AORN Surgical Conference & Expo Education Sessions
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he educational opportunities at the AORN Surgical Conference & Expo 2014, and the associated continuing education contact hours, remain one of the biggest draws for nurses who attend the conference. The well-rounded curriculum at the 61st annual conference challenged sacred cows, such as whether the RN circulator and scrub person must perform the counts together, and exposed attendees to a wide variety of topics, including reducing pharmaceutical waste, clinical outcomes for pain management, environmental cleaning, specimen management, electronic documentation and data collection, and collaboration between the OR and sterile processing department. Additional topics included considerations for OR construction and design and giving an effective deposition. Specialized content was provided for nurse managers, such as establishing a “reliability culture,” and for ambulatory nurses, such as applying the AORN recommended practices to the ambulatory setting. Following are descriptions of some of the sessions.
ENVIRONMENTALLY SUSTAINABLE CONSTRUCTION Incorporating evidence-based design principles into hospital construction may be a significant investment, but the rewards are invaluable for patients and personnel and contribute to the overall success of the organization, said Rebecca McKenzie, MSN, MBA, RN. During “Evidence-Based Design Principles Transform Hospital Construction Projects,” she explained that health care leaders are challenged to incorporate the latest research and evidence-based designs when replacing aging health care facilities to create ORs that enhance operational efficiency and allow future adaptation of the next generation of health care clinical advancements.
McKenzie explained that measuring the effect of design elements is complex; therefore, when planning a health care construction project, certain principles, including current trends in health care facility design, must be considered. Do not underestimate the degree of community interest in and involvement with the construction project, she added. One important issue for community members is to ensure that environmentally sustainable construction is used. The goals in satisfying this need are to reduce operating costs, facilitate healthier and more productive occupants, and conserve natural resources. One example that McKenzie described is recycling steam and condensation from the facility’s steam sterilizers. To test functionality and avoid potentially costly mistakes during construction, the team at Duke University Medical Center, Durham, North Carolina, built a mock-up OR in a warehouse. McKenzie described how industry partners brought in and set up their equipment and products, and key stakeholders from all clinical areas tested the room with real-life scenarios. “Build vertically,” McKenzie recommended, “with the sterile processing department (SPD) under the OR.” This allows ORs to be grouped around sterile
AORN Education Session attendees learn ways to help improve their practice back home.
http://dx.doi.org/10.1016/j.aorn.2014.04.005
Ó AORN, Inc, 2014
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cores and for each sterile core to have an elevator to access the SPD below. Research supports transitioning the postanesthesia care unit (PACU) from the traditional open-bay approach to a more private threewalled design with modular walls converted to fixed walls to improve patient flow to and from the PACU. There are many issues that managers and executive team members have to consider when planning for health care facility construction projects, said Priscilla J. Ramseur, MSN, RN, CNOR. This includes strategically hiring personnel based on financial and full-time employee projections, determining bed and unit allocation, managing human resources and clinical service unit planning teams, and implementing electronic health records. Planning for proper orientation for all personnel is important but especially so for new nurse graduates, Ramseur said. Some staff education strategies that Ramseur described included n n n n n
AORN CONFERENCE EDUCATION SESSIONS AORN’s 45,000 members who work in an ambulatory surgery environment, explained Terri Link, MPH, RN, CNOR, CIC, AORN ambulatory education specialist. During “Specific Ambulatory Information for AORN Perioperative Standards and Recommended Practices,” Link explained that AORN developed this division to meet the needs of freestanding ambulatory surgery centers (ASCs) and office-based surgery centers that may have different needs than those of acute care facilities. To help readers identify ASC content in the Perioperative Standards and Recommended Practices, applicable content is flagged with a purple logo both in the table of contents and in the body of each recommended practices (RP) document. Mary Ogg, MSN, RN, CNOR, perioperative nursing specialist at AORN, emphasized that
producing facts and statistics sheets, providing open house tours with maps, using scavenger hunts to orient personnel, using patient simulations for reality-based orientation, and performing competency evaluation for all levels of personnel.
McKenzie emphasized the importance of including personnel from all departments when designing the new facility. Some suggestions that personnel recommended included taking advantage of engineering modalities such as nonslip flooring, same-sided rooms and configurations, and geographical adjacencies; using concepts that allow patient privacy and respect; and separating soiled and clean supplies transportation routes from patient transportation and product entries. Ramseur added that all key stakeholders should be linked to the project and have a vested interest in its success. APPLYING RECOMMENDED PRACTICES TO THE AMBULATORY SETTING AORN launched an Ambulatory Surgery Division in January 2013 to help represent the 38% of 686 j AORN Journal
Terri Link describes how to apply AORN standards and recommended practices to perioperative practice in ambulatory settings.
AORN CONFERENCE EDUCATION SESSIONS AORN’s RP documents are applicable to all procedural areas in both inpatient and outpatient settings. She noted that the RP documents are created via a rigorous evidence-rating process to ensure that they are evidence based. Ogg explained that a synthesis of the evidence is useful for explaining the “why” of changing practice to perioperative counterparts, particularly surgeons. Perioperative nurses in ASCs should follow the same evidence-based standards and recommended practices as their counterparts in acute, inpatient facilities. “The difference is how ASC personnel and administrators incorporate the recommendations into their policies and procedures,” Ogg said. She described how ASC managers can use the RP intervention statements as the basis for policy statements by simply changing intervention “should” statements to policy “must” statements. Link reviewed a scenario in which the surgical team at an ASC determined that a sponge was missing during a ganglion cyst excision under local anesthesia at 5 PM, when no radiology personnel were on-site. Link provided the audience with options for how the surgical team could respond to this situation, depending on their facility’s policies and procedures: n
Call a radiology technician in to take an x-ray. n Delay skin closure until the radiology technician arrives and takes the x-ray and the radiologist interprets the x-ray and clears it for the missing sponge. n Have the surgeon take a scan with the portable fluoroscopy unit. n Have the surgeon interpret the fluoroscopic scan to confirm the presence or absence of the missing sponge. As attendees responded to the options, Link used the opportunity to review the ASC-specific information provided at the end of the AORN “Recommended practices for the prevention of retained surgical items.” Link described how an ASC’s policy and procedure should be crafted regarding actions to take when on-site radiology
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services are not available to take an x-ray and interpret the result. As described in the scenario, it may be appropriate, depending on the facility’s policies and procedures, for a surgeon to locate the retained item if he or she is credentialed and privileged to use and interpret fluoroscopy studies. Jan Davidson, MSN, RN, CNOR, CASC, director of AORN’s Ambulatory Surgery Division, explained that ASC members should participate in the public commenting period for new RP documents to identify recommended practices that are applicable to ASC and office-based surgery settings. She added that nurses should recognize the importance of developing policies that reflect the differences between ASCs and inpatient facilities. AORN SYNTEGRITY: CONVERTING DATA FROM INFORMATION TO WISDOM At the session “Care Planning Using AORN SyntegrityÒ,” Kathleen D. Woods, BSN, RN, former AORN informatics nurse specialist, and Lynn W. Trabold, BS, RN-BC, a perioperative clinical informatics specialist at Abington Health, Abington, Pennsylvania, taught attendees about the Perioperative Nursing Data Set (PNDS), AORN Syntegrity, and how the two contribute to nursing processes and patient safety. AORN Syntegrity, a framework for integrating perioperative data with electronic health records, is based on the PNDS, the only standardized perioperative nursing language. The PNDS helps perioperative nurses communicate accurately, Woods said, and by using the PNDS to document perioperative nursing activities, nurses can demonstrate their contribution to patient care; ultimately, these data can be used for research. The aim of everything a perioperative nurse does is to minimize harm and protect the patient, the hallmark of a good care plan. Woods said, “Perioperative nurses do use care plans,” although many may not think they do. To illustrate her point, Woods presented a sample case study of a woman scheduled to undergo a bowel resection with possible diverting colostomy. She walked attendees through the nursing process, showing how AORN AORN Journal j 687
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Lynn Trabold describes how her facility implemented AORN Syntegrity to standardize the vocabulary used in the facility’s documentation system.
Syntegrity provides the necessary coded elements that correlate to the relevant steps in assessment, outcome, implementation, and evaluation. Nurses usually document patient care narratives one patient at a time. By standardizing communication and making it more accurate, PNDS and AORN Syntegrity do more than just allow the perioperative nurse to document perioperative care of a single patient; the extracted data can be used to tell the story of a population. “We need to go from a story of one to a story of many,” Woods said. “If we keep documenting for only one patient, we’re not going to get to the point where data can drive our actions.” Woods said, “AORN Syntegrity and the PNDS can help convert data to information, information to knowledge, and knowledge to wisdom.” Data on their own (eg, age, body mass index) have no 688 j AORN Journal
AORN CONFERENCE EDUCATION SESSIONS meaning. By showing how the data are relevant to a procedure, the data become useful information. After nurses have the correct knowledge and understand how their data affect all patients, they can develop the wisdom, or critical thinking, to prevent and react to situations that endanger patients. Trabold assisted her facility in implementing AORN Syntegrity and explained that they selected this documentation solution because they wanted a standardized vocabulary that would help ensure they were meeting standards and regulations without having to reinvent the wheel. They have been able to benchmark their facility against like organizations because they have more data for comparison and less free text. Trabold described the challenges they experienced, particularly that their vendor was not intimately familiar with the PNDS. She recommended that those considering implementation of electronic health records and AORN Syntegrity should ensure that their vendor is comfortable with AORN Syntegrity and PNDS. Trabold concluded the session by encouraging perioperative nurses to push back and be persistent if their managers or vendors are resistant to using AORN Syntegrity and PNDS because the improvement in patient outcomes justifies the effort. Editor’s note: The second edition of the Perioperative Nursing Data Set (PNDS) was superseded by the third edition (PNDS 3) in 2011. The PNDS 3 terminology is only distributed through AORN and AORN Syntegrity licensed vendors. For questions about PNDS 3 implementation into electronic health records and electronic perioperative record solutions, please contact the AORN Syntegrity team via e-mail at [email protected]. AORN Syntegrity is a registered trademark of AORN, Inc, Denver, CO. AORN RECOMMENDED PRACTICES FOR ENVIRONMENTAL CLEANING AND SPECIMEN MANAGEMENT Amber Wood, MSN, RN, CNOR, CIC, and Sharon Van Wicklin, MSN, RN, CNOR, CRNFA, CPSN, PLNC, perioperative nursing specialists at AORN,
AORN CONFERENCE EDUCATION SESSIONS presented “The Latest on Two New Recommended Practices: Environmental Cleaning and Specimen Management.” For the new “flip session” format, attendees listened to a preconference webinar and then attended the session, where they discussed patient scenarios and asked questions. There are several new concepts in the revised AORN “Recommended practices for environmental cleaning,” Wood said. These topics include using multidisciplinary teams for policymaking, using targeted cleaning procedures for high-touch objects, identifying what constitutes enhanced environmental cleaning, specifying cleaning methodologies (eg, top to bottom, clockwise, assignment of responsibilities), and measuring the cleanliness achieved (eg, visual inspection, fluorescent marking). For the scenario for environmental cleaning, Wood described a patient who underwent a
Amber Wood encourages attendees to break into groups to discuss the fictional scenario about errors in environmental cleaning.
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coronary artery bypass procedure and developed ventilator-associated pneumonia caused by a contaminated valve on the anesthesia machine. An investigation revealed that no knobs on the anesthesia machine had been cleaned. During discussion, attendees identified that a gap existed in assigning responsibility for cleaning the anesthesia equipment. One attendee noted that color coding equipment to identify who “owns” the equipment can help ensure that the equipment is cleaned and that no more than one person cleans it. In addition, attendees identified steps that perioperative personnel can take to help prevent missed cleaning, such as educating health care providers not to wrap and put away equipment after use unless it has been cleaned. Wood directed members to obtain the newly posted Environmental Cleaning Tool Kit on the AORN web site. She ended the session by telling attendees, “If you don’t believe in anything, you better believe in germs!” Van Wicklin covered the new concepts in the revised AORN “Recommended practices for specimen management.” The revised title more accurately depicts the role and actions of the perioperative RN as the manager of the patient’s care. The recommended practices document discusses how to manage a variety of surgical specimens (eg, new focus on documentation of time of excision and fixation of breast cancer specimens), describes how to prevent common errors in specimen management with simple redundancies, and alternatives to using formalin for fixation and preservation of specimens (eg, vacuum sealing). For the scenario, Van Wicklin described a series of small mistakes and misunderstandings that occurred during two consecutive procedures (eg, diagnostic, therapeutic) on one patient. In the scenario, a biopsy specimen incorrectly taken from the right kidney rather than the left led to assumptions about a cancer diagnosis, erroneous removal of a healthy kidney, and subsequent removal of the cancerous kidney, leaving the patient reliant on dialysis and needing a kidney transplant. During discussion of the scenario, attendees identified AORN Journal j 689
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multiple errors that had occurred, and with Van Wicklin’s help, they also determined the responsibilities of all involved parties: n n
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The patient was responsible for knowing on which side the biopsy was to be performed. The RN circulator had a responsibility not to pre-chart and to correct all paperwork when she determined that there was an inconsistency between the procedure that was scheduled and the one that was being performed. The RN circulator and radiology interventionist should have jointly ensured that the specimen was labeled correctly. The interventionist and surgeon were both responsible for performing site marking with the patient before their respective procedures. The surgeon was responsible for performing the informed consent process with the patient, which cannot be abdicated to the nurse.
AORN CONFERENCE EDUCATION SESSIONS regulate pharmaceutical waste, including the Controlled Substances Act (US Department of Justice, Drug Enforcement Agency), the Resource Conservation and Recovery Act-C hazardous waste rules (Environmental Protection Agency), Managing Pharmaceutical Waste (Healthcare Environmental Resource Center), and the University of Wisconsin Extension (Pharmaceutical Waste Reduction web site). Bickford also described how to use online tools to find ways to reduce pharmaceutical waste. During the session at the AORN Conference, Bickford instructed attendees to divide into groups and provided them with scenarios about commonly wasted medications (eg, dantrolene, pain medications, propofol, antibiotics). Attendees discussed the scenarios, as well as storage, disposal, and alternatives to current common practices. They followed a step-by-step process to develop strategies
One attendee summed it up best: “Nurses should never be afraid to questiondthat’s our responsibility as the patient advocate.” REDUCING PHARMACEUTICAL WASTE All hospitals and patient care sites must deal with pharmaceutical waste and disposal issues. This is because many of the medications that are used in health care settings are regulated and also can pose safety and environmental risks, explained Barb Bickford, MS, PG, a medical waste coordinator with the Wisconsin Department of Natural Resources, during “Pharmaceutical Waste: Handson Strategies to Reduce Waste in Perioperative Settings and Access Resources for Safe Disposal.” Nowhere is this more evident than in the perioperative area, where personnel handle and administer a large variety of medications. For the new “flip session” format, attendees listened to a preconference webinar and then attended the session, where they had the opportunity to ask questions. In the webinar, Bickford explained the regulations and organizations that 690 j AORN Journal
Barb Bickford describes the resources that are available to help reduce pharmaceutical waste.
AORN CONFERENCE EDUCATION SESSIONS to reduce the wastage, search the database for ideas, and evaluate their solutions to determine which strategy would be the best to implement first. After the group discussion activities, a spokesperson from each group presented their strategies and lessons learned. Bickford encouraged attendees to take the resulting solutions home for implementation in their ORs. A secondary goal of the flip session was for attendees to network and establish a group of contacts with whom to share successes and challenges regarding pharmaceutical waste. Bickford encouraged attendees to interact online with her at the Wisconsin Department of Natural Resources, as well as with Bonnie Denholm, MSN, BS, RN, CNOR, perioperative nursing specialist at AORN, and with other perioperative nurses on ORNurseLinkTM (http://ornurselink.aorn.org), where the results of the flip session scenarios are available.
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failure paths to a “class” of critical adverse events rather than focusing on the last single event. Team members also identify levels of dependency in the count process. Fully dependent counts (ie, RN circulator and scrub person count together) have been identified as a major weak link that results in count discrepancies. Killen explained that numerous strategies are being instituted at Memorial Sloan-Kettering Cancer Center to reduce RFOs, such as using forcing functions (eg, cues that force a hard stop in a process to prevent an error from occurring). These forcing functions include count cues (eg, the laparotomy sponge count equals a number that is not divisible by five) and visual cues (eg, the empty hole in the five-pack of peanuts immediately indicates that a peanut is missing). Killen also recommended enforcing “simple rules.” For example,
Editor’s note: ORNurseLink is a trademark of AORN, Inc, Denver, CO. RN CIRCULATOR AND SCRUB PERSON COUNT SIMULTANEOUSLYdIS THIS A SACRED COW? “We propose that the RN circulator does not need to be involved in the initial sponge and instrument count,” said Aileen R. Killen, PhD, RN, CPPS, during “Prevention of RFOs [Retained Foreign Objects]: It’s Not About the Count.” The RN circulator and scrub person still simultaneously perform counts of “ones,” such as needles. “We are here to challenge your thought processes,” Killen said. Sociotechnical-probabilistic risk assessment (ST-PRA) offers health care organizations a technique to analyze the relationships between errors, choices, and technical aspects of current strategies, explained David Marx, JD, BS, president of Outcome Engineering, Plano, Texas. He is a contractor working with personnel at Memorial Sloan-Kettering Cancer Center, New York, to resolve the problems with RFOs. As part of a risk assessment, perioperative team members identify
David Marx describes how to build reliable and sustainable intervention strategies to reduce adverse events.
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if at all possible, never place an item in a cavity without using a visual cue (eg, tying a radiofrequency identification [RFID] sponge onto the item, which remains outside the cavity). Attendees were particularly interested in hearing how it can be safe for the scrub person to perform the initial sponge count independent of the RN circulator. Killen explained that at Memorial Sloan-Kettering Cancer Center, most sponges contain RFID chips. All sponges are added to the field and counted by sweeping them with an RFID wand. The scrub person also performs an “independent count” of the RFID sponges before the procedure begins. The technological RFID count and the scrub person’s count are considered the first sponge count. For instrument counts, a staff member from the central processing department (CPD) performs and documents an instrument count when assembling the set. This is considered the first independent count of instruments. Killen noted that CPD counts have a failure rate of 1:1,000 compared with the RN circulator and scrub person count, which has a failure rate of 1:100. Instrument counts performed after the scrub person begins to set up the sterile field are error prone. At Memorial SloanKettering Cancer Center, the scrub person performs another independent instrument count before setting up the back table, which he or she compares with the CPD count sheet. The instrument counts performed independently by the CPD person and the scrub person are considered the initial instrument count. Completing the RFID sponge count and the instrument counts in this manner improves efficiency because the scrub person can proceed to organizing the sterile field without having to wait for the RN circulator to return from the preoperative area. REBECCA HOLM MSN, RN, CNOR CLINICAL EDITOR
OR EXECUTIVE SUMMIT KICKS OFF WITH A CALL FOR SAFETY The inaugural OR Executive Summit kicked off with a stirring presentation by Kerry M. Johnson, 692 j AORN Journal
MS, founding partner and chief innovation officer of HPI, who discussed building a strong safety culture through human reliability programs during “Reliability Science and the Socio-Technical Model.” Leveraging more than 25 years of experience in improving reliability for nuclear power, transportation, manufacturing, and health care, Johnson shared his insights related to managing human performance in health care environments. The presentation focused on achieving a “reliability culture” to prevent failures and highlighted the journey for health care organizations to improve reliability. Johnson outlined six key points to consider for creating a reliable and safe culture: 1. 2. 3. 4.
Safety is a science. Attention is the currency of leadership. Safety is a dynamic nonevent. Medical staff members are critical to sustaining safety as a core value. 5. Everyone makes errors. 6. Staff members, physicians, and leaders must turn proven error prevention strategies into practice habits. Organizations can become high-reliability organizations by following a set of five principles: a sensitivity to operations, a preoccupation with failure, a reluctance to simplify, a commitment to resilience, and a deference to expertise. To establish high reliability in health care, Johnson advocated establishing one global measure of patient safety and examined three tiers for classifying safety events. He classified safety events as a serious safety event, a precursor safety event, and a near-miss safety event. Organizations should focus on eliminating serious safety events before shifting their focus to precursor and near-miss safety events, which serve as elements of an early warning system. Health care organizations should focus on three areas of opportunity to improve safety: prevention (ie, implementing error prevention techniques), detection (ie, paying attention), and correction (ie, correcting the root cause). Johnson stressed the
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just a priority but also a core value that cannot be compromised.
OR Executive Summit speaker Kerry M. Johnson outlines six key points to consider for creating a reliable and safe culture.
importance of common-cause analysis and highlighted the top contributing factors to patient harm, including checking (eg, time outs, hand overs), coordinating care, and assessing. Common cause analysis data can be a powerful tool for organizations to understand what needs improvement. Johnson also emphasized that everyone plays a role in creating a safe culture; board members and senior leaders should own and manage a safe culture, while medical staff members should own and promote a safe culture. Sustaining a safety culture requires full engagement of staff members, and organizations should designate a small, influential group of physician leaders to mold a high-reliability medical staff culture. In closing, Johnson reiterated that a continuous journey toward zero serious harm events is the only acceptable goal. Patient safety should be seen as not
PROCESS INNOVATION BETWEEN OR AND STERILE PROCESSING PERSONNEL Natalie D. Velazquez, BSN, RN, CNOR, and Patricia Yeo, MBA, MSN, RN, CNOR, from Rush University Medical Center, Chicago, Illinois, discussed efforts to improve collaboration between OR and sterile processing (SP) personnel during “Innovation Between OR & SP Personnel Resulted in Success.” According to Yeo, OR efficiency had become secondary to instrumentation at Rush University. Inefficiency in their ORs caused numerous issues, and the sterile processing department (SPD) experienced related setbacks. Personnel approached the issue with a five-step process that included assessment, diagnosis, planning, implementation, and evaluation. During the assessment phase, surgeons completed a survey to help explain the breakdowns occurring in different areas. The survey included questions related to case cart completion, the need to use immediate-use steam sterilization (IUSS) for trays, and procedure delays resulting from instrumentation issues. Personnel used key performance indicatorsdincluding dirty instruments, unprocessed trays, tray errors, and the use of IUSSdto track and improve processes in the ORs and the SPD. In addition, personnel completed “flash logs” to document the reason for IUSS, the surgeon’s name, the quantity of instruments needing IUSS, and the shift during which it occurred. During the diagnosis phase, personnel concentrated on process and communication issues. They identified specific communication needs, including the need to develop an understanding of each department’s respective jobs, share data, and schedule formal meetings among personnel from different departments. As part of the planning phase, personnel reviewed processes as they related to instrumentation and that were unique to the SPD, the OR, and transportation. Personnel focused on reducing AORN Journal j 693
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Natalie D. Velazquez describes the five-step process used at her facility to improve collaboration between personnel in the OR and sterile processing department. Also pictured: Patricia Yeo.
turnaround time in the OR and examined data to deduce the relationship between turnaround time and decontamination processes. Personnel also looked at policies and procedures related to decontamination, assembly, sterilization, quality, and visual cues. Visual cues related to decontamination were made readily accessible to staff and included images that depicted when instruments were ready for the washer and correct and incorrect methods related to the use of powered equipment. During the implementation phase, personnel implemented the role of OR liaisons, who were assigned to specific specialties, such as neurosurgery, orthopedics, pediatrics, and robotics. The OR liaisons’ primary duties included checking case carts in the morning, conferring with nurses, owning problems, interfacing with surgeons, completing post-case audits, and taking on special projects for their assigned service line (eg, building trays). Weekly meetings were scheduled with the SPD 694 j AORN Journal
AORN CONFERENCE EDUCATION SESSIONS manager, the director of surgery, OR liaisons, and the vice president of operations to encourage collaborative communication. Also, as part of the implementation phase, SP personnel developed visual training of key performance indicators. Decontamination and sterilization processes were tracked on an hourly basis to see whether staff members met related goals (eg, avoiding tray errors). Personnel then used the data to identify the root cause of errors and address needed changes for process improvement. During the evaluation phase, personnel examined key performance indicators metrics to see how scores changed from baseline measures, which were collected in 2011. To improve scores, efforts concentrated on updating the orientation process for new personnel and tailoring education to address individual employee performance, staying on top of key performance indicators, and paying attention to trends. LESLIE KNUDSON CONTENT EDITOR
PAIN MEDICINE: OPTIMIZING CARE USING OUTCOMES MEASURES Chronic pain is an ongoing, persistent problem for patients and their caregivers, according to Fred N. Davis, MD, who presented “The Importance of Measuring Clinical Outcomes for Pain Medicine.” Although pain medicine has evolved greatly, “the idea that you can’t have outcomes if you can’t measure them is new to pain management,” Dr Davis said. Dr Davis explained that access to outcomes data allows more personalized care. “We don’t generally diagnose for pain itself because it hides behind [the cause of the pain] . . . Having [pain management data] is important for translating the unique individual experience of a patient into a common language and for framing the therapeutic relationship.” He described perioperative nurses as the face of interventional pain care. “Nurses who can review outcome measures have a window into the patient’s
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Dr Fred N. Davis discusses the need for assessing clinical outcomes for pain medicine.
pain experience to understand what’s behind the disc or the sciatica so [they] can facilitate wholeperson care.” Facilitating whole-person care is part of an emerging health care trend of providers to regard patients with chronic pain as a whole person instead of “as a ‘case’ or a ‘disk problem,’” according to Dr Davis. The questions then become the following: how can providers in the acute care setting, ambulatory setting, and physician’s office determine differences in pain care from patient to patient, how can they assess risks related to pain management, and how can they predict and measure outcomes? Dr Davis described a pain care management system that was designed to assess disease risk and gather patient-reported pain health information. He referred to that system as a “digital toolbox” that includes a patient assessment matrix, a patient selfassessment, a dashboard showing real-time data for
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patient care, and clinical performance summaries to show results of provider and practice care management. Measuring individual pain care components (eg, traditional pain scales, opioid risk, functional and social impairments, perceived and objective measures) allowed a large regional pain medicine practice to track clinical outcomes of care over the course of the disease and to use initial and cumulative pain health data to inform clinical decision making in real time. For example, in a retrospective analysis of treatment modalities for 2,157 patients with lumbar spinal stenosis who received care between January 2011 and March 2013, researchers used analysis of outcomes measures to determine which conservative treatment options achieved the best therapeutic results. Results showed that lumbar epidural corticosteroid injections and selective nerve root blocks provided approximately 62% relief of pain, physical therapy alone provided 10% improvement in objective lower body functional impairment, and lumbar epidural corticosteroid injections plus physical therapy provided 19.6% improvement in objective lower body functional impairment as well as 62% relief of pain. Regarding future trends in pain care, Dr Davis said he sees specialists sharing pain care management information with primary care providers. “Seventy percent of pain is treated by the primary care physician, and 20% of pain is treated by the specialist,” Dr Davis said. With specific regard to patient care in the ambulatory setting, Dr Davis identified the following takeaways: n
Nurses in the ambulatory setting are an extension of the patient’s pain care team, not an independent team working on a procedure. n A familiar face and a familiar touch are what patients remember. Leaders in ambulatory settings should strive to have the same nurses and same team care for that patient. n Patients with chronic pain have a very strong need to be treated well and not to feel as if they are being processed. These patients must
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know that somebody cares about them and wants to work with them. Often, this role falls to the nurses.
IRIS LLEWELLYN PUBLICATIONS EDITOR
AORN RECOMMENDS CHANGES TO SURGICAL SUITE DESIGN The substerile room may be obsolete, according to Ramona L. Conner, MSN, RN, CNOR, manager of standards and recommended practices at AORN, who presented “Big Changes in Surgical Suite Design for 2014 and Beyond.” The presentation, given to a crowd with standing room only, covered this and other changes to the AORN “Recommended practices for a safe environment of care: part 2” (EOC 2). “Is anything we do substerile?” Conner asked. After a loud and resonating “no” from the audience, she said, “We don’t do sterile processing this way, let’s stop building our facilities this way.” Instead, Conner suggested, facilities should be built so the sterile processing department and OR are located closer together. In addition to being outdated, substerile rooms cost a lot of money. They are expensive to maintain over time, Conner said, and fixed costs include the following “conservative” estimates:
infection preventionists, and representatives from all affected disciplines, such as anesthesia professionals, unlicensed assistive personnel, and housekeepers. “Get everybody involved because they all have a portion of the end product,” Burlingame said. It is also important to bring external team members, such as the architect and engineer, together to explain what the facility needs, said Douglas S. Erickson, FASHE, CHFM, HFDP, CHC, president of TME, Inc, and chief executive officer of the Facilities Guidelines Institute. “They work for youd you don’t work for them,” he said. “You have to be the ones who truly understand what you need.” That means asking questions and challenging any information that is not understood, because construction and design language is unique. Erickson gave the example of “borrowed light panels,”
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equipment: $40,000 to $100,000 n mechanical and electrical: $60,000 n floor space per room: $1,200 per sq ft 50 sq ft ¼ $60,000 At a total of $160,000 per room, for a facility that has 20 ORs, the cost is approximately $1.6 million. This is in addition to maintenance and personnel costs. Establishing a multidisciplinary team to manage construction projects is one of the recommendations in the new EOC 2 document. This is an increasingly common recommendation, according to Byron Burlingame, MS, RN, CNOR, perioperative nursing specialist at AORN and lead author of EOC 2. He said that the team should include nurses, 696 j AORN Journal
Douglas S. Erickson encourages nurses to ask questions and clarify information from the engineer and architect during an OR construction project.
AORN CONFERENCE EDUCATION SESSIONS which in everyday language means “windows.” He also said to insist on mock-ups because they “give you the physical feeling of that operating room.” Today, this also can be accomplished through three-dimensional imaging. Other updated topics included in EOC 2 include the following: n
what constitutes restricted, semirestricted, and nonrestricted areas; n attire restrictions; and n humidity recommendations and monitoring requirements. The new document is a revision of “Recommended practices for traffic patterns.” The name was changed to more accurately represent the expanded focus of the content. The document was created in collaboration with the Facilities Guidelines Institute and the American Society for Healthcare Engineering, with the mutual goal of providing consistent guidance to engineers, architects, and surgical personnel. The new document is expected to be live on the AORN eSubscription in May 2014. HONESTY AND BREVITY ARE KEY IN GIVING A DEPOSITION The five perfect answers during a deposition are “yes,” “no,” “I don’t know,” “I don’t remember,” and “please rephrase the question,” said J. Alan Zulick, JD, during “The Fine Art of Giving an Effective Deposition: What Every Perioperative Nurse Should Know.” Most nurses will be called to give a deposition at least once during the course of their career. The keys to giving a good deposition and protecting oneself are to be truthful and concise. The deposition process is a fact-finding mission for attorneys who are responding to a complaint. In the case of health care lawsuits, the complaint is typically from a patient or a patient’s family members. It is important for the perioperative nurse being deposed to review the health record to refresh his or her memory of the case. Perioperative nurses may serve as either a fact witness or an expert
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witness. Fact witnesses are called because they witnessed an event, whereas expert witnesses are called based on their knowledge and experience. “If you’re a fact witness, your job is to get in and get out with as little damage to your credibility as you can,” Zulick said, telling attendees to use the five perfect answers. Denise Jackson, MSN, RN, CNS, CRNFA, discussed how to prepare physically and mentally for a deposition. Physically, it is important to get a good night’s sleep the night before and to wear professional clothing as opposed to jeans or scrubs. She also said that because depositions can last anywhere from 30 minutes to five hours, it is important to plan on eating before the deposition. To prepare mentally, rehearsing responses and practicing with one’s own attorney can help. Nurses should be able to articulate their credentials, role, and experience, as well as what they know about
Denise Jackson discusses how to prepare physically and mentally for a deposition.
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the incident, and answers should be succinct. This is important because the opposing counsel is looking for inconsistencies and trying to get more information to help their case and discredit witnesses. Jackson offered attendees a list of do’s and don’t’s for giving an effective deposition. Some of the “do” recommendations included the nurse ensuring that he or she understands the question and asking for clarification if needed, speaking clearly, pausing before answering, asking for a break if needed, and limiting testimony to the nurse’s area of expertise. Finally, the nurse must “be professional no matter what,” Jackson said. Jackson discouraged guessing or speculating, interrupting the attorney who is asking the questions, answering questions about other professionals, and
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AORN CONFERENCE EDUCATION SESSIONS answering compound questions together. “Don’t educate the opposing counsel,” Jackson advised. “Use medical terminology, and don’t dumb it down or explain it to them.” The perioperative nurse is the nursing expert in a deposition and should answer concisely and refrain from giving explanations. “I’m not saying you can’t explain yourself,” Zulick said, “but your impulse to educate needs to be tamped down. Your impulse to be a helper to the other side needs to be tamped down. You’re all helpers by profession, but you’re not a helper in a deposition. The other side is not your friend and is never going to be your friend.” KIMBERLY J. RETZLAFF MANAGING EDITOR
T
he educational opportunities at the AORN Surgical Conference & Expo 2014, and the associated continuing education contact hours, remain one of the biggest draws for nurses who attend the conference. The well-rounded curriculum at the 61st annual conference challenged sacred cows, such as whether the RN circulator and scrub person must perform the counts together, and exposed attendees to a wide variety of topics, including reducing pharmaceutical waste, clinical outcomes for pain management, environmental cleaning, specimen management, electronic documentation and data collection, and collaboration between the OR and sterile processing department. Additional topics included considerations for OR construction and design and giving an effective deposition. Specialized content was provided for nurse managers, such as establishing a “reliability culture,” and for ambulatory nurses, such as applying the AORN recommended practices to the ambulatory setting. Following are descriptions of some of the sessions.
ENVIRONMENTALLY SUSTAINABLE CONSTRUCTION Incorporating evidence-based design principles into hospital construction may be a significant investment, but the rewards are invaluable for patients and personnel and contribute to the overall success of the organization, said Rebecca McKenzie, MSN, MBA, RN. During “Evidence-Based Design Principles Transform Hospital Construction Projects,” she explained that health care leaders are challenged to incorporate the latest research and evidence-based designs when replacing aging health care facilities to create ORs that enhance operational efficiency and allow future adaptation of the next generation of health care clinical advancements.
McKenzie explained that measuring the effect of design elements is complex; therefore, when planning a health care construction project, certain principles, including current trends in health care facility design, must be considered. Do not underestimate the degree of community interest in and involvement with the construction project, she added. One important issue for community members is to ensure that environmentally sustainable construction is used. The goals in satisfying this need are to reduce operating costs, facilitate healthier and more productive occupants, and conserve natural resources. One example that McKenzie described is recycling steam and condensation from the facility’s steam sterilizers. To test functionality and avoid potentially costly mistakes during construction, the team at Duke University Medical Center, Durham, North Carolina, built a mock-up OR in a warehouse. McKenzie described how industry partners brought in and set up their equipment and products, and key stakeholders from all clinical areas tested the room with real-life scenarios. “Build vertically,” McKenzie recommended, “with the sterile processing department (SPD) under the OR.” This allows ORs to be grouped around sterile
AORN Education Session attendees learn ways to help improve their practice back home.
http://dx.doi.org/10.1016/j.aorn.2014.04.005
Ó AORN, Inc, 2014
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cores and for each sterile core to have an elevator to access the SPD below. Research supports transitioning the postanesthesia care unit (PACU) from the traditional open-bay approach to a more private threewalled design with modular walls converted to fixed walls to improve patient flow to and from the PACU. There are many issues that managers and executive team members have to consider when planning for health care facility construction projects, said Priscilla J. Ramseur, MSN, RN, CNOR. This includes strategically hiring personnel based on financial and full-time employee projections, determining bed and unit allocation, managing human resources and clinical service unit planning teams, and implementing electronic health records. Planning for proper orientation for all personnel is important but especially so for new nurse graduates, Ramseur said. Some staff education strategies that Ramseur described included n n n n n
AORN CONFERENCE EDUCATION SESSIONS AORN’s 45,000 members who work in an ambulatory surgery environment, explained Terri Link, MPH, RN, CNOR, CIC, AORN ambulatory education specialist. During “Specific Ambulatory Information for AORN Perioperative Standards and Recommended Practices,” Link explained that AORN developed this division to meet the needs of freestanding ambulatory surgery centers (ASCs) and office-based surgery centers that may have different needs than those of acute care facilities. To help readers identify ASC content in the Perioperative Standards and Recommended Practices, applicable content is flagged with a purple logo both in the table of contents and in the body of each recommended practices (RP) document. Mary Ogg, MSN, RN, CNOR, perioperative nursing specialist at AORN, emphasized that
producing facts and statistics sheets, providing open house tours with maps, using scavenger hunts to orient personnel, using patient simulations for reality-based orientation, and performing competency evaluation for all levels of personnel.
McKenzie emphasized the importance of including personnel from all departments when designing the new facility. Some suggestions that personnel recommended included taking advantage of engineering modalities such as nonslip flooring, same-sided rooms and configurations, and geographical adjacencies; using concepts that allow patient privacy and respect; and separating soiled and clean supplies transportation routes from patient transportation and product entries. Ramseur added that all key stakeholders should be linked to the project and have a vested interest in its success. APPLYING RECOMMENDED PRACTICES TO THE AMBULATORY SETTING AORN launched an Ambulatory Surgery Division in January 2013 to help represent the 38% of 686 j AORN Journal
Terri Link describes how to apply AORN standards and recommended practices to perioperative practice in ambulatory settings.
AORN CONFERENCE EDUCATION SESSIONS AORN’s RP documents are applicable to all procedural areas in both inpatient and outpatient settings. She noted that the RP documents are created via a rigorous evidence-rating process to ensure that they are evidence based. Ogg explained that a synthesis of the evidence is useful for explaining the “why” of changing practice to perioperative counterparts, particularly surgeons. Perioperative nurses in ASCs should follow the same evidence-based standards and recommended practices as their counterparts in acute, inpatient facilities. “The difference is how ASC personnel and administrators incorporate the recommendations into their policies and procedures,” Ogg said. She described how ASC managers can use the RP intervention statements as the basis for policy statements by simply changing intervention “should” statements to policy “must” statements. Link reviewed a scenario in which the surgical team at an ASC determined that a sponge was missing during a ganglion cyst excision under local anesthesia at 5 PM, when no radiology personnel were on-site. Link provided the audience with options for how the surgical team could respond to this situation, depending on their facility’s policies and procedures: n
Call a radiology technician in to take an x-ray. n Delay skin closure until the radiology technician arrives and takes the x-ray and the radiologist interprets the x-ray and clears it for the missing sponge. n Have the surgeon take a scan with the portable fluoroscopy unit. n Have the surgeon interpret the fluoroscopic scan to confirm the presence or absence of the missing sponge. As attendees responded to the options, Link used the opportunity to review the ASC-specific information provided at the end of the AORN “Recommended practices for the prevention of retained surgical items.” Link described how an ASC’s policy and procedure should be crafted regarding actions to take when on-site radiology
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services are not available to take an x-ray and interpret the result. As described in the scenario, it may be appropriate, depending on the facility’s policies and procedures, for a surgeon to locate the retained item if he or she is credentialed and privileged to use and interpret fluoroscopy studies. Jan Davidson, MSN, RN, CNOR, CASC, director of AORN’s Ambulatory Surgery Division, explained that ASC members should participate in the public commenting period for new RP documents to identify recommended practices that are applicable to ASC and office-based surgery settings. She added that nurses should recognize the importance of developing policies that reflect the differences between ASCs and inpatient facilities. AORN SYNTEGRITY: CONVERTING DATA FROM INFORMATION TO WISDOM At the session “Care Planning Using AORN SyntegrityÒ,” Kathleen D. Woods, BSN, RN, former AORN informatics nurse specialist, and Lynn W. Trabold, BS, RN-BC, a perioperative clinical informatics specialist at Abington Health, Abington, Pennsylvania, taught attendees about the Perioperative Nursing Data Set (PNDS), AORN Syntegrity, and how the two contribute to nursing processes and patient safety. AORN Syntegrity, a framework for integrating perioperative data with electronic health records, is based on the PNDS, the only standardized perioperative nursing language. The PNDS helps perioperative nurses communicate accurately, Woods said, and by using the PNDS to document perioperative nursing activities, nurses can demonstrate their contribution to patient care; ultimately, these data can be used for research. The aim of everything a perioperative nurse does is to minimize harm and protect the patient, the hallmark of a good care plan. Woods said, “Perioperative nurses do use care plans,” although many may not think they do. To illustrate her point, Woods presented a sample case study of a woman scheduled to undergo a bowel resection with possible diverting colostomy. She walked attendees through the nursing process, showing how AORN AORN Journal j 687
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Lynn Trabold describes how her facility implemented AORN Syntegrity to standardize the vocabulary used in the facility’s documentation system.
Syntegrity provides the necessary coded elements that correlate to the relevant steps in assessment, outcome, implementation, and evaluation. Nurses usually document patient care narratives one patient at a time. By standardizing communication and making it more accurate, PNDS and AORN Syntegrity do more than just allow the perioperative nurse to document perioperative care of a single patient; the extracted data can be used to tell the story of a population. “We need to go from a story of one to a story of many,” Woods said. “If we keep documenting for only one patient, we’re not going to get to the point where data can drive our actions.” Woods said, “AORN Syntegrity and the PNDS can help convert data to information, information to knowledge, and knowledge to wisdom.” Data on their own (eg, age, body mass index) have no 688 j AORN Journal
AORN CONFERENCE EDUCATION SESSIONS meaning. By showing how the data are relevant to a procedure, the data become useful information. After nurses have the correct knowledge and understand how their data affect all patients, they can develop the wisdom, or critical thinking, to prevent and react to situations that endanger patients. Trabold assisted her facility in implementing AORN Syntegrity and explained that they selected this documentation solution because they wanted a standardized vocabulary that would help ensure they were meeting standards and regulations without having to reinvent the wheel. They have been able to benchmark their facility against like organizations because they have more data for comparison and less free text. Trabold described the challenges they experienced, particularly that their vendor was not intimately familiar with the PNDS. She recommended that those considering implementation of electronic health records and AORN Syntegrity should ensure that their vendor is comfortable with AORN Syntegrity and PNDS. Trabold concluded the session by encouraging perioperative nurses to push back and be persistent if their managers or vendors are resistant to using AORN Syntegrity and PNDS because the improvement in patient outcomes justifies the effort. Editor’s note: The second edition of the Perioperative Nursing Data Set (PNDS) was superseded by the third edition (PNDS 3) in 2011. The PNDS 3 terminology is only distributed through AORN and AORN Syntegrity licensed vendors. For questions about PNDS 3 implementation into electronic health records and electronic perioperative record solutions, please contact the AORN Syntegrity team via e-mail at [email protected]. AORN Syntegrity is a registered trademark of AORN, Inc, Denver, CO. AORN RECOMMENDED PRACTICES FOR ENVIRONMENTAL CLEANING AND SPECIMEN MANAGEMENT Amber Wood, MSN, RN, CNOR, CIC, and Sharon Van Wicklin, MSN, RN, CNOR, CRNFA, CPSN, PLNC, perioperative nursing specialists at AORN,
AORN CONFERENCE EDUCATION SESSIONS presented “The Latest on Two New Recommended Practices: Environmental Cleaning and Specimen Management.” For the new “flip session” format, attendees listened to a preconference webinar and then attended the session, where they discussed patient scenarios and asked questions. There are several new concepts in the revised AORN “Recommended practices for environmental cleaning,” Wood said. These topics include using multidisciplinary teams for policymaking, using targeted cleaning procedures for high-touch objects, identifying what constitutes enhanced environmental cleaning, specifying cleaning methodologies (eg, top to bottom, clockwise, assignment of responsibilities), and measuring the cleanliness achieved (eg, visual inspection, fluorescent marking). For the scenario for environmental cleaning, Wood described a patient who underwent a
Amber Wood encourages attendees to break into groups to discuss the fictional scenario about errors in environmental cleaning.
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coronary artery bypass procedure and developed ventilator-associated pneumonia caused by a contaminated valve on the anesthesia machine. An investigation revealed that no knobs on the anesthesia machine had been cleaned. During discussion, attendees identified that a gap existed in assigning responsibility for cleaning the anesthesia equipment. One attendee noted that color coding equipment to identify who “owns” the equipment can help ensure that the equipment is cleaned and that no more than one person cleans it. In addition, attendees identified steps that perioperative personnel can take to help prevent missed cleaning, such as educating health care providers not to wrap and put away equipment after use unless it has been cleaned. Wood directed members to obtain the newly posted Environmental Cleaning Tool Kit on the AORN web site. She ended the session by telling attendees, “If you don’t believe in anything, you better believe in germs!” Van Wicklin covered the new concepts in the revised AORN “Recommended practices for specimen management.” The revised title more accurately depicts the role and actions of the perioperative RN as the manager of the patient’s care. The recommended practices document discusses how to manage a variety of surgical specimens (eg, new focus on documentation of time of excision and fixation of breast cancer specimens), describes how to prevent common errors in specimen management with simple redundancies, and alternatives to using formalin for fixation and preservation of specimens (eg, vacuum sealing). For the scenario, Van Wicklin described a series of small mistakes and misunderstandings that occurred during two consecutive procedures (eg, diagnostic, therapeutic) on one patient. In the scenario, a biopsy specimen incorrectly taken from the right kidney rather than the left led to assumptions about a cancer diagnosis, erroneous removal of a healthy kidney, and subsequent removal of the cancerous kidney, leaving the patient reliant on dialysis and needing a kidney transplant. During discussion of the scenario, attendees identified AORN Journal j 689
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multiple errors that had occurred, and with Van Wicklin’s help, they also determined the responsibilities of all involved parties: n n
n
n
n
The patient was responsible for knowing on which side the biopsy was to be performed. The RN circulator had a responsibility not to pre-chart and to correct all paperwork when she determined that there was an inconsistency between the procedure that was scheduled and the one that was being performed. The RN circulator and radiology interventionist should have jointly ensured that the specimen was labeled correctly. The interventionist and surgeon were both responsible for performing site marking with the patient before their respective procedures. The surgeon was responsible for performing the informed consent process with the patient, which cannot be abdicated to the nurse.
AORN CONFERENCE EDUCATION SESSIONS regulate pharmaceutical waste, including the Controlled Substances Act (US Department of Justice, Drug Enforcement Agency), the Resource Conservation and Recovery Act-C hazardous waste rules (Environmental Protection Agency), Managing Pharmaceutical Waste (Healthcare Environmental Resource Center), and the University of Wisconsin Extension (Pharmaceutical Waste Reduction web site). Bickford also described how to use online tools to find ways to reduce pharmaceutical waste. During the session at the AORN Conference, Bickford instructed attendees to divide into groups and provided them with scenarios about commonly wasted medications (eg, dantrolene, pain medications, propofol, antibiotics). Attendees discussed the scenarios, as well as storage, disposal, and alternatives to current common practices. They followed a step-by-step process to develop strategies
One attendee summed it up best: “Nurses should never be afraid to questiondthat’s our responsibility as the patient advocate.” REDUCING PHARMACEUTICAL WASTE All hospitals and patient care sites must deal with pharmaceutical waste and disposal issues. This is because many of the medications that are used in health care settings are regulated and also can pose safety and environmental risks, explained Barb Bickford, MS, PG, a medical waste coordinator with the Wisconsin Department of Natural Resources, during “Pharmaceutical Waste: Handson Strategies to Reduce Waste in Perioperative Settings and Access Resources for Safe Disposal.” Nowhere is this more evident than in the perioperative area, where personnel handle and administer a large variety of medications. For the new “flip session” format, attendees listened to a preconference webinar and then attended the session, where they had the opportunity to ask questions. In the webinar, Bickford explained the regulations and organizations that 690 j AORN Journal
Barb Bickford describes the resources that are available to help reduce pharmaceutical waste.
AORN CONFERENCE EDUCATION SESSIONS to reduce the wastage, search the database for ideas, and evaluate their solutions to determine which strategy would be the best to implement first. After the group discussion activities, a spokesperson from each group presented their strategies and lessons learned. Bickford encouraged attendees to take the resulting solutions home for implementation in their ORs. A secondary goal of the flip session was for attendees to network and establish a group of contacts with whom to share successes and challenges regarding pharmaceutical waste. Bickford encouraged attendees to interact online with her at the Wisconsin Department of Natural Resources, as well as with Bonnie Denholm, MSN, BS, RN, CNOR, perioperative nursing specialist at AORN, and with other perioperative nurses on ORNurseLinkTM (http://ornurselink.aorn.org), where the results of the flip session scenarios are available.
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failure paths to a “class” of critical adverse events rather than focusing on the last single event. Team members also identify levels of dependency in the count process. Fully dependent counts (ie, RN circulator and scrub person count together) have been identified as a major weak link that results in count discrepancies. Killen explained that numerous strategies are being instituted at Memorial Sloan-Kettering Cancer Center to reduce RFOs, such as using forcing functions (eg, cues that force a hard stop in a process to prevent an error from occurring). These forcing functions include count cues (eg, the laparotomy sponge count equals a number that is not divisible by five) and visual cues (eg, the empty hole in the five-pack of peanuts immediately indicates that a peanut is missing). Killen also recommended enforcing “simple rules.” For example,
Editor’s note: ORNurseLink is a trademark of AORN, Inc, Denver, CO. RN CIRCULATOR AND SCRUB PERSON COUNT SIMULTANEOUSLYdIS THIS A SACRED COW? “We propose that the RN circulator does not need to be involved in the initial sponge and instrument count,” said Aileen R. Killen, PhD, RN, CPPS, during “Prevention of RFOs [Retained Foreign Objects]: It’s Not About the Count.” The RN circulator and scrub person still simultaneously perform counts of “ones,” such as needles. “We are here to challenge your thought processes,” Killen said. Sociotechnical-probabilistic risk assessment (ST-PRA) offers health care organizations a technique to analyze the relationships between errors, choices, and technical aspects of current strategies, explained David Marx, JD, BS, president of Outcome Engineering, Plano, Texas. He is a contractor working with personnel at Memorial Sloan-Kettering Cancer Center, New York, to resolve the problems with RFOs. As part of a risk assessment, perioperative team members identify
David Marx describes how to build reliable and sustainable intervention strategies to reduce adverse events.
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if at all possible, never place an item in a cavity without using a visual cue (eg, tying a radiofrequency identification [RFID] sponge onto the item, which remains outside the cavity). Attendees were particularly interested in hearing how it can be safe for the scrub person to perform the initial sponge count independent of the RN circulator. Killen explained that at Memorial Sloan-Kettering Cancer Center, most sponges contain RFID chips. All sponges are added to the field and counted by sweeping them with an RFID wand. The scrub person also performs an “independent count” of the RFID sponges before the procedure begins. The technological RFID count and the scrub person’s count are considered the first sponge count. For instrument counts, a staff member from the central processing department (CPD) performs and documents an instrument count when assembling the set. This is considered the first independent count of instruments. Killen noted that CPD counts have a failure rate of 1:1,000 compared with the RN circulator and scrub person count, which has a failure rate of 1:100. Instrument counts performed after the scrub person begins to set up the sterile field are error prone. At Memorial SloanKettering Cancer Center, the scrub person performs another independent instrument count before setting up the back table, which he or she compares with the CPD count sheet. The instrument counts performed independently by the CPD person and the scrub person are considered the initial instrument count. Completing the RFID sponge count and the instrument counts in this manner improves efficiency because the scrub person can proceed to organizing the sterile field without having to wait for the RN circulator to return from the preoperative area. REBECCA HOLM MSN, RN, CNOR CLINICAL EDITOR
OR EXECUTIVE SUMMIT KICKS OFF WITH A CALL FOR SAFETY The inaugural OR Executive Summit kicked off with a stirring presentation by Kerry M. Johnson, 692 j AORN Journal
MS, founding partner and chief innovation officer of HPI, who discussed building a strong safety culture through human reliability programs during “Reliability Science and the Socio-Technical Model.” Leveraging more than 25 years of experience in improving reliability for nuclear power, transportation, manufacturing, and health care, Johnson shared his insights related to managing human performance in health care environments. The presentation focused on achieving a “reliability culture” to prevent failures and highlighted the journey for health care organizations to improve reliability. Johnson outlined six key points to consider for creating a reliable and safe culture: 1. 2. 3. 4.
Safety is a science. Attention is the currency of leadership. Safety is a dynamic nonevent. Medical staff members are critical to sustaining safety as a core value. 5. Everyone makes errors. 6. Staff members, physicians, and leaders must turn proven error prevention strategies into practice habits. Organizations can become high-reliability organizations by following a set of five principles: a sensitivity to operations, a preoccupation with failure, a reluctance to simplify, a commitment to resilience, and a deference to expertise. To establish high reliability in health care, Johnson advocated establishing one global measure of patient safety and examined three tiers for classifying safety events. He classified safety events as a serious safety event, a precursor safety event, and a near-miss safety event. Organizations should focus on eliminating serious safety events before shifting their focus to precursor and near-miss safety events, which serve as elements of an early warning system. Health care organizations should focus on three areas of opportunity to improve safety: prevention (ie, implementing error prevention techniques), detection (ie, paying attention), and correction (ie, correcting the root cause). Johnson stressed the
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just a priority but also a core value that cannot be compromised.
OR Executive Summit speaker Kerry M. Johnson outlines six key points to consider for creating a reliable and safe culture.
importance of common-cause analysis and highlighted the top contributing factors to patient harm, including checking (eg, time outs, hand overs), coordinating care, and assessing. Common cause analysis data can be a powerful tool for organizations to understand what needs improvement. Johnson also emphasized that everyone plays a role in creating a safe culture; board members and senior leaders should own and manage a safe culture, while medical staff members should own and promote a safe culture. Sustaining a safety culture requires full engagement of staff members, and organizations should designate a small, influential group of physician leaders to mold a high-reliability medical staff culture. In closing, Johnson reiterated that a continuous journey toward zero serious harm events is the only acceptable goal. Patient safety should be seen as not
PROCESS INNOVATION BETWEEN OR AND STERILE PROCESSING PERSONNEL Natalie D. Velazquez, BSN, RN, CNOR, and Patricia Yeo, MBA, MSN, RN, CNOR, from Rush University Medical Center, Chicago, Illinois, discussed efforts to improve collaboration between OR and sterile processing (SP) personnel during “Innovation Between OR & SP Personnel Resulted in Success.” According to Yeo, OR efficiency had become secondary to instrumentation at Rush University. Inefficiency in their ORs caused numerous issues, and the sterile processing department (SPD) experienced related setbacks. Personnel approached the issue with a five-step process that included assessment, diagnosis, planning, implementation, and evaluation. During the assessment phase, surgeons completed a survey to help explain the breakdowns occurring in different areas. The survey included questions related to case cart completion, the need to use immediate-use steam sterilization (IUSS) for trays, and procedure delays resulting from instrumentation issues. Personnel used key performance indicatorsdincluding dirty instruments, unprocessed trays, tray errors, and the use of IUSSdto track and improve processes in the ORs and the SPD. In addition, personnel completed “flash logs” to document the reason for IUSS, the surgeon’s name, the quantity of instruments needing IUSS, and the shift during which it occurred. During the diagnosis phase, personnel concentrated on process and communication issues. They identified specific communication needs, including the need to develop an understanding of each department’s respective jobs, share data, and schedule formal meetings among personnel from different departments. As part of the planning phase, personnel reviewed processes as they related to instrumentation and that were unique to the SPD, the OR, and transportation. Personnel focused on reducing AORN Journal j 693
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Natalie D. Velazquez describes the five-step process used at her facility to improve collaboration between personnel in the OR and sterile processing department. Also pictured: Patricia Yeo.
turnaround time in the OR and examined data to deduce the relationship between turnaround time and decontamination processes. Personnel also looked at policies and procedures related to decontamination, assembly, sterilization, quality, and visual cues. Visual cues related to decontamination were made readily accessible to staff and included images that depicted when instruments were ready for the washer and correct and incorrect methods related to the use of powered equipment. During the implementation phase, personnel implemented the role of OR liaisons, who were assigned to specific specialties, such as neurosurgery, orthopedics, pediatrics, and robotics. The OR liaisons’ primary duties included checking case carts in the morning, conferring with nurses, owning problems, interfacing with surgeons, completing post-case audits, and taking on special projects for their assigned service line (eg, building trays). Weekly meetings were scheduled with the SPD 694 j AORN Journal
AORN CONFERENCE EDUCATION SESSIONS manager, the director of surgery, OR liaisons, and the vice president of operations to encourage collaborative communication. Also, as part of the implementation phase, SP personnel developed visual training of key performance indicators. Decontamination and sterilization processes were tracked on an hourly basis to see whether staff members met related goals (eg, avoiding tray errors). Personnel then used the data to identify the root cause of errors and address needed changes for process improvement. During the evaluation phase, personnel examined key performance indicators metrics to see how scores changed from baseline measures, which were collected in 2011. To improve scores, efforts concentrated on updating the orientation process for new personnel and tailoring education to address individual employee performance, staying on top of key performance indicators, and paying attention to trends. LESLIE KNUDSON CONTENT EDITOR
PAIN MEDICINE: OPTIMIZING CARE USING OUTCOMES MEASURES Chronic pain is an ongoing, persistent problem for patients and their caregivers, according to Fred N. Davis, MD, who presented “The Importance of Measuring Clinical Outcomes for Pain Medicine.” Although pain medicine has evolved greatly, “the idea that you can’t have outcomes if you can’t measure them is new to pain management,” Dr Davis said. Dr Davis explained that access to outcomes data allows more personalized care. “We don’t generally diagnose for pain itself because it hides behind [the cause of the pain] . . . Having [pain management data] is important for translating the unique individual experience of a patient into a common language and for framing the therapeutic relationship.” He described perioperative nurses as the face of interventional pain care. “Nurses who can review outcome measures have a window into the patient’s
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Dr Fred N. Davis discusses the need for assessing clinical outcomes for pain medicine.
pain experience to understand what’s behind the disc or the sciatica so [they] can facilitate wholeperson care.” Facilitating whole-person care is part of an emerging health care trend of providers to regard patients with chronic pain as a whole person instead of “as a ‘case’ or a ‘disk problem,’” according to Dr Davis. The questions then become the following: how can providers in the acute care setting, ambulatory setting, and physician’s office determine differences in pain care from patient to patient, how can they assess risks related to pain management, and how can they predict and measure outcomes? Dr Davis described a pain care management system that was designed to assess disease risk and gather patient-reported pain health information. He referred to that system as a “digital toolbox” that includes a patient assessment matrix, a patient selfassessment, a dashboard showing real-time data for
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patient care, and clinical performance summaries to show results of provider and practice care management. Measuring individual pain care components (eg, traditional pain scales, opioid risk, functional and social impairments, perceived and objective measures) allowed a large regional pain medicine practice to track clinical outcomes of care over the course of the disease and to use initial and cumulative pain health data to inform clinical decision making in real time. For example, in a retrospective analysis of treatment modalities for 2,157 patients with lumbar spinal stenosis who received care between January 2011 and March 2013, researchers used analysis of outcomes measures to determine which conservative treatment options achieved the best therapeutic results. Results showed that lumbar epidural corticosteroid injections and selective nerve root blocks provided approximately 62% relief of pain, physical therapy alone provided 10% improvement in objective lower body functional impairment, and lumbar epidural corticosteroid injections plus physical therapy provided 19.6% improvement in objective lower body functional impairment as well as 62% relief of pain. Regarding future trends in pain care, Dr Davis said he sees specialists sharing pain care management information with primary care providers. “Seventy percent of pain is treated by the primary care physician, and 20% of pain is treated by the specialist,” Dr Davis said. With specific regard to patient care in the ambulatory setting, Dr Davis identified the following takeaways: n
Nurses in the ambulatory setting are an extension of the patient’s pain care team, not an independent team working on a procedure. n A familiar face and a familiar touch are what patients remember. Leaders in ambulatory settings should strive to have the same nurses and same team care for that patient. n Patients with chronic pain have a very strong need to be treated well and not to feel as if they are being processed. These patients must
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know that somebody cares about them and wants to work with them. Often, this role falls to the nurses.
IRIS LLEWELLYN PUBLICATIONS EDITOR
AORN RECOMMENDS CHANGES TO SURGICAL SUITE DESIGN The substerile room may be obsolete, according to Ramona L. Conner, MSN, RN, CNOR, manager of standards and recommended practices at AORN, who presented “Big Changes in Surgical Suite Design for 2014 and Beyond.” The presentation, given to a crowd with standing room only, covered this and other changes to the AORN “Recommended practices for a safe environment of care: part 2” (EOC 2). “Is anything we do substerile?” Conner asked. After a loud and resonating “no” from the audience, she said, “We don’t do sterile processing this way, let’s stop building our facilities this way.” Instead, Conner suggested, facilities should be built so the sterile processing department and OR are located closer together. In addition to being outdated, substerile rooms cost a lot of money. They are expensive to maintain over time, Conner said, and fixed costs include the following “conservative” estimates:
infection preventionists, and representatives from all affected disciplines, such as anesthesia professionals, unlicensed assistive personnel, and housekeepers. “Get everybody involved because they all have a portion of the end product,” Burlingame said. It is also important to bring external team members, such as the architect and engineer, together to explain what the facility needs, said Douglas S. Erickson, FASHE, CHFM, HFDP, CHC, president of TME, Inc, and chief executive officer of the Facilities Guidelines Institute. “They work for youd you don’t work for them,” he said. “You have to be the ones who truly understand what you need.” That means asking questions and challenging any information that is not understood, because construction and design language is unique. Erickson gave the example of “borrowed light panels,”
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equipment: $40,000 to $100,000 n mechanical and electrical: $60,000 n floor space per room: $1,200 per sq ft 50 sq ft ¼ $60,000 At a total of $160,000 per room, for a facility that has 20 ORs, the cost is approximately $1.6 million. This is in addition to maintenance and personnel costs. Establishing a multidisciplinary team to manage construction projects is one of the recommendations in the new EOC 2 document. This is an increasingly common recommendation, according to Byron Burlingame, MS, RN, CNOR, perioperative nursing specialist at AORN and lead author of EOC 2. He said that the team should include nurses, 696 j AORN Journal
Douglas S. Erickson encourages nurses to ask questions and clarify information from the engineer and architect during an OR construction project.
AORN CONFERENCE EDUCATION SESSIONS which in everyday language means “windows.” He also said to insist on mock-ups because they “give you the physical feeling of that operating room.” Today, this also can be accomplished through three-dimensional imaging. Other updated topics included in EOC 2 include the following: n
what constitutes restricted, semirestricted, and nonrestricted areas; n attire restrictions; and n humidity recommendations and monitoring requirements. The new document is a revision of “Recommended practices for traffic patterns.” The name was changed to more accurately represent the expanded focus of the content. The document was created in collaboration with the Facilities Guidelines Institute and the American Society for Healthcare Engineering, with the mutual goal of providing consistent guidance to engineers, architects, and surgical personnel. The new document is expected to be live on the AORN eSubscription in May 2014. HONESTY AND BREVITY ARE KEY IN GIVING A DEPOSITION The five perfect answers during a deposition are “yes,” “no,” “I don’t know,” “I don’t remember,” and “please rephrase the question,” said J. Alan Zulick, JD, during “The Fine Art of Giving an Effective Deposition: What Every Perioperative Nurse Should Know.” Most nurses will be called to give a deposition at least once during the course of their career. The keys to giving a good deposition and protecting oneself are to be truthful and concise. The deposition process is a fact-finding mission for attorneys who are responding to a complaint. In the case of health care lawsuits, the complaint is typically from a patient or a patient’s family members. It is important for the perioperative nurse being deposed to review the health record to refresh his or her memory of the case. Perioperative nurses may serve as either a fact witness or an expert
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witness. Fact witnesses are called because they witnessed an event, whereas expert witnesses are called based on their knowledge and experience. “If you’re a fact witness, your job is to get in and get out with as little damage to your credibility as you can,” Zulick said, telling attendees to use the five perfect answers. Denise Jackson, MSN, RN, CNS, CRNFA, discussed how to prepare physically and mentally for a deposition. Physically, it is important to get a good night’s sleep the night before and to wear professional clothing as opposed to jeans or scrubs. She also said that because depositions can last anywhere from 30 minutes to five hours, it is important to plan on eating before the deposition. To prepare mentally, rehearsing responses and practicing with one’s own attorney can help. Nurses should be able to articulate their credentials, role, and experience, as well as what they know about
Denise Jackson discusses how to prepare physically and mentally for a deposition.
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Vol 99 No 6
the incident, and answers should be succinct. This is important because the opposing counsel is looking for inconsistencies and trying to get more information to help their case and discredit witnesses. Jackson offered attendees a list of do’s and don’t’s for giving an effective deposition. Some of the “do” recommendations included the nurse ensuring that he or she understands the question and asking for clarification if needed, speaking clearly, pausing before answering, asking for a break if needed, and limiting testimony to the nurse’s area of expertise. Finally, the nurse must “be professional no matter what,” Jackson said. Jackson discouraged guessing or speculating, interrupting the attorney who is asking the questions, answering questions about other professionals, and
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AORN CONFERENCE EDUCATION SESSIONS answering compound questions together. “Don’t educate the opposing counsel,” Jackson advised. “Use medical terminology, and don’t dumb it down or explain it to them.” The perioperative nurse is the nursing expert in a deposition and should answer concisely and refrain from giving explanations. “I’m not saying you can’t explain yourself,” Zulick said, “but your impulse to educate needs to be tamped down. Your impulse to be a helper to the other side needs to be tamped down. You’re all helpers by profession, but you’re not a helper in a deposition. The other side is not your friend and is never going to be your friend.” KIMBERLY J. RETZLAFF MANAGING EDITOR
