

Implementation
During a seven-week period from June to August 2018, a test of change was conducted in the APEC. RNs surveyed 1392 patients undergoing elective surgery. Respondents were asked a Yes/No question on latex allergy history followed by three questions pertaining to latex allergen exposure and food cross sensitivities.  Respondents with an Unknown answer to the first question were placed in the same group as those with No answers.

Outcome
Results showed that 61% (40/66) of positive latex allergy respondents had an associated affirmative answer to one or more of the follow up questions. Additionally, 9.5% (132/1392) of total respondents who answered No/Unknown to latex allergy confirmed a history of one or more reactions to known latex allergens and food cross sensitivities.

Implications for Perioperative Nursing
A formal process to assess for latex allergy and sensitivity is important to promote patient safety. Staff education on the use of the latex allergy screening tool in every preoperative patient assessment will increase the identification of at risk patients and decrease adverse events related to latex products. It is the responsibility of every perioperative RN to identify patients who are latex sensitive, educate them about latex sensitivity/allergy and encourage them to seek screenings to verify latex allergy.

Less Pain and Less Opioid Use Reported Post-Operatively in Patients Undergoing Haptic Guided, Robotic-Arm Assisted Total Knee Arthroplasty (RATKA)

Author:
Kevin Barga, MS, RN, Sr. Project Manager, Stryker

Abstract: Introduction: The opioid crisis in the US has heightened awareness among healthcare professionals surrounding the need for an effective pain management strategy - prescribing opioids only when indicated, at the lowest effective dose and for the shortest duration necessary. This study explores the impact of robotic technology on pain and opioid use in patients undergoing total knee arthroplasty (TKA).

Methods: A focused review of recent publications that collected data on pain and opioid use with the haptic guided robotic-arm assisted technology was done. Three prospective cohort studies were identified. The first study compared 40 consecutive RATKA to 40 consecutive manual procedures. The second study compared 140 consecutive patients undergoing RATKA and 92 consecutive patients undergoing manual TKA. The third study compared 75 RATKA to 75 computer-navigated TKAs. All studies collected early post-operative pain (Visual Analog Scale - VAS scores) and analgesia requirements (morphine equivalents per day). One study compared pain at rest and pain with activity at 2 and 6-weeks post-op.

Results: In the early post-operative period, statistically significant less pain was reported in patients undergoing RATKA compared to manual TKA and computer navigation. One study showed statistically significant less pain in patients at rest and with activity. Statistically significant reduction in total morphine equivalent consumption in RATKA over manual and computer navigated TKA has been reported and 2 studies reported statistically significant shorter length of hospital stay in RATKA patients (Table 1).

Conclusion: Three cohort studies performed in different regions (UK, US and Australia) showed that patients undergoing haptic guided RATKA had less pain and required less opioids in the early post-op period compared to patients undergoing TKA with manual instruments or conventional computer navigation. Less pain was attributed to accuracy to plan of component placement and reduced injury to soft tissues.

References:
Kayani, B. et al. Robotic-arm assisted total knee arthroplasty is associated with improved early functional recovery and reduced time to hospital discharge compared with conventional jig-based total knee arthroplasty. Bone Joint J 2018;100-B:930–7.

Bhimani, S. et al. Postoperative Pain and Opioid Usage in Patients Undergoing Robotic-Assisted Total Knee Arthroplasty (TKA) versus Conventional TKA. EKS Orthopedic Conference. 2-3 May 2019. Valencia, Spain.

Stoker, MB et al., Do Total Knee Arthroplasty Surgical Instruments Influence Clinical Outcomes? A Prospective Parallel Study of 150 Patients. 2019 ORS Annual Meeting. 2-5 February 2019. Austin, TX.

Managing Perioperative Stress, Burnout, and Resilience in Today’s Operating Room

Authors:
Timothy Bell, BSN, RN, Director of Surgical Services, Harris Regional Hospital/ Western Carolina Univesity
Ramona Whichello, DNP, RN, Associate Professor, Western Carolina University
Sheila Price, MS, RN, Assistant Professor, Western Carolina University

Abstract: Statement of Problem: An integrated literature review was conducted to provide an understanding of perioperative stress, burnout, and resilience in today’s operating rooms.  Stress and burnout are a reality for nurses in the operating room.  Stressors come from a variety of contexts that include: the operating room environment, complexity of cases, in-experienced work-force, disruptive physicians, long call hours, and inadequate staffing models.  Sustained stress can have a negative impact on surgical nurses and lead to burnout syndrome.  Resilience is the ability for an individual to manage the effects of continued stress through adaptive behaviors that allows the person to function emotionally and physically normal despite the increased stressors.

Methodology:  An integrated literature was conducted to evaluate evidence-based information on the effects of perioperative nurse stress, burnout, and resilience in today’s operating room suites. Databases included Medline, Cumulative Index for Nursing and Allied Health Literature (CINAHL), and Association of PeriOperative Nurses. Examination for causes of nurse burnout and techniques that can be implemented to build resilience in the high stress role of the perioperative nursing were reviewed.  Twenty articles met inclusion and exclusion criteria.

Results/Findings:  There was a direct correlation between stress and burnout to resiliency among surgical nurses.  Continued stress can lead to burnout syndrome.  Nurses who experience burnout become emotionally and physically withdrawn.  Resilient nurses have the ability to overcome stress and adversity.  Resiliency programs promote self-efficacy, coping, and hope.  Surgical services managers can improve the overall surgical environment by decreasing stressors of staff.

Implications:  Reduced stressors and improved surgical environments promotes a positive work-place for surgical nurses.   Promotion of resiliency in surgical services helps nurses overcome stressors that may lead to eventual burnout.  Resiliency can be used as a tool to improve staff morale and maintain a positive working environment.

Support for Research:  None

Medication Time Out: Concurrent Use of Methylene Blue and Serotonin Reuptake Inhibitors

Author:
Thomas Halton, RN, Ambulatory Surgery Center

Abstract: Serotonin reuptake inhibitors ( SRI's) are one of the most commonly prescribed antidepressants. They can ease symptoms of moderate to severe depression, are relatively safe and typically cause fewer side effects than other types of antidepressants do. SRI's ease depression by increasing levels of serotonin in the brain. Serotonin is one of the chemical messengers (neurotransmitters) that carry signals between brain cells. SRIs block the reabsorption (reuptake) of serotonin in the brain, making more serotonin available. The use of Methylene Blue during surgery is a potent MAO inhibitor often administered intravenously by anesthesia providers for a variety of clinical uses such as an intraoperative urologic marker dye. When combined with a variety of medications with serotonergic activity, may contribute to serious sequelae secondary to serotonin toxicity. A retrospective QI examination of a patient with a medication history of taking SRI’s is presented. A Strategy to heighten staff awareness during the Medication Time Out prior to starting surgery is presented to prevent harm. Methylene Blue is a potent monoamine oxidase (MAO) inhibitor, and in combination with other serotonergic agents such as serotonin reuptake inhibitors (SSRIs), MB can produce serotonin toxicity in the perioperative period.

Military Surgical Team Communication: Implications for Safety

Author:
LTC Christopher Stucky, PhD, RN, CNOR, CSSM, NEA-BC, Nurse Scientist, CNSCI, Womack Army Medical Center

Abstract: Introduction: Medical error is the third leading cause of death in the United States, contributing to suboptimal care, serious patient injury, and mortality among beneficiaries in the Military Health System (MHS).  Recent media reports have scrutinized the safety and quality of military healthcare, including surgical complications, infection rates, clinician competence, and a reluctance of leaders to investigate operational processes.  Military leaders have aggressively committed to a continuous cycle of process improvement and a culture of safety with the goal to transform the MHS into a high-reliability organization (HRO).  The cornerstone of patient safety is effective clinician communication.  Military surgical teams are particularly susceptible to communication error because of potential barriers created by military rank, clinical specialty, and military culture.  With an operations tempo requiring the military to continually deploy small, agile surgical teams, effective interpersonal communication among these team members is vital to providing life-saving care on the battlefield.

Methods:  The purpose of our exploratory, prospective, cross-sectional study was to examine the association between social distance and interpersonal communication in a military surgical setting.  Using social network analysis to map the relationships and structure of interpersonal relations, we developed six networks (interaction frequency, close working relationship, socialization, advice-seeking, advice-giving, speaking-up/voice) and two models that represented communication effectiveness ratings for each participant.  We used the geodesic or network distance as a predictor of team member network position and assessed the relationship of distance to pairwise communication effectiveness with permutation-based quadratic assignment procedures.  We hypothesized that the shorter the network geodesic distance between two individuals, the smaller the difference between their communication effectiveness.

Results:  We administered a network survey to 50 surgical teams comprised of 45 multidisciplinary clinicians with 522 dyadic relationships.  There were significant and positive correlations between differences in communication effectiveness and geodesic distances across all five networks for both general (r = 0.819 – 0.894, p < .001 for all correlations) and task-specific (r = 0.729 – 0.834, p < .001 for all correlations) communication. This suggests that closer network ties between individuals are associated with smaller differences in communication effectiveness.  In the quadratic assignment procedures regression model, geodesic distance predicted task-specific communication (β = 0.056 - 0.163, p < .001 for all networks).  Interaction frequency, socialization, and advice-giving had the largest effect on task-specific communication difference.  We did not uncover authority gradients that affect speaking-up patterns among surgical clinicians.

Conclusions:  The findings have important implications for safety and quality.  Stronger connections in the interaction frequency, close working relationship, socialization, and advice networks were associated with smaller differences in communication effectiveness.  The ability of team members to communicate clinical information effectively is essential to building a culture of safety and is vital to progress towards high-reliability.  The military faces distinct communication challenges because of policies to rotate personnel, the presence of a clear rank structure, and anti-fraternization regulations.  Despite these challenges, overall communication effectiveness in military teams will likely improve by maintaining team consistency, fostering team cohesion, and allowing for frequent interaction both inside and outside of the work environment.

Novel Sterilization Process for Surgical Instruments

Authors:
Mary Bayers-Thering, MS, MBA, Research Manager, Kaleida Health/Buffalo General Medical Center
Juliette Mader, BSN, RN, Director Perioperative Services, Kaleida Health
Nancy Schoolfield, BA, CHL, CIS, CRCST, ST, Campus Director-Sterile Processing, Kaleida Health
Brian McGrath, M.D., UB MD Orthopaedics and Sports Medicine

Abstract: INTRODUCTION There is a need to improve sterile processing of surgical instrumentation. Our null hypothesis was that the TS Pod system would not improve the sterile processing of operating room equipment.

METHODS:  Three methods for orthopaedic instrument sterilization, over an 18 month period, were evaluated.   Processing time, costs, number of lifts, sterilization “incidents” and durability were reviewed.

RESULTS The TS PODS was evaluated over 18-months, preparing 2100 orthopedic joint replacement cases, based on processing time (time from decontamination to operating room availability), costs, lifts, sterilization “incidents”, and durability.  The processing time for surgical instruments is 45 min less using the TS POD method. Twenty percent of the time saving was observed prior to the autoclave, 70% of the savings was observed in the TS PODS rapid dry time,  10% time savings was in the transfer from the autoclave’s sterile racks to the case cart. There was no significant difference in the cost of disposable materials between the 3 methods. The staff lifted an average of 300 lbs. less using the TS POD. There was only one lift of each tray to load the TS POD. We observed a 0.5% incidents of breaks in sterilization in the non TS pod group, and 0.1% incident using the TS PODs.

CONCLUSION: The TS POD system demonstrated a clinically significant improvement in sterile processing of surgical instruments with a savings of 45 minutes.  The time savings can allow enough time to potentially add a surgical procedure. The incidence of sterile compromise was < 0.5 % in all groups.  There was a 300 lbs. reduction in lifting during sterilization of our orthopedic joint replacement cases. The reduction in strain on our employees will result in fewer injuries and a decrease in lost work hrs.  Instruments are stored in the TS PODS.

Nurse Intervention to Improve Patient Satisfaction Scores

Authors:
Fred Perry, BSN, RN, CNOR, CSSM, Surgical Coordinator Orthopedics, Neuro, Hand, and Neuro, HCA Healthcare Hospital Medical Center
Dennis Tidwell, BSN, RN Med, CNOR, Director, HCA Healthcare Hospital Medical Center
Candace Scheresky, BSN, RN, Orthopedic Coordinator, Memorial Hermann Hospital

Abstract: HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) is a patient satisfaction survey required by CMS (Centers for Medicare and Medicaid Services). The survey results are publicly reported; therefore results directly impact a hospital’s reputation. At our Hospital in Houston Texas, we noted that the fourth quarter of 2017 HCAHPS scores were dropping compared to the previous two quarters. In order to reverse this trend we reviewed both the patient comments and talked directly with our patients to discover the root cause of the drop in scores. We found that the patients and their families were pleased with our admission process. and the Day Surgery process.. A disconnect occurred when the family and patient were separated as the patient
entered Pre-Op Holding. From that point until the surgery was finished there was little communication from surgery until the family was placed in a conference room to talk with the surgeon. Often the patient was sent to the Day Surgery Unit or the floor without the family being aware of the transfer.

We addressed these concerns by initiating changes in our process.
1. On admission a contact phone number was obtained.
2. The family was given a pager to alert them when the surgery was finished.
3. When the patient moved to the operating room or if a delay occurs, the family would be notified
of the change.
4. The family is notified once the surgery has started.
5. The family would be updated each hour as the surgery progressed.
6. Another call would be made to the family by the nurse as the case was ending.
7. The contact phone number would alert the family of the patient transfer.

Within the next month, an increase in the HCAHP score was noted, with improving scores since.

OR Foot Traffic: A Modifiable Risk Factor for Surgical Site Infections

Author:
Debora S. Mulling, DNP, APRN, CNOR, DNP, University Health Care System, Inc.

Abstract: Purpose: The purpose of this quality improvement (QI) project was to observe and document the prevalence and reason for operating room (OR) door openings (DOs) and to develop a facility-specific evidenced-based initiative that seeks to minimize or alleviate excessive and unnecessary OR foot traffic.

Content: Discussions and observations among OR staff in our facility provided anecdotal evidence that AORN guidelines regarding OR traffic behavior were not being utilized by perioperative staff. Investigation of current patient care practice standards in our institution revealed no existing guidelines for OR traffic behavior. The need for an OR foot traffic QI project was further substantiated by a preliminary observational study performed in February 2017 by the systems engineering department (SED) which revealed excessive OR DOs when compared to other facilities in the United States.

Strategy for Implementation: A QI project was conducted utilizing the OR Foot Traffic Surveillance Tool for collection of data. The project involved 3 phases. Phase 1: Baseline data collected during pre-incision through post-incision surgical time frames. Phase 2: Development of an evidenced-based educational intervention for OR staff which addressed factors impacting frequency of OR-DOs. Phase 3: Data collection to determine the impact of the intervention on OR-DOs. OR-DO data for electively scheduled surgeries was collected for baseline (n=24 surgical procedures) and post-interventional (n=26 surgical procedures) DOs respectively in December 2017 and March 2018 for a total of 50 cases. Each data collection period was conducted over a 2-week interval by the DNP candidate.

Outcomes: The mean baseline OR DOs was 24.95 (95% CI 22.76 – 27.13) DOs/hour compared to 23.81 (95% CI 21.39-26.23, P-value 0.474) DOs/hour post-educational intervention: a 4.6% decrease in OR DOs. Common reasons for OR door openings for were procurement of supplies and communication. Personnel classifications most attributable DOs were circulators, scrub technicians, anesthesia personnel, and vendors.

PACU Critical Care Program: Increasing Preceptor Knowledge and Confidence to Foster Future Generations of RNs

Authors:
Ayumi Fielden, MSN, RN, CCRN-K, CPAN, Critical Care Clinical Nurse Expert, Houston Methodist Hospital
Laura Ortiz, MSN, BBA, RN, CCRN, OB Perioperative Coordinator & Educator, Houston Methodist Hospital
Pamela Northrop, MSN, RN, CPAN, CAPA, Nurse Education Specialist, Houston Methodist Hospital
Holly Rodriguez, BSN, RN-BC, CCRN-CMC, Staff nurse, Houston Methodist Hospital

Abstract: Introduction:
An academic medical center’s Post-Anesthesia Care Units (PACU) have increased bed space due to increasing surgical volume, patient acuity, and lack of Intensive Care Unit (ICU) beds. Often patients in the PACU require ICU care, requiring an increased stay in PACU due to increased monitoring requirements and medical interventions to stabilize patients postoperatively. Additional Critical Care (CC) training was evident as PACU Registered Nurses (RN) voiced widespread lack of confidence and knowledge in caring for post-surgical ICU patients. Providing CC education to all current PACU RNs is as unrealistic as it is time consuming and cost ineffective.

Purpose of the study:
The project’s goal was to create a program that increases CC knowledge and confidence levels in the PACU RN preceptors, who mentor and precept new employees, meanwhile mentoring current PACU staff.

Strategies for implementation:
A four class series, increasing in difficulty was completed over several months to allow the participants to learn and apply the concepts in small increments to maximize learning. Concepts included: post-surgical patient assessment, device management of various pacemakers, external ventricular devices, hemodynamics, lab interpretation and post-surgical complication management. Instruction consisted of didactic lectures and High Fidelity Simulation (HFS). A fifty-question pre and post intervention CC knowledge test and a thirteen-question Likert scale confidence survey measured the effectiveness of the program. Furthermore, a forty-item RAPIDS-Tool was used on day one and on the final day during HFS to evaluate participants’ performance rescuing a patient’s deteriorating condition.

Outcomes/Results:
Confidence levels increased from 3.14 to 4.14 noting a 20.1% increase. The CC knowledge score increased by 27.4%. Additionally, the RAPIDS-Tool score increased from 15.3 to 36.5, noting a 53.1% score increase.

Discussion:
Results indicate that the CC class improved confidence and knowledge; most importantly, it improved assessment skills and response to deteriorating patients. Participants voiced their intent to teach learned CC concepts to new employees and colleagues.

Implications for Perianesthesia Nurses and Future Research:
Including the CC program to PACU preceptor programs may benefit all PACU RNs via confident PACU preceptors/ mentors who share their new knowledge with other staff members caring for critical PACU patients.

Partnerships Between Nursing & Child Life Specialists: More than Just Fun and Games!

Authors:
Angie Common, BSN, CMS-RN, CNML, Clinical Nurse Supervisor, Michigan Medicine
Jessica Jarvis, CCLS, CFLE, Child Life Specialist, Michigan Medicine
Kathy Miller, MHA, BSN, RN, Registered Nurse, Michigan Medicine
Adam Gunckle, MSN, CRNA, Nurse Anesthesia , Michigan Medicine

Abstract: Background
• BCSC is the first Ambulatory Surgery Center (ASC) at Michigan Medicine to partner Nursing & Child Life Specialists (CLS)
• Pediatric patients have less anxiety and use less oral premedication with the intervention of a CLS and interactive distraction or play (Seiden et al, 2014).
Goals
• Decrease use of premedication in pre-op
• Decrease PACU length of stay (LOS)

Methods
• Stakeholders:
o Patients & families
o Nurses & patient care techs
o Child Life Specialists
o Anesthesiologists & CRNAs
• Child Life education for all perianesthesia and OR staff - June 2018
• iPads donated by the Mott Golf Foundation & private donors
• Age appropriate toy list identified by pre-op/PACU nurses
• Hallway designed for patients to select toys and obtain weight/height measurement
• Child Life interventions in pre-op
• iPad surgery handbook created by RNs & CLS to preview the operating room environment with patient and families
• MiChart report built to review all pediatric patients scheduled for surgery at BCSC
• Auto-page initiated to Nursing & Child Life when a pediatric patient checks-in for surgery

Evaluation
• Evaluation of success measured by percentage of premedication given to pediatric patients at BCSC vs LSC (Livonia Surgery Center)
• Evaluation of success measured by average length of PACU stay at BCSC vs LSC

Results
• Data collected on 86 pediatric patients (age 11 & younger) at both BCSC and LSC
• At BCSC CLS intervention present on 97.6% of patients in pre-op. Currently LSC does not employ a CLS.
• Percentage of premedication at BCSC is 20.9% vs LSC at 32.5%
• Average PACU LOS at BCSC is 64 minutes vs LSC 75 minutes

Significance/Conclusion
• Partnership between Nursing & CLS in ASC has resulted in a significant decrease in the use of premedication in pre-op
• Interventions with Nursing & CLS in ASC has proven to decrease the average PACU LOS

Pause....Specimen Safety Pause That Is

Author:
LeDell M Neufer, RN, CNOR, RN, Geisinger Medical Center

Abstract: Retention of foreign objects during an operative procedure is a devastating complication which can lead to additional operations, potential for infection, increased length of stay and other
complications for the patient. At our institution, we developed a multidisciplinary Task Force to assess risk strategies to mitigate surgical complications, such as retention of foreign objects. A retained surgical object is not exclusive to sponges, needles and instruments. With our high volume of minimally invasive procedures we discovered that a retained specimen is also a potential complication that required a prevention strategy.

We agreed that standardization of reliable practice, transparency and empowerment of the team are the key strategies to mitigate error in the operating room. In addition, we discovered that our
policies were complicated and redundant due to RCA (root cause analysis) and no longer clear in content. Therefore, the Specimen Safety Pause was developed by the Task Force. The Specimen Safety Pause is a verbal verification of specimens which takes place with the entire surgical team. The circulating RN calls for the Specimen Safety Pause just prior to initial count. The Surgeon sweeps the wound and determines that the surgical site is free from any retained objects including specimens. The Circulator verbally reviews the specimens obtained including documentation of specific pathology orders. Entire surgical team completes verification and/or necessary corrections. After confirmation is given by the Surgeon, the count is initiated.

Following a validation of specimens and correct count the surgical closure can begin. The Circulator records the pause in the Electronic Medical Record. All members of the surgical team have embraced this process as an effective way to improve patient safety. The implementation of the Specimen Safety Pause allowed us to assess and improve our practice, mitigate risk and empower our team to success. As a Health System improving practice to ensure patient safety demonstrates caring.

Perioperative Nursing Performance Improvement Recycling Initiative

Authors:
Barbara Belanger, MSN, RN, CNOR, Perioperative Clinical Nurse, Massachusetts General Hospital
Patrice Osgood, DNP, RN, CNOR, NE-BC, Associate Chief Operating Nurse, Massachusetts General Hospital
Sharon Bouyer-Ferullo, DNP, MA, RN, CNOR, Perioperative Project Manager, Massachusetts General Hospital

Abstract: Clinical Issue

“AORN believes that the perioperative [nurse] should serve as a steward of the environment…As stewards, perioperative [nurses] should actively promote and participate in sustainability practices that preserve natural resources, reduce waste, and minimize exposure to hazardous materials. Environmentally responsible practices must [comply with] local, state, and federal regulations, and should align with guidelines from professional organizations” (AORN, 2014, p. 1).  Massachusetts General Hospital (MGH) is committed to promoting recycling and sustainability in the organization’s work and patient care delivery environment.  This is demonstrated by initiatives, such as, a composting collaborative in the food delivery service area and green building innovations, policies guiding organization-wide processes, and departmental green teams.  (Partners, 2018).

AORN guidelines and MGH’s commitment are reflected in Patrice Osgood’s, RN, DNP, CNOR, NE-BC, Associate Chief Nurse continuous support for environmental sustainability in the Perioperative Services.  Dr. Osgood met with Barbara Belanger RN, MSN, CNOR to discuss an opportunity to implement performance improvement initiatives with recycling in the Operating Room. With Dr. Osgood’s guidance, leadership and support, the interdisciplinary OR Recycling Committee was organized to evaluate current practice, identify opportunities for performance improvement, collaborate to implement these ideas into practice, and evaluate the outcomes. The recycling, reducing and reusing triangle was a core concept in every discussion.  Statistical data regarding healthcare waste supported the perioperative nurses’ performance improvement efforts.

Description of Team

It was decided that an interdisciplinary membership would best promote performance improvement efforts with sustainability.  Inter-disciplinary perspectives of work place environmental issues and availability of resources. Barbara Belanger assumed the Committee Chair Position. Caitlin Yeaton, RN, BSN assumed the Committee Co-Chair Position.  Clinical nurses from several surgical services volunteered to join this committee as a voice for their peers. MGH Sustainability Director, Guillermo Banchiere and Partners’ Sustainability Director, Monica Nakielski, MGH Environment of Care Manager, Kevin Hegarty, and Patrice Osgood provided leadership support for innovations developed by the perioperative nurses. The Anesthesia team was represented by the Anesthesia Technology team leader. Sharon Bouyer-Ferullo, Perioperative Staff Specialist provided organization and direction for the committee work and communication.

Preparation and Planning

A charter was developed to guide the committee’s work as it evolved. Dynamic global changes with recycling influenced the planning process. Objectives were established for sustainability and included:

• To further reduce the carbon footprint of the OR by increasing recycling, reusing, and reducing waste coming out of the OR


• To understand the waste stream outside of the OR


• To collaborate with our colleagues and peers to understand what works and what does not work


• To start with small steps for success


• To implement practices that would decrease waste going to landfill


• To promote awareness


• To ensure there is clarity in the communication of practice changes

Assessment

Members toured the waste stream at MGH and affiliated regional recycling facilities, such as the single stream waste and paper recycling facilities. A survey sent to the OR staff collected qualitative data that evaluated current practice and barriers to effective recycling in the OR.  Barriers identified included but were not limited to space, lack of convenience, and inconsistency with individual understanding of what could be recycled. Quantitative data was collected through a pilot audit on waste generated by staff opening and not using items on the sterile field. The interdisciplinary perspective of our committee provided insight into what was possible and what might not be possible at this time.

Implementation

The committee findings and education of preliminary practice changes was communicated to the OR staff by the committee nurses in a presentation.  Collaborative educational opportunities with changes specific to the Pre-op and PACU areas were implemented.  A collaborative effort with the anesthesia team was initiated.

A pilot project was implemented to recycle waste in the lounge.

Discussions with vendors of available reprocessing practices led the education and implementation efforts to improve reprocessing compression sleeves in all areas of the Perioperative Services.

A trial with selling bags with the hospital logo in the gift shop made from blue wrap provided an option for reuse of blue wrap.

Triangular shaped recycling bins with dark green bags were placed in every OR room, lounges and locker room to promote convenience and standardization of practice. The triangular shape and green bags are universal symbols for recycling.

The committee members developed signs to promote clarity regarding what can be recycled and what is waste.  These signs were placed on or near every green recycling bin.

Outcome

A follow-up survey revealed staff satisfaction with standardized recycling bins and attention focused to improve recycling efforts in the OR.

The pilot audit to evaluate the cost of waste from unused opened sterile supplies increased awareness at the point of care.  Practice changes to open only what was needed was observed.

The amount of compression sleeves reprocessed increased – to the point where additional pick-up times had to be scheduled.

Communication of recycling updates and changes were implemented in the OR newsletter, presentations at staff meetings, peer-to-peer and email correspondence.

Implications for Perioperative Nursing

Our committee understands the dynamic nature of global recycling and the impact on developing effective recycling processes in the OR.  Perioperative nurses will continue to evaluate and reevaluate efforts to promote sustainability from an intuitive and convenient perspective supported by data outcomes.

References

ANA. (2018). Retrieved at ANA. (2018). Retrieved at https://www.nursingworld.org/

Association of Operating Room Nurses (AORN), 2014, AORN position statement on environmental responsibility, AORN, Inc. p. 1-7.

AST. (2015, October 10). AST Guidelines for Environmental Practices in the Operating Room. Retrieved from AST.org/.

Lausten, G., (2007, April), Reduce-recycle-reuse: Guidelines for promoting perioperative waste management, AORN Journal, 85:4, p. 717-728

Partners Healthcare. (2018). Sustainability. Retrieved at https://www.partners.org.

Stanton, C. (2011). Creating a sustainable care environment. AORN Connections, 93(6), C1-C9.

Perioperative Skin It's Not Always Warm, Dry, and Intact

Author:
Heather Kooiker, MSN, RN, CNL, CNOR, CRNFA, Clinical Nurse Leader Surgical Services, Metro Health Univeristy of Michigan Health

Abstract: The centers for Medicaid and Medicare Services consider hospital-acquired skin injuries a Never-Event, and yet hospital systems across the country struggle with increasing numbers of hospital-related skin injuries. Skin injury risk identification, prevention, and intervention have primarily been a focus on inpatient hospital units, although the literature suggests that the incidence of pressure injury occurring following surgery or a procedure may contribute to over half of all hospital-related skin injuries. Many pressure injured patients are not identified as high risk upon admission to the surgical or procedural areas, and thus, skin injury prevention has typically not been a focus of care in these departments. The global aim of this project is to create a culture of “Never” for skin injuries; to bridge the communication gap between procedural and inpatient nursing departments; to see a decrease in skin injuries, while also realizing an increase in department staff participation and increased patient satisfaction and trust. The scope of this project includes all the phases of care within surgical services and procedural areas. All identified areas will launch an evidence-based skin injury prevention bundle on May 27, 2018 with a goal of 95% participation of all roles by July 1, 2018. Participation will be measured using an audit process and observation. Evidence of a decrease in skin injuries will be collected using a focus case study report, and interventions resulting in improvement will be sustained through audits and compliance monitoring.  The Knowledge-to-Action-Cycle is the frame work method that will be used to initiate and complete this project.  In conclusion, decreasing the risks of skin injury on a perioperative/procedural patient depends on risk identification. By utilizing a validated risk assessment tool and implementing an evidence-based skin injury prevention bundle, skin injuries will decrease in occurrence in the surgical/procedural areas.

PPE in the Prevention of Occupational Exposure

Author:
Cheron M Rojo, AA, CRCST, CIS, CER, CFER, CHL, Clinical Education Coordinator, Healthmark Industries

Abstract: The sterile processing decontamination area is a fast-moving multiplex environment where sterile processing technicians must protect themselves from harsh chemicals and biohazards. This environment can contribute to cutting corners with personal protective equipment (PPE) by not using it correctly or by not having all the equipment necessary to fully protect themselves or be compliant with standards and regulatory bodies. AORN has recommendations for personal protective equipment which provide guidance on location, single-use vs reusable items, and what PPE consists of. Additionally, the CDC, OSHA, and AAMI contribute regulations and standards to support the use of personal protective equipment. Accurate compliance with personal protective equipment prevents the risk of biohazard occupational exposure. This poster “PPE in the prevention of Occupational Exposures” focuses on the compliance surrounding personal protective equipment in coherence to standards and regulations.

Prions to Pathways: Safeguarding Against Creutzfeldt-Jakob Disease in the Operating Room

Authors:
Jessica Mary Adams Atkinson, BSN, BSAVS, RN, Operating Room Manager, Maine Medical Center
Sonja Carol Orff, MS, RN, CNL, Quality and Safety Coordinator, Maine Medical Center

Abstract: Creutzfeldt-Jakob Disease (CJD) is a rare, transmissible, and fatal illness. As defined by the Center for Disease Control, CJD is a rapidly progressive, invariably fatal neurodegenerative disorder believed to be caused by an abnormal isoform of a cellular glycoprotein known as the prion protein. The estimated occurrence worldwide and in the United States has been reported to affect approximately 1:1,000,000 people per year. The signs and symptoms of this disease can be misleading and brain biopsy is used to support diagnosis. The potential presence of CJD in the perioperative patient requires interdisciplinary care team collaboration. Today, the literature is limited, the body of knowledge is evolving and thus, there is modest evidence for the clinicians to translate into clinical practice. However, awareness and proactivity will safeguard the OR environment, staff, patients, and the institution against this insidious and often misdiagnosed disease. The purpose of this safety concept poster is to increase the understanding of CJD and its implications in the OR setting qualitatively. The focus will be to describe and demonstrate measures for consideration when developing institutional policy for management of the undirected brain biopsy. Experiences will also be shared how one institution transformed and optimized prevention strategies through enhancing patient identification pathways, developing multidirectional coordination and communication tools, and cultivating interprofessional debriefings resulting in harmonized patient care.

Key Words: Creutzfeldt-Jakob Disease, CJD, Operating Room, OR

Reducing Hospital Acquired Pressure Injury (HAPI) In CVOR

Author:
Joan Maschke, Nurse Manager, AdventHealth

Abstract: A perioperative pressure injury is any pressure-related injury that appears within the first 48-72 hours after surgery.  Hospital‐acquired PIs (HAPIs) negatively impact clinical outcomes, quality of life, healthcare cost and have become a “never” event from the standpoint of Medicare reimbursement.  Any patient undergoing surgery are at risk for pressure injury.  The Cardiovascular surgical patient population are at high-risk for HAPIs due to co-morbidities, ASA score greater than three and surgical procedures longer than 3 hours, exposing the patient to prolonged unrelieved pressure on the skin, possible friction and/or sheering during transfer.  Pressure injury prevention in the CVOR perioperative setting is an enormous undertaking, as options to reposition patients to relieve pressure are limited during cardiac surgery.

Purpose:  Today’s state-of-the-art Medical technology has manufactured Overlays that are engineered to address primary device related factors (such as prolonged pressure, skin shear, heat and moisture removal at the support surface interface) that contribute to pressure ulcers and discomfort in patients who are immobilized.  The purpose of this project is to evaluate the effectiveness of the dynamic support of an alternating low-air loss profile surface that provides periodic off-loading to augment tissue perfusion, and removes excess heat and moisture that can contribute to pressure injuries.

Description of the nursing initiative:  To implement best practices related to reducing pressure injuries in CVOR.

Implementation strategies:  Conduct a 90 Day Pilot Project utilizing a low-profile, alternating pressure overlay system on all 8 CVOR beds for all cases for 90 days, regardless of risk factors to evaluate its effectiveness in preventing peri-operative HAPIs during cardiac surgical procedure.

Evaluation of the impact/effectiveness on the organization:  During the 90-day pilot, 1109 cardiac procedures were performed with the use of the overlay and 1109 cardiac patients did not develop a PI with the use of the alternating pressure overlay.  Following the pilot, the department converted back to historical pressure injuries, averaging 1.25 patient(s)/month.  The novel technology was easily adopted by key stakeholders, operating staff, surgeon and patients with no adverse effects.  The pilot project provided evidence that the innovative overlay system prevented peri-operative pressure injuries for 3 months, a total of 1109 cardiac patients.

Further studies are underway to evaluate the ongoing effective and implementation of the overlay for the CVOR department with the intention to be utilized in other operating rooms were patients undergo long duration surgeries.

Implications for nursing practice:  Implications for perioperative nursing practice include utilizing an alternating pressure overlay as a measure to mitigate the risk of pressure injury in surgical patients scheduled for procedures 3 hours or greater in length. Ongoing, evidence based data and additional research is needed to identify best pressure injury prevention positioning devices that may be applied to all types of surgical patients.

Literature Support:  The best treatment for a pressure injury is PREVENTION.

Author Bio and Education

Joan G. Maschke MSN, RN, CNOR, RNC

Clinical Nurse Educator for Systems Surgical Services at Florida Hospital, Orlando, Florida.  Previously to this role, 25 years in the operating suites.  My interest, for pressure injury prevention grew, when I become a member of Florida Hospital HAPU Committee.  Opportunities for improvement were identified.  I became the lead of a special HAPI task force for Surgical Services.

Obtained nursing diploma at Centennial College in Scarborough, Ontario, Canada.  Immigrated to the United States in 2004 and pursued a Bachelor’s of science degree in nursing, Master of Science Nursing Informatics with American Sentinel University on-line education.

Comprehensive multi-system level, knowledge and experience pursuing opportunities to expand and develop leadership strategies with the latest technologies in our healthcare delivery system.

Certification Perioperative Nursing Practice: CNOR and National Certification Maternal Newborn Nursing: RNC

Professional Associates:  AORN, Sigma Theta Tau International Honor Society of Nursing, and College of Nurses.

Conflict of Interest (COI)

Declare no affiliations that could be perceived as conflicts of interest for this poster presentation.

Reducing Length of Stay with Education on an Enhanced Surgical Recovery (ESR) Protocol

Authors:
Lynda Schoppe, MSN, RN, CNOR, CNEcl, Perioperative Clinical Nurse Educator, St. David's South Austin Medical Center
Tara Buck, MSN, RN, CNOR, CSSM, Surgical Services Clinical Nurse Educator, St. David's South Austin Medical Center

Abstract: Reducing Length of Stay with Education on an Enhanced Surgical Recovery (ESR) Protocol Variability in care processes between providers is suggested as a factor in the recovery time for ESR patients. Studies indicate standardization of care with an ESR protocol will improve patient outcomes and experience. The protocol is a perioperative care bundle that applies unique care strategies, such as preoperative education and special nutritional requirements before surgery, fluid monitoring during surgery, and non-opioid pain relief approaches after surgery to help enhance postoperative recovery and reduce postoperative morbidity and length of stay (LOS).

In 2016, Healthcare Corporation of America (HCA) and St. David’s South Austin Medical Center (SAMC) ran an ESR trial for patients undergoing complex gastrointestinal and colorectal surgeries. The trial results showed a reduction in LOS of 3.67 days, a reduction in narcotic use and a reduced incidence of complications. Because of these overwhelmingly positive results SAMC is anticipating the inclusion of more surgeons from other specialties in the use of the ESR protocols.

Many different players are involved in what can be complex and unfamiliar care of ESR patients; one important aspect of applying an ESR protocol is to reduce practice variability among providers. When ESR protocol deviations occurred they were traced back to gaps in communication and education. The team worked to develop education and tools to standardize care actions, communications, and knowledge sharing among perioperative personnel caring for ESR patients, with the ultimate goal of reducing patient length of stay and the improving patient experience.
Our poster project outlines the development of education and implementation of tools provided to staff. The perioperative nursing staff providing care are critical to the successful implementation of the ESR protocol. By providing tools, resources, and education to the perioperative team, we secured a more collaborative and cohesive team attitude.

Solving the Error Crisis: Investigating the Specimen Process

Author:
Melodie Anderson, MSN, RN, CNOR, Perioperative Professional Nursing Development Specialist III, Southern Illinois Health Care

Abstract: Daily various types of tissue are removed to provide a diagnosis and treatment for our patients.  The patient goes through pain, fear, time off from work, cost of various tests, as well as juggling family issues to have a surgical procedure.  After the procedure they may have to wait for a period of time for the diagnosis of the specimen.  These results will provide insight to our physicians in planning and developing the individualized treatment for our patients.

June 3 to July 14, there were 10 reported events regarding specimen issues across the 3 facilities.  These events were from surgery/endoscopy rooms, imaging, and the emergency area.  Issues seen were lost specimens, labeling of specimen with inappropriate anatomical location, type of tissue, examination to be ordered, inadequate amount fixation of specimen and logging of specimens received in pathology.  An investigation was performed from the time the specimen was removed from the patient to the time the pathologist performs the examinations and testing of the specimen.

A walk through of the process was performed to identify opportunities that cause concerns in providing our patients with the diagnosis of the tissue so treatment can begin.  The timeline chosen was from the time the physician determines a specimen is to be taken, to the time the pathologist receives the specimen to perform the examinations and tests ordered from the physician.

Description of the team:

Team members included:

• Management and front line staff from each area in Perioperative Area:
  
  
  
  • Operating rooms
  
  
  • Endoscopy suites
  
  
  • Same Day Surgery/Ambulatory areas
  
  
  • Surgeon to champion the process
  
  
  
  


• Pathology department
  
  
  
  • Front line staff
  
  
  • Pathologist to champion the process
  
  
  
  


• Information Technology
  
  
  
  • IT staff to provide guidance and implementation for charting in the electrical medical records
  
  
  
  


• Process Improvement

Preparation and Planning:

The team examined and research best practices in specimen collection, and identifying commonalities that cause errors.

The team discussed the specimen process by:

• Identify problems in the specimen process


• Examining errors that had happened and ways or issues that could have caused problems in the current process


• Identified what part of the process we wanted to improve in
  
  
  
  • Start from the time the Surgeon identifies the need for a specimen and follow the steps to when pathology receives the specimen for examination.
  
  
  
  

The team:

• Mapped out each process for each facility


• Investigated and researched any similarities or differences


• Examined steps that could potentially work at each of the facilities


• Removed unnecessary steps in the process


• Developed a process to reduce redundancies


• Examined errors that had happened to identify any relationships, such as
  
  
  
  • Staff member/Physician
  
  
  • Specialty/type of surgery
  
  
  • Time of day
  
  
  • Number of specimens from a procedure
  
  
  • Labeling
    
    
    
    • Not labeling correctly, is a known safety factor that can carry adverse outcomes
      
      
      
      • Patient harm
      
      
      • Inappropriate treatment
      
      
      • Lengthy investigations
      
      
      • Corrective actions
      
      
      • Sometimes legal actions
      
      
      
      
    
    
    • Site of specimen
    
    
    • Laterality / level / multiple sites of specimens
    
    
    • Incorrect pathology exam ordered
    
    
    • Lost or no trace of specimen taken
    
    
    
    
  
  
  • Develop a process to trial
  
  
  
  

Assessment

• Team members were sent to a different facility where they did not work, to identify ways that were different


• Those members were able to assess a different process to see what could be used at each of the facilities:
  
  
  
  • Identify different ways that could be implemented at each facilities
  
  
  • Detect ways to shorten the steps in the process
  
  
  • Recognized areas that could cause an error in specimen collecting
  
  
  
  

Implementation

• Developed education for the process.


• Physician, pathologist, and front line staff from each area that was represented provided the education to each of the facility areas


• Staff at each of the facilities trialed the new specimen process


• Specimens were logged and investigated daily to identify any errors
  
  
  
  • Each specimen was examined to verify if any errors occurred in the new process
  
  
  • Errors were analyzed to confirm cause
  
  
  • Each error was investigated to develop ways to prevent the error from reoccurring.
  
  
  
  


• Team members walked the new process with staff from the perioperative areas to assist in answering questions that may occur.

Outcomes

Changes that occurred:

• Physician verifies with circulator and surgical scrub tech of a specimen.


• Appropriate verbal orders are given for the specimen.


• Circulator labels container for the specimen accordingly with physician’s verbal orders.


• Circulator verifies specimen label containing name of tissue, anatomical location, and orders given for tests with the surgical scrub technician.


• Implementation of orders for tissue documented through EHR only. (Removal of duplicate documentation)


• Appropriate fixative is placed on specimen for test by the circulator.


• Two nurses verify specimen.  (Removal of triplicate forms).


• Specimen is taken directly to the specimen deposit location after the debriefing, but prior to taking patient to Phase I Recovery.


• Specimen is logged into the log book to verify deposit of specimen and the EHR documentation printout is also placed in the log.


• Physician must sign the documentation of the specimen and place in patient chart.


• Pathology picks up specimens and documents in department’s logbook of pick up.


• Pathology transports specimen to their department and logs specimen.


• Pathology prepares specimen for pathologist accordingly to pathology protocol


• Education developed and given in various formats:  morning huddles, staff meetings, in-services, power point presentations, flyers, and modules.


• Improve specimen containers used within the departments.


• Able to delete incorrect orders became available with help of EHR

Major impacts

• Saves time and resources.


• More time for one-on-one patient care.


• Ensures debriefing post procedure.


• Increase staff satisfaction.


• Improve patient quality of care


• Prevents errors.


• Decrease frustration of staff.


• Eliminate rework.

Standardization

• Discovered the need for more printers to prevent staff from adding steps to the process in obtaining print outs of requisitions and labels for a specimen.


• Consistently notify errors in real time


• Communication of specimens in time out, de-brief, and hand-off.


• Orientation and training developed


• Annual education to monitor staff competency


• Future possibilities
  
  
  
  • Improvement with documentation labeling in the upgrading of computer software
  
  
  
  

The spike in 2018 occurred from upgrade in our EMR.  The errors mainly consisted of label printing, ordering and documentation.  No specimens were lost or not process appropriately.

The outcomes of errors are reported to Senior leadership on the Perioperative Service’s Dashboard to discuss issues that have happened and monitor results.

Implications for Perioperative Nursing

• Streamline the process and create a Standard Operating Process for specimens.


• Reduce risk for lost, mislabeling, or inappropriate fixative application to specimens.


• Improve quality of specimen integrity.


• Provide accurate diagnosis of the specimen


• Expedite the diagnosis to decrease wait time in patient treatment


• Maintain consistency of process at all three hospitals to promote collaboration among staff and practice the same process for obtaining and sending specimens to the pathology department


• Competent staff at all facilities


• Promote accountability among staff

Taking Back Surgical Flow

Authors:
Jennifer Prater, BSN, RN, CCRN, CPAN, Nurse Manager, Post Anesthesia Care Unit and Same Day Post Op, Abington Jefferson Health
Katie Domrzalski, BSN, RN, Team Coordinator, Post Anesthesia Care Unit and Same Day Post Op, Abington Jefferson Health

Abstract: Background
A centralized patient flow center (PFC) model was developed in our organization to control bed assignments and patient flow within the organization. This model promoted flow from the emergency room and internally throughout the hospital, primarily in response to “The Patient Flow Standard” issued by the Joint Commission. This standard, which went into effect January 1, 2014, recommended organizations have systems in place to prevent patients from “boarding” in the ED for greater than 4 hours. ED flow became an organizational goal for our institution and PACU quickly realized that surgical patients were at the bottom of the priority list for bed assignments. We proposed that direct contact with the receiving floors would improve wait times for surgical beds by eliminating additional steps and phone calls for bed assignments.
See diagram #1 for our initial bed request process. This involved 14 steps from meeting discharge criteria to leaving PACU. The new process (diagram #2) involves 8 steps.

Approach
In July 2017, PACU “took back the surgical flow”. A plan was developed in collaboration with a team of staff RNs from the PACU and the post-op surgical floors. This plan was presented to the director of the PFC and approved for a trial. Flow time involves ‘PACU discharge criteria time’ to ‘transport out time’ and comes directly from electronic documentation. Data was collected prior to the implementation of the new process and post-implementation. After several PDSA cycles, PACU now calls the charge nurse directly on each floor when the patient has met PACU discharge criteria and is ready for a bed. A monthly surgical patient flow collaborative meeting is held with the PACU, the PFC, and charge nurse representatives from each surgical floor, including the ICUs. This allows frontline staff to discuss flow issues and implement process changes as needed. Monthly flow times are shared and reviewed at this meeting. To maintain transparency, PACU still enters the assigned room numbers on the tracking board so that the PFC can see which rooms have been assigned.

Findings
Flow times went from an average PACU wait time of 59.6 minutes to a current wait time of 33.7 minutes. OR (PACU) holds went from 42 holds/month (552 minutes) to a current 0 OR/PACU holds.

In addition to our improved efficiencies, strong interdepartmental relationships have developed.

Our limitations to these findings are as follows:
• Consistency of PACU documentation for accurate data collection
• Variability of OR volume, cases, and OR flow
• Fluctuations in hospital census and overall bed availability
• Floor staffing and availability
• There are times when it may be appropriate to hold a patient in the PACU and send an ED patient to the room

Conclusion
This model of direct communication to the appropriate inpatient floor can be mimicked anywhere. We recognize the expertise of the PFC in placing in-house and ETC patients, and we realized benefits and efficiencies for our surgical patients by initiating direct contact with the receiving floor. The key to success is keeping communication open between the PFC, the ED, and the PACU and always prioritizing patient needs.

The Effectiveness of Video Education on Pre-operative Parental Knowledge and Anxiety

Author:
Terri Marcischak, Assistant Professor, APRN

Abstract: Pre-operative anxiety is a common and anticipated response to patients expecting to undergo anesthesia in preparation for surgery. Pre-operative parental anxiety can lead to increased anxiety in children, which is associated with physiologic alterations in the child. Pre-operative video education is an inexpensive method to increase knowledge and decrease pre-operative parental anxiety related to the perioperative process. An eight-minute educational video education tool was developed by the APRN and academic medical center that showed the parents and child what they could expect to see and hear the day of surgery. By addressing parental fear of the unknown, this project was able to both increase knowledge and decrease anxiety in the parents of children scheduled to undergo surgery.

The Highest Level of Disinfection Happens in a Centralized Processing Location

Authors:
Michelle Rabelo, MSN, RN, CRN, Nurse Manager, Tampa General Hospital
Carmen Murphy, MSN, RN, CIC, Infection Preventionist, Tampa Generall Hospital

The Journey From Evidence to Policy: Nursing Leads the Way: Writing the InterOperative Hyperthermic IntraPeritoneal Chemotherapy Administration Protocol

Author:
Marcy Mahoney Ackert, MSN, RN, PeriOperative Staff RN, SCLHEALTH (Saint Joseph Hospital, Denver CO)

Abstract: On review, we found our guidelines and those from other systems regarding protection of staff during PeriOp chemotherapy cases lacking. A clear gap in Evidenced Based knowledge was identified. The focus of this project was to incorporate EB research to write a thorough Policy to protect Staff from unintended exposure.

A team of key stakeholders and SMEs was formed and reviewed literature on occupational exposure and safe handling practices. The Policy was revised to include both EB practice and contributions from 139 interviewed Staff. Gaps in knowledge and skills were discussed.

An annually updated Policy (safeguarding against occupational exposure) is now in place.This includes specific Time-outs, equipment, workflows, staff assignments, and specimen handling. Constant reviews of practice occur and gaps in knowledge and skill have been closed through education/training.

The practice of PeriOp Nursing is ever-changing and MUST stay updated on new information. RNs are well positioned to influence practice and thus Policy changes. Using a multi-professional team approach was essential to success as was the support from the System. The PeriOperative Director was and is key to moving this complex Policy into Approval.

** we need Plain Language Policies for Frontline Healthcare workers

The OR and Beyond - CIS and Nursing Collaborate to Reduce Surgical Site Infections

Author:
Mary Mahabee-Betts, Nurse Mananger Perioperative Quality and Safety, Temple University Hospital

Abstract: Pre-operative anxiety is a common and anticipated response to patients expecting to undergo anesthesia in preparation for surgery. Pre-operative parental anxiety can lead to increased anxiety in children, which is associated with physiologic alterations in the child. Pre-operative video education is an inexpensive method to increase knowledge and decrease pre-operative parental anxiety related to the perioperative process. An eight-minute educational video education tool was developed by the APRN and academic medical center that showed the parents and child what they could expect to see and hear the day of surgery. By addressing parental fear of the unknown, this project was able to both increase knowledge and decrease anxiety in the parents of children scheduled to undergo surgery.

Timeouts Beyond the Operating Room: Expanding Universal Protocol to Inpatient Units

Authors:
Margaret Vance, MSN, RN, CNOR, Clinical Nurse Education Specialist, Pennsylvania Hospital: Penn Medicine
Tamala Proctor, MSN, RN, CCRN, Clinical Nurse Education Specialist, Pennsylvania Hospital
Kristen Schmidt, MSN, RN, CNOR, Senior Performance Improvement Advisor, Pennsylvania Hospital
Kaitlin Ronning, MSN, RN, CPAN, Clinical Nurse Education Specialist, Pennsylvania Hospital

Abstract: Purpose/Objectives

At the conclusion of the presentation, the learner will be able to: Recall national and regional trends in wrong site procedures. Understand safety trends within Pennsylvania Hospital’s Perioperative Services division. Verbalize the essential elements of the procedural Time Out at Pennsylvania Hospital per the entity-wide Universal Protocol Policy. Utilize the AHRQ TeamSTEPPS framework to facilitate effective communication within surgical/procedural teams. Articulate the escalation plan for non-compliance with Universal Protocol.

Content

National, regional, and local data on wrong site surgeries. The Joint Commission’s position statement on causes of wrong site surgeries.  Discussion on hospital actual and near miss events. Highlights of policy that was revised to increase compliance with regulatory standards. Implementation of TeamSTEPPS language.  Development of an escalation plan supported by perioperative leadership.

Strategies for Implementation

• Mandatory interactive multidisciplinary staff education sessions. Multiple sessions were delivered to interprofessional partners that included nurses, anesthesia providers, physicians, and technologists.


• Post educational program quiz.


• Pre and post implementation audits.


• Visual tools created with standardized language for each time out participant in the procedural rooms.


• Mini education sessions delivered to the inpatient units to target bedside procedures.


• Part of the perioperative division’s mandatory annual competency program.

Outcomes

Pre implementation timeout audits were at a 60% compliance rate.  Immediate post intervention audits resulting at a compliance rate of 83% to date. Increased knowledge to approximately 300 of perioperative services employees.

To Improve the Setup of Anesthetic Injection Trolley for Optimal Delivery of Anesthesia Induction Procedure

Author:
Janice Heng, Nurse Clinician, Singapore General Hospital

Abstract: PURPOSE/OBJECTIVES
To improve the setup of anesthetic injection trolley for optimal delivery of anesthesia induction procedure.

CONTENT
The setup of an anesthetic injection trolley include drawers and compartments for storing of pharmaceutical supplies, syringes, needles, intravenous cannulas, infuvalves, medication labels, sharps container and a general waste bag.  This ensures minimal time spent in gathering items required for induction of anesthesia.

However, with the current design medical gloves are located at a distance away from the injection trolley at a designated place, as they are shared by all staff in the Operating Room (OR). The general trash bag is hung on two ‘S’ hooks, making it cumbersome and dragging on the floor when it is filled. Feedback from anesthesiologists, verified by observations; making it necessary to improve the setup of the anesthetic injection trolley.

STRATEGIES FOR IMPLEMENTATION
The team used design thinking process to create prototypes for testing. These include:

• Create a place on the anesthetic injection trolley for gloves. First prototype glove holder was made of clear plastic Perspex material to accommodate two glove boxes. However, the plastic material broke easily and joints were difficult to clean, leading to infection control issues.


• Remove the ‘S’ hook and create a holder with base for the general wastes bag.

They were installed in one of the OR for in-field evaluation. Further modifications were made upon considering feedbacks from end-users.

OUTCOME
The second and final prototype of the glove holder was made from durable stainless steel, which can be easily cleaned by the nurses. Customized stainless steel holder with base for the general wastes bag provided a clear segregation of clean and dirty, thus optimized infection control practices. This new injection trolley setup was well received by the anesthesiologists and implemented to all the ORs at the National Heart Centre and Singapore General Hospital.

Use of Stabilized Ozonated Water for Infection Control in Hospital Environment

Authors:
Alice Leong Foong Wah, RN, OTNC, BHSN, MHSM, Deputy Director, Nursing, Khoo Teck Puat Hospital / Ministry of Health
Koh Kwong Fah, MBBS, MMED, FAMS, Senior Consultant, Anaesthesia, Khoo Teck Puat Hospital / Ministry of Health
Foo Meow Ling, BSN, RN, Nurse Clinician, Infection Control, Khoo Teck Puat Hospital / Ministry of Health
Ling Nee Ker, BEEE, Assistant Director, Operations Admin, Khoo Teck Puat Hospital / Ministry of Health
Jia Min, BSN, RN, Nurse Manager, Khoo Teck Puat Hospital / Ministry of Health

Abstract: Statement of problem:
Hospital pathogens can survive on surfaces and become reservoirs for spreading infection. Cleansing agents used in hospital is effective in disinfection, however they can be toxic and corrosive. Ozonated water has been widely used in food industry for disinfection. It is effective against Staphylococcus Aureus and Pseudomonas Aeruginosa with as little as 5ppm.

Each weekend, more than 100 procedure trolleys are transferred from Operating Theatre (OT) to Central Sterile Supplies Unit (CSSU) for washing and disinfection. This practice required substantial number of resources and time.

Our study aims to determine if trolleys can be cleaned using ozonated water within OT rather than sending them to CSSU for cleaning with Ultraclean(R) solution. This will save manpower, effort and time.

Methodology:
Ultraclean solution(R) and ozonated water (5-7 ppm) were used to clean trolleys using standardised methods. Forty trolleys randomly selected, 20 for each group were studied. The efficacy of cleaning was measured using Hygiena ATP system through detection of adenosine triphosphate levels.

Results/findings:

	Trolley Number	Trolley Before Cleaning RLU>100	Trolley After Cleaning RLU <100	Trolley After Cleaning RLU <50	Trolley After Cleaning RLU < 250	ATP Reduction level >90%
Ultraclean	20	10	19	19	16	60%
O3	20	14	18	14	13	50%

Relative Light Unit (RLU) is the measure of ATP; the greater the RLU, the greater the ATP and microbial load.

RLU threshold for public areas <100, patient rooms < 50, OT and ICU <20.

Conclusion & Recommendations:
The study showed that cleaning of procedure trolleys with ozonated water is able to achieve comparable microbial reduction as when Ultraclean(R) was used. Findings also showed that process and methodology of cleaning of trolleys is as important as solutions used as microbial grow on surfaces with time. We concluded that ozonated water can be used to clean trolleys. We recommended continue use of alcohol wipes on trolleys before utilization to minimise microbial contamination.

Support for research:
We thank our hospital management for supporting us with the 16^th Rapid Prototyping Grant. We like to express our gratitude to Infection Control and Perioperative Teams for their collaborative support in this project.

 

Using Telehealth Intervention to Improve Surgical Outcomes for Uncontrolled DM

Author:
Christine Mott, APRN/Teaching Assistant Professor, WVU Medicine/WVU School of Nursing

Abstract: Uncontrolled diabetes during perioperative period can result in a variety of adverse post op outcomes. Telehealth interventions have been identified as a potential solution to improving glycemic control for patients who experience health disparities and for patients in the preoperative period. A quality improvement project was conducted with 50 participants with uncontrolled DM type 2. Intervention involved scripted message on improving glycemic control during the preoperative period. Results were not statistically significant but there may be some clinical significance in participants choosing to delay surgery and potentially preventing adverse outcomes.