All posts by Marrianne

Operating Room, Patient Safety

Communication in the OR

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The operating room is a culturally diverse background with various levels of multidisciplinary professionals working collaboratively to deliver optimized care.

 

 

A study by the British Journal of Anaesthesia, identifies;

 

 

 

  • Failures in peri-operative communication contributed to patient injury in 43% of 910 anaesthesia malpractice claims

 

 

  • The most common root cause of communication failure was insufficient or inaccurate information, occurring in 30% of procedures

 

 

As part of a team that assessed RCA’s and near misses, communication was highlighted as a contributing factor in a majority of cases. Nurses stated they did not feel heard and confident, especially as a novice.

 

 

Surgeons may also feel unsupported by staff they are unfamiliar with or who are unfamiliar with the flow of surgery.

 

 

We need to empower all operating room professionals to work collaboratively, but we also need to empower and provide knowledge and support to our clinicians, in order to support, and deliver enhanced patient care.

 

 

The annual cost of medical errors likely exceeds $17 billion, with 35% being surgery related

 

 

 

A recent publication, Towards the Future of Surgery, 2024 has highlighted the need for surgeons to further develop their soft skills.

 

 

This is something we should all consider. Here’s a little insight.

 

 

 

“It is clear how patient outcomes are becoming less and less dependent on technical skills (however, this is always essential) and increasingly dependent on non-technical skills. Surgeons have the potential to improve patient outcomes, reduce medical errors, and improve patient satisfaction through their leadership on the multidisciplinary team.”

 

 

“Leadership in surgery entails many non-technical skills, including professionalism, technical competence, motivation, innovation, teamwork, communication skills, decision making, business acumen, ethics, emotional competence, resilience and effective teaching.”

 

 

“Surgeons have the potential to improve patient outcomes, reduce medical errors, and improve patient satisfaction through their leadership on the multidisciplinary team.”

 

 

 

I believe we all have the ability to improve patient outcomes.

 

 

Our use of checklists, such as the Surgical Safety Checklist has reduced errors by 30%.

 

 

Research shows we can improve patient outcomes by developing a team culture by easily identifying surgical team members, via scrub or cap identification.

 

 

Team huddle has also improved team collaboration and work flow.

 

 

Effective communication aims to streamline practices and utilizing resources to share information is key when stakes and patient lives are at risk.

 

 

 

Lets all aim to improve communication, empower clinicians and share our clinical expertise.

 

 

 

 

 

 

ttps://www.bjanaesthesia.org.uk/article/S0007-0912(21)00349-4/fulltext

 

 

Towards the Future of Surgery, 2024

 

https://link.springer.com/book/10.1007/978-3-031-47623-5

Operating Room, Patient Safety

Situational Awareness in the OR

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The OR is an environment where the room for error in minimal, time is critical and perfection is expected 100% of the time.

 

 

Situational Awareness that can have a significant impact on the flow of surgery, time & costs.

 

 

Situational awareness encompasses the ability to observe, listen, absorb and act swiftly. 

 

 

A change in the environment can be sudden and simultaneous. Eg, a surgeon may have an uncontrolled bleeding vessel, whilst the anaesthetist is having problems securing a dislodged airway.

 

 

Distractions are the costly, which is why 100% attention should be focused on the patient and care delivery.

 

 

Each OR nurse/tech/ODP, should be aware of the environment in order to work as a team, prioritise and support the care required, in order to stabilise a situation.

 

 

Demonstrating situational awareness is critical to patient safety and team cohesiveness.

 

 

Recognising a change in the environment, and troubleshooting or prioritising a task prior to verbal direction can save time. An instrument nurse/tech/ODP may only need to move their eyes, in a certain direction, in order to communicate a task, to the circulator.

 

A circulator may use verbal and non-verbal communication to the instrument nurse/tech/ODP if there is an observation that is of concern, such as low irrigation fluids, especially if the surgeon has a bleeding vessel.

 

 

 

 

Timing is key and costly.

 

 

 

 

If the need to obtain a bag of fluids is required by the circulator, it is important they obtain direction by the instrument nurse/tech/ODP, as they may prefer the circulator to stay in the OR, due to the case going ‘open’, thus, requiring additional instrumentation & equipment.

 

Situational awareness requires assertiveness, listening to cues and observing minute changes, by all team members.

 

 

 

It can take years to develop & evolve these astute, efficient & life saving skills. 

 

 

 

 

Many senior OR staff have developed these astute skills over the years. Which is why experience and expertise should never be under valued or under estimated.

 

 

 

What does one minute of operating room time cost your organisation?

 

 

Education, Operating Room, Operating Room- Tips, Surgical Equipment, Surgical Supplies, Sutures

A Little About Sutures & Surgical Considerations

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About Sutures-Needle Point 

 

  1. Cutting Edge – 2x types- Conventional & Reverse
  • Has 2x opposing sides that slice through tissue
  • Cutting Conventional needles are predominantly used on skin closures

2. Taper Point

  • Needle is flattened or rounded
  • Spreads tissue without cutting, less traumatic, decreased bleeding
  • Widely used in various tissue, muscle, fat, peritoneum

3. Taper Point-Blunt

  • Tapered needle with blunt point
  • Used to prevent needle stick injuries

4. Taper Cut Needle

  • Predominantly used in Vascular & Cardio Thoracic surgery
  • Used on hard calcified tissue and on prosthetic grafts
  • Cutting needle passes through tissue easily and taper point passes through friable tissue

 

 

Surgical Considerations

 

Point sizes of a needle vary, according to the tissue and room or ‘bite’ size required

 

 

Points to consider when choosing a needle holder and loading a suture.

 

  1. Deep cavities require longer needle holders
  2. Thicker tissue may require stronger needle holders
  3. Load suture 1/3 of the distance from the swag
  4. Load suture at a 90 degree angle
  5. Needle should be loaded near the tip of the needle holder
  6. Confirm if the surgeon is right or left handed, load accordingly
  7. Needle holder should hold the needle in place and not move the needle when being used, usually the second clasp will hold in place
  8. Always be mindful of the tissue, the needle size and the length and size of the needle holder. Eg a small needle on a large & heavy needle holder may place pressure on the needle and break it.

 

 

Additional Considerations

 

  • Never give an orthopaedic surgeon a small needle holder, unless they ask for one

 

  • Always collect various size needle holders if unsure of size prior to surgery

 

  • Always confirm the suture type, needle size, needle point prior to opening a suture, they are costly and can be placed in the wrong packet at the end of a long day by a tired team member
Costs, Uncategorized

What is the Cost of Opened & Unused Sterile Supplies?

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According to a John Hopkins study, $15M US is lost in hospitals annually in unused sterile supplies.

 

Another study looking at neurosurgical procedures, identified $968.00US is wasted per surgical case on opened & unused supplies, this equates to a loss of $2.9M US, annually, in neurosurgery alone.

 

Preparation and knowledge on a surgical approach and procedure, may assist the team to determine the number of supplies required.

 

A senior colleague is able to estimate how many sterile packs are required at the beginning of a case, and the number required, on standby.

 

This preparation and forethought, reduces the time the circulator is out of the OR, and is therefore, available, to meet the immediate needs, of the surgical team.

 

Surgical cases vary, and understanding details about a patients medical background may assist the surgical team to identify the number of supplies required.

 

Eg, if a patient has not stopped anti-coagulents, may increase the need for additional items.

 

Communication with a surgeon prior to the surgery and confirming items before they are opened, reduces costs and wastage, however this may also invite unnecessary tension.

 

Situational awareness should be adhered to, at all times.

 

References

https://www.hopkinsmedicine.org/news/media/releases/study_documents_millions_in_unused_medical_supplies_in_us_operating_rooms_each_year

https://thejns.org/view/journals/j-neurosurg/126/2/article-p620.xml

https://kffhealthnews.org/news/tossing-unused-surgical-supplies-wastes-millions-of-dollars-study-finds/

Electro Surgical Unit, Patient Safety

Patient Safety using an Electro-Surgical Unit

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Patients rely on healthcare facilities & health professionals to look after them during their surgical journey. The aim is to leave a healthcare facility in a more optimal state than when they were admitted.

In the OR an electro surgical unit is used in 80% of surgical cases, this involves an electrical current that can be localised- Bipolar (cautery), or is an electrical circuit- Monopolar. Incidences of electro surgical injuries according to research are under reported.

 

Monopolar is an electrical current that flows through the patient and requires a patient return electrode which connects to the electro surgical unit.

Thermal injury is a result of a burn from the use of electro surgery. This is why jewellery, piercings and any metal implants should be flagged with the peri-operative team, prior to surgery.

Laparoscopic cases have been show to increase the incidence of a surgical burn injury.

 

Research suggests that 3.6 per 1,000 laparoscopic procedures may result in a burn injury.

 

Electro surgical units are also a fire source, they are commonly referred to as a fire stick.

 

“It is currently estimated that around 500 to 600 surgical fires occur annually in the United States”, this impacts on patient safety but also impacts on healthcare facilities, costing them ‘millions of dollars annually”.

 

In order to reduce surgical burns the surgical team are responsible for assessing equipment & instruments prior to all surgical cases.

 

It is important that all surgical instruments are checked prior to use, to prevent thermal injuries, particularly in laparoscopic/robotic cases, where the insulation of laparoscopic instruments can become worn and compromised.

Leads & connections should also be checked.

 

Patient positioning is also extremely important so that no body part is touching any metal, especially in lithotomy and prone cases.

 

There are other safety precautions healthcare workers need to be mindful of, including prep solutions- pooling, alcohol and the use of oxygen, especially in the airway.

 

Pacemakers and any metal implants should also be flagged with the peri-operative team, in order for them to prepare the right equipment in advance of the surgery.

 

Depending on the type of surgery, bipolar may be a safer option.

 

Lets educate & support our healthcare workers

 

Educating and supporting clinicians is vital to empowering and informing best and safe practice.

Training & education requires time by employees and employers.

 

The value in supporting electrosurgery education benefits the facility by empowering and encouraging safe practice in addition to increasing a clinicians level of competence and understanding, all of which impacts, on safe surgical care & outcomes.

 

 

References
https://pubmed.ncbi.nlm.nih.gov/30472721/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7456630/
https://www.jscimedcentral.com/jounal-article-info/Journal-of%C2%A0Dermatology%C2%A0and-Clinical-Research/Peri-Operative-Management-of-the–Patient-with-Body-Piercings-8253
https://www.infectioncontroltoday.com/view/managing-new-class-electrosurgical-risk
https://jackson-medical.com/prevent-electrosurgical-fires/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5599256/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3407433/
https://www.sciencedirect.com/science/article/abs/pii/S0002961016310285
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7456630/
Patient Safety, Policies

Costs of staff ‘running’ for supplies outside of the OR, could cost up to $1,500.00.

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A hospitals operating room, store room, can be overwhelming, lots of surgical trays, equipment & supplies everywhere, most of the time in an order that make sense to a supply administrator but not to the surgical team..argh and with limited details to find what you actually need, quickly.

 

This impacts on costs, why, because there are many times when a surgeon may need additional supplies, unexpectedly, intra-operatively. When equipment can not be easily found this builds tension in the OR, in addition to prolonging surgical time, which can also impact on patient outcomes.

 

Research suggests that nurses spend 26% of intra-operative time outside of the OR, attending to additional needs of the surgeon, which would involve collecting additional equipment and supplies to support an optimized surgical outcome.

 

If the equipment required is necessary this can bring the entire operating room to a stand still, costing approximately $1,500.00 for the loss of 15minutes, waiting for the nurse to find the equipment.

 

Research also suggests that nurses ‘spend 21minutes per shift looking for lost equipment, taking them away from direct patient care’.

 

Hospitals need to provide the infrastructure for clinicians to optimize patient safety and to support them in their roles which would remove unnecessary stress, that wastes critical time. Improving clinical resources to streamline practices will improve efficiency and productivity, which will impact on staff and patients.

 

https://www.sciencedirect.com/science/article/pii/S1743919118305338

 

 

https://www.himss.org/resources/applying-rtls-technology-improve-nurse-efficiency-and-patient-care#:~:text=Time%20spent%20looking%20for%20equipment%20certainly%20takes%20them%20away%20from,shift%20searching%20for%20lost%20equipment.

Patient Safety, Policies, Technology

Implications of Equipment Failure During Surgery

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Research states that, ‘Implications of equipment failure during surgery’, occurred in 92% of surgical cases.

According to research,’equipment failures occurred in 76.9% of surgical cases. Equipment availability was impacted by 37.3% of surgical cases.

Unfortunately this is not surprising to those in the industry. I have witnessed first hand the lack of operating room checks, due to, time poor staff, who are already overloaded with paperwork and surgical setups.

When I first started working in the operating room as an instrument and circulating nurse, one of the first things I was taught, was to check the OR environment. This involved turning wall switches on and off, increasing/decreasing hardware settings.

Fast forward twenty plus years and there is more equipment to check, that is more technical and complex.

Staff are not given time to check equipment and the environment, which leads to intra-operative delays, stress and tension. Surgical time is impacted, patient safety is impacted, the waitlist is impacted and costs increase.

I hope that as we engage in more specialised practices that time is spent on checking the surgical environment and hard ware prior to the start of a surgical case load, or that specialised technical support is available to take the load off our already time poor health care professionals.

If you are a facility that provides your staff with additional time to setup and check equipment or has a technical support person. I would love to hear from you.

Contact Us

 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9685966/

 

https://qualitysafety.bmj.com/content/22/9/710

 

 

Patient Safety, Uncategorized

Intra-Operative Pressure Injuries (PI)

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A patient has surgery to address a disease, illness, or trauma. They are vulnerable and anxious and surgery maybe the final option.

Surgery can be costly and a patient does not need another complication, such as a Pressure Injury (PI).

According to the Agency for Healthcare Research & Quality, pressure ulcers cost $9.1-$11.6 billion per year in the US. Cost of individual patient care ranges from $20,900 to 151,700 per pressure ulcer.

https://www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu1.html#:~:text=Cost%3A%20Pressure%20ulcers%20cost%20%249.1-%2411.6%20billion%20per%20year,ranges%20from%20%2420%2C900%20to%20151%2C700%20per%20pressure%20ulcer.

As healthcare professionals it is our role and responsibility to provide the best care we can, to our patients.

This is why pressure area care should be assessed and addressed.

There are a number factors that impact on intra-operative pressure care and what equipment should be used to support blood circulation and minimise pressure on vessels and tissue.

A patients own health and comorbidity can also impact on the predisposition for a postoperative PI.

Correct patient positioning, monitoring pressure sites and utilising equipment can aid in reducing PI. Moisture and heat sources such as a warming blankets can also play a role in the likelihood of skin breaking down.

It can be difficult to identify early stages of skin breakdown intra-operatively, which is why assessments and precautions should be undertaken preoperatively and postoperatively.

Research in identifying and educating health care workers is necessary to reduce the risks to patients. A 2019 study detected that 1 in 150 patients developed an intra-operative stage 1 PI. This study highlights the need for education and further research to assess a patients risk and implement strategies to reduce PI.

See more from AORN about how much a PI is costing your facility.

https://www.aorn.org/syntegrity/resources/tools-calculators/pressure-injury-calc#:~:text=Pressure%20ulcers%20costs%20hospitals%20up%20to%20%2426.8%20billion,first%2C%20calculate%20how%20much%20they%E2%80%99re%20costing%20your%20facility.

Patient Safety, Scrub

Communication in the OR & Valuing Senior OR Staff

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The operating room is an environment where the room for error is minimal and time is always critical.
Surgery is becoming more complex, technical & challenging, which is why, communication & experience should be valued, especially when it comes to operating room professionals.

Effective verbal, observation & listening skills are qualities all surgical team members must demonstrate. Rothrock (2011) states that, “ improved communication is imbedded in human factors, culture, and social systems, all of which are more complex than checklists, mnemonics, and acronyms”.

A senior and experienced OR nurse, ST or ODP is able to recognise a change in the environment, they are able to ‘read the room’ & assess where attention should be focused.

They are able to ask concise questions at pivotal moments.

Example, does the laparoscopic or robotic case need to be ‘opened’? If so what trays & equipment do I require? Is there a bleeding vessel, are more fluids required for irrigation, are additional clips, ties, endoloops required?

Senior staff are able to think ahead because of their experience and surgical exposure especially if they are skilled across multiple surgical specialties.

Time can be critical during these intense moments and cohesive teamwork is vital in reducing surgical time. Surgical errors and complications arise when there is tension.

Time and experience matter, and there is usually a higher cost for these skilled clinicians, is the money worth it? Yes indeed!

Experienced OR staff  bring a wealth of experience, they have trouble shooting skills & clinical knowledge, they are able to think quickly and prioritize the needs of the surgical team.

Surgical time can have a direct impact on a patient, leading to longer post-op recovery which can impact on reduced bed availability and increased hospital costs.

Thank you to all the senior operating room professionals who have a wealth of skills and experience. Never forget how valuable you are.

Patient Safety, Policies

Who is responsible for monitoring the Intra-Operative IDC?

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I wanted to get your feedback on this issue as I observe this intermittently across varying OR’s and I wondered who should take ownership or is it a collective level of responsibility?
The IDC (indwelling catheter) may have been placed by the surgical team, nurse or OR professional, once insitu, who is responsible for monitoring the urine output and if needed updating the fluid balance chart?
I have observed catheters not draining as the catheter was kinked after positioning the patient and this was only observed after I had completed a surgical count, connected equipment and opened all supplies, as a circulator there are other priorities which take place.
I have also observed the catheter being full, requiring a jug to empty it intra-operatively, and the other day the catheter had not drained anything after 1.5hrs into the case.
There are a number of reasons why the urine was not draining, this is for another blog, however my main concern is, who should be responsible for observing and monitoring urine output intra-operatively, or is it a collective level of responsibility?
Technology

Supporting All Operating Room Professionals

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So tell me what are your thoughts on the amount of documentation we are asked to complete whilst we are caring for our patient under anaesthetic.

In the hospitals I have worked, we have a scrub nurse, anaesthetic nurse & circulator or scout nurse. The documentation is both paper and electronic. Responsibilities about paper work vary, as a rule this is how it generally plays out, here in Australia.

1) Pre admission checklist usually completed by the anaesthetic nurse

2) Scanning of instrument trays or attaching stickers to patient notes

3) Time Out Checklist/ VTE Assessment- scrub/scout team

4) Intra – Operative nursing care form- scout nurse

5) Count Sheet- scrub/scout team

6) Chargeable Sheet- scout nurse

7) Prosthesis Sheet-scout nurse

Not to forget

8) Pathology documentation

I am sure that I may have missed some, please contact me regarding any other types of documentation your health facility may have.

I know there are a number of hospitals who still do not have computers in their operating rooms, as a result this documentation is completed manually. Then there are some OR’s that do have computers but not all of the documentation can be accessed via a PC, this requires us multi tasking on paper and PC.

What are your thoughts on this, is there an easier and more efficient way of managing this mandatory paper work. I think we are all in the same vote, although I am not sure if this process works any better in other parts of the world. Would appreciate your thoughts on this.

Regards

Marrianne (Allis Technology)