The OR Manager Conference Poster Gallery provides a forum for presenting completed research or in-progress research with preliminary results, and presents research, performance improvement projects, or clinical practice innovations visually using graphs, illustrations, or photographs. We strive to promote communication and collaborative research among nurses, provide opportunities for exchange of research and performance improvement, and explore advances in perioperative clinical practice.
Thursday, September 22, 2016
1:00 p.m. – 2:00 p.m.
3:30 p.m. – 4:30 p.m.
Posters will be on display in the Exhibit Hall for the duration of the Exhibition. Poster authors will be available at the conference to answer any questions during the Poster Sessions.
Beginning Wednesday, September 21, OR Manager Conference attendees may review the posters and take an online quiz for 10.0 CE credit hours. Login details will be distributed via email on 9/21.
To access the 2015 e-posters and online quizzes, click here.
If you need assistance accessing the e-poster gallery, please contact Taylor Shaw at 301-354-1751.
Jennifer Simonetti , MSN, RN, CPN, Perioperative Nurse Educator, Cohen Children's Medical Center/ Northwell Health
Sharon Goodman, MA, CPNP, RN-BC, Service Line Nurse Educator, Cohen Children's Medical Center/ Northwell Health
Abstract: One out of six children is diagnosed with special needs and many will require surgery or procedures. To improve their stressful experience and individualize their care, the “Bee Mindful” program was implemented. Currently the special needs populations are provided the same services as children without special needs during their perioperative experience. This process for a child with unique needs is often extremely stressful, over-stimulating, and overwhelming, resulting in poor experiences for the patient, family, and the healthcare team. Literature supports that this traditional approach results in the patient/family to have aversions to future medical and surgical care. A multifaceted interactive educational program for all healthcare providers caring for the vulnerable special needs population was designed to provide an introduction of our program to “Bee Mindful, ” a clustered care approach for caring for this unique population. In the design of the program the team was mindful in that these disorders last a lifetime. Healthcare professionals will encounter individuals of all ages and therefore the concepts of the education needed to be adaptable to meet the individual’s needs. As a children’s hospital among a 21 healthcare system our curriculum was not only translatable for pediatrics but for our adult perioperative patients with special needs as well. The Let’s Bee Mindful program is in the beginning stages of implementation to all 21 hospitals in the health system that cares for pediatric patients. Additional focus of the program is to target local surgeon offices so that on day one, pre-procedure, children with special needs will be afforded the program to help ensure a positive experience on day of surgery and recovery. By partnering with caregivers and surgeons, we have shown that early identification and the planning of a clustered care approach can transform the delivery of care provided to this population.
Linda Homan, RN, BSN, CIC, Senior Manager, Clinical and Professional Service, University of Utah Hospitals and Clinics
Stephan Sato, RN, BSN, Clinical Nurse Coordinator, Main Operating Room, Ecolab Healthcare
Tracy Azulay, Account Executive, Ecolab, Inc.
Abstract: The purpose of this project was to evaluate a method to maintain irrigation fluid at a constant temperature during burn surgery. Studies show that extremely warm saline activates platelet production, accelerates clotting and decreases patient blood loss. In this Operating Room (OR) that performs 850 burn surgeries annually, it is common practice to use saline heated to 120° Fahrenheit (F) to soak lap sponges, cover extremities or place on areas that have been excised or debrided during surgery. To deliver saline solution at 120° F, it was heated to a temperature of 150° F in a warming cabinet outside the OR suite, brought into the OR and poured into an un-warmed basin. There were several drawbacks to this process:
• Storing fluids at 150° F was discouraged by the manufacturer of the saline, as high temperature could cause leaching of chemicals from the plastic bottle into the saline solution.
• Handling saline at 150° F increased the risk of burns to OR staff if the fluid was splashed while pouring.
• There was difficulty maintaining irrigation solution at the desired 120° F.
• Temperature at the time of use was inexact, gauged by gloved hand or not at all.
• Typically, 50 or more liters of saline were used during one burn surgery when only approximately 20 liters were needed, with 30 liters being discarded when the temperature was judged to have dropped below 120° F.
To address these challenges, the Burn OR began using an irrigation fluid warmer/sterile drape combination located in the OR. This fluid warmer/drape allowed the staff to monitor and regulate the temperature of saline to ensure a constant 120° F. This ensured that irrigation fluid was delivered at a consistent temperature, increasing patient and staff safety and decreasing saline use by 60% for savings of $180.00 per case/$153, 000 per year.
Ronald M. Malit, BSN, RNIII, CPAN, CAPA, PACU Charge Nurse, Houston Methodist Sugar Land Hospital
Paschale Dorismond-Parks, BSN, RNIII, CPAN, Charge Nurse, Houston Methodist Sugar Land Hospital
To survey the effectiveness of an alternative non-pharmacological intervention (aromatherapy – Quease Ease) as a rescue treatment in the prevention of immediate post-operative nausea and vomiting (PONV).
An Evidence Based Practice project utilizing the Iowa Model.
A 36-bay Post Anesthesia Care Unit in a community hospital of a 7 hospital system.
Outpatient surgery (AOD) patients, 18 years old and above who had general anesthesia. Patients who refused and had sensitivity to scents were excluded.
A two-member team was formed in collaboration with the Perioperative Clinical Practice Council. Initial steps included development of algorithm, inclusion and exclusion criteria, and a data collection tool (using the Apfel Scoring System for patients’ PONV Risk and Likert Scoring for the survey). A staff education focusing on administration process and data collection followed. Between September to October 2015, 46 respondents were included in this EBP project, three patients were excluded. Utilizing the data collection tool, a survey was done in the immediate post-operative period (Phase 1 Recovery) and continued into Phase 2 (AOD/Discharge Area) to evaluate the effectiveness of aromatherapy. AOD nurses also conducted a survey during their follow up phone calls to evaluate its effectiveness within 24 hours after patient were discharged to home. Finally, a Nursing satisfaction assessment was done post implementation.
Preliminary results showed that aromatherapy was more effective in treating mild nausea than moderate nausea, and was not able to totally relieve severe nausea. Respondents who did not achieve total relief from nausea had 3+ Apfel risk score for PONV. Among respondents, only 40% required antiemetic decreasing usage by 60% when compared to past practice. A survey of all AOD and PACU nurses suggest that aromatherapy was easy to use, beneficial for the patient, and 100% recommended for inclusion to the multi-modal therapy for PONV.
Kevin O'Hara, CEO, Syús, Inc.
Abstract: The use of the terms “wall of fame” and “wall of shame” to motivate surgeons is well intentioned but leaves out a better alternative – providing surgeons with helpful information and gently guiding them toward improvement. Recent scientific studies of the brain and behavior have pointed the way toward an approach to using small “nudges” to drive behavioral changes. Surgeons are known to be self-motivated, driven and competitive. You can tap into those qualities, as well as their scientific training, curiosity, visual orientation and love of data to engage them in their own improvement. You can also use a few simple approaches and tools to guide them using clear, data-driven pathways for mutually beneficial improvements. View our poster to move beyond street-brawling and finger pointing to elegant judo. Attendees will learn about tools they can use right away to improve block performance communication using calculated and detailed improvement paths.
Maria Sliwinski, RN, MHHS, CNOR, Clinical Resource Specialist Surgical Services, Mercy Health St. Elizabeth Boardman Health Center
Sally Danilov, RN, BSN, CIC, Infection Preventionist, Mercy Health St. Elizabeth Boardman Health Center
Abstract: According to current literature, surgical site infections (SSI) are a major cause of morbidity in surgical patients, leading to increased length of stay and health care costs. No single intervention has demonstrated efficacy in reducing SSIs. Despite multiple preventative measures throughout the organization, in 2013, one hospital experienced an increase in the number of SSIs at a rate of 16.3%. To address this concern, an inter-professional team was developed to examine causes and trial interventions on colon, hip, and knee surgeries. The team consisted of physicians, administration, educators, quality nurses, clinical nurses, infection control, and wound care. The team’s goal was to decrease infection rates to a rate of 5% by the end of 2014.
Utilizing Lean processes, the team identified three main areas which could be improved upon to decrease the infection rates. Three subcommittees formed to address these site-specific concerns: physician education relating to appropriate antibiotic selection and timeliness, especially for high risk patients; surgery preoperative skin cleansing utilizing evidence-based best practice; and post-operative dressings, with a focus on appropriate dressing changes utilizing evidence-based processes and products.
Each of these subcommittees took responsibility for various small tests of change and product trialing to improve processes and decrease SSI. Over several months multiple interventions were trialed. Once the best practices were identified, the team focused on a massive educational endeavor across the hospital and physician practice offices.
At the time of submission, the data available was through August, 2014. It showed there was a decrease in SSIs from 2013, an infection rate of 5.7%, which met the project goal. In addition to the decrease in infection rates, we also saw improved patient outcomes, enhanced Surgical Care Improvement Project (SCIP) measures, improved communication between all disciplines, and increased education on evidence-based practices resulted, which ultimately led to a cost savings for the hospital.
Ebony Mitchell, MSN, RN, RN II, Houston Methodist Hospital
Alma Ilustre, BSN, RN, RN III, Houston Methodist Hospital
Clinical Question: “What strategies are most effective in improving the patient experience and scoring high in HCAHPS?”
The purpose of this initiative is to implement a culture change based on available evidences, and driven by relationships and communications to improve Patient Perceptions of Quality Care (PPQC) among surgical patients.
As HCAHPS becomes a standard measure for reimbursement as well as patient/physician referral, service quality will be every hospital organization’s top priority. Patient Perceptions of Quality Care (PPQC) drives patient satisfaction. A small surgical specialty partnered and collaborated with its pre-admission, preoperative and post-anesthesia teams to develop a “culture-change” in order to improve PPQC. This unit-based patient experience initiative consisted of an extensive review of existing literature, followed with an intensive staff education and team engagement. Relationships were supported with the distribution of “Welcome Brochures” and “Service Commitment Letters” to patients and families the day of surgery. Communications were improved through giving family updates regularly while their loved ones were in surgery. Adequate explanation of delays were given by staff to patients and families in a timely manner. This targeted performance improvement was tested for a period of six months. Patient satisfaction scores for both the surgical specialty unit and system-wide were then re-evaluated after completion of unit initiative.
Patient satisfaction scores were compared pre-implementation and post-implementation of unit initiative. Based on this comparison, the overall scores and ratings for likelihood for recommendation were improved and sustained.
Perioperative Nursing Implications
An ongoing team-based approach unit initiative, focused on relationship and communication is an example of best practice for improving the hospital experience of a surgical patient. Furthermore, small scale performance improvement projects such as this one, can significantly impact the overall patient satisfaction scores of the entire organization.
Syed A. Azeem, MHA, MS, FAC-P/PM, LSSBBP, CSSMBB, BB (ASCP) SBB(UIC), MT (AMT), CTS, ATM , Management Analyst, U.S. Department of Veterans Affairs, Logistics Policy & Supply Chain Management (LPSCM), Operations Analysis Division (OAD)
Sharron Hicks, FAC-P/PM, Management Analyst , U.S. Department of Veterans Affairs, Logistics Policy & Supply Chain Management (LPSCM), Operations Analysis Division (OAD)
Abstract: Yes it Can, as Six Sigma is a fact-based, data-driven philosophy of quality improvement that values defect prevention over defect detection. Six Sigma was developed by Motorola and is a data-driven quality strategy used to improve new or existing processes, that helps us focus on developing and delivering nearly perfect products and services. Every project may not require the use of Lean Six Sigma.
Six Sigma is very important as it:
• creates a business environment for improving productivity and efficiency.
• creates a disciplined, knowledge-based approach designed to enhance customer satisfaction.
• creates a customer culture that embraces innovative approaches to technology and business development.
• uses strategy for acquiring, assessing and applying customer expectations.
• can help organization to reduce costs, achieve just-in-time delivery, and shorten lead times for OR Services.
• can be used as problem-solving techniques for patient satisfaction.
• its ultimate desire is to secure a nearly flawless executing process.
Six Sigma processes involve five phases that make up the process called DMAIC (Define, Measure, Analyze, Improve, and control). Waste is any step or action in OR process that is not required (called “Non Value-Adding”). When Waste is removed, only the steps that are required (called “Value-Adding”) (patients, healthcare providers) remain in the process. Lean Six Sigma eliminate 8 Wastes called DOWNTIME.
By adapting innovative and forward-thinking, we can deliver high-quality products to the right customers at the right time at minimum cost. The Six Sigma processes are powerful tools that OR managers can use to identify and solve supply chain problems in surgical services.
Bonny Chattopadhyay, MS Information Systems and Business, Senior Consultant, FTI Consulting
Brian Jain, MBA, Senior Consultant, FTI Consulting
Bradley Eaton, RN, PhD, Director, FTI Consulting
Abstract: Purpose/Objective: Case delays can have a perpetual effect on the surgery schedule, increasing resource consumption and overtime while negatively impacting physician, staff, and patient satisfaction.
Content: A community hospital in Georgia partnered with FTI Consulting to improve overall OR operations. One objective was to reduce delays that were disrupting the surgical schedule and negatively affecting stakeholder satisfaction. Reviewing one year of historical performance, First Case On-Time Starts (FCOTS) ranged from the 32% to 48%.
Strategy for Implementation: To increase stakeholder engagement in the improvement efforts, a Surgeon & Anesthesia Council was developed to focus on improving perioperative operations. Following an in depth assessment and review of current practices and policies, with the support of physician leadership, an interdisciplinary functional team was assembled to analyze the causative factors delaying over half of the cases. FTI Consulting facilitated a two phase approach to identify improvement opportunities, align expectations, and reduce delays:
• Room Readiness: A room readiness tracker was implemented to identify non-provider issues counterproductive to case preparation and staff readiness.
• Patient Readiness: Once room readiness targets were achieved, the patient readiness tracker was initiated to identify Anesthesia, mid-level provider, and Surgeon opportunities.
As part of this, the team established target times for when processes steps should be completed with a goal of 95% success. Performance, improvement opportunities, and targets were discussed in staff meetings and Anesthesia and Surgery Department meetings along with the new guidelines and revised policies and procedures.
Outcomes: Utilizing a multidisciplinary approach to process improvement, policy and procedure revisions were implemented in March 2016 and these rapid improvements were achieved:
• FCOTS improved from a historic high of 48% to 64% within 3 months and 76% in 5 months
• Anesthesia provider arrival times have improved to 88%
• Surgeon arrival times have improved to 75%
• Stakeholder satisfaction has increased
• Lessons learned have been applied to subsequent cases preparation
To ensure sustainability, results are monitored and posted weekly in Day Surgery and the Operating Room, discussed with Surgeon & Anesthesia Council, and shared at Department meetings.
Sheila Capasso, MSN, RN, ANNCN-AG, CAPA, Perianesthesia Advanced Practice Manager, The Miriam Hospital
Barbara Pashnik, RN, Interventional Preventionist, The Miriam Hospital
Katherine Buckhaults, MS,RN,CNOR , Clinical Manager PACU/OR, The Miriam Hospital
Margaret Hennessey, RN, Assistant Clinical Manager (OR), The Miriam Hospital
Karen Holt, BSN, CNOR, Assistant Clinical Manager (OR), The Miriam Hospital
The purpose of this project was to reduce the incidence of Surgical Site Infections (SSI’s) in colorectal patients by using a bundle approach to care.
In 2013, the implementation of a bundle tool was implemented, and in spite of a 95% use, infections in 2014 were still occurring. A comprehensive root cause analysis for all colorectal infections was conducted; including reviewing antibiotic dosing and administration, any operative temperature below 36.8, preoperative and postoperative temperature and organisms identified in cultures. Based on the findings, a multidisciplinary team identified goals of developing and implementing an enhanced evidence-based practice bundle to further reduce hospital acquired SSI’s.
Strategies for implementation:
In early 2015, the new enhanced bundle was launched. Real time nursing audits for patients in each phase of surgery were conducted, with adjustments to work flow to ensure all bundle elements were completed.
The infection preventionist (IP) was in charge of developing the audit, reviewing compliance, and peer feedback to assure bundle elements were hardwired. All compliance issues were reported to the Surgeon Chair and shared at staff meetings to look at improvements. Areas identified for improvement beyond the bundle included normothermia and appropriate antibiotic use.
When staff realized that 54% of the patients had intraoperative temperture below 36.8 C, new warming attire was piloted, along with the utilization of fluid warmers in the pre-operative area, and continued into the operating room.
Antibiotic use and non-compliance was reported to the surgeons in real time with feedback from the surgeons. The overall compliance rate was 72%. In March of 2015 a perioperative oral antibiotic prophylaxis was introduced to include Cefazolin and Metronidazole.
A 69% reduction in the rate of infections was achieved from 2014-2015.
Mary Pat Gilligan , DNP, CNOR, NEA-BC, Director of Perioperative Services, TriHealth
Abstract: The American Association of Critical Care Nurses (2005) has reported that 60% of patient care errors occur due to miscommunication (Xyrichis & Ream, 2007). These findings would suggest the need for a better understanding of communication in the healthcare setting. There is an abundance of literature which discusses communication in the healthcare setting. The Joint Commission (JC), Agency for Healthcare Research and Quality (AHRQ), and World Health Organization (WHO) have stressed the importance of hand-offs and the communication which occurs during the transfer of patient care. The JC introduced National Patient Safety Goal (NPSG) 2E which requires healthcare organizations to develop and implement a standard practice for hand-off communication (Catalano, 2009). The purpose of this project was to support strategies to eliminate the implications of communication inconsistencies and potential adverse events in the perioperative setting. A pre and post survey was distributed to measure the impact of a brief and debrief initiative upon communication and collaboration in the perioperative setting. The implementation of the brief and debrief initiative appears to have had an overall positive impact upon the perception of teamwork and communication in the perioperative setting. A 35% improvement in wound classification accuracy was noted immediately during dissemination of the project. This metric directly reflects accuracy in communication among the team and supports quality in perioperative care practices by ensuring appropriate interventions are implemented which impact length of stay and post-operative outcomes.
Candice Virgin-Cabagnot, RN, BSN, RN Cohort, Keck Medical Center of USC
Jenny Luong, RN, RN Cohort, Keck Medical Center of USC
Krislin Nunez, RN, BSN, RN Cohort, Keck Medical Center of USC
Justina Van Dyne, RN, BA, RN Cohort, Keck Medical Center of USC
Abstract: A retained surgical item (RSI) refers to any item or foreign object left inside of a patient after surgery or any invasive procedure. RSI's can have catastrophic implications for patients, such as increased infections, adhesions, fistulas, obstructions, and even death. It is estimated that there are between 2, 000 - 4, 000 RSI cases a year, with a single case costing between $100, 00 to $200., 00 (Ericksen, 2015) (NoThingLeftBehind). Though nothing can replace a physical two person count, there will always be a possibility for human error. In recent years an effort to support surgical staff with counting, new technologies have been developed to assist in verifying that nothing will be left behind.
Christine Chuey, RN MSN CNOR, Education Program Coordinator, Cedars-Sinai Medical Center
Jennifer Kelly, RN BSN CNOR, RN, Cedars-Sinai Medical Center
Paul Sanchez, ST, Surgical Technologist, Cedars-Sinai Medical Center
Abstract: Microneurovascular procedures are resource-intensive procedures and thus require a significant amount of preparation. Our project asked the question: Will the implementation of a new standardized protocol decrease the incidence of rushing for microneurovascular procedures? We established and implemented a multi-faceted protocol which includes: a custom PBMS pack to reduce the amount of supplies to be opened, a contained, mobile “Free Flap” supply cart for speedy retrieval of frequently used disposables, a standardized equipment list to ensure ancillary staff is aware of required equipment, and early notification of the surgical team to allow sufficient preparation time. We surveyed the staff and measured if the new standardized protocol decreased rushing. Based on our post survey, over 90% of nurses surveyed felt that the Free Flap Cart helped to reduce rushing. Over 70% felt the custom PBMS cart reduced the incidence of rushing. This quality improvement project shows that creating and implementing a new standardized protocol reduced the incidence of rushing for microneurovascular procedures. The new protocol will continue to be used for microneurovascular procedures.
Evelyn Q. Jirasakhiran, MSN, RN, NEA-BC, Chief Nursing Officer, Foundation Surgical Hospital of El Paso
Carmen Patricia Maldonado, RN, CNOR, Director, Surgical Services, Foundation Surgical Hospital of El Paso
Samuel Garcia, BSN, RN, CEN, Director, Nursing Operations, Foundation Surgical Hospital of El Paso
Abstract: This is an initiative of a small surgical hospital to address staffing issues especially in hard to fill areas in a moment’s notice. With support from administration, the nursing leadership, and buy in from the staff, we are cross training our nurses to all areas of the hospital, including the operating room (OR). Working as a team, we put a process in place, and between January - July, 2016, we have filled 193 shifts by cross trained nurses, and we have one medical-surgical nurse who is being cross-trained in the OR.
Emily Vezina, Assistant Nurse Administrator, Roswell Park Cancer Institute
Amanda Englert, Nurse Administrator for Perioperative Services, Roswell Park Cancer Institute
Abstract: Times are changing within the perioperative setting. Acuity and how we manage the level of care are changing too. Post-operative patients no longer only have the traditional post recovery pathway. New research and new trials have proven effective, efficient and safe, therefore, care can be provided with a fast track recovery. This poster focuses on how to get from a two phase recovery phase to a fast track recovery plan inclusive of one recovery phase. The team approach, medication distribution, explanation of fast track, and how to staff it will be explained. Sustainability and cost saving measures are also explored. Fast tracking patients in perioperative settings is a way of the future that is up and coming.
Michele Brunges, RN, MSN, CNOR , Nurse Manager, UF Health
Abstract: Pre-op and Post Anesthesia Care Unit RNs are expected to correctly draw and label blood specimens, ensuring each sample is drawn from the correct patient, labeled with that patient’s name, medical record number, initials of the person drawing and date of specimen draw. Last year there were 39 mislabeled specimens in Perioperative Services and six wrong specimens in tube, meaning they were drawn from one patient but attributed to another. Wrong Specimen in Tube (WSIT) is a high-risk, never event which can result in a delay in a surgical procedure, no available blood for a surgical procedure or adverse patient events such as hemolytic shock or death. These errors have been attributed to distraction when drawing blood specimens and completing the Transfusion Verification Time Out Form. Simulation training using Virtual Humans (VH) can mimic team dynamics when interdisciplinary team members are unavailable. Simulation scenarios were developed using VHs for preventing WSIT which required staff to correctly complete the Transfusion Verification Time Out Form and Blood Bank label, incorporating the TeamSTEPPS techniques in the presence of distractors which included surgical staff and patients. Staff were introduced to the Check-back and CUS Technique tools to prevent interruptions during blood draws. Staff feedback was obtained during the debriefing and opportunities for improvement were identified.
Debbie Hall, MSN, RN, CNOR, NE-BC, Director of Surgical Services, Norton Audubon Hospital
Kristin Pickerell, DNP, RN, NE-BC, CPHQ, Director Quality & Clinical Effectiveness, Norton Audubon Hospital
Abstract: Enhanced recovery after surgery (ERAS) is a multimodal and multidisciplinary perioperative care pathway, based on evidence based practice that is designed to achieve early recovery for patients undergoing major surgery. Use of the ERAS pathway has been shown to improve patient satisfaction and reduce length of stay, readmissions, and postoperative complications. With this poster presentation the reader will gain critical insight into the clinical, leadership, and quality aspects of implementing an ERAS program at an institution. The information presented will allow the reader to acquire practical implementation strategies, tips for anesthesia and surgeon program adoption, education strategies for key stakeholders, tools to develop patient outcome metrics, and methods to gain executive leadership support.
Andrea Barrett, RN, BSN, Nurse Manger, Operating Room , TRIA Orthopaedic Center
Beth Engelsgaard, RN, BSN, Nurse Manager, Pre-op/PACU/Post-op, TRIA Orthopaedic Center
Lori Groven , RN, MSPHN, CIC, Infection Preventionist, TRIA Orthopaedic Center
Abstract: This poster will provide information on ways in which a healthcare organization can build a sustainable environment while maintaining standards of infection control and prevention. After viewing this poster, participants will be able to: identify the requirements for third party reprocessors, describe strategies to implement sustainability initiatives, and describe how to ensure staff safety while maintaining a green environment.
This poster will highlight the importance of following infection prevention standards when implementing green initiatives by providing an overview of evidence based standards as well as examples of green initiatives that meet the standards. It will feature strategies on implementing green initiatives, including considerations for staff and patient safety during and after collection and reprocessing of equipment. It will outline the process to implement third party reprocessing from identifying single use devices, understanding U.S. Food and Drug Administration guidelines for reprocessing single use devices, and selecting a single use device reprocessing vendor. A step by step process for selecting a third party reprocessing vendor will be outlined, including a list of questions to utilize while interviewing potential vendors. Common pitfalls of implementing a sustainable environment will also be discussed with respective solutions. The outcomes of the project will be summarized and will include a discussion of lessons learned as well as additional interventions planned for the future.
Marcia Frieze, CEO, Case Medical
Abstract: Hospitals are a large source of environmental waste consuming copious amounts of energy, CO2, greenhouse emissions and water. This poster provides ways to eliminate waste, reduce toxic emissions, conserve water and properly process medical devices to increase efficiency and environmental safety at hospital facilities.
Sakinah Abdullah, MSN, RN , Manager of Patient Care Services, Sinai Hospital, Lifebridge Health
LifeBridge Health sought to reduce its perioperative costs and improve patient care coordination. The “old way” of reorganizing our fax, post-it note, and manila folder driven processes had failed to sustain quality outcomes. We believed the “new way” was to utilize innovation to make technology the cornerstone of our process improvement strategy to achieve standardized, sustainable, and quality results.
Problem: Perioperative teams across the country face three common challenges: 1) reducing same day case delays and cancellations, 2) improving the patient experience through better care coordination, and 3) improving staff satisfaction by reducing workflow complexity, paperwork and restoring the emphasis on patient care.
Solution: Implement OPTIMI$ER , a technology to facilitate Lifebridge hospitals and surgical practices ability to get 30, 000+ surgical patients we serve every year into surgery safely and on-time. OPTIMI$ER pulls patient information from our existing IT, like EHR, lab, and scheduling, eliminating duplicate data entry and transposition errors. And it features process checklists, automated task alerts, performance analytics, patient status dashboards to ensure all process steps are captured, and real-time communication regarding the status of pre-anesthesia ensuring day-of-surgery clearance is seamless.
Key implementation strategies included: 1) executive team justification that OPTIMI$ER adds value to IT systems already in place, 2) EHR vendor confirmation that OPTIMI$ER complements and not competes with current systems or future upgrades, and 3) demonstrating a breakeven on our investment in Year I. Securing the above facilitated approval for the project team to implement within 3 months.
Within 6 months, implementation of OPTIMI$ER reduced day-of-surgery cancellations and delays, provided incremental revenue, improved the patient experience and coordination between care providers, provided an opportunity to increase patient volumes, and increased RN productivity and satisfaction. The financial benefit we gained on an annualized basis is $2.6 million and staff satisfaction is +78%.
Ebony Mitchell, MSN, RN, RN II, Houston Methodist Hospital
Abstract: There are multiple components leading to improved efficiency and profitability in the highly technologically advanced, clinically intense, multidisciplinary environment of the operating room. Application and evaluation of data analytics in this environment where more than 65% of hospital revenue is generated, not only provides administrators an accurate basis for comparing their organizational performance with that of competitors, but also allows individualized performance tracking over time, thus highlighting opportunities for process improvement. An adequate understanding of the cost associated with day of surgery delays as well as the underlying cases of first case delays provides explanation of subsequent case delays, decreased surgeon satisfaction, and decreased patient satisfaction. Delays frequently occur in the operating room and can potentially negatively effect patient flow and resource utilization. Through proper documentation of perioperative delays, a basis for the development of realistic solutions for improving operating room efficiency can be apparent while providing staff the ability to correctly identify, illustrate, and devise measures to decrease the underlying causes of operating room delays across surgical disciplines.
The purposes of this project are to examine the underlying causes of first case on time start delays, develop a competitive strategy to combat the main cause of first case delays (surgeon late), and reward and recognize surgeons who improve and are on time for first cases monthly.
Implementation: The Apples in the Barrel board was devised as a competitive way to increase surgeon awareness of time and boost surgeon and employee morale. The surgeon’s faces and names were individually printed using color ink on apples placed in the apple tree. Throughout the week, surgical delays were tracked utilizing our computer based charting system and emphasis was placed on the first cases in particular. Each surgeon was categorically (25%, 50%, 75%, or 100%) placed on the apple barrel based on the number of scheduled first cases they completed on time. Surgeons with a monthly total of 100% of first cases start on time were recognized monthly with an apple certificate stating such on their door each time they operate the following month.
Outcomes: Since inception of this apple board, we have noted a decrease in the number of surgeon related first case delays, optimal use of surgical suites, increased patient satisfaction scores, and increased employee and surgeon morale.
Cory Nestman, BS, MS, CRCST, ACE, CHL, FCS, AVP Central Sterile Processing & DME Support Services, Hospital for Special Surgery
Abstract: Innovation in Sterile Processing is sometimes challenging to initiate due to restrictions in space, resources, regulations, design of work space and the complexity of surgical instruments. The use of automation in any aspect of sterile processing is desirable but not often feasible. The use of visual recognition in assisting a Central Sterile Processing (CSP) technician in the tray assembly process has great potential for improving both quality and efficiency. This poster will examine the use of visual recognition in an automated tray assembly unit called AIM (Assisted Instrument Management). The project outlined in this poster launched and attained the following objectives:
Cory Nestman, BS, MS, CRCST, ACE, CHL, FCS, AVP Central Sterile Processing & DME Support Services, Hospital for Special Surgery
Abstract: This poster shall introduce the MTS300 (Multiple Tray Sterilization) System, also known as “The Cube, ” which is an innovative product designed to improve multiple efficiencies within the instrument tray process loop benefiting both OR and SPD areas. Most U.S. hospital OR and SPD departments are experiencing quality defects within the instrument tray process loop which result in case delay, customer dissatisfaction and the use of IUSS. With the infusion of more and larger instrument tray systems and loaner instrument trays, SPD and OR team members are challenged to maintain the sterility throughout the entire process loop and meet the best practice standards for aseptic technique when setting up the back table. The MTS300 technology provides an effective solution to:
Joanne Sherer, MSN, RN, OR Director, University of Pittsburgh Medical Center
Janice Nash, DNP, RN, Associate Professor and Director of Undergraduate Nursing Program, Carlow University
Teya Kamel, DNP, RN, Instructor, Carlow University
Kathleen Nauer, MSN, RN, OR Director, University of Pittsburgh medical Center
Abstract: Perioperative nursing is facing a workforce crisis. There are too few perioperative nurses entering the workforce to replace those that will reach retirement age. In addition, changes in nursing education have made it difficult for students to participate in perioperative clinical experiences. The cost of orienting perioperative nurses is high and the turnover rate in the first year after graduation is significant. To address these issues, nursing leaders from the University of Pittsburgh Medical Center Operating Rooms and Carlow University’s School of Health and Wellness, Department of Nursing partnered to design a summer Perioperative Internship for nursing students.
The perioperative internship was an opportunity for the nursing students to gain theoretical knowledge and practical experiences in perioperative nursing. They were able to complete the Association of Operating Room Nurses Periop 101 for Nursing School Programs. They also logged 120 clinical hours and experienced cardiac, thoracic, neuro, orthopedic, general, ENT, plastic, colorectal, surgical oncology, urologic, gynecologic, robotic, transplant and trauma surgery. They observed and participated in many surgical procedures throughout the internship gaining valuable experience in the surgical arena. This experience offered them a greater knowledge base of patient anatomy and pathophysiologic processes within the perioperative setting than in many other clinical environments.
Weekly Reflective Journals gave the leaders insight into the student nurse experience. The combination of didactic work and hands on work in the ORs proved successful. Preceptors played an integral role in the engagement of the student nurses. The immersion of the student nurses into the OR for an extended period of time proved to be exciting and challenging for them.
This innovative academic and healthcare partnership was developed in hopes of helping to fill the pipeline for perioperative nurses at the University of Pittsburgh Medical Center and meet educational needs at Carlow University’s School of Nursing. This internship brought interested student nurses to the perioperative setting. This partnership provided significant benefits to the students as well as to the academic and healthcare setting.
Victor R. Lange, MSPH, CRC, Director of Infection Prevention, Alta Hospitals System
Abstract: While most clinicians make an effort to avoid needle-stick injuries and hand contamination, less attention is given to preventing infection risk from body fluid or contaminant splashes to the eye. Infectious pathogens can transfer through eye mucous membranes. More than 60% of all reported non-sharp blood and body fluid exposure incidents occur to the conjunctiva, and greater than 90% of these occur without proper eye protection [EPINet]. To demonstrably improve employee safety, we embarked on an interdepartmental, collaborative process improvement program to reduce and prevent eye-splash exposure. Detailed education on eye risk and enhanced protection was provided and easy-to-access eyewear was made available at the mask and glove level. New protocol, reporting, and tracking tools were described. Staff were reminded to review exposure risk prior to entering each environment. Our initial implementation goal was a 70% reduction in eye-splash incidents. Compared to the prior 12 months of baseline data, program implementation resulted in a 100% reduction in eye splashes and, in 90 days, 15 splash saves. Interdepartmental collaboration as well as use and availability of appropriate protective equipment provide an opportunity to virtually eliminate eye exposure and significantly improve healthcare worker safety.
Adonica Dugger, DNP, RN, CNOR, Director OR Services, University Medical Center
Laiken Gardner, BSN, Coordinator, University Medical Center
Abstract: The purpose of this study is to determine if patients whose surgical procedure was performed in an operating room suite with humidity greater than 60% have a higher rate of surgical site infections than patients whose surgical procedures were performed in an operating room with humidity less than or equal to 60% as observed from April to September 2015. The theoretical basis for this study is Florence Nightingale’s Environment Theory, which describes the focus of the perioperative nurse as ensuring the surgical environment is optimal for the patient's health.
A Pearson Correlation was calculated examining the relationship between the post operative infections and humidity greater than 60% in the surgical suite. A weak correlation that was not significant was found (r(2)= -.018, p>.05). Post operative infection is not related to humidity greater than 60% in the surgical suite.
Mary Pat Gilligan, DNP, CNOR, NEA-BC, Director of Perioperative Services, TriHealth
Rick Prince, BS, CSA, Chief Surgical Assistant, TriHealth
Ann Halverstadt, BSN, RN, Infection Preventionist, TriHealth
Karen Blankenship, BSN, RN, CCRN, Manager Surgery, TriHealth
Abstract: Each year, 30% of the estimated needle sticks and other sharps-related injuries that occur happen in the OR. Of injuries, 6% to 16% are self-inflicted while passing suture needles. Sutures are the most frequent percutaneous injury (43.4%). Scalpels are the second most frequent percutaneous injury (17%) followed by syringes (12%). (AORN, 2014) The project focused on reducing percutaneous injuries across our organization through education, adherence to evidence based safe practices, engaging staff with audits, and adding annual medical staff education. The organization's sites have reported 276 total percutaneous injuries for 2014. A 37% reduction in percutaneous injuries was realized in the perioperatives service departments throughout the system.
Our project improved the health status of the people we serve by creating a safer environment, awareness of potential for harm, and reduction of percutaneous injuries.
• General/vascular service line trialed products and utilized a magnetic drape and magnetic basin for returning sharps.
• Implementing a hands-free zone.
• Announcing during brief whether the case is a no pass.
• Requesting that all team members announce when a sharp is in the field or being passed.
• All team members participate in safety audits once a week.
• Presentation provided to organization's surgical residents in August 2016
• Posters displayed in the unit "how many days it has been since our last injury."
• A surgeon champion was designated for this initiative
Carleen Chhun, MSN, RN, Education Program Coordinator, Cedars-Sinai Medical Center
Linda Burnes Bolton, Dr.PH, RN, FAAN, Chief Nursing Officer, Cedars-Sinai Medical Center
Christina Chuey , MSN, RN, Education Program Coordinator, Cedars-Sinai Medical Center
Abstract: Introduction: According to a 2014 AORN-conducted survey, the average age of OR nurses is 53. At Cedars-Sinai Medical Center (CSMC), 30% of OR nurses are over the age of 50. The increasing demand to create succession plans has driven leadership to develop creative educational programs. Leadership from California State University, Los Angeles and CSMC discussed creating an elective Perioperative Nursing class for pre-licensure nursing students. The curriculum consists of two Perioperative elective classes: an introductory course during their junior year and an intermediate course during their senior year. The goal is for students to complete both courses, and have the opportunity to apply to a new grad Perioperative residency program.
1. Did the CSULA pre-licensure junior nursing students benefit from being introduced to the Perioperative introductory course? 2. Will the students consider seeking future employment as OR Nurses at Cedars Sinai Medical Center (CSMC)?
Methods: Plan - We created a Student Nurse Survey to evaluate the Perioperative class experience, and added a question about seeking future employment at CSMC. Do- At the end of the introductory perioperative course, an 11 question survey was distributed to 10 CSULA nursing students. The survey was returned anonymously to the OR administration department. All of the students completed the survey. Study – A 5-point Likert scale was used and the 11 survey responses were analyzed. Act – We used survey responses to help shape the intermediate perioperative curriculum and teaching strategies.
Results: The Likert scores for each question were averaged, and the results displayed “strongly agree” for the most part. 80% of the students agree on spending time in other areas of the Perioperative setting such as PACU. 80 % of the students strongly agree that the on-boarding was adequate for the preparation to the clinical area. 100% of the students strongly agree that they were actively able to participate in the care of patients undergoing surgical procedure, and that they would seek future employment at CSMC.
Conclusion: For the next quarter (Spring 2016), these students will be exposed to Sterile Processing, Pre-Operative area, and PACU. The next step is to include surgical specialties such as orthopedic and neurological surgery to the intermediate Perioperative curriculum. After passing the NCLEX, graduates will complete an accelerated 3-month OR training, compared to the current 6-month OR training program for post-licensure nurses. This collaborative effort between the two institutions marks a significant investment in building an effective succession planning program.
Kaumudi Kulkarni, M.S., Manager of Research and Development, Healthmark Ind.
Alex Bonkowski, B.S., Laboratory Technician, Healthmark Ind.
Stephen Clark, B.S., Laboratory Technician, Healthmark Ind.
Abstract: Brushes designed to clean medical devices during decontamination procedures play an important role in the effective reprocessing. There currently does not exist a standard method for comparing the cleaning power of one brush to another. This is a gap in the validation of brushes designed to clean.
This poster presentation will describe methods that are objective, quantifiable and reproducible, for comparing the characteristics of one cleaning instrument brush to another. A pull tester is used as the tool to conduct the testing.
Quantifiable methods are developed for comparing two cleaning instrument brushes that have been designed to clean the same target area(s). These scientifically based methods allow users to better compare one brush to another. This involves objectives comparisons of similar design from different sources and also different designs of a brush to clean the same device.
Adoption of these methods will be useful to the medical device reprocessors to help them evaluate the performance of commercially available brushes. This information will also help manufacturers of cleaning brushes evaluate their cleaning performance, and thus provide better performing brushes for target areas of medical devices.
Michael A. Bafuma, MSN, RN, CNOR, Clinical Manager, Perioperative Services, The Hospital of Central Connecticut
Lori Pelletier, MSN, RN, CNOR, Perioperative Clinical Specialist, Hospital of Central Connecticut
Gina Piroscafo, BSN, RN, CNOR, Perioperative Supervisor, Hospital of Central Connecticut
Abstract: Cancellation of elective surgeries can result in many negative outcomes. Rescheduling OR cases results in an increased financial burden to the organization, inconvenience to our clients (patient and surgeon), and inefficient utilization of staffing resources and OR block time. A multidisciplinary group to evaluate scheduled surgeries and ensure that patients are receiving the proper level of care was established. Modeled after interdisciplinary rounding that occurs on inpatient units, a daily huddle was implemented in Perioperative Services. OR nursing staff and leadership, anesthesia providers, Sterile Processing and Materials Management personnel, OR schedulers and Pre-Admission Testing nurses are included in this 15 to 30 minute session. The huddle consists of a rolling three-day review where patient-specific issues and case requirements are discussed to ensure everything is in place for the day of surgery. A retrospective analysis of case data collected from 2012-2016 reveals a decreased surgical cancellation rate since implementation of daily huddles in 2014. Increasing communication between disciplines involved in the patient’s episode of care increases patient satisfaction, promotes OR efficiency in scheduling and staffing, and results in fiscally responsible management of materials. Adopting a multi-disciplinary communication philosophy lends credence to improved perioperative efficiency.
Oo Cheng Sim, Senior Nurse Manager, Singapore General Hospital
Teng Peng Kwee, Hospital Executive, Singapore General Hospital
Wong Yoke Siam, Nurse Clinician, Singapore General Hospital
Nureizah Binte Nordin, Senior Staff Nurse, Singapore General Hospital
To reduce the number of returned unused surgical instruments ordered daily from Theatre Sterile Supplies Unit (TSSU) by Ambulatory Surgery Centre (ASC) to 50% in one year.
ASC is a standalone, multidisciplinary day surgery centre in Singapore General Hospital. There are six Operating Rooms (ORs) in the centre that provides state-of-art care and has multidisciplinary operation facilities. Services provided are catered mainly for day surgery or selected inpatients cases, with an average of 33 cases a day.
ASC orders instruments from the TSSU to fulfill daily Operating Theatre (OT) surgical requirements. It was noted that a large proportion 50% of the instruments ordered, were returned unused to TSSU. As many as 3 man hours per day (2 staff were deployed) were spent solely to sort and transfer these sets back. Excessive handling of unused sets may contaminate the sterile packages and potentially compromise patient safety. Furthermore excessive instrument orders, lead to an artificial shortage at TSSU. Any unused instruments held up at ASC, potentially creates a genuine instruments shortage to other clinical areas.
ASC collaborated with TSSU to identify areas and processes for improvement. The following PDSA cycles were implemented:
i) Improve operational efficiency by reviewing T-Doc, an online instrument ordering template. Redundant items were removed and the template was changed from surgeon to case type preference.
ii) To streamline the process of withdrawal and centralise OT store items. OT store items are a buffer that minimizes ad hoc orders to TSSU.
iii) Minimizing transportation waste and improve OT staff productivity by reviewing and updating OT store inventory.
i) The rate of return for instruments ordered from TSSU had reduced to 25%, an improvement from the 50% rate of return (average 500 instruments per months) before project inception.
ii) All stores were centralized and excess inventory items were returned to TSSU for better utilization. These returns amounted to $9700.
iii) Outcome of project was spin off to 2 other departments; National Heart Centre (NHC) and Urology OT.
Carissa Katsov, RN, BSN, CPAN, Registered Nurse, White Plains Hospital
Valerie Arcara, RN, BSN, CPAN, Registered Nurse, White Plains Hospital
Abstract: As clinical nurses in the Ambulatory Surgical Unit, we were interested to determine if the patient chart (i.e. binder) is a fomite, a potential reservoir for harmful pathogens that can promote the incidence of surgical site infections. All patients entering the department have their records contained within a hard plastic binder. A comparison study was done to determine if the charts were a possible vector and therefore contribute to the occurrence of surgical site infections. The results conclude that the patient charts are a fomite and can be a potential source of infection. Hospitals need to take steps to protect their patients by wiping down their charts with hospital grade germicidal cleaner after patient use.
Suzanne Sisk, MSN, RN, NE-BC, Nurse Manager, Paoli Hospital
Dina Bammer, MSN, RN, CNOR, Clinical Nurse Educator, Paoli Hospital
Allison Flanagan, MSN, RN, CNOR, OR Clinical Nurse, Paoli Hopsital
Abstract: Paoli Hospital, an entity of the Main Line Healthcare System (MLHS), is a 231 bed community hospital located in beautiful Chester County, PA. Quality and safety are paramount at Paoli Hospital, which is celebrating its 100th year of offering patients a unique balance of personalized care, advanced medical technology and an extraordinary commitment to patient satisfaction. US News & World Report recognized Paoli as one of the best regional hospitals in the Philadelphia metropolitan area. As an active level II trauma center, we offer a large volume of perioperative services. Stopping the line for patient safety is of utmost importance. This hard stop is a step where the OR nurse and the anesthesia team collaborate to confirm the surgical consent processes.
Our OR was experiencing delays related to the surgical consent not being completed with the surgical signatures by the surgeon. On two occasions it was identified that the patient was taken to the OR suite without a completed surgical consent. Leadership determined that steps need to be taken to resolve this issue quickly. Our perioperative nursing unit councils worked on a process change with a hand off tool between our operating rooms and our ambulatory surgery unit. Steps were taken to change the process whereby the operating nurse and the anesthesia team would meet in our ambulatory area simultaneously to review completion of the documents. A Hard Stop process was initiated to ensure both teams met before moving the patient from ASU to the OR suite. Recently the leadership and the unit council met to review the current process that was initiated with the Hard Stop and steps are underway to further revise the tool. Collaboration with our team supports patient care improvements and changes to the perioperative patient experience.
Kathy Roberts, RN, BA, Director Patient Care Services, Memorial Healthcare
Alternative Payment Methods are either here or coming soon to stay. As a small community hospital we wanted to start preparing for Bundled Payments. Hospitals will be financially responsible for all aspects of care from preadmission through 90 days after discharge. Our goal was to improve our patient experience including quality and patient satisfaction, to improve the health of a population and reduce per capita cost of healthcare.
We identified key stakeholders in this process, engaged physician champions including an orthopedic surgeon and an anesthesiologist. A mulit-disciplinary work group was tasked with developing and implementing this project. Each phase of the patient experience was evaluated through Value Stream Mapping process. Changes were implemented within 90 days from start of project.
New processes implemented included:
• Implementation of a in person pre-op visit with each patient that included: Pre-op assessment, assessment and exam by anesthesiologist, PT/OT evaluation and education, case management evaluation and planning, home visit assessment, and discussion related to pre-op, intra-op, and post-op medications.
• Multiple changes to the medication both pre-operative and intra-operative for pain management and decrease in complications
• Standardization of guidelines and protocols
Three months after implementation of changes our outcomes included:
• Decrease in Foley catheter use
• Eliminated duramorph epidurals
• Decrease in key statistics – Same day cancellations, OR delays, post-op complications/infections, readmission rate and LOS
• Patient satisfaction scores improved profoundly from some in the 8th – 59th percentile to all at or greater the 90th percentile.
Mary Frances Mullins, RN, CRNA, CPAN, CAPA, MSN, DNP, Clinical Nurse Educator, Memorial Medical Center
Abstract: Nearly 25 million people in the United States suffer from obstructive sleep apnea (OSA). This serious, under-recognized, under-diagnosed medical disorder is associated with significant comorbidities as well as increased perioperative risks. Therefore, preoperative screening for OSA using a validated OSA screening tool such as the STOP-Bang OSA screening questionnaire is imperative. Using a quantitative methodology with a comparative design, this author observed for statistically significant differences in the proportion of postoperative hypoxemia between two sample groups. Group A (n=100) was comprised of adult (ages 18-75) general anesthesia elective surgery patients who were screened preoperatively for OSA on the STOP-Bang OSA screening instrument. Group B (n=100) was comprised of adult (ages 18-75) general anesthesia elective surgery patients who were not screened preoperatively for OSA on the STOP-Bang OSA screening instrument. A Chi-square analysis was conducted comparing the proportion of positive postoperative hypoxemia occurrences in the Post Anesthesia Care Unit (PACU). The proportion of patients who experienced hypoxemia in the PACU pre-implementation of the STOP-Bang screening program was not equal to the proportion of patients who experienced hypoxemia in the PACU post implementation of the program, χ2 (1, N = 94) = 2.085, p = .149. This was statistically insignificant, but clinically relevant. Clinician awareness of the potential existence of OSA can guide the perioperative care plan to safely meet the special needs of surgical patients with OSA.
Jan Barber, BSN RN, Service Educator for Gynecology/Urology, University of Michigan Health System
Abstract: Laparoscopic and robotic surgeries of the pelvis require patients to be placed in a steep Trendelenburg position. This places these patients at risk for positioning injuries. Historically many different positioning aids have been utilized in the attempt to prevent patients from sliding. These positioning aids allowed for some cephalad movement. Patients supported with a postioning aid that is in contact with a large muscle mass and additionally attached to the OR bed can be prevent patients from moving cephalad and subsequently reduce their risk of injury.
Amber Mitchell, DrPH, MPH, CPH, President/Executive Director, International Safety Center
Abstract: Vitality of the OR is a balance of managing patients with known or suspected infectious disease and the occupational risks associated with those potential exposures. Discussion about occupational risks in the OR associated with mucocutaneous blood/body fluid exposures compared to sharps injuries and needlesticks are often under-represented. With the globalization of travel and emerging and re-emerging infectious disease trends, measuring, analyzing, and preventing exposures to bloodborne and infectious pathogens are more important today than ever. Occupational incident surveillance data is captured by the International Safety Center's Exposure Prevention Information Network (EPINet) surveillance system from 30 US health systems. This study quantifies splashes and splatters of blood and body fluids (mucocutaneous exposures), especially those with the highest risk—eyes and conjunctiva. It illustrates differences between exposures and PPE use across departments, to the operating room only. Data is compared for the last three reporting years; 2012-2014. With increasing numbers of eye exposures in the OR (35 in 2012, 29 in 2013, 36 in 2014), there is decreasing use of eye protection (28.6%, 20.7%, 8.4%). Eye and conjunctiva exposures are on the rise, but PPE use and compliance are on the decline. This data illustrates the exacerbation of overall occupational risk in a time where emerging infectious disease threats are high. It also showcases the ability for health systems to learn from strategies implemented in the OR so they can build safer environments throughout the facility. Data analysis was made possible through a charitable contribution from TIDI Products.
Jan Stull, RN, MSN, CNOR, Clinical Specialist, Florida Hospital Carrollwood
Stephanie Johnson, RN, BSN, Staff Nurse, Florida Hospital Carrollwood
Diane Shepherd, RN, BSN, CPAN, Manager PAT, Pre-op/PACU, Florida Hospital Carrollwood
Abstract: The Perioperative Glycemic Control Protocol (PGCP) provides guidance to ensure surgical patients at Florida Hospital Carrollwood (FHCW) are treated in a manner consistent with our aim to minimize surgical complications, morbidity, and mortality before, during, and after surgery.
The goal of this clinical project was to decrease post-surgical site infection rates (SSI) in orthopedic and spine surgical patients. Clinical guidelines were established by using evidence based practices found in literature. A multi-disciplined group of health care providers created guidelines as a framework for standardizing glycemic control for ortho/spine surgical patients.
Protocols were written for four time periods for the diabetic surgical patients: prior to arrival on day of surgery, on arrival day of surgery, intra-operatively, and post-operatively.
Outcomes of this study indicate high intra-operative HbA1c levels >7.5% is an independent risk factor for SSI's in spine and orthopedic surgeries and were 60% more likely to spend time in ICU, five times more likely to be readmitted to the hospital, and have twice the mortality rate. With patients with HbA1c < 7%, the SSI rate was cut in half. Control of blood glucose for surgical patients is paramount for improved surgical outcomes at FHCW.
Cheryl Barratt, RN, BS, MHA, Senior Managing Consultant, BRG
Abstract: CoxHealth, the only not-for-profit health system in southwestern Missouri acquired a 150-bed hospital in Branson, Missouri at the end of 2012. To achieve the benefit of the acquisition as quickly as possible, the health system needed a swift integration effort focused on eliminating redundancies and implementing performance improvement opportunities. Leadership engaged Berkeley Research Group (BRG) within the first 30 days of the acquisition. In April 2013, the CoxHealth President and CEO, Steve Edwards, introduced the Working Smarter initiative in response to a changing reimbursement environment in terms of:
• Medicare cuts and lack of Medicaid expansion in Missouri
• Cuts associated the Affordable Care Act
• Cuts associated Disproportionate Share payments
1. Define how to leverage the existing Medical Staff Committee structure to successfully partner with surgeons colleagues to improve overall OR utilization and block utilization.
2. Describe how the power of data, use of best practice literature and the use of technology can be used to right-size surgeon, group and service block allocations.
3. Outline how right-sizing block allocations can have a domino effect on reducing Nursing and Anesthesia staffing costs.
Donna Lagasi, RN, BSN, MSHCM, CNORE, Director, OR Services, The Valley Hospital
Bonnie Weinberg, MSN, RN, CNOR, Clinical Practice Specialist, The Valley Hospital
Abstract: An effectively run operating room needs its staff to be on board with innovations, projects and growth on a day-to-day basis. At Valley Hospital we feel strongly that a shared governance structure that empowers our staff to help in the decision making and understands the goals of the organization will help in their engagement and support.
We created three committees under the OR Shared Governance Council, the Education Committee, the Policy and Procedure Committee, and the Performance Improvement Committee. To become a member of a committee, a staff RN or surgical technologist has to go through an application process. The goal was to attract people who wanted to be on the committee and were willing to do the work needed to accomplish our objectives. Each committee member serves for two years, to ensure fresh ideas and involve more staff in the new structure.
The three committees meet monthly. Each has two facilitators who lead the meetings, one a supervisor and one a front line staff member. The educator on the unit attends all meetings to help answer questions and help with research and find the best evidence, when needed. Agendas and minutes were streamlined for all committees. Every meeting starts with an intention and a safety story. The facilitators meet monthly to discuss where each committee is, and what goals to achieve in the future.
Outcomes we have achieved through our new Shared Governance Structure include an increase in staff engagement and satisfaction, an understanding of the process to get things accomplished, and an understanding of our goals in relation to the organization and health care of the future.
Esmihan Almontaser , PhDc, RN, CPAN, Nurse Educator , Thomas Jefferson University Hospital
The objective of this quality improvement project is to increase patient safety and reduce perioperative errors, specifically within the preoperative/holding areas.
Despite increased focus on patient safety and OR errors, limited research is done in the preoperative/holding area where many of the potential errors are identified. If unnoticed, these errors are patient safety issues and lead to OR delays, creating a financial impact for the institution.
At our large, academic institution, preoperative/holding area nurses were asked to identify situations where patient safety arose. A RedCap survey was used to collect data on the patient, issue, surgeon, service, as well as a space to free text any relevant data. Data was analyzed by the PACU educator and categorized into themes.
Strategies for Implementation
Multiple changes occurred because of this study. Incomplete consents are now scanned in real time and reviewed with surgeons. Incomplete nursing documentation from other units are scanned and reviewed with the educator and nurse manager of that unit. OR errors are discussed with administrators and charge RNs of the OR. The administrators of the surgeons’ office as well as pre-admission testing are involved with improving the screening process so that appropriate preoperative labs and tests are done. Individual in-services for inpatient nurses, traveler nurses and pool nurses have been completed with laminated checklists on preparing a patient for surgery.
After three months of data collection, the four major themes were clinical issues, consent issues, and OR error and floor report. A periflow interdisciplinary meeting was created in addressing and resolving complex interdisciplinary problems and issues. The team is compromised of physicians, nurses, transportation and environment supervisors and vice presidents and now meets biweekly.
Jennifer Simonetti , MSN, RN, CPN, Perioperative Nurse Educator, Cohen Children's Medical Center/ Northwell Health
Sharon Goodman, MA, CPNP, RN-BC, Service Line Nurse Educator, Cohen Children's Medical Center/ Northwell Health
Abstract: Participants from a multi-hospital health system addressed the concern of the decreasing census volumes of pediatrics in community hospitals by redefining a pediatric service line model of care that ensured continued competence, education, and resources necessary for safe patient care. Providing didactic education is a necessary means towards competence, but often leaves practitioners with a low satisfaction/comfort level with a decreased ability to care for patients autonomously. With the inception of this program, both novice and seasoned nurses are provided didactic and experiential experiences which translated to an increase in press ganey scores related to the skill of the nurse and nurse comfort level in caring for pediatrics. A curriculum was developed recognizing and expanding upon a nurses established competencies for both novice and seasoned adult care nurses. This program employs an adult learning approach to a blended model of development. The initial course of learning consists of a reverse classroom concept where participants complete highly interactive pediatric e-learning modules developed by this team. This is followed by a classroom experience to master and apply learned concepts. With two tracks targeted, novice nurses are then provided an experiential component of a percepted rotation within their specialty area at a large tertiary children’s hospital under the direction of a pediatric service line educator. Seasoned and novice nurses will then participate in ongoing inter-professional education at a high fidelity simulation facility where concepts and education are applied and enhanced. In 2015, 218 nurses from 10 hospitals rated comfort level for caring for pediatric patients pre-education at 21% and post-education at 61%, representing a 40% overall increase. In the highest volume system community hospital participating in the press ganey question, the skill of the nurses was compared from 2014, 59.1%, to 2015, 781%, representing a 19% increase in overall patients perception of the skill of the nurse.
Anna Liza D. Fernandez, MSN, RN, CSSM, CHTS-IM, Chief, SPS and RME, Veterans Affairs
Dawn Fitspatrick, MSN, RN, IQCI, RN, Quality Management, Veterans Affairs
Abstract: Purpose/Objectives: The VA National Surgery Office reported that WPB VAMC compliance for on time first and starts within 1 – 15 minutes of scheduled time at 79% for FY 2014. The report ranked WPB VAMC last among the ten VISN 8 facilities for FY 2014. The cost for the time lost during the first 15 minutes was $197, 040.00 for FY 2014. The time lost in the fiscal year 2014 for first starts peaked at 1.5 hours with a total cost of $1, 062, 680.00 and $794, 000.00 for 1st and 2nd Quarters FY 2015.
The Surgical Improvement Through Cultural Transformation aims to improve the overall Surgical Program that will lead to a decrease of operational waste and increase customer satisfaction at the Veterans Affairs at West Palm Beach (WPB VAMC).
Content: Data analysis focuses on identifying factors (a) contributing to the first case delay and (b) factors affecting the difference between the time the second case started and when the second case was surgically scheduled. Deep dive to factors contributing to the greatest delay – patient issues, surgeon/anesthesia issues, SPS issues, and nursing issues
Strategies for implementation: Utilizing Lean Six Sigma methodology, the team formulate inter-and-intradepartmental processes that focus on streamlining process flow challenges among the four stakeholders – veterans, surgeon/anesthesia, SPS, and nursing. Design collaborative program that strengthens surgical service cultural transformation to sustain improvement. Central programs implemented includes (a) Standardized Pre-Op Checklist for Outpatient and Inpatient, (b) Streamlined 100% instrument count sheets, (c) 100% completely updated Preference Pick Sheet, and (d) Organized Operating Room Core through 5S process.
Outcomes: Upon completion of the program, there is a recorded cost saving of approximately $230, 260.00 for the first half of the year. Improved surgical metrics for WPB VAMC in comparison to overall VISN 8.
Robert Scroggins, BSN, RN, CMLSO, Clinical Programs Manager, Buffalo Filter
Abstract: The hazards of surgical smoke have been known for decades, and yet, it seems that there is still reluctance to accept the hazard and to utilize methods to protect workers from this hazardous situation in the operating room. New research is continuously being published that utilizes new technologies to determine the level of hazards and discovering new hazards that were previously unknown. Some of the newest research, within the past five years, has shown the existence and hazard of ultrafine and nano particles as well as the health risks associated with the inhalation of these particles, including COPD, atherosclerosis, and thrombogenesis. This review of new literature pulls together this research to better understand the level of risks endured not only by health care workers in the operative setting, but to the patient as well. New research has uncovered a possibility of fetal developmental harm when laparoscopy is performed on pregnant women and the importance of the removal of plume from the abdominal cavity during such procedures. Other studies have identified ultrafine particles that remain a hazard for an extended period of time after the cessation of electrocautery. Further examination of new information reveals the necessity for better respiratory protection than is commonly provided to workers in the operating room.
Cory Nestman, BS, MS, CRCST, ACE, CHL, FCS, AVP Central Sterile Processing & DME Support Services, Hospital for Special Surgery
Joy Boswell, VP of Operations & Client Support, UniteOR
Cameron Werschkul, CEO, UniteOR
Abstract: Planning surgeries requires many facets that must be addressed and many variables that can dramatically affect patient care and financial costs. With reimbursements of procedures continuing to decrease, every penny counts. Constantly looking for ways to be more efficient throughout the surgery planning process is a necessity in the current healthcare climate.
One variable with immediate impact on improving patient care and lowering financial costs is implementing a process that allows comprehensive communication between OR team members, Sterile Processing team members and Vendors during the surgery planning process.
Three hospitals evaluated their communication process between OR team members, sterile processing team members and vendors during the surgery planning process and identified problem areas where they could be more efficient. The areas with the greatest impact on patient care and financials were case delays and cancellations due to missing or wrong instrumentation and/or instrumentation being unsterile, time being wasted contacting vendors and sterile processing and having to reprocess and clean trays that should not have been opened for the case.
To help resolve the issues identified, the hospitals implemented processes that focused on work-flow, such as acquiring needed instrumentation from vendors, confirming with sterile processing that the required consigned and loaner instruments were ready for the case and creating a communication process between all parties involved in the case. To ensure the success of the changes, the hospitals implemented a software platform that enables comprehensive communication to occur between all parties involved in the surgery planning process, including OR team members, sterile processing team members and vendors.
Maria Kramer, RN, MSN, Director, Neurosurgery Operating Room, Allegheny General Hospital, Allegheny Health Network
Susan Kriznik, RN, CIC, Manager, Infection Prevention, Allegheny General Hospital, Allegheny Health Network
Facilitate process improvements to decrease between-case (BC) turnover times (TOT) and improve BC environmental hygiene (EH).
In 2015, Allegheny General Hospital with 27 operating rooms (ORs), partnered with a vendor to implement a program to improve EH in the OR. Baseline data was collected on cleaning roles, room TOT, high touch object (HTO) cleaning, and equipment storage/use. OR aides responsible for BC cleaning did not have formal training, accountability or a well-defined process to follow and were not considered an integral part of the surgical team. Job morale was low and staff turnover was high in this group. It was observed that room turnovers were inefficient, communication was poor, and not all ORs were being cleaned properly BC. Baseline room TOT (wheels out to room ready for next patient) ranged from 15-45 minutes. OR cleaning protocols consisted of an unstandardized process that utilized shop vacuums, straw brooms and re-processed blue surgical towels as the primary cleaning tools. There was no way to evaluate actual cleaning effectiveness. Baseline thoroughness of cleaning of HTOs BC was assessed at 20%.
Strategies for Implementation:
OR staffing was evaluated. Roles and responsibilities were clearly defined. The OR EH program from the vendor was implemented, consisting of disposable room turnover kits, point of use cleaning carts/tools, fluorescent marker EH monitoring system, hands-on training on EH best practices and a well-defined process for BC cleaning.
Since implementing the program, HTO cleaning has remained above 75%. Morale has increased and staff turnover has ceased. TOT for BC cleaning is now an average of seven minutes. Cleaning staff report that their work is easier, faster and more efficient. Other surgical staff recognize the value of this team, creating improved communication and collaboration. The implementation of a formalized OR EH program has created a culture change while improving cleaning and efficiency outcomes.
Cecille Pallagao, BSN, CNOR, CN III, Cedars Sinai Miedical Center
Danny Saculles, BSN, CNOR, ClInical Nurse IV, Cedars Sinai Medical Center
Literature search shows that never adverse events happen at least 4, 000 times a year in the US. From 2005 to 2012, 772 incidents of Unintended Retained Foreign Objects (URFO) were reported to The Joint Commission’s Sentinel Event database. 95% of these incidents occurred in OR, L&D, and other areas where invasive procedures are performed. Retention of foreign objects other than those intentionally implanted as part of the intervention is an adverse event that is preventable.
As a level one trauma center, the operating room is a high risk environment where major surgical procedures requires packing the chest/ abdomen with sponges as a beneficial adjunct in the treatment of profuse hemorrhage. Our goal as a department is to have zero (0) URFOs by creating a standardized process to improve the communication during handoffs related to the packed items: location, quantity and type of packing.
Quality Research Question
Will a standardized process of therapeutic packing label improve the hand-off communication and attain our goal of 0% URFO?
Plan: Implement a standardized therapeutic packing label to improve communication during hand-offs.
DO: Evaluate baseline knowledge of perioperative nurses on cavity packing guidelines, documentation and hand-offs.
Study: Analyze results of the survey. Review data on URFO.
Act: In-service regarding cavity packing guidelines, documentation and therapeutic packing process was rolled out to staff and other caregivers from different units.
Results showed that out of the 25 respondents of the survey, 50% are aware of the cavity packing guideline; 50% were not; 72% knew where to document and 85% include this information during hand-off. Baseline data of retained URFO incident showed 1 incident from the last 3 months which then warrants the need for re-education, correct documentation, appropriate labeling and improved hand-off communication.
Magnet Component: New Knowledge, Innovations & Improvements
Key words: Unintentional retained foreign objects, Never 27 adverse events, patient safety
Munira Amin, BScN, Administrator - Operating Room and SDC, Aga Khan University Hospital
Ehsan Ali, MBA, Business Manager, Aga Khan University Hospital
Abstract: Standardized quality care is always a challenge in growing hospitals and the focus is on providing safe and quality care. The OR is a vulnerable place for patients where they are at completely dependent on healthcare personnel. Internationally, for promoting safe patient care, Joint Commission has defined certain patient safety goals to be implemented; out of which “Time Out” process is related to prevention of wrong patient, wrong site and wrong procedure.
In a tertiary care hospital in a developing country, compliance to time-out and site marking was a continuous challenge. Time-out and site marking was introduced in the hospital in 2008 but variable practices existed. Moreover, there were quality compromised incidents reported which called for a need to review the practices. The hospital assigned this special quality project to an Operating Room committee which comprised of Surgeons, Anesthetists and Operating Room Administration.
The process of time out was then revised and incorporated based on guidelines from the World Health Organization (WHO Surgical Safety guidelines) and Association of PeriOperative Nurses (AORN). This process was lead by OR administration and all the areas resulting in non-compliance to practice were identified, and revised guidelines were agreed by all stakeholders.
The success of this project including the revision of the existing lengthy and subjective form with a single page checklist having specified roles of each individual in the OR. For successful implementation of the processes, a one week Surgical Safety campaign was organized and “Time-Out” champions were created. Audits are being conducted for reinforcement and successful outcomes. Although change of mindsets and practices of surgeons and physicians lead by nurses/administration was a challenge, with the support of Hospital Executives it was successfully established.
Jennifer Fried, MBA, Chief Executive Officer, ExplORer Surgical
Alex Langerman, MD, SM, FACS, Chief Medical Officer; ENT Surgeon, ExplORer Surgical; Vanderbilt University
Marko Rojnica, MD, MBA, Chief Clinical Officer; General Surgery Resident, ExplORer Surgical; University of Chicago
Abstract: Introduction: Reliable data is essential to cost forecasting and cost reduction strategies. The operating room (OR) is one of the highest cost centers of hospitals, often accounting for over 40% of total expenses, yet granular data on surgical activity is difficult to collect. Based on surgical observations and interviews with surgical teams, we developed an intraoperative workflow management tool (“ExplORer”) and pilot-tested this application in laparoscopic cholecystectomy, a common general surgery procedure. This poster presents the background research and results of this pilot test.
Methods: We conducted background research with direct observation, data collection, and pilot testing at a tertiary care medical center. We conducted interviews both in-person and via the telephone. We then developed an application to help remedy the inefficiencies that arose and collected granular intraoperative surgical data.
Results: ExplORer substantially reduced setup time, the number of missing items, and disruptions. ExplORer also eliminated wasted disposables and saved on average 5% of case costs compared to baseline.
Ashley Walsh, BS, MHA, Perioperative Business Manager, UCHealth
Sanjeev Agrawal, President, Healthcare & CMO, LeanTaaS
Abstract: Perioperative business managers feel significant pressure trying to meet the needs of surgeons and nursing staff while balancing operational targets (utilization, access, revenue). Current block management approaches, which often rely on intuition and thumb rules, make it very challenging to allocate OR block time fairly and efficiently. Administrators don’t have objective data to make decisions, surgeons don’t get the OR time they want, and patients don’t get critical care on time. The stakes are enormous - even a 1 point improvement in utilization can be worth $100K per OR per year. Even for a hospital with 8 - 10 ORs, the value represents millions of dollars and hundreds of extra procedures per year, all of which represent a significant impact on the access and cost of care provided to patients. For large systems the value can run into $10's of millions.
We have developed -- alongside LeanTaaS, the leading healthcare predictive analytics company trusted by 40+ providers -- an objective, dynamic solution for block schedule management called “iQueue for Operating Rooms”. iQueue uses a predictive analytics model to reveal the key causes of under-utilization and usage patterns over time, and applies machine learning to do 3 things:
Matthew Dane, Director, Nursing, Baptist Memorial Hospital - Memphis
Carolyn Schreeder, DM, MSN, University of Tennessee at Chattanooga
Linda Hill, DNSc, DNP, CRNA, University of Tennessee at Chattanooga
Abstract: Current perioperative training programs for Registered Nurses and Surgical Technologists do not provide detailed job breakdown and instruction regarding the surgery room turn over process. Turn over time is defined as the time a patient leaves the operating room suite until the time the next patient enters the same operating room suite for the same surgeon for subsequent cases. Inadequate “Turn Over Training” creates inefficiencies in the operating room, causing decreased room utilization, loss of additional revenue, and decreased patient and physician satisfaction. Detailed training could provide increased efficiency and decrease turnover time by providing role clarity, utilization of parallel processes, and eliminating “dead” time.
The purpose of this project will be to determine the following: (P) In Circulating Nurses and Surgical Technologist within the General Surgery Department at Baptist Memphis (I) how does applying Toyota Kata and Training Within Industry (TWI), (C) compared to current state, (O) affect operational efficiency and patient throughput (T) over a six month period. Operational efficiency will be measured by three primary metrics: percentage of first case on time starts, turnover time average, and operating room utilization. Short term objectives will be: reduction in overall operating room turnover times by 5 minutes/case in a 3 month period, increase in operating room on time starts by 30% in a 3 month period, and decrease in average delay minutes per case by 5 minutes/case in a 3 month period. The primary long-term objective will be to increase OR utilization during peak operating room time to 70% within 6 months. Future implications and application for this project are to build Job Breakdown and training into AORN Period 101 training program and include Turn Over time job breakdown in annual competency validation process.