Research, Evidence-Based Practice, and Clinical Improvement/Innovation Posters
A
ORN Surgical Conference & Expo 2014 attendees had the opportunity to earn up to 31 contact hours by reviewing the poster book and evaluating 34 research and 37 evidencebased practice posters in eight poster sessions, and 211 clinical improvement/innovation posters in 23 poster sessions. Posters are available online, for those poster authors who agreed to share their posters online, at http://www.eventscribe.com/2014/ posters/aorn/home.asp. RESEARCH POSTERS The top three posters were recognized with an award in the research category by members of AORN’s Nursing Research Committee. Following are the abstracts from the three winning research posters. 1st Place: Factors Associated With RN Turnover in Perioperative Units Catima Potter, MPH; JiSun Choi, PhD, RN Retention of younger perioperative nurses is an issue. This may create additional problems as the nursing workforce continues to age and retire. The research study’s aim was to examine nursing work context and RN characteristics associated with perioperative RN turnover. The sample consisted of 565 perioperative units in 260 US hospitals. Linked 2012 data on RN turnover and RN survey work context items from a national nursing quality database were used. Unit-level annualized turnover (ie, separation) rates were calculated for RNs. Hierarchical Poisson regression analysis was performed at the unit level. The mean unit level perioperative RN turnover rate was 1.92%. Nearly 18% of all RN separations had less than two years of experience at the hospital. More influence over schedule and a higher percentage of RNs with specialty certification
1st Place in the research category: Factors Associated With RN Turnover in Perioperative Units. Pictured: Catima Potter
were associated with lower perioperative RN unit turnover. Perioperative units with longer RN unit tenure reported lower RN turnover. Overall, the model had a moderate fit (R2 ¼ 0.68). Although the perioperative turnover rate was low, findings indicated that factors such as scheduling influence, specialty certification, and RN unit tenure were associated with turnover among perioperative RNs. Nurse leadership personnel should assess workforce characteristics in addition to work context when developing retention strategies. 2nd Place: A Focused Ethnography: Experiences of RNs Transitioning to the OR Mary A. Brinkman, PhD, RN, CNOR The OR is a unique setting and specialty area of nursing practice that requires optimal orientation and education to render safe and efficient patient care. Unfortunately, there will be a significant shortage of nurses in the OR in the next five to 10 years. The need for new nurses in the OR is essential because many OR nurses in the workforce
http://dx.doi.org/10.1016/j.aorn.2014.04.011
Ó AORN, Inc, 2014
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will retire within the next five years. Currently, most nursing programs no longer offer perioperative courses in their curriculum. Subsequently, this trend has led to the need for hospitals to educate and orient new nurses to their ORs. As hospitals educate their own OR nurses, retention after orientation becomes a priority. The purpose of this study was to explore nurses’ experiences as they transition to a new area of nursing practice, the OR. A qualitative focused ethnography was conducted. Fourteen RNs transitioning to the OR agreed to participate in this study. The OR was a first-time experience for the RNs. The setting was a large teaching hospital located in an urban area. Observations and interviews were conducted with the RNs to explore their experiences as they transitioned in the OR. The transition included learning the didactics of OR nursing through the web-based AORN Nursing 101 online computer course, practicing learned skills in a simulation laboratory, and rotating through surgical specialty areas under the supervision of an RN preceptor. Influences that facilitated the RNs’ transition to the OR were the positive learning experience, their perception of belonging and acceptance into the OR culture, the stimulating environment, supportive personnel, collegiality among peers, and presence of nursing in the OR. Influences that hindered the RNs’ transition to the
2nd place in the research category: A Focused Ethnography: Experiences of RNs Transitioning to the OR. Pictured: Mary A. Brinkman
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AORN CONFERENCE POSTERS OR were inconsistency in precepting, being in a hostile environment, limited exposure to the OR before the transition, and an overwhelming environment. Meleis’ Situational Transition model emerged in the RNs’ experiences transitioning to the OR. The need to educate nurses in the OR is essential to assure safety and positive outcomes for the surgical patient. Structured perioperative courses implemented by hospitals or with partnerships with nursing programs can enhance the education, transition, and retention of nurses new to the OR. The importance of a nurse educator having an advanced degree with experience in the OR specialty was essential in coordinating and mentoring nurses transitioning to this new practice area. The RNs who are prepared to precept were vital in the education and retention of RNs transitioning to the OR. The need for consistent preceptors was recognized as an essential factor to the RNs’ successful transition. The findings contribute to evidence-base practice for the design and implementation of perioperative courses for new nurses. 3rd Place: Transient Hypothermia Post-Cardiopulmonary Bypass: When Cold ISN’T COOL Patrel B. Nobles, BSN, RN; Cathy D. Jennings, DNP, RN, ACNS-BC; Sarah E. Frazier, BSN, BS, RN Background: Cardiopulmonary bypass (CPB) is an essential component for most cardiac surgical procedures. Using CPB-induced hypothermia can decrease the patient’s metabolic demand, protect the brain and other vital organs, and increase tolerance for cardiac ischemia during surgery. Yet, afterdrop, the unintentional decrease in body temperature between separation from CPB and arrival in the cardiac surgery intensive care unit (CSICU), can be problematic for cardiac surgery patients. This unintentional transient hypothermia is defined as a core temperature of less than 36 C (96.8 F) lasting less than 24 hours after CPB. Transient hypothermia is associated with increased perioperative blood loss, mechanical ventilation time, and CSICU and overall length of hospital stay.
AORN CONFERENCE POSTERS Methods: This quality improvement project had two phases. Phase 1 was a retrospective review of patient records to determine the incidence of transient hypothermia in this group (n ¼ 73) and to assess the following postoperative patient outcomes: number of units of packed red blood cell transfusions, hours on the ventilator, hours spent in the CSICU, and hours spent in the hospital after surgery. This group also served as the control group. In phase 2, sterile forced-air warming blankets were applied on all patients in the cardiac surgery OR during the rewarming phase of CPB and left in place through transfer to the CSICU. The same outcomes were evaluated for this group (n ¼ 57). Outcomes: Results revealed that patients receiving the forced-air warming blankets (Phase 2) had a statistically significant higher core temperature on admission to CSICU (P ¼ .018). Although not statistically significant, patients in the forced-air warming blanket group also n
received fewer red blood cell transfusions (0.67 units versus 0.85 units, a difference of 0.18 units), n required fewer hours of mechanical ventilation (13.9 hours versus 19.3 hours, a difference of 5.4 hours), n had shorter lengths of stay in CSICU (86.5 hours versus 102.1 hours, a difference of 15.6 hours), and
3rd place in the research category: Transient Hypothermia Post-Cardiopulmonary Bypass: When Cold ISN’T COOL. Pictured: Patrel B. Nobles and Sarah E. Frazier
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had shorter lengths of stay in the hospital (170.2 hours versus 195.7 hours, a difference of 25.5 hours).
Conclusion: Potential for clinical benefit from prevention of transient hypothermia is evidencebased and has resulted in a change in practice to include forced-air warming after CPB for all patients undergoing a cardiac surgical procedure. EVIDENCE-BASED PRACTICE POSTERS The top three posters were recognized with an award in the evidence-based practice category by members of AORN’s Nursing Research Committee. Following are the abstracts from the three winning evidence-based practice posters. 1st Place: Engaging Staff in LEAN Methodology Results in Increased Efficiency, Satisfaction, and Decreased Turnover Times Dawna L. Willsey, MSN, RN, CNOR; Coleen L. Lutz, RN; Kimberly A. McEvoy-Dodson, MBA, BSN, RN, CNOR, FACHE; Wendy Lin, MPH As health care and surgical procedures become more complex, the demand and optimization of resources increase as well. Expedient turnover time, as defined by a surgical patient “wheels out” of the OR to “wheels in,” has plagued surgery leaders. The increased complexity of technology and resources erode and disrupt efficient performance. Turnover time improvement efforts had been attempted by several services and could not be sustained. Orthopedics had fallen to the bottom quartile compared with nationally benchmarked turnover statistics. Patient and surgeon satisfaction were issues as wait times increased and surgery utilization decreased. Spinal fusion procedures, performed by a single surgeon, were chosen as the focus for implementation of Lean methodology processes. Team members were interdisciplinary, representing all phases of spinal surgery: preoperative, intraoperative, and postoperative. Although the focus of this project was on surgical procedure turnover, all processes AORN Journal j 715
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1st place in the evidence-based practice category: Engaging Staff in LEAN Methodology Results in Increased Efficiency, Satisfaction, and Decreased Turnover Times. Pictured: Coleen L. Lutz and Dawna L. Willsey
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2nd place in the evidence-based practice category: Focus on Quality Care. Pictured: Hugo Xi and Lena Pearson
2nd Place: Focus on Quality Care Hugo Xi, MD, MBA; Lena Pearson, MS, BSN, RN, CNOR
and that evidence-based interventions can substantially reduce the incidence of HAIs. The Patient Protection and Affordable Care Act will place up to 9.5% of Centers for Medicare & Medicaid Services (CMS) payments “at risk” for hospitals in fiscal year 2017. Quality and payfor-performance incentives can be implemented to help offset this loss. The Focus on Quality Care Program helps hospitals to eliminate variability in processes that will result in less waste, fewer errors, and better outcomes. The program implements a process from start to finish, including identification of evidence-based best practices, an action plan, training, support tools, and optimization of the product portfolio. The program includes an automated tablet computer-based OR audit tool, which helps ensure consistency and standardize data collection from audits across hospitals. In more than 100 audits, aggregate data collected by the audit tool demonstrated significant variability in surgical skin preparation procedures within and between facilities. The variability could have significant implications to costs and patient outcomes.
Annually in the United States, 1.7 million patients develop a health careeassociated infection (HAI) and nearly 100,000 will die from one; system-wide, the cost of HAIs is $35 billion. Recent studies demonstrate that at least 50% of HAIs are preventable
3rd Place: Count Twice Scan Once: Zero Tolerance for Retained Surgical Sponges Deborah G. Shealy, ADN, RN; Cynthia Shealy, BSN, RN; William H. McRae III, MD
related to surgical spinal fusion were evaluated. Several Lean tools were taught and used during this process, including process and value stream mapping, Kaizen events, development of standard operating procedures, 30-60-90 day audits, and huddles. The overall turnover time was measurably decreased for spinal fusion procedures, as well as an increase in OR efficiency. Process improvement measures and cultural learning were applied department wide. Patient, surgeon, and personnel satisfaction increased through the innovations of new processes. Ongoing audit and accountability tracking has demonstrated that the outcomes have been sustained. The initial membership of this team was designed to have at least one member who could lead the next focused improvement team effort. Next steps will be to apply lessons learned from this project to teams across departments and service lines.
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AORN CONFERENCE POSTERS The unintentionally retained surgical item is a devastating experience for every patient and surgical team. Surgical sponges account for 70% of retained surgical items. The first line of defense to prevent these events is manual counting, according to AORN standards and recommended practices. At Memorial, root cause analysis performed on every retained surgical item between 2005 and 2009 yielded opportunities for system improvement, except for human error. The root cause was determined to be human error at an undetermined time during the count process, resulting in an inaccurate initial count or inaccurate closing counts. The surgical team believed their counts were correct, all policy and procedures had been followed, and that neither the patient nor procedure met risk factors for a precautionary x-ray. It was time to explore other safeguards to prevent these events from occurring by leveraging technology to include barcoding and radiofrequency (RF) detection systems. The surgical team trialed two systems. A radiofrequency detection system was chosen and implemented in July 2011. With two years of data now available (ie, approximately 30,000 procedures), there have been zero occurrences of retained surgical sponges. Policy and protocols were developed for using the RF system for surgical patients. The implications for perioperative nursing are significant. Tangible benefits include reduction of patient
3rd place in the evidence-based practice category: Count Twice Scan Once: Zero Tolerance for Retained Surgical Sponges. Pictured: Deborah G. Shealy
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morbidity (eg, infection, returns to the OR, mortality) and associated costs as well as improved OR efficiency. Intangible benefits include increased patient and team satisfaction. So, count twice; scan once. CLINICAL IMPROVEMENT/INNOVATION POSTERS This is the first year that posters were judged online using the virtual gallery. Only posters that were uploaded were judged and the top 10% of those posters received an Award of Excellence. The posters were judged by the AORN Surgical Conference & Expo Task Force. The following award winners are presented in order by poster number. Put Your Hands Up: Best Practice For Healthy Hands of Operating Room Personnel Robin C. Salzbach, RN, CNOR; Gloria Y. Hinkle, BSN, RN, CNOR Clinical Issue: An increase in the occurrence of skin disorders of the hands of OR personnel at Carilion facilities was noted after a change was made in the surgical hand rub for the ORs. Preparation and Planning: The objective of this project was to define evidence-based practice for surgical hand antisepsis and hygiene, including products, accessibility, and methodology. The plan was to research hand hygiene and make recommendations for best practice and plan interventions. Implementation: The surgical hand rub was changed to adhere to the recommendation of 61% alcohol, 1% chlorhexidine, and humectants, which is less irritating than the previously used product. Redundant products were removed from the scrub sinks. There were different kinds of hand soap, and the one with the most chemicals in its content was removed. Education was provided via inservice programs regarding the changes. More hospitalapproved moisturizing lotions were installed around high areas of need. Evidence supported that the surgical hand rub can be used as the first scrub of the day, but must be completed with a nail AORN Journal j 717
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Put Your Hands Up: Best Practice For Healthy Hands of Operating Room Personnel. Pictured: Robin C. Salzbach
cleaner; therefore, nail cleaners were added to the scrub sinks. Conclusions/Implications for Practice: A study by McCormick and Colleagues showed that an increase in the use of lotion led to a 50% increase in hand cleaning frequency. It would be reasonable to conclude that the increase of hand lotions, better products, and education would increase hand hygiene compliance and decrease patient infection in the OR and warrants further study. Multidisciplinary Fire/Evacuation Drill: Planning & Execution Karin Underberg, MEd, BSN, RN, CNOR; Gee Mei Tan, MMED; Debnath Chattergee Clinical Issue: Fires in the OR are relatively rare, but can result in potentially devastating complications. Description of the Team: A multidisciplinary planning team was assembled with personnel from the anesthesia, perioperative nursing, surgery, and safety departments. Preparation and Planning: The AORN Fire Safety Tool Kit scenarios were adapted to cover a variety of pediatric procedures, resulting in 10 fire simulation scenarios. Ten simulation-trained facilitators were identified and briefed on the plan.
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Multidisciplinary Fire/Evacuation Drill: Planning & Execution. Pictured: Karin Underberg
Assessment: Nursing personnel have participated in fire and evacuation drills on an annual basis. This was the first time the entire team rehearsed what to do in the event of a fire or mass evacuation. Implementation: Ten simultaneous fire scenarios were conducted, each with a complete surgical team participating. Observers from the anesthesia, perioperative nursing, and safety departments evaluated the event. One team’s fire response and evacuation drill were videotaped. Outcome: Post-event surveys indicated that all team members had a positive experience; all respondents agreed or strongly agreed that the fire simulation was educational and time spent was worthwhile. Implications for Perioperative Nursing: Teamwork and training are essential in the OR environment; therefore, we can no longer train in silos when we operate in a team environment. Annual education is essential to respond effectively in the event of an OR fire. The Response Time of MGH OR Nursing Evening Trauma Team to Emergent Craniotomies Rener Venico, BSN, RN, CNOR; Breanna Dunne, BSN, RN; Susan Aguiar, MBA, RN, CNOR; Therese A. Merriman, BSN, RN
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The Response Time of MGH OR Nursing Evening Trauma Team to Emergent Craniotomies.
Our team is called the MGH OR nursing evening trauma team. The team is composed of expert, advanced, and novice RNs, certified surgical technicians, instrument and equipment technicians, a nurse manager, and a charge nurse. The team takes over all the surgical procedures in the OR after 3 PM, including waitlist procedures, urgent procedures, and, more importantly, emergent procedures. Our personnel are trained in all surgical services and specialties. As a level 1 trauma center, MGH Boston caters to referrals and emergent procedures from all over New England. Our ORs have more than 70 ORs. Within the newly opened Lunder building, Lunder 4 boasts 12 state of the art ORs designed for neurological and vascular surgery. On the evening shift, neurosurgery is a high-volume service. At the beginning of the shift, a room in the Lunder 4 is designated as the “neuro crunch room.” This room is prepared for any emergent neurosurgery procedures, more importantly, for craniotomies. This poster presents the response time needed by nursing personnel in collaboration with surgical and anesthesia teams to start a procedure from the time it was booked until initial skin incision. We used data collected from spring 2013 to summer 2013. This presentation may be used for future process improvement. Innovative Adaption to Declining Reimbursement Kimberly Valentine, BSN, RN, CNOR; Lynn Scalise, MBA, BSN, RN
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A decline in reimbursement for orthopedic surgeries led personnel at Mayo Clinic to develop innovative strategies to reduce procedure costs while simultaneously adhering to our high standards for quality. A collaborative approach between orthopedic surgeons, orthopedic team leaders, surgical team members, and supply chain personnel led to the standardization of orthopedic implants and supplies. The objective was to achieve a reduction in overall procedure costs to meet reimbursement. Our methodology was fostered by a team approach to decrease waste, standardize custom packs and supplies, standardize implants, and ensure compliance with contracts for cost containment. An analysis of cost per procedure identified several opportunities for improvement. Comparing supplies and implants used per surgeon on similar procedures confirmed the need for standardization. Evaluating the necessity of all supplies opened for each surgeon’s most frequent procedures resulted in an elimination of excess supplies. Reports were generated from the data collected and shared with our surgeons. Implementation was accomplished by achieving stakeholder buy-in, physician and employee education, and execution of process changes to achieve waste reduction. The cost/case data provided the rationale to drive practice change without compromising quality patient care. One outcome of the project
Innovative Adaption to Declining Reimbursement. Pictured: Kimberly Valentine
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showed a decrease in the cost/procedure of total knee arthroplasty by $525.00. A Staff Driven Collaborative Vacation Process Shokjean Yee, MA, RN, CNOR; Carole M. Cass, MSN, RN, CNOR; Elizabeth S. Pincus, MSN, MBA, RN, CNOR, ACNS-BC; Kristen Crookes, BSN, RN; Dawn Parnas, RN Clinical Issue: Vacation selection is a subject that is difficult to manage in many institutions. Finding the balance between flexibility and institutional coverage at the workplace is challenging. The possibility of denied requests around popular weeks may cause employee dissatisfaction. Description of Team: The vacation committee was formed with representation of all employees, services, and shifts. Preparation and Planning: The vacation committee determined issues and proposed amendments to the existing guidelines. Polls were conducted to address concern regarding vacations. To determine solutions, the committee used breakout sessions and selective brainstorming groups, and conducted a personnel survey. Assessment: Survey administered: n
How the selection process should be determined (eg, annually, biannually, first-come first-served)? n Should vacations be open across the OR or determined by individual service lines? n Should vacations be determined by shift days and evenings or events (eg, weddings, graduations)? Implementation: Results from the survey responses were evaluated by the Shared Governance Council and a collaborative guideline was forged by majority voting. Rules were established and allocation of vacation was divided into services and shifts, and slot allotments were determined with use of a random generator.
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A Staff Driven Collaborative Vacation Process. Pictured: Kristen Crookes, Carole M. Cass, and Shokjean Yee
Outcome: Results were presented during departments meetings. A collaborative guideline is now used to determine vacation selection. Implications for Perioperative Nursing: The strategies implemented are driven by personnel, are creative, and provide a unit fit. Feedback is collected yearly, and new guidelines are added by majority vote. This vacation initiative is a personnel directed, collaborative effort complementing unit need while strengthening personnel satisfaction. Safety Checklist: Improving Patient Safety Yessenia Valentin-Salgado, MS, RN, CNOR; Lystra M. Swift, MA, RN, CNOR; Mary May Saulan, MPA, BSN, CNOR Increased complexity of surgical procedures coupled with multitudes of competing priorities can lead to opportunities for disasters. At Memorial Sloan Kettering Cancer Center, we routinely perform procedures of varying complexities, some involving up to six surgical specialties. We have recognized that even experts are fallible. A safety summit was held to evaluate existing practices and develop new processes for rare but potentially catastrophic surgical events. Emergency checklists were developed to eliminate reliance on inherently imperfect human memory and provide a systematic way to explore options. This empowers all members of
AORN CONFERENCE POSTERS the perioperative team to respond assertively and efficiently to emergency situations, such as: n n n n n n n n n n n n n n n
air embolism, anaphylaxis, bleeding, bradycardia, cardiac arrest, failed airway, fire, hypotension, hypoxia, malignant hypothermia, tachycardia, incorrect count, robotic to open procedure, robot malfunction, or sharps injury.
Multidisciplinary simulations are performed to train all surgeons, anesthesia professionals, and nursing personnel regarding how to function during critical events. Checklist simulations have now been incorporated into our annual mandatory competency program. As a prerequisite, all anesthesia professionals and surgical providers are certified in advanced cardiac life support. Preliminary feedback regarding checklist use indicates that the emergency checklists provide standardization, increase personnel satisfaction, and improve proficiency in handling intraoperative emergencies.
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Let’s Clear the Air: There is No Such Thing as Safe Surgical Smoke Sherry L. Chavis, RN, CNOR; Melanie I. Becker, BSN, RN, CNOR; Vicki L. Wagner, MSN, RN, CNOR; Mercelita I. Bowerman, BSN, RN, CNOR; Mary Shirley Jamias, RN, CNOR Clinical Issue: Evidence of the harmful effects of surgical smoke is prevalent in literature and recognized by organizations like AORN, The Joint Commission, and the National Institute for Occupational Safety and Health. In the absence of consistent and effective management, surgical smoke continues to permeate the perioperative environment potentially causing harm to patients and personnel. Description of the Team: Our team consisted of perioperative nurses, team leaders, educators, and managers. Preparation and Planning: Articles from professional publications, AORN recommended practices, the AORN Management of Surgical Smoke Tool Kit, and organizational policies and procedures were reviewed. Assessment: A pre-education personnel survey was conducted to assess existing surgical smoke management practices. Quantitative data was reviewed to determine pre-education smoke evacuator usage. Implementation: A three-part, multimedia education program was implemented for OR personnel. Additional implementation strategies maintained momentum to include n n n n n
Safety Checklist: Improving Patient Safety.
an “everyone is a champion” initiative, updated preference cards, updated OR cores with appropriate supply items, provision of practical personnel resources, and a “Look Who is NOT Smoking” initiative.
Outcome: A posteducation personnel survey was conducted and comparison data demonstrated improvement. Postimplementation quantitative AORN Journal j 721
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AORN CONFERENCE POSTERS care between medical personnel (eg, surgeons, ED physicians, anesthesia professional, OR personnel).
Let’s Clear the Air: There is No Such Thing as Safe Surgical Smoke. Pictured: Sherry L. Chavis, Vicki L. Wagner, and Mercelita I. Bowerman
data demonstrated an increase in smoke evacuator usage. Implications for Perioperative Nursing: The success of this initiative reduced the presence of surgical smoke plume in the perioperative environment, resulting in a safer environment for patients and personnel. Fast Track to OR for Trauma/Emergency/ Unstable Patients Lydia E. McQuinn, BSN, RN; Betty A. McGee, ADN, RN, CNOR Clinical Issue: Problems identified included
Planning and Implementation: A failure mode and effects analysis (FMEA) was conducted, which addressed the need to form a trauma quality committee for surgical services to help identify areas of opportunity in our trauma service. A trauma and surgical vision statement was created to identify needs for the ED/trauma service line. Collaborative efforts and communication were established between the ED Physicians/nursing and respiratory therapy to facilitate transport of the trauma patient to the OR. The need was identified to have ED physician and personnel remain with the patient to continue to monitor and support the patient until the OR RN and anesthesia professional were present to receive the hand-over report safely from ED personnel. Outcomes: There now exists a medical consensus of ED physicians for how to handle emergent needs of the OR and team for unstable pediatric patients. This includes timely communication between the ED and OR of when to expect trauma patient. Trauma patients are transported, monitored, and supported by ED personnel in the OR until the hand-over can be completed to OR personnel. A cart containing surgical attire for ED personnel to don to enter the OR suite was created
n
a need to improve efficiencies of care provided to pediatric trauma patients to enhance the medical coordination between physician leaders; n lack of consistent communication between the emergency department (ED) and OR, which resulted in patients being transported to the OR when perioperative personnel or the anesthesia professional were not immediately available; and n lack of a face-to-face hand-over between OR nurses and ED physicians. Purpose: Improve the efficiency of care and outcomes for unstable pediatric trauma patients from the ED to the OR with coordination of surgical 722 j AORN Journal
Fast Track to OR for Trauma/Emergency/Unstable Patients. Pictured: Betty A. McGee and Lydia E. McQuinn
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and placed by the elevator for ease of access. An OR RN completes a trauma review sheet for every trauma patient received in the OR. The statistics are tabulated and reviewed monthly by members of the trauma quality committee to identify processes in need of improvement. Conclusion: Our goal ultimately is to save lives and improve patient outcomes. With the implementation of fast track to the OR, we have decreased the wait time, established a collaboration between surgical and ED personnel, expedited safe care for unstable trauma patients during transport to the OR from the ED, and facilitated a thorough face-to-face hand-over in the OR between the ED personnel, anesthesia professionals, and OR personnel. The trauma quality committee meets monthly to review each procedure for any process improvements needed. Standardized Back Table and Mayo Setup Monica L. Heyn, BSN, RN, CNOR; Debra L. Rode, RN, CNOR; Stacy E. Lyons Weatherly, BSN, RN, CNOR; Linda L. Pinkston, MSN, RN, CNOR Scottsdale Healthcare, consisting of four hospitals and one outpatient surgery center, is a leader in surgical services in the Phoenix metropolitan area. Among its five surgery departments, considerable variations were discovered in the setup of back tables and Mayo stands in surgical procedures. A multidisciplinary team of executive sponsors, managers, front-line personnel, and physician champions worked together on a system-wide rapid process improvement (RPI) project to design a “standardized best setup” for general surgery procedures with the intent to expand into all service lines. Our objectives in standardizing the process were to improve safety and quality, and to reduce waste using LEAN methodologies and best practices. In simulating what the standardized best setup would look like, the workgroup exhibited innovation through active discussion of using setup zones; refined the process through collaboration
Standardized Back Table and Mayo Setup. Pictured: Debra L. Rode and Monica L. Heyn
across areas; and developed educational, training, communication, and implementation plans. Diagramming and vector graphics of the standardized best setups were also created as reference documents for education and training. An audit tool was developed to ensure compliance and to provide feedback. The standardized setups were applied system wide and project communication posters were created and displayed in all surgical departments. Suture Inventory Control Project Katharine Zegler, RN, CNOR During the move to the new University Hospital, we discovered many sutures in inventory and noted a number about to expire. This is an avoidable waste of resources. The objective of the project was to streamline suture inventory. This was approached two ways: cost-saving methods and educational programs. For cost savings, 12-month and four-month order history and June inventory were requested from suture representatives. New par levels and suggested deletions were determined from this data. A list of sutures ordered zero to two times in 12 months was given to the clinical coordinators of each service for suggested deletion. They approved 43 sutures for deletion for a onetime cost saving of $9,292.03. New par levels were determined, resulting in 184 boxes removed
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Suture Inventory Control Project. Pictured: Katharine Zegler
Clinical Pathology Specimens: Operating Rooms to Results. Pictured: Renee A. Prince
from shelves and $32,129.81 less being carried in inventory. Suture for return or exchange was valued at $34,000 and we were able to receive a one-time order of 184 boxes of our most frequently used sutures with the exchange. Total cost savings equaled $75,421.84. Education programs were provided using a suture cross-reference chart so personnel unfamiliar with all kinds of suture could suggest an appropriate substitute. A “Did You Know” poster was created with suture factoids. The project outcome identified opportunities to reduce cost and refocus ordering to need based. Nursing efficiency was increased with education.
personnel, staff RNs, a perioperative technologist supervisor, and personnel from the clinical pathology and pathology quality assurance departments. The implementation of a new delivery process effectively decreased specimen defects, increased speed in delivery times, and allowed the perioperative nurses to remain uninterrupted at the patient’s bedside.
Clinical Pathology Specimens: Operating Rooms to Results Renee A. Prince, MHA, BSN, RN Clinical pathology (CP) specimens collected in ORs are sent to the specimen processing area for a variety of clinical reasons that are important or vital to the care of the patient. The OR and specimen processing area have observed that the current process for the delivery of these specimens to the specimen processing area does not assure 100% delivery. As a result, specimens have been lost, delayed in transport, or are delivered too late to render accurate results. We observed that the process has too many gaps to ensure that the specimens are delivered to the designated laboratory on time. The team comprised nursing administration 724 j AORN Journal
Creating Partnerships for Tissue Management Excellence Kimberly Cheuvront, PhD, MBA, MT(ASCP, AMT); Georgiana L. Grove, BSN, RN, CNOR; Jacqueline A. Sions, MSN, RN, CNOR, NE-BC; Myra J. Beach, MBA, BSN, RN, CNOR; J. W. Bowers, BSN, RN, CNOR, TNCC; Cinthia R. Cendana, BSN, RN, C NOR; Jesse R. Hixson, RN; Mary C. Wilson, BSN, RN, CNOR Clinical Issue: Tissue management at WVU Healthcare was very labor intensive because of the eight locations throughout the operative suites and a cumbersome tracking system. To enhance nursing satisfaction, partnerships were formed to achieve tissue management excellence. Team: The implementation team consisted of an RN, a perioperative quality coordinator, and personnel from materials management and information technology. Preparation/Planning/Assessment: Facility managers coordinated construction of the tissue
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Creating Partnerships for Tissue Management Excellence. Pictured: Mary C. Wilson, Jacqueline A. Sions, and Georgiana L. Grove
room and tracking programs were evaluated. We used various transport containers for tissues on a trial basis. Inventory personnel needed to achieve 24-hour coverage and the square footage necessary to house tissue in one centrally located space were determined. Careful review of all biological products, including shelf life, redundancy of product, and regulatory requirements, occurred. Implementation: Tissue inventory room construction was completed in August 2012. Tracking software went live January 2013. Outcome: With implementation of new tracking software and centralized tissue storage, compliance requirements for the US Food and Drug Administration and The Joint Commission are easily achieved and tissue management is improved. Implications for Perioperative Nursing: OR nurses are able to focus on patient care and are not leaving the OR for extended periods of time to access individual tissue storage units throughout the OR. The Culture of Lateral Violence in Nursing Kelly C. Nader, DNP, RN, CNOR; Karen M. O’Connell, PhD, RN, CEN; Linda J. Wanzer, DNP, RN, CNOR, COL(Ret) Problem: Lateral violence is becoming a crisis in the profession of nursing. Behaviors include disruptive, demeaning, and uncivil acts that are
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The Culture of Lateral Violence in Nursing.
affecting our ability to communicate, learn, retain nurses, and provide safe patient care. Lack of awareness and the tolerance demonstrated by leadership personnel towards this disruptive behavior is allowing this to become a normative culture throughout our profession. Purpose: The purpose of this evidence-based project was to analyze the literature for content to include in a policy code of conduct to minimize lateral violence and maintain effective communication among nurses. Method: A descriptive integrative review of the literature framed by Purpora and Blegen’s Horizontal Violence and the Quality and Safety of Patient Care conceptual model was conducted using the Bibb-Wanzer Identifying, Organizing, and Synthesizing (IOS) strategy to guide the procedural phase of the study. Searches of PubMed, Cumulative Index to Nursing and Allied Health Literature, references, and the World Wide Web were conducted and resulted in 41 articles. Results: After the literature synthesis, six trends with targeted interventions were identified that should be incorporated into the creation of an organizational policy code of conduct to minimize lateral violence and enhance communication in nursing. Formal implementation should include a zero-tolerance policy code of conduct that is created using shared governance. Synergistic interventions include educational initiatives, AORN Journal j 725
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communication skills, supportive leadership, and establishment of healthy organizational values and ethics. Perioperative Nursing Implications: A zerotolerance policy is only the first step toward creating a healthy work culture. The evidence obtained in this literature review supports the need for a synergistic, multipronged, zero-tolerance program that is strongly supported by leadership personnel. The organizational culture has a massive effect on tolerance and awareness of lateral violence. Lack of action on the part of leadership personnel endorses negative behavior and will lead to program failure. Implementing Postanesthesia Discharge Criteria in a Pediatric Setting Julie A. Martin, MBA, BSN, CNOR; Lori McDaniel, BSN, RN, CPN; Amber Riordan, BSN, RN, CPN; Lee-Anne Waterman, RN, CPN Several discharge criteria scales exist for use in the perioperative setting. The phase-one postanesthesia care unit uses one scale in our hospital, but the criteria were not clearly defined for discharge from phase two to home. This resulted in variations in practice when nurses relied on individual judgment and experience. A team of RNs collaborated with the department of anesthesiology to create phasetwo discharge criteria that could be used in a pediatric setting and provided general guidelines to discharge a child home safely. The team conducted a literature search and survey of similar pediatric hospitals and identified three primary discharge criteria scales being used. A discharge criteria scoring tool and guidelines relevant to pediatrics
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Implementing Postanesthesia Discharge Criteria in a Pediatric Setting. Pictured: Lee-Anne Waterman and Julie A. Martin
was proposed to the anesthesia and nursing departments, and implemented in 2013. Clearly defined phase-two discharge criteria resulted in a higher nursing satisfaction rate and more consistent practice. Based on the literature search, the team changed practice to not require consumption of fluids by mouth as a discharge criterion, except for select patients. Perianesthesia nurses collaborated with the department of anesthesiology to develop discharge criteria for pediatric surgical patients, which provided consistency in practice (standardization of care) and increased nursing confidence of when it is safe to discharge the patient to home. Editor’s note: AORN is currently soliciting submissions for poster presentations for the AORN Surgical Conference & Expo 2015. The deadline is October 3, 2014. Interested authors can find more information at http://www.aorn.org/Events/CallFor Proposals/Poster_Guidelines.aspx.
A
ORN Surgical Conference & Expo 2014 attendees had the opportunity to earn up to 31 contact hours by reviewing the poster book and evaluating 34 research and 37 evidencebased practice posters in eight poster sessions, and 211 clinical improvement/innovation posters in 23 poster sessions. Posters are available online, for those poster authors who agreed to share their posters online, at http://www.eventscribe.com/2014/ posters/aorn/home.asp. RESEARCH POSTERS The top three posters were recognized with an award in the research category by members of AORN’s Nursing Research Committee. Following are the abstracts from the three winning research posters. 1st Place: Factors Associated With RN Turnover in Perioperative Units Catima Potter, MPH; JiSun Choi, PhD, RN Retention of younger perioperative nurses is an issue. This may create additional problems as the nursing workforce continues to age and retire. The research study’s aim was to examine nursing work context and RN characteristics associated with perioperative RN turnover. The sample consisted of 565 perioperative units in 260 US hospitals. Linked 2012 data on RN turnover and RN survey work context items from a national nursing quality database were used. Unit-level annualized turnover (ie, separation) rates were calculated for RNs. Hierarchical Poisson regression analysis was performed at the unit level. The mean unit level perioperative RN turnover rate was 1.92%. Nearly 18% of all RN separations had less than two years of experience at the hospital. More influence over schedule and a higher percentage of RNs with specialty certification
1st Place in the research category: Factors Associated With RN Turnover in Perioperative Units. Pictured: Catima Potter
were associated with lower perioperative RN unit turnover. Perioperative units with longer RN unit tenure reported lower RN turnover. Overall, the model had a moderate fit (R2 ¼ 0.68). Although the perioperative turnover rate was low, findings indicated that factors such as scheduling influence, specialty certification, and RN unit tenure were associated with turnover among perioperative RNs. Nurse leadership personnel should assess workforce characteristics in addition to work context when developing retention strategies. 2nd Place: A Focused Ethnography: Experiences of RNs Transitioning to the OR Mary A. Brinkman, PhD, RN, CNOR The OR is a unique setting and specialty area of nursing practice that requires optimal orientation and education to render safe and efficient patient care. Unfortunately, there will be a significant shortage of nurses in the OR in the next five to 10 years. The need for new nurses in the OR is essential because many OR nurses in the workforce
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will retire within the next five years. Currently, most nursing programs no longer offer perioperative courses in their curriculum. Subsequently, this trend has led to the need for hospitals to educate and orient new nurses to their ORs. As hospitals educate their own OR nurses, retention after orientation becomes a priority. The purpose of this study was to explore nurses’ experiences as they transition to a new area of nursing practice, the OR. A qualitative focused ethnography was conducted. Fourteen RNs transitioning to the OR agreed to participate in this study. The OR was a first-time experience for the RNs. The setting was a large teaching hospital located in an urban area. Observations and interviews were conducted with the RNs to explore their experiences as they transitioned in the OR. The transition included learning the didactics of OR nursing through the web-based AORN Nursing 101 online computer course, practicing learned skills in a simulation laboratory, and rotating through surgical specialty areas under the supervision of an RN preceptor. Influences that facilitated the RNs’ transition to the OR were the positive learning experience, their perception of belonging and acceptance into the OR culture, the stimulating environment, supportive personnel, collegiality among peers, and presence of nursing in the OR. Influences that hindered the RNs’ transition to the
2nd place in the research category: A Focused Ethnography: Experiences of RNs Transitioning to the OR. Pictured: Mary A. Brinkman
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AORN CONFERENCE POSTERS OR were inconsistency in precepting, being in a hostile environment, limited exposure to the OR before the transition, and an overwhelming environment. Meleis’ Situational Transition model emerged in the RNs’ experiences transitioning to the OR. The need to educate nurses in the OR is essential to assure safety and positive outcomes for the surgical patient. Structured perioperative courses implemented by hospitals or with partnerships with nursing programs can enhance the education, transition, and retention of nurses new to the OR. The importance of a nurse educator having an advanced degree with experience in the OR specialty was essential in coordinating and mentoring nurses transitioning to this new practice area. The RNs who are prepared to precept were vital in the education and retention of RNs transitioning to the OR. The need for consistent preceptors was recognized as an essential factor to the RNs’ successful transition. The findings contribute to evidence-base practice for the design and implementation of perioperative courses for new nurses. 3rd Place: Transient Hypothermia Post-Cardiopulmonary Bypass: When Cold ISN’T COOL Patrel B. Nobles, BSN, RN; Cathy D. Jennings, DNP, RN, ACNS-BC; Sarah E. Frazier, BSN, BS, RN Background: Cardiopulmonary bypass (CPB) is an essential component for most cardiac surgical procedures. Using CPB-induced hypothermia can decrease the patient’s metabolic demand, protect the brain and other vital organs, and increase tolerance for cardiac ischemia during surgery. Yet, afterdrop, the unintentional decrease in body temperature between separation from CPB and arrival in the cardiac surgery intensive care unit (CSICU), can be problematic for cardiac surgery patients. This unintentional transient hypothermia is defined as a core temperature of less than 36 C (96.8 F) lasting less than 24 hours after CPB. Transient hypothermia is associated with increased perioperative blood loss, mechanical ventilation time, and CSICU and overall length of hospital stay.
AORN CONFERENCE POSTERS Methods: This quality improvement project had two phases. Phase 1 was a retrospective review of patient records to determine the incidence of transient hypothermia in this group (n ¼ 73) and to assess the following postoperative patient outcomes: number of units of packed red blood cell transfusions, hours on the ventilator, hours spent in the CSICU, and hours spent in the hospital after surgery. This group also served as the control group. In phase 2, sterile forced-air warming blankets were applied on all patients in the cardiac surgery OR during the rewarming phase of CPB and left in place through transfer to the CSICU. The same outcomes were evaluated for this group (n ¼ 57). Outcomes: Results revealed that patients receiving the forced-air warming blankets (Phase 2) had a statistically significant higher core temperature on admission to CSICU (P ¼ .018). Although not statistically significant, patients in the forced-air warming blanket group also n
received fewer red blood cell transfusions (0.67 units versus 0.85 units, a difference of 0.18 units), n required fewer hours of mechanical ventilation (13.9 hours versus 19.3 hours, a difference of 5.4 hours), n had shorter lengths of stay in CSICU (86.5 hours versus 102.1 hours, a difference of 15.6 hours), and
3rd place in the research category: Transient Hypothermia Post-Cardiopulmonary Bypass: When Cold ISN’T COOL. Pictured: Patrel B. Nobles and Sarah E. Frazier
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had shorter lengths of stay in the hospital (170.2 hours versus 195.7 hours, a difference of 25.5 hours).
Conclusion: Potential for clinical benefit from prevention of transient hypothermia is evidencebased and has resulted in a change in practice to include forced-air warming after CPB for all patients undergoing a cardiac surgical procedure. EVIDENCE-BASED PRACTICE POSTERS The top three posters were recognized with an award in the evidence-based practice category by members of AORN’s Nursing Research Committee. Following are the abstracts from the three winning evidence-based practice posters. 1st Place: Engaging Staff in LEAN Methodology Results in Increased Efficiency, Satisfaction, and Decreased Turnover Times Dawna L. Willsey, MSN, RN, CNOR; Coleen L. Lutz, RN; Kimberly A. McEvoy-Dodson, MBA, BSN, RN, CNOR, FACHE; Wendy Lin, MPH As health care and surgical procedures become more complex, the demand and optimization of resources increase as well. Expedient turnover time, as defined by a surgical patient “wheels out” of the OR to “wheels in,” has plagued surgery leaders. The increased complexity of technology and resources erode and disrupt efficient performance. Turnover time improvement efforts had been attempted by several services and could not be sustained. Orthopedics had fallen to the bottom quartile compared with nationally benchmarked turnover statistics. Patient and surgeon satisfaction were issues as wait times increased and surgery utilization decreased. Spinal fusion procedures, performed by a single surgeon, were chosen as the focus for implementation of Lean methodology processes. Team members were interdisciplinary, representing all phases of spinal surgery: preoperative, intraoperative, and postoperative. Although the focus of this project was on surgical procedure turnover, all processes AORN Journal j 715
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1st place in the evidence-based practice category: Engaging Staff in LEAN Methodology Results in Increased Efficiency, Satisfaction, and Decreased Turnover Times. Pictured: Coleen L. Lutz and Dawna L. Willsey
AORN CONFERENCE POSTERS
2nd place in the evidence-based practice category: Focus on Quality Care. Pictured: Hugo Xi and Lena Pearson
2nd Place: Focus on Quality Care Hugo Xi, MD, MBA; Lena Pearson, MS, BSN, RN, CNOR
and that evidence-based interventions can substantially reduce the incidence of HAIs. The Patient Protection and Affordable Care Act will place up to 9.5% of Centers for Medicare & Medicaid Services (CMS) payments “at risk” for hospitals in fiscal year 2017. Quality and payfor-performance incentives can be implemented to help offset this loss. The Focus on Quality Care Program helps hospitals to eliminate variability in processes that will result in less waste, fewer errors, and better outcomes. The program implements a process from start to finish, including identification of evidence-based best practices, an action plan, training, support tools, and optimization of the product portfolio. The program includes an automated tablet computer-based OR audit tool, which helps ensure consistency and standardize data collection from audits across hospitals. In more than 100 audits, aggregate data collected by the audit tool demonstrated significant variability in surgical skin preparation procedures within and between facilities. The variability could have significant implications to costs and patient outcomes.
Annually in the United States, 1.7 million patients develop a health careeassociated infection (HAI) and nearly 100,000 will die from one; system-wide, the cost of HAIs is $35 billion. Recent studies demonstrate that at least 50% of HAIs are preventable
3rd Place: Count Twice Scan Once: Zero Tolerance for Retained Surgical Sponges Deborah G. Shealy, ADN, RN; Cynthia Shealy, BSN, RN; William H. McRae III, MD
related to surgical spinal fusion were evaluated. Several Lean tools were taught and used during this process, including process and value stream mapping, Kaizen events, development of standard operating procedures, 30-60-90 day audits, and huddles. The overall turnover time was measurably decreased for spinal fusion procedures, as well as an increase in OR efficiency. Process improvement measures and cultural learning were applied department wide. Patient, surgeon, and personnel satisfaction increased through the innovations of new processes. Ongoing audit and accountability tracking has demonstrated that the outcomes have been sustained. The initial membership of this team was designed to have at least one member who could lead the next focused improvement team effort. Next steps will be to apply lessons learned from this project to teams across departments and service lines.
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AORN CONFERENCE POSTERS The unintentionally retained surgical item is a devastating experience for every patient and surgical team. Surgical sponges account for 70% of retained surgical items. The first line of defense to prevent these events is manual counting, according to AORN standards and recommended practices. At Memorial, root cause analysis performed on every retained surgical item between 2005 and 2009 yielded opportunities for system improvement, except for human error. The root cause was determined to be human error at an undetermined time during the count process, resulting in an inaccurate initial count or inaccurate closing counts. The surgical team believed their counts were correct, all policy and procedures had been followed, and that neither the patient nor procedure met risk factors for a precautionary x-ray. It was time to explore other safeguards to prevent these events from occurring by leveraging technology to include barcoding and radiofrequency (RF) detection systems. The surgical team trialed two systems. A radiofrequency detection system was chosen and implemented in July 2011. With two years of data now available (ie, approximately 30,000 procedures), there have been zero occurrences of retained surgical sponges. Policy and protocols were developed for using the RF system for surgical patients. The implications for perioperative nursing are significant. Tangible benefits include reduction of patient
3rd place in the evidence-based practice category: Count Twice Scan Once: Zero Tolerance for Retained Surgical Sponges. Pictured: Deborah G. Shealy
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morbidity (eg, infection, returns to the OR, mortality) and associated costs as well as improved OR efficiency. Intangible benefits include increased patient and team satisfaction. So, count twice; scan once. CLINICAL IMPROVEMENT/INNOVATION POSTERS This is the first year that posters were judged online using the virtual gallery. Only posters that were uploaded were judged and the top 10% of those posters received an Award of Excellence. The posters were judged by the AORN Surgical Conference & Expo Task Force. The following award winners are presented in order by poster number. Put Your Hands Up: Best Practice For Healthy Hands of Operating Room Personnel Robin C. Salzbach, RN, CNOR; Gloria Y. Hinkle, BSN, RN, CNOR Clinical Issue: An increase in the occurrence of skin disorders of the hands of OR personnel at Carilion facilities was noted after a change was made in the surgical hand rub for the ORs. Preparation and Planning: The objective of this project was to define evidence-based practice for surgical hand antisepsis and hygiene, including products, accessibility, and methodology. The plan was to research hand hygiene and make recommendations for best practice and plan interventions. Implementation: The surgical hand rub was changed to adhere to the recommendation of 61% alcohol, 1% chlorhexidine, and humectants, which is less irritating than the previously used product. Redundant products were removed from the scrub sinks. There were different kinds of hand soap, and the one with the most chemicals in its content was removed. Education was provided via inservice programs regarding the changes. More hospitalapproved moisturizing lotions were installed around high areas of need. Evidence supported that the surgical hand rub can be used as the first scrub of the day, but must be completed with a nail AORN Journal j 717
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Put Your Hands Up: Best Practice For Healthy Hands of Operating Room Personnel. Pictured: Robin C. Salzbach
cleaner; therefore, nail cleaners were added to the scrub sinks. Conclusions/Implications for Practice: A study by McCormick and Colleagues showed that an increase in the use of lotion led to a 50% increase in hand cleaning frequency. It would be reasonable to conclude that the increase of hand lotions, better products, and education would increase hand hygiene compliance and decrease patient infection in the OR and warrants further study. Multidisciplinary Fire/Evacuation Drill: Planning & Execution Karin Underberg, MEd, BSN, RN, CNOR; Gee Mei Tan, MMED; Debnath Chattergee Clinical Issue: Fires in the OR are relatively rare, but can result in potentially devastating complications. Description of the Team: A multidisciplinary planning team was assembled with personnel from the anesthesia, perioperative nursing, surgery, and safety departments. Preparation and Planning: The AORN Fire Safety Tool Kit scenarios were adapted to cover a variety of pediatric procedures, resulting in 10 fire simulation scenarios. Ten simulation-trained facilitators were identified and briefed on the plan.
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Multidisciplinary Fire/Evacuation Drill: Planning & Execution. Pictured: Karin Underberg
Assessment: Nursing personnel have participated in fire and evacuation drills on an annual basis. This was the first time the entire team rehearsed what to do in the event of a fire or mass evacuation. Implementation: Ten simultaneous fire scenarios were conducted, each with a complete surgical team participating. Observers from the anesthesia, perioperative nursing, and safety departments evaluated the event. One team’s fire response and evacuation drill were videotaped. Outcome: Post-event surveys indicated that all team members had a positive experience; all respondents agreed or strongly agreed that the fire simulation was educational and time spent was worthwhile. Implications for Perioperative Nursing: Teamwork and training are essential in the OR environment; therefore, we can no longer train in silos when we operate in a team environment. Annual education is essential to respond effectively in the event of an OR fire. The Response Time of MGH OR Nursing Evening Trauma Team to Emergent Craniotomies Rener Venico, BSN, RN, CNOR; Breanna Dunne, BSN, RN; Susan Aguiar, MBA, RN, CNOR; Therese A. Merriman, BSN, RN
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The Response Time of MGH OR Nursing Evening Trauma Team to Emergent Craniotomies.
Our team is called the MGH OR nursing evening trauma team. The team is composed of expert, advanced, and novice RNs, certified surgical technicians, instrument and equipment technicians, a nurse manager, and a charge nurse. The team takes over all the surgical procedures in the OR after 3 PM, including waitlist procedures, urgent procedures, and, more importantly, emergent procedures. Our personnel are trained in all surgical services and specialties. As a level 1 trauma center, MGH Boston caters to referrals and emergent procedures from all over New England. Our ORs have more than 70 ORs. Within the newly opened Lunder building, Lunder 4 boasts 12 state of the art ORs designed for neurological and vascular surgery. On the evening shift, neurosurgery is a high-volume service. At the beginning of the shift, a room in the Lunder 4 is designated as the “neuro crunch room.” This room is prepared for any emergent neurosurgery procedures, more importantly, for craniotomies. This poster presents the response time needed by nursing personnel in collaboration with surgical and anesthesia teams to start a procedure from the time it was booked until initial skin incision. We used data collected from spring 2013 to summer 2013. This presentation may be used for future process improvement. Innovative Adaption to Declining Reimbursement Kimberly Valentine, BSN, RN, CNOR; Lynn Scalise, MBA, BSN, RN
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A decline in reimbursement for orthopedic surgeries led personnel at Mayo Clinic to develop innovative strategies to reduce procedure costs while simultaneously adhering to our high standards for quality. A collaborative approach between orthopedic surgeons, orthopedic team leaders, surgical team members, and supply chain personnel led to the standardization of orthopedic implants and supplies. The objective was to achieve a reduction in overall procedure costs to meet reimbursement. Our methodology was fostered by a team approach to decrease waste, standardize custom packs and supplies, standardize implants, and ensure compliance with contracts for cost containment. An analysis of cost per procedure identified several opportunities for improvement. Comparing supplies and implants used per surgeon on similar procedures confirmed the need for standardization. Evaluating the necessity of all supplies opened for each surgeon’s most frequent procedures resulted in an elimination of excess supplies. Reports were generated from the data collected and shared with our surgeons. Implementation was accomplished by achieving stakeholder buy-in, physician and employee education, and execution of process changes to achieve waste reduction. The cost/case data provided the rationale to drive practice change without compromising quality patient care. One outcome of the project
Innovative Adaption to Declining Reimbursement. Pictured: Kimberly Valentine
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showed a decrease in the cost/procedure of total knee arthroplasty by $525.00. A Staff Driven Collaborative Vacation Process Shokjean Yee, MA, RN, CNOR; Carole M. Cass, MSN, RN, CNOR; Elizabeth S. Pincus, MSN, MBA, RN, CNOR, ACNS-BC; Kristen Crookes, BSN, RN; Dawn Parnas, RN Clinical Issue: Vacation selection is a subject that is difficult to manage in many institutions. Finding the balance between flexibility and institutional coverage at the workplace is challenging. The possibility of denied requests around popular weeks may cause employee dissatisfaction. Description of Team: The vacation committee was formed with representation of all employees, services, and shifts. Preparation and Planning: The vacation committee determined issues and proposed amendments to the existing guidelines. Polls were conducted to address concern regarding vacations. To determine solutions, the committee used breakout sessions and selective brainstorming groups, and conducted a personnel survey. Assessment: Survey administered: n
How the selection process should be determined (eg, annually, biannually, first-come first-served)? n Should vacations be open across the OR or determined by individual service lines? n Should vacations be determined by shift days and evenings or events (eg, weddings, graduations)? Implementation: Results from the survey responses were evaluated by the Shared Governance Council and a collaborative guideline was forged by majority voting. Rules were established and allocation of vacation was divided into services and shifts, and slot allotments were determined with use of a random generator.
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A Staff Driven Collaborative Vacation Process. Pictured: Kristen Crookes, Carole M. Cass, and Shokjean Yee
Outcome: Results were presented during departments meetings. A collaborative guideline is now used to determine vacation selection. Implications for Perioperative Nursing: The strategies implemented are driven by personnel, are creative, and provide a unit fit. Feedback is collected yearly, and new guidelines are added by majority vote. This vacation initiative is a personnel directed, collaborative effort complementing unit need while strengthening personnel satisfaction. Safety Checklist: Improving Patient Safety Yessenia Valentin-Salgado, MS, RN, CNOR; Lystra M. Swift, MA, RN, CNOR; Mary May Saulan, MPA, BSN, CNOR Increased complexity of surgical procedures coupled with multitudes of competing priorities can lead to opportunities for disasters. At Memorial Sloan Kettering Cancer Center, we routinely perform procedures of varying complexities, some involving up to six surgical specialties. We have recognized that even experts are fallible. A safety summit was held to evaluate existing practices and develop new processes for rare but potentially catastrophic surgical events. Emergency checklists were developed to eliminate reliance on inherently imperfect human memory and provide a systematic way to explore options. This empowers all members of
AORN CONFERENCE POSTERS the perioperative team to respond assertively and efficiently to emergency situations, such as: n n n n n n n n n n n n n n n
air embolism, anaphylaxis, bleeding, bradycardia, cardiac arrest, failed airway, fire, hypotension, hypoxia, malignant hypothermia, tachycardia, incorrect count, robotic to open procedure, robot malfunction, or sharps injury.
Multidisciplinary simulations are performed to train all surgeons, anesthesia professionals, and nursing personnel regarding how to function during critical events. Checklist simulations have now been incorporated into our annual mandatory competency program. As a prerequisite, all anesthesia professionals and surgical providers are certified in advanced cardiac life support. Preliminary feedback regarding checklist use indicates that the emergency checklists provide standardization, increase personnel satisfaction, and improve proficiency in handling intraoperative emergencies.
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Let’s Clear the Air: There is No Such Thing as Safe Surgical Smoke Sherry L. Chavis, RN, CNOR; Melanie I. Becker, BSN, RN, CNOR; Vicki L. Wagner, MSN, RN, CNOR; Mercelita I. Bowerman, BSN, RN, CNOR; Mary Shirley Jamias, RN, CNOR Clinical Issue: Evidence of the harmful effects of surgical smoke is prevalent in literature and recognized by organizations like AORN, The Joint Commission, and the National Institute for Occupational Safety and Health. In the absence of consistent and effective management, surgical smoke continues to permeate the perioperative environment potentially causing harm to patients and personnel. Description of the Team: Our team consisted of perioperative nurses, team leaders, educators, and managers. Preparation and Planning: Articles from professional publications, AORN recommended practices, the AORN Management of Surgical Smoke Tool Kit, and organizational policies and procedures were reviewed. Assessment: A pre-education personnel survey was conducted to assess existing surgical smoke management practices. Quantitative data was reviewed to determine pre-education smoke evacuator usage. Implementation: A three-part, multimedia education program was implemented for OR personnel. Additional implementation strategies maintained momentum to include n n n n n
Safety Checklist: Improving Patient Safety.
an “everyone is a champion” initiative, updated preference cards, updated OR cores with appropriate supply items, provision of practical personnel resources, and a “Look Who is NOT Smoking” initiative.
Outcome: A posteducation personnel survey was conducted and comparison data demonstrated improvement. Postimplementation quantitative AORN Journal j 721
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Let’s Clear the Air: There is No Such Thing as Safe Surgical Smoke. Pictured: Sherry L. Chavis, Vicki L. Wagner, and Mercelita I. Bowerman
data demonstrated an increase in smoke evacuator usage. Implications for Perioperative Nursing: The success of this initiative reduced the presence of surgical smoke plume in the perioperative environment, resulting in a safer environment for patients and personnel. Fast Track to OR for Trauma/Emergency/ Unstable Patients Lydia E. McQuinn, BSN, RN; Betty A. McGee, ADN, RN, CNOR Clinical Issue: Problems identified included
Planning and Implementation: A failure mode and effects analysis (FMEA) was conducted, which addressed the need to form a trauma quality committee for surgical services to help identify areas of opportunity in our trauma service. A trauma and surgical vision statement was created to identify needs for the ED/trauma service line. Collaborative efforts and communication were established between the ED Physicians/nursing and respiratory therapy to facilitate transport of the trauma patient to the OR. The need was identified to have ED physician and personnel remain with the patient to continue to monitor and support the patient until the OR RN and anesthesia professional were present to receive the hand-over report safely from ED personnel. Outcomes: There now exists a medical consensus of ED physicians for how to handle emergent needs of the OR and team for unstable pediatric patients. This includes timely communication between the ED and OR of when to expect trauma patient. Trauma patients are transported, monitored, and supported by ED personnel in the OR until the hand-over can be completed to OR personnel. A cart containing surgical attire for ED personnel to don to enter the OR suite was created
n
a need to improve efficiencies of care provided to pediatric trauma patients to enhance the medical coordination between physician leaders; n lack of consistent communication between the emergency department (ED) and OR, which resulted in patients being transported to the OR when perioperative personnel or the anesthesia professional were not immediately available; and n lack of a face-to-face hand-over between OR nurses and ED physicians. Purpose: Improve the efficiency of care and outcomes for unstable pediatric trauma patients from the ED to the OR with coordination of surgical 722 j AORN Journal
Fast Track to OR for Trauma/Emergency/Unstable Patients. Pictured: Betty A. McGee and Lydia E. McQuinn
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and placed by the elevator for ease of access. An OR RN completes a trauma review sheet for every trauma patient received in the OR. The statistics are tabulated and reviewed monthly by members of the trauma quality committee to identify processes in need of improvement. Conclusion: Our goal ultimately is to save lives and improve patient outcomes. With the implementation of fast track to the OR, we have decreased the wait time, established a collaboration between surgical and ED personnel, expedited safe care for unstable trauma patients during transport to the OR from the ED, and facilitated a thorough face-to-face hand-over in the OR between the ED personnel, anesthesia professionals, and OR personnel. The trauma quality committee meets monthly to review each procedure for any process improvements needed. Standardized Back Table and Mayo Setup Monica L. Heyn, BSN, RN, CNOR; Debra L. Rode, RN, CNOR; Stacy E. Lyons Weatherly, BSN, RN, CNOR; Linda L. Pinkston, MSN, RN, CNOR Scottsdale Healthcare, consisting of four hospitals and one outpatient surgery center, is a leader in surgical services in the Phoenix metropolitan area. Among its five surgery departments, considerable variations were discovered in the setup of back tables and Mayo stands in surgical procedures. A multidisciplinary team of executive sponsors, managers, front-line personnel, and physician champions worked together on a system-wide rapid process improvement (RPI) project to design a “standardized best setup” for general surgery procedures with the intent to expand into all service lines. Our objectives in standardizing the process were to improve safety and quality, and to reduce waste using LEAN methodologies and best practices. In simulating what the standardized best setup would look like, the workgroup exhibited innovation through active discussion of using setup zones; refined the process through collaboration
Standardized Back Table and Mayo Setup. Pictured: Debra L. Rode and Monica L. Heyn
across areas; and developed educational, training, communication, and implementation plans. Diagramming and vector graphics of the standardized best setups were also created as reference documents for education and training. An audit tool was developed to ensure compliance and to provide feedback. The standardized setups were applied system wide and project communication posters were created and displayed in all surgical departments. Suture Inventory Control Project Katharine Zegler, RN, CNOR During the move to the new University Hospital, we discovered many sutures in inventory and noted a number about to expire. This is an avoidable waste of resources. The objective of the project was to streamline suture inventory. This was approached two ways: cost-saving methods and educational programs. For cost savings, 12-month and four-month order history and June inventory were requested from suture representatives. New par levels and suggested deletions were determined from this data. A list of sutures ordered zero to two times in 12 months was given to the clinical coordinators of each service for suggested deletion. They approved 43 sutures for deletion for a onetime cost saving of $9,292.03. New par levels were determined, resulting in 184 boxes removed
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Suture Inventory Control Project. Pictured: Katharine Zegler
Clinical Pathology Specimens: Operating Rooms to Results. Pictured: Renee A. Prince
from shelves and $32,129.81 less being carried in inventory. Suture for return or exchange was valued at $34,000 and we were able to receive a one-time order of 184 boxes of our most frequently used sutures with the exchange. Total cost savings equaled $75,421.84. Education programs were provided using a suture cross-reference chart so personnel unfamiliar with all kinds of suture could suggest an appropriate substitute. A “Did You Know” poster was created with suture factoids. The project outcome identified opportunities to reduce cost and refocus ordering to need based. Nursing efficiency was increased with education.
personnel, staff RNs, a perioperative technologist supervisor, and personnel from the clinical pathology and pathology quality assurance departments. The implementation of a new delivery process effectively decreased specimen defects, increased speed in delivery times, and allowed the perioperative nurses to remain uninterrupted at the patient’s bedside.
Clinical Pathology Specimens: Operating Rooms to Results Renee A. Prince, MHA, BSN, RN Clinical pathology (CP) specimens collected in ORs are sent to the specimen processing area for a variety of clinical reasons that are important or vital to the care of the patient. The OR and specimen processing area have observed that the current process for the delivery of these specimens to the specimen processing area does not assure 100% delivery. As a result, specimens have been lost, delayed in transport, or are delivered too late to render accurate results. We observed that the process has too many gaps to ensure that the specimens are delivered to the designated laboratory on time. The team comprised nursing administration 724 j AORN Journal
Creating Partnerships for Tissue Management Excellence Kimberly Cheuvront, PhD, MBA, MT(ASCP, AMT); Georgiana L. Grove, BSN, RN, CNOR; Jacqueline A. Sions, MSN, RN, CNOR, NE-BC; Myra J. Beach, MBA, BSN, RN, CNOR; J. W. Bowers, BSN, RN, CNOR, TNCC; Cinthia R. Cendana, BSN, RN, C NOR; Jesse R. Hixson, RN; Mary C. Wilson, BSN, RN, CNOR Clinical Issue: Tissue management at WVU Healthcare was very labor intensive because of the eight locations throughout the operative suites and a cumbersome tracking system. To enhance nursing satisfaction, partnerships were formed to achieve tissue management excellence. Team: The implementation team consisted of an RN, a perioperative quality coordinator, and personnel from materials management and information technology. Preparation/Planning/Assessment: Facility managers coordinated construction of the tissue
AORN CONFERENCE POSTERS
Creating Partnerships for Tissue Management Excellence. Pictured: Mary C. Wilson, Jacqueline A. Sions, and Georgiana L. Grove
room and tracking programs were evaluated. We used various transport containers for tissues on a trial basis. Inventory personnel needed to achieve 24-hour coverage and the square footage necessary to house tissue in one centrally located space were determined. Careful review of all biological products, including shelf life, redundancy of product, and regulatory requirements, occurred. Implementation: Tissue inventory room construction was completed in August 2012. Tracking software went live January 2013. Outcome: With implementation of new tracking software and centralized tissue storage, compliance requirements for the US Food and Drug Administration and The Joint Commission are easily achieved and tissue management is improved. Implications for Perioperative Nursing: OR nurses are able to focus on patient care and are not leaving the OR for extended periods of time to access individual tissue storage units throughout the OR. The Culture of Lateral Violence in Nursing Kelly C. Nader, DNP, RN, CNOR; Karen M. O’Connell, PhD, RN, CEN; Linda J. Wanzer, DNP, RN, CNOR, COL(Ret) Problem: Lateral violence is becoming a crisis in the profession of nursing. Behaviors include disruptive, demeaning, and uncivil acts that are
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The Culture of Lateral Violence in Nursing.
affecting our ability to communicate, learn, retain nurses, and provide safe patient care. Lack of awareness and the tolerance demonstrated by leadership personnel towards this disruptive behavior is allowing this to become a normative culture throughout our profession. Purpose: The purpose of this evidence-based project was to analyze the literature for content to include in a policy code of conduct to minimize lateral violence and maintain effective communication among nurses. Method: A descriptive integrative review of the literature framed by Purpora and Blegen’s Horizontal Violence and the Quality and Safety of Patient Care conceptual model was conducted using the Bibb-Wanzer Identifying, Organizing, and Synthesizing (IOS) strategy to guide the procedural phase of the study. Searches of PubMed, Cumulative Index to Nursing and Allied Health Literature, references, and the World Wide Web were conducted and resulted in 41 articles. Results: After the literature synthesis, six trends with targeted interventions were identified that should be incorporated into the creation of an organizational policy code of conduct to minimize lateral violence and enhance communication in nursing. Formal implementation should include a zero-tolerance policy code of conduct that is created using shared governance. Synergistic interventions include educational initiatives, AORN Journal j 725
June 2014
Vol 99 No 6
AORN CONFERENCE POSTERS
communication skills, supportive leadership, and establishment of healthy organizational values and ethics. Perioperative Nursing Implications: A zerotolerance policy is only the first step toward creating a healthy work culture. The evidence obtained in this literature review supports the need for a synergistic, multipronged, zero-tolerance program that is strongly supported by leadership personnel. The organizational culture has a massive effect on tolerance and awareness of lateral violence. Lack of action on the part of leadership personnel endorses negative behavior and will lead to program failure. Implementing Postanesthesia Discharge Criteria in a Pediatric Setting Julie A. Martin, MBA, BSN, CNOR; Lori McDaniel, BSN, RN, CPN; Amber Riordan, BSN, RN, CPN; Lee-Anne Waterman, RN, CPN Several discharge criteria scales exist for use in the perioperative setting. The phase-one postanesthesia care unit uses one scale in our hospital, but the criteria were not clearly defined for discharge from phase two to home. This resulted in variations in practice when nurses relied on individual judgment and experience. A team of RNs collaborated with the department of anesthesiology to create phasetwo discharge criteria that could be used in a pediatric setting and provided general guidelines to discharge a child home safely. The team conducted a literature search and survey of similar pediatric hospitals and identified three primary discharge criteria scales being used. A discharge criteria scoring tool and guidelines relevant to pediatrics
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Implementing Postanesthesia Discharge Criteria in a Pediatric Setting. Pictured: Lee-Anne Waterman and Julie A. Martin
was proposed to the anesthesia and nursing departments, and implemented in 2013. Clearly defined phase-two discharge criteria resulted in a higher nursing satisfaction rate and more consistent practice. Based on the literature search, the team changed practice to not require consumption of fluids by mouth as a discharge criterion, except for select patients. Perianesthesia nurses collaborated with the department of anesthesiology to develop discharge criteria for pediatric surgical patients, which provided consistency in practice (standardization of care) and increased nursing confidence of when it is safe to discharge the patient to home. Editor’s note: AORN is currently soliciting submissions for poster presentations for the AORN Surgical Conference & Expo 2015. The deadline is October 3, 2014. Interested authors can find more information at http://www.aorn.org/Events/CallFor Proposals/Poster_Guidelines.aspx.
