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J Nurs Care Qual Vol. 30, No. 2, pp. 167–174 c 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright
Relationship Between Operating Room Nursing Staff Expertise and Patient Outcomes Melissa Bathish, PhD, RN, CPNP; Margaret McLaughlin, PhD, RN; AkkeNeel Talsma, PhD, RN, FAAN This secondary analysis evaluated the association of operating room scrub staff expertise, based on frequency of working on a specific surgical procedure, with the development of surgical site infections. The odds of developing surgical site infections decreased by 5.7% (odds ratio = 0.943; 95% confidence interval, 0.834-1.067) with increased expertise, although a statistically significant association was not established (P = .354). The relationship between operating room scrub staff expertise and patient outcomes is important to understand. Key words: nursing expertise, operating room, patient outcomes, perioperative nursing, surgical site infections
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ACH YEAR, an estimated 1 of every 25 people around the globe undergoes some form of major surgery in an operating room (OR).1 In 2006, nearly 46 million surgical procedures occurred in American hospitals, with more than a third of these performed on patients 65 years and older.2 Recently, the demand for health care has increased with the passage of the Patient Protection and Affordable Care Act3 and the complexity of care
Author Affiliations: University of Michigan School of Nursing, Ann Arbor, Michigan (Dr Bathish); School of Medicine, University of Michigan, Ann Arbor (Dr Talsma); and Indiana University School of Nursing, Indianapolis (Dr McLaughlin). The authors declare no conflict of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.jncqjournal.com). Correspondence: Melissa Bathish, PhD, RN, CPNP, University of Michigan School of Nursing, 400 N. Ingalls, Room 2345, Ann Arbor, MI 48109. (mbathish@ umich.edu). Accepted for publication: September 17, 2014. Published ahead of print: November 25, 2014 DOI: 10.1097/NCQ.0000000000000092
has become more advanced with longevity of life.4 Concurrently, a projected nursing workforce shortage is predicted to reach 800 000 registered nurses (RNs) by the year 20205 and up to 1 million by the year 20306 due to an aging workforce,7,8 an outflow of nurses from the profession with the economic recovery,9 and a shortage of nursing faculty to accommodate qualified applicants into nursing programs around the country.10 The World Health Organization has identified OR performance as an important component of providing safe and effective procedures for surgical patients.11 One core element of the role of the OR nurse is to ensure patient safety during operations.12 Repeated, consistent performance of specific surgical procedures gives OR nursing staff the opportunity to master skills, leading to clinical expertise, and possibly improved patient outcomes.13 Performance identification and evaluation of nursing staff have, however, focused primarily on competence.14-16 Nevertheless, with current workforce and population trends, the complex environment of today’s OR, and the nationwide focus on quality care and patient safety, OR nursing staff need to exceed competence, demonstrating expertise in their areas of practice. 167
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Nurses’ level of expertise influences their quality of care and clinical judgment.17 The contribution of OR nursing staff expertise on patient outcomes such as surgical site infections (SSIs), however, is unknown. Surgical site infections are the second most common health care–associated infection in the United States and remain a major cause of morbidity and mortality.18,19 Nationally, SSIs were associated with an additional 406 730 hospitaldays and hospital costs exceeding $900 million. Surgical site infections also extended the length of stay by an average of 9.7 days while increasing cost by $20 842 per admission. An additional 91 613 readmissions for treatment of SSIs accounted for a further 521 933 days of care at a cost of nearly $700 million.19 Thus, evaluating OR nursing expertise and the development of postoperative SSI may present an opportunity to help reduce SSIs, improve patient outcomes, and save millions of health care dollars. Many studies have examined relationships between surgeon expertise and patient outcomes.20-24 In the surgical literature, increased surgical volume, or the number of surgical cases performed, has been linked to expertise.25 Several areas of surgery (vascular, thoracic, colorectal, orthopedic, breast, urology, neurosurgery, and otolaryngology) have identified correlations between increased surgical volume and improved outcomes.20-25 Performing high volumes of selective procedures is known as surgical specialization. Surgical specialization ultimately enhances performance and surgical expertise. Notably, it has been linked to positive patient outcomes in many different specialty areas including, but not limited to, colorectal, endocrine, and breast cancer surgical procedures.26-28 In a review of the literature by Chowdhury and colleagues29 examining the effects of surgical volume and specialization on patient outcomes, it was found that the contribution of multidisciplinary team members along with surgical expertise should be examined in relationship to improved patient outcomes. After controlling for volume discrepancies among hospitals and surgeons, the benefit of specialization went beyond
“practice makes perfect”29(p154) and was an accumulated benefit of high volume and the contribution of other health care personnel. McLaughlin et al30 conducted a study of 25 hospitals in 15 different states examining the use and types of specialty surgical service teams and found that 68% of the hospitals surveyed used specialty teams in their ORs. This prevalence of the use of specialty teams affords nurses the opportunity to specialize in a surgical area and has important implications for OR nurses. Alfredsdottir and Bjornsdottir12 asked OR nurses employed at a university hospital in Iceland that used specialty teams about their role in patient safety. The organization of work into specialty teams was essential to enhance patient safety in their OR. Better patient outcomes have also been shown to exist with the use of RN agency for OR care.31 Perioperative agency nurses are usually specialized, consistently working in the same surgical service, rendering them “experts” in their specialty surgical area, which may positively impact patient outcomes. The objective of this study was to evaluate whether nursing expertise in the OR was associated with favorable patient outcomes. The specific aim was to evaluate whether nursing scrub staff expertise, specifically in general surgical cases, decreases the likelihood of patients developing SSI postoperatively. METHODS Design and sample A cross-sectional cohort design was used for secondary data analysis. A subset of general surgery cases (n = 923) collected at a large, Midwestern, university-based medical center in 2008 was used in this study that merged a random sample of general surgical case-level data with preoperative comorbidity and postoperative patient outcomes data. The data were collected as a result of the medical center’s participation in the ACS NSQIP (American College of Surgeons National Surgical Quality Improvement Plan).32 General surgery procedures included endocrinology, gastrointestinal, oncology, transplant, trauma
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Relationship Between OR Nursing Staff Expertise and Patient Outcomes burn, and minimally invasive surgical procedures. Personal identifiers were removed from all individual and case-level data and reassigned anonymous identifiers. The study was deemed to be exempt by the university and medical center institutional review boards. Measures The primary independent variable of interest was general surgical nursing scrub staff expertise. According to the Association of periOperative Registered Nurses, scrub nurses work within the sterile field during a surgical procedure, interacting directly with the surgeon throughout a surgery. The scrub role can be delegated to an RN, licensed practical nurse, licensed vocational nurse, or unlicensed assistive personnel or “scrub technician.”33 Much like surgical scrub nurses, surgical technologists include both the behavioral and technical aspects of surgical technology, have the necessary knowledge and ability to deliver quality patient care during the operative period, and ensure maintenance of a sterile field during a surgical procedure.34 Operating room RNs and surgical technologists were considered OR nursing scrub staff in this study. Scrub nurses have a critical role in infection prevention due to their direct involvement in surgical patient care: performing surgical draping, handling sterile equipment, and maintaining a sterile environment during surgical and invasive procedures. Surgical cases can have a single scrub nurse or multiple scrub nursing staff members participating in the operation. The number of nursing scrub staff is dependent on many organizational and patient-related factors such as the length and complexity of the surgical case, staffing and scheduling consequences, and workflow issues. Any of these factors may influence the number of scrub staff present for all or part of a surgical procedure. Therefore, OR nursing scrub staff expertise was weighted on the basis of the number of nursing scrub staff participating in a surgical case, the amount of time each member was scrubbed into the case, and the amount of time spent specifically scrubbing in general
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surgical cases as opposed to other specialty areas. The following equation was used to calculate the scrub nurse expertise variable: {(Scrub nurse staff 1 s time on case) (#1 s total time scrubbing in general surgery [2008]) + (Scrub nurse staff 2 s time on case) (#2 s total time scrubbing in general surgery [2008]) + (#3) + n . . .} (Total case duration)
In summary, OR scrub nurse expertise was calculated for each surgical case by multiplying the amount of time each nursing scrub staff member spent in the case by his or her cumulative time spent in the OR scrub nurse role in general surgical cases in 1 year (2008). These values were summed and then divided by the total case duration. The total case duration was defined as the length of the surgical procedure in hours and minutes from the time of the patient’s surgical incision until the end of patient’s surgical site wound dressing. Operating room scrub nursing expertise values per case were then multiplied by 100 for logistic regression interpretation, where every unit increase (100 hours) of scrubbing in general surgery cases in 2008 affects the predicted odds of developing SSI. Potential predictor variables assessed for inclusion in the analysis were demographic variables, comorbidity variables, and OR context variables. Demographic variables were composed of patient age, patient gender, body mass index, and smoking status. Comorbidity variables evaluated were American Society of Anesthesiologists (ASA) classification system, Relative Value Unit (RVU), presence of bleeding-related diseases, cancer, cardiac disease, cerebrovascular accident, diabetes, alcohol abuse, gastrointestinal disease, peripheralvascular disease, pulmonary conditions, and renal conditions. Surgery type (emergent or nonemergent cases), preoperative admit status (inpatient, outpatient, or admit day procedures), and the shift surgery started and ended (day, evening, or night shift) were the OR context variables analyzed for inclusion.
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The dependent variable of interest was SSI. It was measured as a dichotomous variable, demonstrating the presence or absence of infection. Surgical site infections included the development of (a) superficial incisional SSI, (b) deep incisional SSI, and (c) organ-space SSI within 30 days postoperatively. Data for SSI development were abstracted using available medical record documentation by highly trained clinical nurse reviewers to capture reliable ACS NSQIP data.35 Data analysis Statistical analysis was performed using SPSS version 18.0 software. All statistical analyses were 2-tailed with a P < .05 being considered statistically significant. Descriptive analyses explored sample (patient, scrub nurse staff, and OR context) characteristics. Twosample t tests for normally distributed variables and the Mann-Whitney U test for nonnormally distributed variables identified differences in continuous variables. Chi-square analysis or the Fisher exact test compared means in categorical variables. Logistic regression was applied to evaluate the prediction of general surgical scrub nurse expertise on SSIs. Predictor variables were chosen on the basis of research questions and statistical significance (P < .05). The final model included scrub person expertise, ASA, RVU, and patient preoperative admit status. The ASA classification system consists of 6 categories and assesses the degree of a patient’s “sickness” or “physical state”; ASA status 1 is a normal, healthy patient up to ASA status 6, which is a brain-dead person whose organs are being removed for donation. The ASA creates a uniform system for statistical analysis.36 The RVU is a measure of the complexity of the operation.37 The RVU controls for time, skill, and training of the physician. Goodness of fit was formally evaluated using the Hosmer-Lemeshow goodness-of-fit test.38 RESULTS Two hundred twenty RNs and scrub technicians comprised the scrub staff sample in this
study of 923 general surgery cases. Most (n = 158; 71.8%) were RNs and 28.2% (n = 62) were scrub technicians. The average scrub staff (RN or technician) in the OR spent approximately 51% of their time in the scrub role (M = 0.51, SD = 0.35) and participated in an average of 178 cases throughout the year (M = 178, SD = 18). The total number of scrub staff per case ranged from 1 to 8, with a mean of 2.25 scrub staff members per case. Hours of general surgery scrub staff expertise in 2008 comprised a wide range, from 5 hours 50 minutes to 1623 hours 21 minutes (M = 394:29, SD = 9.887). The average patient age was 53 years. Sixtytwo percent of the patients (n = 571) were females, with 81.4% (n = 752) being white. AN SSI was reported for 6.1% (n = 56) of the general surgery cases, which is 4.1% above the national average for SSI postoperatively for all types of surgical procedures.13 Although not significant, results show that patients with SSI are older (56 years) than patients without SSI (aged 53 years). However, no significant differences were found in body mass index or gender and SSI. Table 1 (see Supplemental Digital Content Table, available at: http://links.lww.com/ JNCQ/A129) presents differences in patient comorbidities and SSI outcome. Patients with SSI have significantly (P < .001) higher RVU (M = 24.8, SD = 9.8) than patients who do not develop SSI (M = 17.2, SD = 10.0), meaning that the more complex the patients’ condition, the more likely they are to develop an SSI postoperatively. Surprisingly, patients with a history of cerebrovascular accident differed significantly from the non-SSI group (P = .018) and were more likely to develop SSI postoperatively. There was a significant difference (P = .04) in the SSI group in ASA patient status classification.39 Exactly half (n = 28; 50%) of the sample that developed SSI postoperatively had an ASA patient status of 3: a patient with noncapacitating severe systemic disease such as diabetes, poorly controlled hypertension, or an implanted pacemaker. Almost half (n = 25; 44.6%) were classified as patient status 2, which is considered
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Relationship Between OR Nursing Staff Expertise and Patient Outcomes a patient with mild systemic disease such as controlled diabetes, well-controlled hypertension, or mild lung disease. No other comorbidities showed significant differences in relationship to SSI. Table 2 (see Supplemental Digital Content Table, available at: http://links.lww.com/ JNCQ/A130) illustrates differences in OR context variables among patients with and without SSI. Only the “preoperative admit status” showed a statistically significant difference in the development of SSI, with a majority of patients having an admit day procedure (n = 33; 58.9%). Interestingly, almost half of the cases developing SSIs postoperatively (n = 29; 51.8%) started during the day shift between 7 AM and 3 PM, with a majority also ending during the day shift (n = 48; 85.7%). Unconditional logistic regression was performed to assess the impact of expertise on the likelihood of the development of SSIs. The model contained 4 predictor variables (expertise, RVU, ASA, and preoperative admit status). Expertise was the independent variable of interest; RVU, ASA, and preoperative admit status (OR context variable) were predictor variables significantly associated (P < .05) with the development of SSI in this sample and included in the final logistic regression model. The full model (Table) containing all predictors with the expertise variable was statis2 = 33.32; P ≤ .001), tically significant (χ4,894 indicating that the model was able to distinguish between patients who did and did not develop SSI. The model as a whole explained
between 3.7% (Cox and Snell R2 ) and 9.9% (Nagelkerke R2 ) of the variance in development of SSIs and correctly classified 93.8% of cases. Only 2 of the independent variables made a unique statistically significant contribution to the model: RVU (P = .004) and preoperative admit status (P = .009). The strongest significant predictor of developing SSI postoperatively was the RVU, recording an odds ratio of 1.034 (95% confidence interval, 1.011-1.058). This indicated that those with higher surgical complexity were 3.4% more likely to develop SSI, controlling for all other factors in the model. Also, although not statistically significant, the odds ratio of 0.943 (95% confidence interval, 0.834-1.067) for scrub person expertise was less than 1, indicating that for every additional unit of expertise (100 hours of scrubbing in general surgery cases in 2008), patients were 0.943 times less likely to have developed SSIs when controlling for other factors in the model. Therefore, the odds of developing SSIs decreased by 5.7% with increased expertise, all other factors being equal. In sum, although not significant in this study, patient severity of illness and scrub person expertise showed expected directionality of the odds ratios, possibly demonstrating sensitivity to sample size and/or measurement approaches. DISCUSSION This study evaluated the relationship between perioperative scrub staff expertise and the development of SSIs based on
Table. Logistic Regression Analysis for Predicting Surgical Site Infection (N = 923) Variable Expertise RVU ASA-PS Admit status
B
SE B
OR
95% CI
P
− .058 .034 .205 − .518
.063 .012 .105 .197
0.943 1.034 1.227 0.596
0.843-1.067 1.011-1.058 0.998-1.509 0.405-0.877
.354 .004a .052 .009a
Abbreviations: ASA-PS, American Society of Anesthesiologists Physical Status; B, standardized β coefficient; CI, confidence interval; OR, odds ratio; P, statistical significance; RVU, relative value unit; SE B, standard error of β. a P < .01.
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specialization, as has been used in expertiserelated studies of surgeons.20-25 An important result was the 5.7% (P = .354) protection against SSI development with increased scrub person expertise in this study. One potential explanation for the lack of a significant relationship between expertise and SSIs may have been due to the exclusion of the contribution of other health care personnel expertise such as the surgeon and the circulating nurse. Our results suggest that future investigations should incorporate OR scrub nurse, circulating nurse, and surgeon expertise in relationship with patient outcomes. It is not surprising, however, that surgical case complexity, or RVU, was the strongest predictor in the development of SSIs after controlling for expertise, ASA, and preoperative admit status. Our findings confirm existing evidence that higher RVU scores have been associated with SSI risk.40,41 Surgical site infections can occur up to 30 days postoperatively. Studies have identified surgeon expertise as being directly related to more immediate patient outcomes such as shorter lengths of operating time.42,43 Future studies should investigate OR nursing expertise and more immediate surgical outcomes, such as OR duration, incorrect counts, or retained foreign objects, to examine whether expertise makes an impact on these more immediate surgical outcomes. This study demonstrates that OR nurse expertise should be further investigated and evaluated with multiple outcomes and in different hospital settings. Limitations This study was subject to some limitations. First, the sample size was limited and might explain the lack of significance with this sample. Incorporating additional hospitals and study years will further clarify our results. Ex-
pertise was operationalized using surgical specialty, and additional expertise-related variables should also be considered in future studies. We assume that the staffing pattern observed for 2008 is representative of other years; adding additional hospitals and study years will corroborate this assumption. Nursing implications The exploration of nursing expertise is important, given current nursing workforce issues. With many nurses retiring and a projected nursing shortage,9 we need to understand the development of nursing expertise in ways that are different from those of traditional expertise identification based on one’s years of experience to manage the rift that may occur in workforce expertise.4,11,44 Bathish45 found that it was not experience or higher education that was significantly associated with expertise but rather the amount of deliberate practice in which one engages. Similarly, specialization in the OR is one way of developing the expertise needed to practice in the ever-increasing high-acuity, hightechnology, and changing climate of today’s health care environment. The use of specialization in the OR may be a framework for identifying characteristics of nursing expertise that can facilitate and describe what nurses do and how they do it to ensure quality patient care. Surgical site infections continue to cost money and time, as well as plague health care provision. Matching levels of OR nursing staff expertise with specific surgical procedures may be a step toward demystifying the incidence of SSIs. Capturing the concept of OR nursing expertise in a manner that aligns with existing work with physicians is a promising area of research warranting further evaluation and important in light of current health care trends.
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Relationship Between OR Nursing Staff Expertise and Patient Outcomes 2. DeFrances CJ, Lucas CA, Buie VC, Golosinskiy A. 2006 National Hospital Discharge Survey. National health statistics reports no 5. Hyattsville, MD: National Center for Health Statistics. 2008. 3. The Patient Protection and Affordable Care Act, Pub L No. 111-148, §2702, 124 Stat 119, 318-319 (2010). 4. Schatz S, Marraffino A, Allen C, Tanaka A. Humansystems integration, simulation, and the nursing shortage. In: Proceedings of the International Symposium of Human Factors and Ergonomics in Healthcare. Vol 2. Thousand Oaks, CA: Sage; 2013:135-142. 5. US Department of Health and Human Services. Projected supply, demand, and shortages of registered nurses 2000-2020 [report]. http://www.ahcancal.org/research data/staffing/ Documents/Registered Nurse Supply Demand.pdf. Published 2002. Accessed August 11, 2014. 6. Juraschek SP, Zhang X, Ranganathan V, Lin VW. United States registered nurse workforce report card and shortage forecast. Am J Med Qual. 2012;27(3):241-249. 7. Buerhaus P, Staiger D, Auerbach D. Implications of a rapidly aging registered nurse workforce. JAMA. 2000;283(22):2948-2954. 8. Buerhaus PI, Auerbach DI, Staiger DO, Muench U. Projections of the long-term growth of the registered nurse workforce: a regional analysis. Nurs Econ. 2013;31(1):13-17. 9. Staiger DO, Auerbach DI, Buerhaus PI. Registered nurse labor supply and the recession—are we in a bubble? N Engl J Med. 2012;366:1463-1465. 10. Kovner CT, Djukic M. The nursing career process from application through the first 2 years of employment. J Prof Nurs. 2009;25(4):197-203. 11. World Health Organization. WHO guidelines for safe surgery 2009: safe surgery saves lives. http://www.who.int/patientsafety/safesurgery/ tools resources/9789241598552/en. Published 2009. Accessed August 9, 2014. 12. Alfredsdottir H, Bjornsdottir K. Nursing and patient safety in the operating room. J Adv Nurs. 2008;61(1):29-37. 13. Boissoneau R, Sprengel AD, Snell WE. A national study: the use of specialty surgical teams. Health Mark Q. 1999;17(1):49-58. 14. Gillespie BM, Hamlin L. A synthesis of the literature on “competence” as it applies to perioperative nursing. AORN J. 2009;90(2):245-258. 15. Gillespie BM, Chaboyer W, Wallis M, Chang HA, Werder H. Operating theatre nurses’ perceptions of competence: a focus group study. J Adv Nurs. 2009;65(5):1019-1028. 16. King L, Clark JM. Intuition and the development of expertise in surgical ward and intensive care nurses. J Adv Nurs. 2002;37(4):322-329. 17. Benner P. From novice to expert. Excellence and Power in Clinical Nursing Practice. Menlo Park, CA: Addison Wesley; 1984.
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18. Centers for Disease Control and Prevention. Procedure associated events: SSI. http://www.cdc. gov/nhsn/PDFs/pscManual/9pscSSIcurrent.pdf. Published 2014. Accessed April 10, 2014. 19. de Lissovoy G, Fraeman K, Hutchins V, Murphy D, Song D, Vaughn BB. Surgical site infection: incidence and impact on hospital utilization and treatment costs. Am J Infect Control. 2009;37:387-397. 20. Cox CE, Salud CJ, Cantor A, et al. Learning curves for breast cancer sentinel lymph node mapping based on surgical volume analysis. J Am Coll Surg. 2001;193:593-600. 21. Begg CB, Riedel ER, Bach PB, et al. Variations in morbidity after radical prostatectomy. N Engl J Med. 2002;346:1138-1144. 22. Birkmeyer JD, Stukel TA, Siewers AE, Goodney PP, Wennberg DE, Lucas FL. Surgeon volume and operative mortality in the United States. N Engl J Med. 2003;349(22):2117-2127. 23. Morton RP, Gray L, Tandon DA, Izzard M, McIvor NP. Efficacy of neck dissection: are surgical volumes important? Laryngoscope. 2009;119:1147-1152. 24. Nallamothu BK, Gurm HS, Ting HH, et al. Operator experience and carotid stenting outcomes in Medicare beneficiaries. JAMA. 2011;306(12): 1338-1343. 25. Andrews S. Does concentration of surgical expertise improve outcomes for laparoscopic cholecystectomy? 9 year audit cycle. Surgeon. 2013;11(6): 309-312. 26. Rea JD, Lu KC, Diggs BS, Cone MM, Hardiman KM, Herzig DO. Specialized practice reduces inpatient mortality, length of stay, and cost in the care of colorectal patients. Dis Colon Rectum. 2011;54(7): 780-786. 27. Stavrakis AI, Ituarte PH, Ko CY, Yeh MW. Surgeon volume as a predictor of outcomes in inpatient and outpatient endocrine surgery. Surgery. 2007;142(6):887899. 28. Waljee JF, Hawley S, Alderman AK, Morrow M, Katz SJ. Patient satisfaction with treatment of breast cancer: does surgeon specialization matter? Clin Oncol. 2007;25(24):3694-3698. 29. Chowdhury MM, Dagash H, Pierro A. A systematic review of the impact of volume of surgery and specialization on patient outcome. Br J Surg. 2007;94(2):145-161. 30. McLaughlin M, Bathish M, Talsma AN. The use of specialty surgical teams in operating rooms. Paper presented at: Proceedings of the AORN Congress; March 2-7, 2013; San Diego, CA. 31. Newhouse RP, Johantgen M, Pronovost PJ, Johnson E. Perioperative nurses and patient outcomes— mortality, complications, and length of stay. J Nurs Adm. 2010;40(10):508-528. 32. Talsma A, Anderson C, Guo Y, Campbell DA. Evaluation of OR staffing and post-operative patient outcomes. AORN J. 2013;97(2):230-242.
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33. Association of periOperative Registered Nurses. Standards, Recommended Practices, and Guidelines: Position Statement on Role of the Scrub Person. Denver, CO: Association of periOperative Registered Nurses; 2010. 34. Association of Surgical Technologists. Standards of practice. http://www.ast.org/AboutUs/Standards of Practice. Published 2014. Accessed August 9, 2014. 35. QCMetrix. http://www.QCMetrix.com. Published 2011. Accessed August 9, 2014. 36. Cleveland Clinic. ASA physical classification system. http://my.clevelandclinic.org/health/treatments_ and_procedures/hic_ASA_Physical_Classification_ System. Published 2011. Accessed April 10, 2011. 37. Centers for Medicare & Medicaid Services. National Physician Fee Schedule Relative Value File. http:// www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/PhysicianFeeSched/PFS-Relative-ValueFiles-Items/RVU14A.html. Published 2013. Accessed March 1, 2013. 38. Tabachnik BD, Fidell LS. Using Multivariate Statistics. 5th ed. Boston, MA: Pearson Education; 2007. 39. American Society of Anesthesiologists. http://www. asahq.org. Published 2011. Accessed August 11, 2014.
40. Neumayer L, Hosokawa P, Itari K, El-Tamer M, Henderson WG, Khuri SF. Multivariable predictors of postoperative surgical site infection after general and vascular surgery: results from the patient safety in surgery study. J Am Coll Surg. 2007;204(6):11781187. 41. Merkow RP, Bentrem DJ, Cohen ME, et al. Effect of cancer surgery complexity on short-term outcomes, risk predictions, and hospital comparisons. J Am Coll Surg. 2013;217(4):685-693. 42. Willeke F, Willeke M, Hinz U, et al. Effect of surgeon expertise on the outcome in primary hyperparathyroidism. Arch Surg. 1998;133:1066-1070. 43. Marusch F, Gastinger I, Schneider C, et al. Experience as a factor influencing the indications for laparoscopic colorectal surgery and the results. Surg Endosc. 2001;15(2):116-120. 44. Ericsson KA, Whyte J, Ward P. Expert performance in nursing: reviewing research on expertise in nursing within the framework of the expertperformance approach. Adv Nurs Sci. 2007;30: E58-E71. 45. Bathish MA. Deliberate Practice in Nursing [dissertation]. Ann Arbor, MI: University of Michigan; 2014.
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J Nurs Care Qual Vol. 30, No. 2, pp. 167–174 c 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright
Relationship Between Operating Room Nursing Staff Expertise and Patient Outcomes Melissa Bathish, PhD, RN, CPNP; Margaret McLaughlin, PhD, RN; AkkeNeel Talsma, PhD, RN, FAAN This secondary analysis evaluated the association of operating room scrub staff expertise, based on frequency of working on a specific surgical procedure, with the development of surgical site infections. The odds of developing surgical site infections decreased by 5.7% (odds ratio = 0.943; 95% confidence interval, 0.834-1.067) with increased expertise, although a statistically significant association was not established (P = .354). The relationship between operating room scrub staff expertise and patient outcomes is important to understand. Key words: nursing expertise, operating room, patient outcomes, perioperative nursing, surgical site infections
E
ACH YEAR, an estimated 1 of every 25 people around the globe undergoes some form of major surgery in an operating room (OR).1 In 2006, nearly 46 million surgical procedures occurred in American hospitals, with more than a third of these performed on patients 65 years and older.2 Recently, the demand for health care has increased with the passage of the Patient Protection and Affordable Care Act3 and the complexity of care
Author Affiliations: University of Michigan School of Nursing, Ann Arbor, Michigan (Dr Bathish); School of Medicine, University of Michigan, Ann Arbor (Dr Talsma); and Indiana University School of Nursing, Indianapolis (Dr McLaughlin). The authors declare no conflict of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.jncqjournal.com). Correspondence: Melissa Bathish, PhD, RN, CPNP, University of Michigan School of Nursing, 400 N. Ingalls, Room 2345, Ann Arbor, MI 48109. (mbathish@ umich.edu). Accepted for publication: September 17, 2014. Published ahead of print: November 25, 2014 DOI: 10.1097/NCQ.0000000000000092
has become more advanced with longevity of life.4 Concurrently, a projected nursing workforce shortage is predicted to reach 800 000 registered nurses (RNs) by the year 20205 and up to 1 million by the year 20306 due to an aging workforce,7,8 an outflow of nurses from the profession with the economic recovery,9 and a shortage of nursing faculty to accommodate qualified applicants into nursing programs around the country.10 The World Health Organization has identified OR performance as an important component of providing safe and effective procedures for surgical patients.11 One core element of the role of the OR nurse is to ensure patient safety during operations.12 Repeated, consistent performance of specific surgical procedures gives OR nursing staff the opportunity to master skills, leading to clinical expertise, and possibly improved patient outcomes.13 Performance identification and evaluation of nursing staff have, however, focused primarily on competence.14-16 Nevertheless, with current workforce and population trends, the complex environment of today’s OR, and the nationwide focus on quality care and patient safety, OR nursing staff need to exceed competence, demonstrating expertise in their areas of practice. 167
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Nurses’ level of expertise influences their quality of care and clinical judgment.17 The contribution of OR nursing staff expertise on patient outcomes such as surgical site infections (SSIs), however, is unknown. Surgical site infections are the second most common health care–associated infection in the United States and remain a major cause of morbidity and mortality.18,19 Nationally, SSIs were associated with an additional 406 730 hospitaldays and hospital costs exceeding $900 million. Surgical site infections also extended the length of stay by an average of 9.7 days while increasing cost by $20 842 per admission. An additional 91 613 readmissions for treatment of SSIs accounted for a further 521 933 days of care at a cost of nearly $700 million.19 Thus, evaluating OR nursing expertise and the development of postoperative SSI may present an opportunity to help reduce SSIs, improve patient outcomes, and save millions of health care dollars. Many studies have examined relationships between surgeon expertise and patient outcomes.20-24 In the surgical literature, increased surgical volume, or the number of surgical cases performed, has been linked to expertise.25 Several areas of surgery (vascular, thoracic, colorectal, orthopedic, breast, urology, neurosurgery, and otolaryngology) have identified correlations between increased surgical volume and improved outcomes.20-25 Performing high volumes of selective procedures is known as surgical specialization. Surgical specialization ultimately enhances performance and surgical expertise. Notably, it has been linked to positive patient outcomes in many different specialty areas including, but not limited to, colorectal, endocrine, and breast cancer surgical procedures.26-28 In a review of the literature by Chowdhury and colleagues29 examining the effects of surgical volume and specialization on patient outcomes, it was found that the contribution of multidisciplinary team members along with surgical expertise should be examined in relationship to improved patient outcomes. After controlling for volume discrepancies among hospitals and surgeons, the benefit of specialization went beyond
“practice makes perfect”29(p154) and was an accumulated benefit of high volume and the contribution of other health care personnel. McLaughlin et al30 conducted a study of 25 hospitals in 15 different states examining the use and types of specialty surgical service teams and found that 68% of the hospitals surveyed used specialty teams in their ORs. This prevalence of the use of specialty teams affords nurses the opportunity to specialize in a surgical area and has important implications for OR nurses. Alfredsdottir and Bjornsdottir12 asked OR nurses employed at a university hospital in Iceland that used specialty teams about their role in patient safety. The organization of work into specialty teams was essential to enhance patient safety in their OR. Better patient outcomes have also been shown to exist with the use of RN agency for OR care.31 Perioperative agency nurses are usually specialized, consistently working in the same surgical service, rendering them “experts” in their specialty surgical area, which may positively impact patient outcomes. The objective of this study was to evaluate whether nursing expertise in the OR was associated with favorable patient outcomes. The specific aim was to evaluate whether nursing scrub staff expertise, specifically in general surgical cases, decreases the likelihood of patients developing SSI postoperatively. METHODS Design and sample A cross-sectional cohort design was used for secondary data analysis. A subset of general surgery cases (n = 923) collected at a large, Midwestern, university-based medical center in 2008 was used in this study that merged a random sample of general surgical case-level data with preoperative comorbidity and postoperative patient outcomes data. The data were collected as a result of the medical center’s participation in the ACS NSQIP (American College of Surgeons National Surgical Quality Improvement Plan).32 General surgery procedures included endocrinology, gastrointestinal, oncology, transplant, trauma
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Relationship Between OR Nursing Staff Expertise and Patient Outcomes burn, and minimally invasive surgical procedures. Personal identifiers were removed from all individual and case-level data and reassigned anonymous identifiers. The study was deemed to be exempt by the university and medical center institutional review boards. Measures The primary independent variable of interest was general surgical nursing scrub staff expertise. According to the Association of periOperative Registered Nurses, scrub nurses work within the sterile field during a surgical procedure, interacting directly with the surgeon throughout a surgery. The scrub role can be delegated to an RN, licensed practical nurse, licensed vocational nurse, or unlicensed assistive personnel or “scrub technician.”33 Much like surgical scrub nurses, surgical technologists include both the behavioral and technical aspects of surgical technology, have the necessary knowledge and ability to deliver quality patient care during the operative period, and ensure maintenance of a sterile field during a surgical procedure.34 Operating room RNs and surgical technologists were considered OR nursing scrub staff in this study. Scrub nurses have a critical role in infection prevention due to their direct involvement in surgical patient care: performing surgical draping, handling sterile equipment, and maintaining a sterile environment during surgical and invasive procedures. Surgical cases can have a single scrub nurse or multiple scrub nursing staff members participating in the operation. The number of nursing scrub staff is dependent on many organizational and patient-related factors such as the length and complexity of the surgical case, staffing and scheduling consequences, and workflow issues. Any of these factors may influence the number of scrub staff present for all or part of a surgical procedure. Therefore, OR nursing scrub staff expertise was weighted on the basis of the number of nursing scrub staff participating in a surgical case, the amount of time each member was scrubbed into the case, and the amount of time spent specifically scrubbing in general
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surgical cases as opposed to other specialty areas. The following equation was used to calculate the scrub nurse expertise variable: {(Scrub nurse staff 1 s time on case) (#1 s total time scrubbing in general surgery [2008]) + (Scrub nurse staff 2 s time on case) (#2 s total time scrubbing in general surgery [2008]) + (#3) + n . . .} (Total case duration)
In summary, OR scrub nurse expertise was calculated for each surgical case by multiplying the amount of time each nursing scrub staff member spent in the case by his or her cumulative time spent in the OR scrub nurse role in general surgical cases in 1 year (2008). These values were summed and then divided by the total case duration. The total case duration was defined as the length of the surgical procedure in hours and minutes from the time of the patient’s surgical incision until the end of patient’s surgical site wound dressing. Operating room scrub nursing expertise values per case were then multiplied by 100 for logistic regression interpretation, where every unit increase (100 hours) of scrubbing in general surgery cases in 2008 affects the predicted odds of developing SSI. Potential predictor variables assessed for inclusion in the analysis were demographic variables, comorbidity variables, and OR context variables. Demographic variables were composed of patient age, patient gender, body mass index, and smoking status. Comorbidity variables evaluated were American Society of Anesthesiologists (ASA) classification system, Relative Value Unit (RVU), presence of bleeding-related diseases, cancer, cardiac disease, cerebrovascular accident, diabetes, alcohol abuse, gastrointestinal disease, peripheralvascular disease, pulmonary conditions, and renal conditions. Surgery type (emergent or nonemergent cases), preoperative admit status (inpatient, outpatient, or admit day procedures), and the shift surgery started and ended (day, evening, or night shift) were the OR context variables analyzed for inclusion.
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The dependent variable of interest was SSI. It was measured as a dichotomous variable, demonstrating the presence or absence of infection. Surgical site infections included the development of (a) superficial incisional SSI, (b) deep incisional SSI, and (c) organ-space SSI within 30 days postoperatively. Data for SSI development were abstracted using available medical record documentation by highly trained clinical nurse reviewers to capture reliable ACS NSQIP data.35 Data analysis Statistical analysis was performed using SPSS version 18.0 software. All statistical analyses were 2-tailed with a P < .05 being considered statistically significant. Descriptive analyses explored sample (patient, scrub nurse staff, and OR context) characteristics. Twosample t tests for normally distributed variables and the Mann-Whitney U test for nonnormally distributed variables identified differences in continuous variables. Chi-square analysis or the Fisher exact test compared means in categorical variables. Logistic regression was applied to evaluate the prediction of general surgical scrub nurse expertise on SSIs. Predictor variables were chosen on the basis of research questions and statistical significance (P < .05). The final model included scrub person expertise, ASA, RVU, and patient preoperative admit status. The ASA classification system consists of 6 categories and assesses the degree of a patient’s “sickness” or “physical state”; ASA status 1 is a normal, healthy patient up to ASA status 6, which is a brain-dead person whose organs are being removed for donation. The ASA creates a uniform system for statistical analysis.36 The RVU is a measure of the complexity of the operation.37 The RVU controls for time, skill, and training of the physician. Goodness of fit was formally evaluated using the Hosmer-Lemeshow goodness-of-fit test.38 RESULTS Two hundred twenty RNs and scrub technicians comprised the scrub staff sample in this
study of 923 general surgery cases. Most (n = 158; 71.8%) were RNs and 28.2% (n = 62) were scrub technicians. The average scrub staff (RN or technician) in the OR spent approximately 51% of their time in the scrub role (M = 0.51, SD = 0.35) and participated in an average of 178 cases throughout the year (M = 178, SD = 18). The total number of scrub staff per case ranged from 1 to 8, with a mean of 2.25 scrub staff members per case. Hours of general surgery scrub staff expertise in 2008 comprised a wide range, from 5 hours 50 minutes to 1623 hours 21 minutes (M = 394:29, SD = 9.887). The average patient age was 53 years. Sixtytwo percent of the patients (n = 571) were females, with 81.4% (n = 752) being white. AN SSI was reported for 6.1% (n = 56) of the general surgery cases, which is 4.1% above the national average for SSI postoperatively for all types of surgical procedures.13 Although not significant, results show that patients with SSI are older (56 years) than patients without SSI (aged 53 years). However, no significant differences were found in body mass index or gender and SSI. Table 1 (see Supplemental Digital Content Table, available at: http://links.lww.com/ JNCQ/A129) presents differences in patient comorbidities and SSI outcome. Patients with SSI have significantly (P < .001) higher RVU (M = 24.8, SD = 9.8) than patients who do not develop SSI (M = 17.2, SD = 10.0), meaning that the more complex the patients’ condition, the more likely they are to develop an SSI postoperatively. Surprisingly, patients with a history of cerebrovascular accident differed significantly from the non-SSI group (P = .018) and were more likely to develop SSI postoperatively. There was a significant difference (P = .04) in the SSI group in ASA patient status classification.39 Exactly half (n = 28; 50%) of the sample that developed SSI postoperatively had an ASA patient status of 3: a patient with noncapacitating severe systemic disease such as diabetes, poorly controlled hypertension, or an implanted pacemaker. Almost half (n = 25; 44.6%) were classified as patient status 2, which is considered
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Relationship Between OR Nursing Staff Expertise and Patient Outcomes a patient with mild systemic disease such as controlled diabetes, well-controlled hypertension, or mild lung disease. No other comorbidities showed significant differences in relationship to SSI. Table 2 (see Supplemental Digital Content Table, available at: http://links.lww.com/ JNCQ/A130) illustrates differences in OR context variables among patients with and without SSI. Only the “preoperative admit status” showed a statistically significant difference in the development of SSI, with a majority of patients having an admit day procedure (n = 33; 58.9%). Interestingly, almost half of the cases developing SSIs postoperatively (n = 29; 51.8%) started during the day shift between 7 AM and 3 PM, with a majority also ending during the day shift (n = 48; 85.7%). Unconditional logistic regression was performed to assess the impact of expertise on the likelihood of the development of SSIs. The model contained 4 predictor variables (expertise, RVU, ASA, and preoperative admit status). Expertise was the independent variable of interest; RVU, ASA, and preoperative admit status (OR context variable) were predictor variables significantly associated (P < .05) with the development of SSI in this sample and included in the final logistic regression model. The full model (Table) containing all predictors with the expertise variable was statis2 = 33.32; P ≤ .001), tically significant (χ4,894 indicating that the model was able to distinguish between patients who did and did not develop SSI. The model as a whole explained
between 3.7% (Cox and Snell R2 ) and 9.9% (Nagelkerke R2 ) of the variance in development of SSIs and correctly classified 93.8% of cases. Only 2 of the independent variables made a unique statistically significant contribution to the model: RVU (P = .004) and preoperative admit status (P = .009). The strongest significant predictor of developing SSI postoperatively was the RVU, recording an odds ratio of 1.034 (95% confidence interval, 1.011-1.058). This indicated that those with higher surgical complexity were 3.4% more likely to develop SSI, controlling for all other factors in the model. Also, although not statistically significant, the odds ratio of 0.943 (95% confidence interval, 0.834-1.067) for scrub person expertise was less than 1, indicating that for every additional unit of expertise (100 hours of scrubbing in general surgery cases in 2008), patients were 0.943 times less likely to have developed SSIs when controlling for other factors in the model. Therefore, the odds of developing SSIs decreased by 5.7% with increased expertise, all other factors being equal. In sum, although not significant in this study, patient severity of illness and scrub person expertise showed expected directionality of the odds ratios, possibly demonstrating sensitivity to sample size and/or measurement approaches. DISCUSSION This study evaluated the relationship between perioperative scrub staff expertise and the development of SSIs based on
Table. Logistic Regression Analysis for Predicting Surgical Site Infection (N = 923) Variable Expertise RVU ASA-PS Admit status
B
SE B
OR
95% CI
P
− .058 .034 .205 − .518
.063 .012 .105 .197
0.943 1.034 1.227 0.596
0.843-1.067 1.011-1.058 0.998-1.509 0.405-0.877
.354 .004a .052 .009a
Abbreviations: ASA-PS, American Society of Anesthesiologists Physical Status; B, standardized β coefficient; CI, confidence interval; OR, odds ratio; P, statistical significance; RVU, relative value unit; SE B, standard error of β. a P < .01.
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specialization, as has been used in expertiserelated studies of surgeons.20-25 An important result was the 5.7% (P = .354) protection against SSI development with increased scrub person expertise in this study. One potential explanation for the lack of a significant relationship between expertise and SSIs may have been due to the exclusion of the contribution of other health care personnel expertise such as the surgeon and the circulating nurse. Our results suggest that future investigations should incorporate OR scrub nurse, circulating nurse, and surgeon expertise in relationship with patient outcomes. It is not surprising, however, that surgical case complexity, or RVU, was the strongest predictor in the development of SSIs after controlling for expertise, ASA, and preoperative admit status. Our findings confirm existing evidence that higher RVU scores have been associated with SSI risk.40,41 Surgical site infections can occur up to 30 days postoperatively. Studies have identified surgeon expertise as being directly related to more immediate patient outcomes such as shorter lengths of operating time.42,43 Future studies should investigate OR nursing expertise and more immediate surgical outcomes, such as OR duration, incorrect counts, or retained foreign objects, to examine whether expertise makes an impact on these more immediate surgical outcomes. This study demonstrates that OR nurse expertise should be further investigated and evaluated with multiple outcomes and in different hospital settings. Limitations This study was subject to some limitations. First, the sample size was limited and might explain the lack of significance with this sample. Incorporating additional hospitals and study years will further clarify our results. Ex-
pertise was operationalized using surgical specialty, and additional expertise-related variables should also be considered in future studies. We assume that the staffing pattern observed for 2008 is representative of other years; adding additional hospitals and study years will corroborate this assumption. Nursing implications The exploration of nursing expertise is important, given current nursing workforce issues. With many nurses retiring and a projected nursing shortage,9 we need to understand the development of nursing expertise in ways that are different from those of traditional expertise identification based on one’s years of experience to manage the rift that may occur in workforce expertise.4,11,44 Bathish45 found that it was not experience or higher education that was significantly associated with expertise but rather the amount of deliberate practice in which one engages. Similarly, specialization in the OR is one way of developing the expertise needed to practice in the ever-increasing high-acuity, hightechnology, and changing climate of today’s health care environment. The use of specialization in the OR may be a framework for identifying characteristics of nursing expertise that can facilitate and describe what nurses do and how they do it to ensure quality patient care. Surgical site infections continue to cost money and time, as well as plague health care provision. Matching levels of OR nursing staff expertise with specific surgical procedures may be a step toward demystifying the incidence of SSIs. Capturing the concept of OR nursing expertise in a manner that aligns with existing work with physicians is a promising area of research warranting further evaluation and important in light of current health care trends.
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