June E Salman, RN
OR nursing in ambulatory surgery Although I had spent ten years in surgical nursing, five years in a five-room operating suite, and another five in a new eleven-room addition, I hesitated at the offer to head the nursing staff at a new freestanding ambulatory surgery center called Northwest Surgicare in suburban Chicago. Would I be satisfied with a schedule of what is considered relatively minor surgery? Would it be boring not to participate in major surgical cases? On the other hand, wouldn’t it be a challenge to be involved in setting up the first such facility in Illinois? After a few weeks of deliberation, I accepted the position. Now as I look back over the four years the center has been in operation, I can say it has been rewarding to be involved
June E Salrnan, RN, is head nurse at Northwest Surgicare, Arlington Heights, 111. She is a diploma graduate of Ravenswood Hospital School of Nursing, Chicago. This article is adapted from a speech given at the 26th AORN Congress.
with a new concept of health care. We have performed over 13,650procedures, including tonsillectomies; adenoidectomies; myringotomies; nasal polypectomies; submucous resections; eye muscle procedures; cataract extractions; herniorrhaphies; laparoscopic tuba1 sterilizations; dilatation and curettage; and dental, urology, and plastic surgeryMy work with the center began seven months before construction was completed. I remained in my position at the hospital and in my spare time began compiling lists of supplies, instruments, and equipment. It was a massive but fascinating undertaking. With Herbert Natof, MD, business manager and medical consultant for the center, I spent hours studying the architect’s plans to decide on placement of autoclaves, cabinets, and the utility and service areas. Meeting with sales representatives and studying supply catalogs, we evaluated and compared costs of equipment, soft goods, and disposable items. Having worked at an area hospital, I was familiar with the surgeons’ instrument preferences, which made selections easier. Purchasing was good experience because it made me aware of the high cost of supplies, helping me to be more cautious in ordering only what will be used. Also during this period we formulated procedure manuals and personnel policies.
AORN Journal, March 1979, V o l 2 9 , No 4
663
In the reception area, patients fill out a short medical history and sign the operative consent.
Several months before opening we began interviewing for staff. The Surgicare investors had agreed with my request to hire an all-registered nurse st&. Dr Natof and I believed this would provide the flexibility required in a small facility with a minimal staff. Because the center was modeled on the Phoenix Surgicenter, which had opened with an all-RN staff, my request met with virtually no resistance. Our interviews were carefully conducted. We knew we would not be nursing the acutely ill, yet we had intensive concern to treat each patient kindly and gently. We wanted a staff who would strive to make each patient feel special. Well-adjusted personnel would be needed to relate to anxious patients and families. Some patients express their fears by assuming a hostile attitude or becoming withdrawn, so we needed a staff that could react in a warm, understanding manner. These were qualities we felt strongly about and stressed in
664
the interviews. We knew we could deliver excellent health care, but we wanted to go beyond that to include “something extra, something special” service. Interviews were held in an informal setting, and ample time was allowed for each applicant. Much of the interview was spent in informal exchange, emphasizing applicants’ feelings about patient care. We were interested in their attitudes. Operating room experience was required for surgical positions and recovery or intensive care experience for the recovery positions. Dr Natof was present at all interviews to explain the structure and concept of the center. Six registered nurses were chosen after several weeks of interviews-four for surgery and two for the recovery room. When the center opened, we would be using two of the four operating rooms. Two weeks were set aside for orientation, which increased to almost four because of last-minute construc-
AORN Journal, March 1979, Vol29, No 4
Patients go to the work-up area, where they change to a surgical gown and foam slippers.
tion problems. Orientation was a new experience for all of us. A mock session was held, and friends were asked to pose as patients. We wanted a trial run to iron out any problems before opening, so we treated our friends at every step, from admitting through discharge. It was an excellent way to pick up the little problems we hadn’t thought of. For example, we found a lack of privacy in the admitting procedure. When patients were questioned about their medical history and insurance coverage, it was possible for others in the waiting area to overhear them. The solution was bringing the patient into the receptionist’s alcove to obtain this information. In the work-up area, there was no way for the circulating nurse to know readily which of three cubicles her patient occupied, so clips were installed on the doors to hold name cards. Patients are scheduled with us by
their surgeons through the receptionist. Each patient is mailed a brochure completely explaining the facility, what lab tests are required, preoperative instructions regarding general anesthesia, tentative time of surgery, and a fee for the procedure. In addition, all patients are contacted by telephone the day prior to surgery, and verbal instructions on the same subjects are given. Upon arrival, usually one hour prior to the scheduled surgery time, patients are sent to a lab in the building for a hemoglobin test and urinalysis. Any special lab work the surgeon wants done must be requested and an appointment made with the lab several days in advance to ensure return of results before surgery. Chest films a r e not done routinely. The attending surgeon sends a history and physical report for each patient to the center prior to the day of surgery. After going t o the lab, patients return
AORN Journal, March 1979, Vol29, No 4
665
t o the reception area to fill out a short medical history, which is part of the chart, and sign the operative consent. Lab results are phoned to us and noted on the chart. Patients are then directed to the work-up area, which is similar to a holding area. Here a second receptionist assists them in changing into a surgical gown and foam slippers. She measures their weight, blood pressure, pulse, and temperature. We cannot justify employing a nurse in this area because this involves an entire morning and minimal nursing service. When these results are charted, the anesthesiologist is informed so he may visit and examine the patient, explain the type of anesthetic to be used for their procedure, and review the medical history. The patient’s questions are thoroughly answered at this point. After the anesthesiologist’s visit, the circulating nurse introduces herself and escorts the patient to the operating room. Most patients receive no preoperative medication, and they walk into the operating room with the circulating nurse. This helps counteract their helpless feelings and serves to maintain a positive attitude, which we believe should prevail from the moment of arrival. Some patients, who are scheduled for local anesthesia, receive preoperative medication and are transported to the operating room on a cart. Toddlers are usually carried in by the nurse and allowed to bring a favorite toy or blanket with them. We allow one parent to be with the child in the recovery room as soon as the child is fully awake. This is a great comfort for youngster and parent since they are separated only during the operation and the short period before awakening. We have treated a fairly large number of retarded children and adults. This is the ideal facility for these patients since there is so little disruption in their routine. Separating these indi-
666
viduals from their environment is always more traumatic than it is for other patients. General anesthesia in the ambulatory facility is different from hospital technique. Most procedures are shorter, and the patients are maintained on a lighter plane to afford more rapid emergence. Patients are soon awake in the recovery room, and a nurse is at their bedside until they are fully conscious. During the remainder of their stay vital signs are checked periodically. The primary aspect of nursing care in the recovery room is providing assurance and encouragement. Ambulatory patients need to know they may go home safely the same day of surgery. Parents also need reassurance about this. Sometimes after general anesthesia patients suffer nausea, and it must be explained this will pass. After one or two hours in the recovery room, our patients are encouraged to get up to a reclining chair. We offer coffee, tea, cold beverages, and popsicles as soon as they can be tolerated. After patients are up for awhile, they usually decide it’s time to go home. Written postoperative instructions from each surgeon are reviewed verbally with the patient and family by a recovery room nurse. These instructions accompany the patient and explain activity, diet, and signs of complication. Anesthesiologists are responsible for discharging and are present in the facility until the last patient has gone home. Each patient having general anesthesia is called the day after surgery to ascertain whether any problems occurred. The response to this call is charted on his record. In addition, each patient is given a stamped, addressed postcard to return in two weeks. This provides us feedback about any complications such as postoperative infection, bleeding, or prolonged nausea or vomiting. There is
AORN Journal, March 1979, Vol29, No 4
Patients soon are awake in the recovery room, and a nurse is at their bedside until they are fully conscious.
also a space for comments. The response has been very rewarding. Patients tell us they have never been treated so warmly yet efficiently. We have also received beneficial suggestions. Any complaints received, which are very few, are followed up by a phone call to acknowledge they were received and discuss the problem. Among the complaints was one from a mother and father about not both being allowed in the recovery room with their child at the same time. We explained, in the follow-up call, that it is impossible because of the size of the pediatric recovery area. Another mother wrote criticizing the entire procedure from admission to discharge. She was contacted and told her complaint could be taken t o the Consumer Advisory Board, but she chose not to. Some typical patient comments are, “The staff obviously has been chosen for outstanding qualities of concern, expertise, and diplomacy. The general at-
mosphere helps relieve anxiety.” “We were very pleased by the entire staff. I only wish more hospitals could be so excellent.” We have all equipment necessary for emergencies, such as a resuscitation cart, laparotomy and tracheostomy trays. In one tuba1 sterilization procedure, it became necessary to perform a laparotomy because of internal bleeding. After hemostasis was achieved, the patient was taken to the recovery room in the normal manner. When her condition was stable, she was transported by ambulance t o a nearby hospital, where the surgeon had made arrangements for a direct admission. Surgicare bylaws require all staff physicians to be on staff with full admitting privileges a t a n accredited hospital. Photocopies of the patient’s chart accompanied her to the hospital. Unlike this case, the majority of direct hospital transfers are for observation, not emergencies. All of these have
AORN Journal, March 1979,V o l 2 9 , No 4
667
been discharged from the hospital the following day. Fortunately, our resuscitation cart and tracheostomy tray have not yet been used. Looking back on my experience at Surgicare, I find it easy to say I have little desire to return to hospital nursing. This has been a fulfilling experience. To be honest, occasionally I long to scrub for a major surgical case, but I still feel the rewards are greater for me here. The nursing staff expresses the same feelings. The patients' response cards are copied and posted for the staff to read. They prove the people are grateful for their care and motivate the nurses to continue their warm, personal ap-
proach. Having an all-RN staff is an asset, and there is pride in being on a team striving for patient satisfaction. As professionals, we don't encounter the jealousies often encountered in large institutions with mixed staffing. We are equally responsible for work. For example, we act as our own Central Supply, setting up instrument trays, wrapping supplies, sterilizing, and setting up cases for the day. The OR nurses can function in the recovery room if necessary, and one recovery room nurse receives enough orientation in surgery to allow her to circulate if we are short of staff. 0
Test your knowledge Nursing activities in the operating room can be classified into specific steps of the nursing process. To help your understanding of t h e nursing process in action, identify the action described and write the correct step of the nursing process in the blank provided.
6. Reviewing postoperative infection rate
The steps of the nursing process are assessment 0 planning 0 implementation evaluation.
9. Holding staff conference prior to day's
~
~
7. Reporting on intraoperative period to
postanesthesia recovery room nurse 8. Reading history, physical examination,
and laboratory results on chart sched u Ie 10. Postoperative visit 1 1. Cleaning operating room following
1. Preparing special equipment for a
procedure
procedure 12. Purchasing supplies for use in
2. Talking with the patient in the hold
operating room
area 3. Positioning the patient on the
operating bed 4.
Counting sponges
5. Interviewing parents of a pediatric
patient
668
AORN Journal, March 1979, Vol29, No 4
OR nursing in ambulatory surgery Although I had spent ten years in surgical nursing, five years in a five-room operating suite, and another five in a new eleven-room addition, I hesitated at the offer to head the nursing staff at a new freestanding ambulatory surgery center called Northwest Surgicare in suburban Chicago. Would I be satisfied with a schedule of what is considered relatively minor surgery? Would it be boring not to participate in major surgical cases? On the other hand, wouldn’t it be a challenge to be involved in setting up the first such facility in Illinois? After a few weeks of deliberation, I accepted the position. Now as I look back over the four years the center has been in operation, I can say it has been rewarding to be involved
June E Salrnan, RN, is head nurse at Northwest Surgicare, Arlington Heights, 111. She is a diploma graduate of Ravenswood Hospital School of Nursing, Chicago. This article is adapted from a speech given at the 26th AORN Congress.
with a new concept of health care. We have performed over 13,650procedures, including tonsillectomies; adenoidectomies; myringotomies; nasal polypectomies; submucous resections; eye muscle procedures; cataract extractions; herniorrhaphies; laparoscopic tuba1 sterilizations; dilatation and curettage; and dental, urology, and plastic surgeryMy work with the center began seven months before construction was completed. I remained in my position at the hospital and in my spare time began compiling lists of supplies, instruments, and equipment. It was a massive but fascinating undertaking. With Herbert Natof, MD, business manager and medical consultant for the center, I spent hours studying the architect’s plans to decide on placement of autoclaves, cabinets, and the utility and service areas. Meeting with sales representatives and studying supply catalogs, we evaluated and compared costs of equipment, soft goods, and disposable items. Having worked at an area hospital, I was familiar with the surgeons’ instrument preferences, which made selections easier. Purchasing was good experience because it made me aware of the high cost of supplies, helping me to be more cautious in ordering only what will be used. Also during this period we formulated procedure manuals and personnel policies.
AORN Journal, March 1979, V o l 2 9 , No 4
663
In the reception area, patients fill out a short medical history and sign the operative consent.
Several months before opening we began interviewing for staff. The Surgicare investors had agreed with my request to hire an all-registered nurse st&. Dr Natof and I believed this would provide the flexibility required in a small facility with a minimal staff. Because the center was modeled on the Phoenix Surgicenter, which had opened with an all-RN staff, my request met with virtually no resistance. Our interviews were carefully conducted. We knew we would not be nursing the acutely ill, yet we had intensive concern to treat each patient kindly and gently. We wanted a staff who would strive to make each patient feel special. Well-adjusted personnel would be needed to relate to anxious patients and families. Some patients express their fears by assuming a hostile attitude or becoming withdrawn, so we needed a staff that could react in a warm, understanding manner. These were qualities we felt strongly about and stressed in
664
the interviews. We knew we could deliver excellent health care, but we wanted to go beyond that to include “something extra, something special” service. Interviews were held in an informal setting, and ample time was allowed for each applicant. Much of the interview was spent in informal exchange, emphasizing applicants’ feelings about patient care. We were interested in their attitudes. Operating room experience was required for surgical positions and recovery or intensive care experience for the recovery positions. Dr Natof was present at all interviews to explain the structure and concept of the center. Six registered nurses were chosen after several weeks of interviews-four for surgery and two for the recovery room. When the center opened, we would be using two of the four operating rooms. Two weeks were set aside for orientation, which increased to almost four because of last-minute construc-
AORN Journal, March 1979, Vol29, No 4
Patients go to the work-up area, where they change to a surgical gown and foam slippers.
tion problems. Orientation was a new experience for all of us. A mock session was held, and friends were asked to pose as patients. We wanted a trial run to iron out any problems before opening, so we treated our friends at every step, from admitting through discharge. It was an excellent way to pick up the little problems we hadn’t thought of. For example, we found a lack of privacy in the admitting procedure. When patients were questioned about their medical history and insurance coverage, it was possible for others in the waiting area to overhear them. The solution was bringing the patient into the receptionist’s alcove to obtain this information. In the work-up area, there was no way for the circulating nurse to know readily which of three cubicles her patient occupied, so clips were installed on the doors to hold name cards. Patients are scheduled with us by
their surgeons through the receptionist. Each patient is mailed a brochure completely explaining the facility, what lab tests are required, preoperative instructions regarding general anesthesia, tentative time of surgery, and a fee for the procedure. In addition, all patients are contacted by telephone the day prior to surgery, and verbal instructions on the same subjects are given. Upon arrival, usually one hour prior to the scheduled surgery time, patients are sent to a lab in the building for a hemoglobin test and urinalysis. Any special lab work the surgeon wants done must be requested and an appointment made with the lab several days in advance to ensure return of results before surgery. Chest films a r e not done routinely. The attending surgeon sends a history and physical report for each patient to the center prior to the day of surgery. After going t o the lab, patients return
AORN Journal, March 1979, Vol29, No 4
665
t o the reception area to fill out a short medical history, which is part of the chart, and sign the operative consent. Lab results are phoned to us and noted on the chart. Patients are then directed to the work-up area, which is similar to a holding area. Here a second receptionist assists them in changing into a surgical gown and foam slippers. She measures their weight, blood pressure, pulse, and temperature. We cannot justify employing a nurse in this area because this involves an entire morning and minimal nursing service. When these results are charted, the anesthesiologist is informed so he may visit and examine the patient, explain the type of anesthetic to be used for their procedure, and review the medical history. The patient’s questions are thoroughly answered at this point. After the anesthesiologist’s visit, the circulating nurse introduces herself and escorts the patient to the operating room. Most patients receive no preoperative medication, and they walk into the operating room with the circulating nurse. This helps counteract their helpless feelings and serves to maintain a positive attitude, which we believe should prevail from the moment of arrival. Some patients, who are scheduled for local anesthesia, receive preoperative medication and are transported to the operating room on a cart. Toddlers are usually carried in by the nurse and allowed to bring a favorite toy or blanket with them. We allow one parent to be with the child in the recovery room as soon as the child is fully awake. This is a great comfort for youngster and parent since they are separated only during the operation and the short period before awakening. We have treated a fairly large number of retarded children and adults. This is the ideal facility for these patients since there is so little disruption in their routine. Separating these indi-
666
viduals from their environment is always more traumatic than it is for other patients. General anesthesia in the ambulatory facility is different from hospital technique. Most procedures are shorter, and the patients are maintained on a lighter plane to afford more rapid emergence. Patients are soon awake in the recovery room, and a nurse is at their bedside until they are fully conscious. During the remainder of their stay vital signs are checked periodically. The primary aspect of nursing care in the recovery room is providing assurance and encouragement. Ambulatory patients need to know they may go home safely the same day of surgery. Parents also need reassurance about this. Sometimes after general anesthesia patients suffer nausea, and it must be explained this will pass. After one or two hours in the recovery room, our patients are encouraged to get up to a reclining chair. We offer coffee, tea, cold beverages, and popsicles as soon as they can be tolerated. After patients are up for awhile, they usually decide it’s time to go home. Written postoperative instructions from each surgeon are reviewed verbally with the patient and family by a recovery room nurse. These instructions accompany the patient and explain activity, diet, and signs of complication. Anesthesiologists are responsible for discharging and are present in the facility until the last patient has gone home. Each patient having general anesthesia is called the day after surgery to ascertain whether any problems occurred. The response to this call is charted on his record. In addition, each patient is given a stamped, addressed postcard to return in two weeks. This provides us feedback about any complications such as postoperative infection, bleeding, or prolonged nausea or vomiting. There is
AORN Journal, March 1979, Vol29, No 4
Patients soon are awake in the recovery room, and a nurse is at their bedside until they are fully conscious.
also a space for comments. The response has been very rewarding. Patients tell us they have never been treated so warmly yet efficiently. We have also received beneficial suggestions. Any complaints received, which are very few, are followed up by a phone call to acknowledge they were received and discuss the problem. Among the complaints was one from a mother and father about not both being allowed in the recovery room with their child at the same time. We explained, in the follow-up call, that it is impossible because of the size of the pediatric recovery area. Another mother wrote criticizing the entire procedure from admission to discharge. She was contacted and told her complaint could be taken t o the Consumer Advisory Board, but she chose not to. Some typical patient comments are, “The staff obviously has been chosen for outstanding qualities of concern, expertise, and diplomacy. The general at-
mosphere helps relieve anxiety.” “We were very pleased by the entire staff. I only wish more hospitals could be so excellent.” We have all equipment necessary for emergencies, such as a resuscitation cart, laparotomy and tracheostomy trays. In one tuba1 sterilization procedure, it became necessary to perform a laparotomy because of internal bleeding. After hemostasis was achieved, the patient was taken to the recovery room in the normal manner. When her condition was stable, she was transported by ambulance t o a nearby hospital, where the surgeon had made arrangements for a direct admission. Surgicare bylaws require all staff physicians to be on staff with full admitting privileges a t a n accredited hospital. Photocopies of the patient’s chart accompanied her to the hospital. Unlike this case, the majority of direct hospital transfers are for observation, not emergencies. All of these have
AORN Journal, March 1979,V o l 2 9 , No 4
667
been discharged from the hospital the following day. Fortunately, our resuscitation cart and tracheostomy tray have not yet been used. Looking back on my experience at Surgicare, I find it easy to say I have little desire to return to hospital nursing. This has been a fulfilling experience. To be honest, occasionally I long to scrub for a major surgical case, but I still feel the rewards are greater for me here. The nursing staff expresses the same feelings. The patients' response cards are copied and posted for the staff to read. They prove the people are grateful for their care and motivate the nurses to continue their warm, personal ap-
proach. Having an all-RN staff is an asset, and there is pride in being on a team striving for patient satisfaction. As professionals, we don't encounter the jealousies often encountered in large institutions with mixed staffing. We are equally responsible for work. For example, we act as our own Central Supply, setting up instrument trays, wrapping supplies, sterilizing, and setting up cases for the day. The OR nurses can function in the recovery room if necessary, and one recovery room nurse receives enough orientation in surgery to allow her to circulate if we are short of staff. 0
Test your knowledge Nursing activities in the operating room can be classified into specific steps of the nursing process. To help your understanding of t h e nursing process in action, identify the action described and write the correct step of the nursing process in the blank provided.
6. Reviewing postoperative infection rate
The steps of the nursing process are assessment 0 planning 0 implementation evaluation.
9. Holding staff conference prior to day's
~
~
7. Reporting on intraoperative period to
postanesthesia recovery room nurse 8. Reading history, physical examination,
and laboratory results on chart sched u Ie 10. Postoperative visit 1 1. Cleaning operating room following
1. Preparing special equipment for a
procedure
procedure 12. Purchasing supplies for use in
2. Talking with the patient in the hold
operating room
area 3. Positioning the patient on the
operating bed 4.
Counting sponges
5. Interviewing parents of a pediatric
patient
668
AORN Journal, March 1979, Vol29, No 4
