Perioperative workflow: barriers to efficiency, risks, and satisfaction

AN IN-DEPTH, INTERDISCIPLINARY CASE study was conducted to map and describe the information, material, and functional processes common to high-volume surgical specialty procedures at a southeastern US hospital.RESEARCHERS IDENTIFIED PROCESS defects and their effects using both observation and staff member interviews.OUTDATED INFORMATION and structural barriers to communications were responsible for many procedural delays, procedural interruptions, and staff member work-arounds.OPPORTUNITIES FOR IMPROVEMENT are identified, including redesigns and enhancement of information technology systems. AORN J 87 (January 2008) 187-208. © AORN, Inc, 2008.     

Patients' recall and perceptions regarding consent to blood transfusion at Universitas Academic Hospital,Bloemfontein, South Africa

We studied the recall and perceptions of transfused patients at a single centre. Fifty-three patients were included. In 11 (20.8%) cases, no written informed consent document could be traced. Four patients who had informed consent documents in their records had no recollection of the consent process. Approximately 11% of patients stated that the consent process was performed using unfamiliar terms. When compared to Caucasian and mixed race respondents, more African respondents (83%) would have preferred the presence of a family member (p < 0.01). Although not all the patients experienced the informed consent positively, it did not impact on their perception of the blood transfusion itself.     

Informed consent: An Israeli bone marrow transplant unit's perspective

Israeli bone marrow transplant (BMT) patients are drawn from a heterogenous population of Israeli Jews, Israeli Arabs and patients from outside Israel. This presents difficulties in communicating the ethical dilemmas that surround the BMT procedure to the patients and their families. Among these dilemmas is the issue of informed consent. A pilot study was conducted to assess the current informed consent practices in an Israeli BMT Unit. The sample consisted of 13 Hebrew speaking patients. The purpose of the study was to evaluate BMT patients: (i) information seeking behaviour; (ii) preferences for participation in treatment decisions; and (iii) attitudes and behaviours towards the current informed consent document. The study found that patients did not read the informed consent form. Of the nine patients who read it, three considered it superfluous and seven signed it almost immediately after reading it. Surprisingly, the results also showed that, despite the greater degree of risk associated with BMT treatment, the information seeking behaviour scores of BMT patients were similar to those of cancer patients receiving oncology treatment on an ambulatory basis.     

Results of a survey on current surgical smoke control practices

RESEARCHERS AT DUKE UNIVERSITY Medical Center, Durham, NC, conducted a simple, web-based survey of AORN members to evaluate surgical smoke control practices.SURVEY RESPONDENTS from various medical specialties and facilities throughout North America indicated their facilities' level of compliance with established surgical smoke control measures.SURVEY RESULTS INDICATE that many facilities have not implemented best practices for protecting patients and health care workers from surgical smoke hazards, especially smoke created during electrosurgical, electrocautery, and diathermy procedures. AORN J 87 (April 2008) 739-749. © AORN, Inc, 2008.     

The role of the consent document in informed consent for pediatric leukemia trials

PURPOSE: To examine both the use of the consent document during the informed consent process for pediatric leukemia clinical trials, as well as relationships between the use of the document and parental understanding of essential elements of informed consent. METHODS: Participants included 140 parents of children diagnosed with pediatric leukemia. Informed consent conferences in which randomized clinical trials were discussed were observed, audiotaped, and coded for specific behaviors. Parents were also interviewed within 48 h of their participation in informed consent conferences. RESULTS: Observations revealed that 74% of cases included explanation of consent documents during consent conferences. Parents who reported that they read the consent document were more likely to understand differences between the clinical trial and off study therapy and were more likely to understand the right to withdraw. Reading of the consent document was not associated with understanding of voluntariness. In comparison to racial/ethnic majority parents, racial/ethnic minority parents were less likely to report that they read the consent document, understand voluntariness or the right to withdraw, and were less likely to be able to distinguish between the clinical trial and off study therapy. Low SES was associated with a lower probability of reading the consent document and being able to distinguish between clinical trials and off study therapy. CONCLUSIONS: Attention to the importance of reading the consent document and improving communication during consent conferences is likely to enhance understanding of essential elements of informed consent.     

Counting difficulties: retained instruments, sponges, and needles

PATIENTS IN WHOM A SPONGE or instrument is left after surgery may suffer complications including pain, infection, abscess, or intestinal obstruction.CONSEQUENCES OF RETAINED ITEMS for surgical team members may include malpractice lawsuits and adverse actions from the National Practitioner Data Bank and state licensing board.ADHERENCE TO AORN recommended practices for counting and facility counting policies can protect both patients and practitioners. AORN J 87 (February 2008) 315-321. © AORN, Inc, 2008.     

Blood conservation in a congenital cardiac surgery program

BLOODLESS SURGERY PROGRAMS are being instituted because of increasing public concerns about blood transfusions and the need to accommodate some patients' religious beliefs. Patients' desires to forego transfusion must be identified during the preoperative screening process and subsequently reflected on the surgical consent.PATIENTS ARE MANAGED preoperatively with erythropoietin and dietary supplements. The surgical team employs a variety of intraoperative and postoperative blood conservation techniques to help avoid the need for transfusion.A RETROSPECTIVE REVIEW of congenital cardiac procedures in a blood conservation program confirmed that bloodless cardiac surgery is effective. AORN J 87 (June 2008) 1180-1186. © AORN, Inc, 2008.     

Prevention of unplanned perioperative hypothermia

HYPOTHERMIA is one of the most common complications experienced by surgical patients. Better postoperative patient outcomes are achieved when normothermia is maintained.PERIOPERATIVE NURSES should understand how to maintain normothermia, the causes of hypothermia, and adverse patient outcomes that result from hypothermia. Nursing interventions to help prevent hypothermia can be implemented during each phase of perioperative care. AORN J 88 (September 2008) 358-364. © AORN, Inc, 2008.     

Parental Perceptions in Pediatric Cardiac Fast-Track Surgery

This project investigated parents' and caregivers' perceptions of the fast-track surgery process with regard to their child's surgical procedure and hospital stay. The goal of this project was to review and improve the fast-track process.Participants were parents/caregivers of pediatric patients (ie, younger than 18 years) who had undergone a low-complexity cardiac surgical procedure on a fast-track basis at Great Ormond Street Hospital for Children, London, United Kingdom, between January 2006 and January 2008.Findings suggest that parents/caregivers overestimate the time it takes for several key milestones in the fast-track process to occur and that there is a need for preoperative and preadmission education that will allow parents/caregivers to be more involved in their child's care. AORN J 89 (April 2009) 725-731. © AORN, Inc, 2009.     

Wrong Site Surgery Near Misses and Actual Occurrences

Under coordination by the Patient Safety Authority, staff members in facilities across Pennsylvania analyzed 97 wrong site surgery near misses and 44 actual occurrences using a common analysis form from August 2007 to August 2008. These assessments were aggregated and compared by the Patient Safety Authority.Assessments in which near misses were identified that did not advance to actual wrong site occurrences were significantly more likely to report compliance with patient identification and preoperative reconciliation protocols, accurate scheduling, notation of the surgical site on the consent form, participation of the surgeon in preoperative verification, participation of all surgical team members in the time out, time outs performed with the site marking visible after draping, and the surgeon explicitly empowering team members to speak up if concerned and acknowledging concerns when expressed. AORN J 90 (August 2009) 215-222. © AORN, Inc, 2009.     

Hand-Off Communication: A Requisite for Perioperative Patient Safety

TRANSITIONS FROM ONE CARE PROVIDER to another put patients at increased risk of injuries and errors. A standardized approach to hand-off communication helps minimize these risks.ONE RECOGNIZED APPROACH to addressing this concern is the SBAR (ie, situation, background, assessment, recommendation) communication technique. Reference cards with the SBAR communication approach can be used by all staff members during hand offs in the preoperative, intraoperative, and postoperative phases of surgical patient care. AORN J 88 (November 2008) 763-770. © AORN, Inc, 2008.     

Room for Improvement: A Systematic Review and Meta-analysis on the Informed Consent Process for Emergency Surgery

ObjectiveTo compare recall of complications and surgical details discussed during informed consent and perception of the consent process in patients undergoing emergent vs elective surgery.MethodsStudies were identified from PubMed, Cochrane, Web of Science, and Scopus from January 1, 1966, through April 18, 2018. Included studies compared patient recall and perception regarding informed consent in those undergoing emergent vs elective surgery. Pooled odds ratios (ORs) were calculated for recall of complications and surgical details, patient satisfaction, perception of sufficient information being delivered on surgical risks, report of having read written consent, and factors that interfered with consent.ResultsEleven observational studies (3178 patients) were included. The rate of recall of surgical complications (255 of 504 [50.6%] vs 321 of 446 [72.0%]; OR, 0.29; 95% CI, 0.11-0.80) was lower in patients undergoing emergent vs elective surgery. Meta-analysis revealed a decreased rate of patient satisfaction with the consent process (319 of 459 [69.5%] vs 882 of 1064 [82.9%]; OR. 0.53; 95% CI, 0.34-0.83) and fewer patients having read the consent form (130 of 395 [32.9%] vs 424 of 714 [59.4%]; OR, 0.35; 95% CI, 0.27-0.46) when undergoing emergent compared with elective surgery. Patients undergoing emergent surgery listed pain, analgesic medications, and fatigue as factors likely to interfere with consent.ConclusionPatients undergoing emergent surgery have poor recall of the informed consent process and surgical complications. Furthermore, patients report lower rates of satisfaction, and with fewer patients reading written consent documentation, our findings illuminate problems with the current communication process. There is a need to develop effective tools to improve informed consent in emergency surgery.     

Understanding informed consent.

Understanding and facilitating the informed consent process is our duty as perioperative nurses. Acting as patient advocates, we must determine if our patients have given "informed consent" prior to surgical treatment. When we witness our patients signing consent forms, we must be sure they are competent to sign; that they have spoken with the physician and have discussed the proposed procedure (including the risks, benefits and alternative treatments) and have had their questions answered; and have read the consent form they are being asked to sign. As nurses, we must become aware of our responsibilities related to informed consent. By understanding the concept of informed consent and its legal implications, we will be able not only to the facilitate informed consent process but also to fulfill our legal responsibilities.     

Placental Amniotic Membrane: The Pathway to Ocular Transplantation

OPHTHALMOLOGY RESEARCH has identified a relationship between human placenta and eye tissue. Placental amniotic membrane provides structural healing properties that help restore vision in patients with ocular disease that has been unresponsive to medical treatment.THE PATHWAY from donor placenta retrieval to amniotic membrane transplantation (AMT) involves perioperative nurses from obstetrics and ophthalmology departments who are well versed in federal regulations and eye or tissue bank standards.PERIOPERATIVE NURSES can promote recycling of placentas for preservation and facilitate optimal surgical outcomes for patients undergoing AMT, as well as provide these patients with emotional support and education. AORN J 88 (November 2008) 731-742. © AORN, Inc, 2008.     

The breastfeeding surgical patient

IN THE UNITED STATES, more than 10 million women are either pregnant or breastfeeding at any given time. Of the women currently pregnant, over 70% will initially choose to breastfeed.THE NEEDS OF A BREASTFEEDING surgical patient are unique and are best met by a supportive surgical team using evidenced-based practice. The outcomes of such care will have long-term effects on both the breastfeeding surgical patient and her infant.EVIDENCED-BASED PRACTICE resources for care of the breastfeeding surgical patient are scarce. This article applies available resources to the perioperative care of the breastfeeding surgical patient. AORN J 87 (April 2008) 759-766. © AORN, Inc, 2008.     

Pediatric laparoscopy

SIGNIFICANT DEVELOPMENTS in minimally invasive surgery (MIS) for the adult population have led to increased application of MIS techniques for pediatric patients.LAPAROSCOPY IS THE MOST COMMON MIS procedure used in pediatrics. Traditional surgical procedures that are now being performed laparoscopically include gastrostomy, pyloromyotomy, and repair of congenital diaphragmatic hernia and imperforate anus.ALL PERIOPERATIVE TEAM MEMBERS must be prepared to provide appropriately sized instruments and equipment to facilitate use of MIS techniques in the pediatric population and must ensure safe patient care to achieve optimal patient outcomes. AORN J 88 (August 2008) 211-236. © AORN, Inc, 2008.     

Standardization of a surgical site precleansing technique for vascular patients

SURGICAL SITE INFECTION (SSI) is a serious complication that can increase hospital costs and length of stay and may be life threatening.THE PREOPERATIVE CHLORHEXIDINE shower is widely recommended to decrease SSI risk, although standardized guidelines for this practice and supporting clinical evidence are lacking.BECAUSE VASCULAR PATIENTS often have comorbidities that hinder preoperative showering, OR nurses at a specialty hospital in Dallas, Texas, developed and implemented an intraoperative surgical site precleansing technique as standard practice for patients undergoing procedures involving the axilla or groin. AORN J 88 (August 2008) 261-265. © AORN, Inc, 2008.     

The hazards of surgical smoke

SURGICAL SMOKE is a part of the environment during operative and invasive procedures. As lasers and electrosurgery have become commonplace, perioperative practitioners are at increased risk for health concerns associated with exposure to surgical smoke.SINCE THE MID 1970s, the body of evidence documenting the hazardous components of surgical smoke has continued to grow. Despite the evidence and recommendations of a variety of organizations, there are no uniform requirements mandating surgical smoke evacuation.THIS ARTICLE REVIEWS current research to identify the potential health hazards as well as the current recommendations related to the filtration and evacuation of surgical smoke. AORN J 87 (April 2008) 721-734. © AORN, Inc, 2008.     

Hypothermia/warming protocols: why are they not widely used in the OR?

HYPOTHERMIA, A COMMON PROBLEM for patients having surgery, adversely affects multiple organ systems and physiologic functions. Research indicates that maintaining normothermia can reduce infection rates, operative blood loss, and length of hospital stay.OFTEN, PREVENTING HYPOTHERMIA is not a high priority to surgical staff members because forced-air warming systems may cause field contamination and passive warming may increase the ambient OR temperature. In addition, inconsistent practices and lack of guidelines may affect team members' efforts.SURGICAL TEAM AWARENESS, education, and understanding of the effects of hypothermia are necessary components to enhance the ways clinicians provide quality, cost-effective patient care. AORN J 87 (February 2008) 333-344. © AORN, Inc, 2008.