Charlotte L. Guglielmi

Design and Impact of an Intraoperative Pathway: A New Operating Room Model for Team-Based Practice

BACKGROUND The concept of a team-based model for delivery of care has been critical at our institution for improving efficiency and safety. Despite these measures, difficulties continue to occur during lengthy operating room procedures. Using a novel team-based practice model, a multidisciplinary team was organized to improve efficiency in microsurgical breast reconstruction. We describe development of an intraoperative pathway for deep inferior epigastric perforator (DIEP) flap breast reconstruction and its impact on various outcomes. STUDY DESIGN We evaluated 150 patients who underwent DIEP flap breast reconstruction at Beth Israel Deaconess Medical Center from 2005 to 2008. Patient groups were subdivided into 50 unilateral and 50 bilateral procedures before the intraoperative pathway and 25 unilateral and 25 bilateral procedures after. Outcomes measured included operative time, complications, operating room and hospital costs, proper administration of prophylactic antibiotics and heparin, and staff satisfaction surveys. RESULTS Mean operative times decreased after pathway implementation in both unilateral (8.2 hours to 6.9 hours; p < 0.001) and bilateral groups (12.8 hours to 10.6 hours; p < 0.001) and complication rates were unchanged. Mean operating room costs decreased in the unilateral group by 10.2% (p = 0.018). Prophylactic heparin administration showed substantial improvements, although antibiotic administration and redosing of antibiotics trended upward. Staff surveys showed improved interdisciplinary communication, transition guidelines, and enhanced efficiency through standardization. CONCLUSIONS Implementation of an intraoperative pathway led to improvements in operative time, cost, quality measures, and staff satisfaction. Refinement of the pathway with team resolution of variances might continue to improve outcomes. Complex, multi-team procedures can derive benefits from standardization and intraoperative pathway development.

Addressing the Nursing Shortage: The Need for Nurse Residency Programs

T he nursing shortage affects every aspect of health care delivery in the United States. Although nursing has enjoyed the second greatest job growth of all US professions, some experts project that the shortage could reach 500,000 by the year 2025. The American Nurses Association projects that the nursing shortage will grow to a staggering 1 million RNs by the year 2020 if the nursing shortage is not aggressively addressed. This represents a nursing shortage of 36% in an environment already struggling to keep pace with the demand for nurses at all levels of education and practice. Complicating this are the ramifications of the recession on the future needs for an adequate nursing work force. From 2007 to 2008, the number of RNs in the work force increased by 243,000 fulltime employees. This growth may create a false sense of security for several reasons for nurse executives as they plan for future staffing needs. Many RNs who were directly affected by the recession re-entered the work force to supplement or support their families economically, but many of these RNs are likely to leave the work force after the economy recovers. In addition, despite this influx

Miscount Incidents: A Novel Approach to Exploring Risk Factors for Unintentionally Retained Surgical Items

BACKGROUND An estimated 1,500 operations result in retained surgical items (RSIs) each year in the United States, resulting in substantial morbidity. The rarity of these events makes studying them difficult, but miscount incidents may provide a window into understanding risk factors for RSIs. METHODS A cohort study of all consecutive operative cases during a 12-month period was conducted at a large academic medical center to identify risk factors for surgical miscounts. A multidisciplinary electronic miscount reconciliation checklist (necessitating both surgeon and nurse input) was introduced into the internally developed electronic Perioperative Information Management System to build a predictive model for RSI cases. RESULTS Among 23,955 operations, 84 resulted in miscount incidents (0.35% [95% confidence interval: 0.28% to 0.43%]). Increased case duration was strongly associated with increased risk of a miscount in unadjusted analyses (p < .0001). In the nested case-control analysis, both the case duration and the number of providers present were independently associated with a more than doubling of the odds of a miscount, even after adjustment for one another, the elective/urgent/emergent status of a case, and personnel changes occurring during the case. CONCLUSIONS The finding that both the length of the case and the number of providers involved in the case were independent risk factors for miscount incidents may offer insight into risk-targeted strategies to prevent RSIs, such as postoperative imaging, bar-coded surgical items, and radiofrequency technology. Miscounts trigger use of the Incorrect Count Safety Checklist, which can be used to determine whether a count completed at the procedures conclusion is consistent across disciplines (circulating nurses, scrub persons, surgeons).

Strategies for Preventing Wrong Site, Wrong Procedure, Wrong Patient Surgery

Note from column coordinator Charlotte Guglielmi: It is my pleasure to introduce a new column for our journal. I have heard time and time again that nurses need to better understand the different perspectives that each member of the surgical team brings to the table on topics that affect the care we deliver to our patients. We know that teamwork and effective communication enhance the safe care of patients. This column will provide a venue for colleagues from multiple disciplines to share opinions and commentary on some of the most critical clinical issues that face all of us. As each topic is identified, a critical question will be posed to the authors who will respond from their perspective. Linda Groah, AORN executive director and chief executive officer, will conclude each discussion with a summary of AORN’s response to the issue. I am

Hand-held Communication Devices: Friend or Foe?

he explosive spread of hand-held commuT nication devices in the past decade has opened up new horizons for communication and access to information. Today, at the touch of my finger, I can connect with family, access my bank account, read my e-mail, check in for a flight, and receive reminder notifications from my calendar. It has been reported that there are more than 255.4 million wireless subscribers in the United States, and a 2012 market research study indicated that 85% of US physicians use smartphones. Like many other industries, health care has been widely affected by this rapid advance in both positive and negative ways.

10 years in, why time out still matters.

n January, The Joint Commission’s Universal Protocol for the Prevention of Wrong Site, Wrong Procedure, and Wrong Person SurgeryTM turned 10 years old. During the past decade, the Universal Protocol has become widely adopted and is nearly synonymous with patient safety. Its three fundamental components are preprocedure verification, site marking, and time out. Perioperative practitioners who use the Universal Protocol to prevent medical errors have learned that process alone does not provide a safety net for preventing wrong-person, wrong-site, or wrong-procedure events in the surgical setting. According to The Joint Commission, failures in leadership, communication, and human factors were the top three causes of more than 900 wrong-site surgeries reported from 2004 to 2013.

Sustaining a Culture of Safety: Are We One Step Forward or Three Steps Back?

or more than a decade, I have been committed to improving the safety culture in the surgical setting. Often, I have engaged in activities and conversations with perioperative colleagues and professionals that were focused on the overall progress toward safer care for all patients. However, it seems that consensus across the medical profession never can be reached on this topic. As the literature reports, part of the problem is that the concept of safety culture is still poorly defined. What we do know is that efforts toward consensus are ongoing.

How to Report Adverse Events Related to the Use of Energy Devices in the Operating Room

A timely and directed response by all members of the surgical team is essential whenever a medical device fails. Beyond meeting the regulatory requirements of reporting, the learning that occurs as a result of the event once disseminated will assist in improving patient outcomes and creating systems that are safer.