Developing Strategies for On-Call Staffing: A Working Guideline for Safe Practices

Effective on-call clinical staffing is critical to providing perioperative services to patients requiring emergency surgical care. Without careful monitoring of continuous work hours and hours worked per week, staffing practices can adversely affect the ability of personnel to function and provide care. Managers and perioperative personnel must carefully evaluate their on-call schedule to ensure the provision of safe medical care for their patients. Perioperative leaders at two hospitals partnered to create a safety guideline for on-call staffing practices, which includes zone guides for determining workload intensity. This guideline has served to help managers evaluate the general safety of their staffing plan and identify on-call practices that may need improvement or support in their areas of responsibility. Key recommendations from the guideline can help perioperative managers at other facilities establish clinical staffing plans and on-call practices that are safe and effective.     

On call: alert or unsafe? A report of the AORN on-call electronic task force

RESEARCH HAS LINKED health care providers' long work hours with patient care errors. Perioperative staff members often work extended hours because of long shifts and being on call.AORN's ON-CALL ELECTRONIC TASK FORCE conducted a survey of nurses to determine their work load, call scheduling, and experiences related to fatigue. Of the 1,013 respondents, 67.7% said they had experienced effects of sleep deprivation.A FOLLOW-UP SURVEY revealed that few call programs are in compliance with AORN's recommended practices. Compliant call programs are detailed for adaptation in other perioperative settings.     

Implementing AORN Recommended Practices for Environmental Cleaning

In recent years, researchers have developed an increasing awareness of the role of the environment in the development of health care–associated infections. AORN’s “Recommended practices for environmental cleaning” is an evidence-based document that provides specific guidance for cleaning processes, for the selection of appropriate cleaning equipment and supplies, and for ongoing education and quality improvement. This updated recommended practices document has an expanded focus on the need for health care personnel to work collaboratively to accomplish adequately thorough cleanliness in a culture of safety and mutual support. Perioperative nurses, as the primary advocates for patients while they are being cared for in the perioperative setting, should help ensure that a safe, clean environment is reestablished after each surgical procedure.     

AORN ergonomic tool 1: Lateral transfer of a patient from a stretcher to an OR bed

Moving patients can result in injuries to patients and staff members. Lateral patient transfers from a stretcher to an OR bed pose a high risk for musculoskeletal disorders, including lower back, shoulder, and neck injuries for perioperative personnel. AORN Ergonomic Tool 1: Lateral Transfer of a Patient from a Stretcher to an OR Bed helps perioperative staff members determine best practices for safe lateral patient transfers. Safe moving of the patient is determined by the starting and ending position required and the patient's weight. Current ergonomic safety concepts and scientific evidence regarding weight limits help to determine how many caregivers are needed to safely move patients and whether mechanical assistance is needed during lateral transfers.     

Implementing AORN Recommended Practices for a Safe Environment of Care,Part II

Construction in and around a working perioperative suite is a challenge beyond merely managing traffic patterns and maintaining the sterile field. The AORN “Recommended practices for a safe environment of care, part II” provides guidance on building design; movement of patients, personnel, supplies, and equipment; environmental controls; safety and security; and control of noise and distractions. Whether the OR suite evolves through construction, reconstruction, or remodeling, a multidisciplinary team of construction experts and health care professionals should create a functional plan and communicate at every stage of the project to maintain a safe environment and achieve a well-designed outcome. Emergency preparedness, a facility-wide security plan, and minimization of noise and distractions in the OR also help enhance the safety of the perioperative environment.     

Artificial nails... very real risks

The current social trend towards personal esthetics has come into conflict with safe perioperative care practices. While artificial nails have become very popular they pose a significant risk to patients. Surgical personnel who scrub while wearing artificial nails are putting their patients at higher risk for post-surgical wound infection. Artificial nails harbour microbes and cannot be cleaned as effectively as short, natural nails. We cannot rely on surgical gloves to always contain these hand organisms. There are reported cases where artificial nails have been the cause of post-surgical infections and even death. OR personnel who scrub should not wear artificial nails.     

Implementing AORN Recommended Practices for Laser Safety

Lasers used in the OR pose many risks to both patients and personnel. AORN's "Recommended practices for laser safety in perioperative practice settings" identifies the potential hazards associated with laser use, such as eye damage and fire- and smoke-related injuries. The practice recommendations are intended to be used as a guide for establishing best practices in the workplace and to give perioperative nurses strategies for implementing the recommended safety measures. A laser safety program should include measures to control access to laser use areas; protect staff members and patients from exposure to the laser beam; provide staff members and patients with the appropriate safety eyewear for use in the laser use area; and protect staff members and patients from surgical smoke, electrical, and fire hazards. Measures such as using a safety checklist or creating a laser cart can help perioperative nurses successfully incorporate the practice recommendations. Patient scenarios are included as examples of how to use the document in real-life situations.     

Moving and handling in the community: update on legislation and best practice

Over ￡ 400 million per year is spent on back injuries to NHS staff, and back injuries are the largest single cause of work-related sickness in the UK health sector. Moving and handling is an integral part of practice in a community setting, and community nurses face unique challenges to ensure the safety of and minimize risk to both patients and themselves. As with any care activity, moving and handling needs have to be assessed, planned for, implemented and evaluated. This article explains the legislation related to moving and handling, with particular application to community nurses. It focuses on the Health and Safety Executive's (2009) advice Working Alone: Health and Safety Guidance on the Risks of Lone Working, which reinforced that employers have responsibility for the health, safety and welfare of all their employees while they are at work. Employers have a duty to assess risks to lone workers and take steps to avoid or control these risks. Employees have the responsibility to take reasonable care of themselves and others. This article also explores the assessment of the specific risks nurses in the community are confronted with and provides advice on addressing and minimizing these risks at work, both in the client's home and in health-care facilities.     

Preventing multidrug-resistant gram-negative organisms in surgical patients

Multidrug-resistant gram-positive infections have consumed the attention of health care organizations as well as the media, but recently multidrug-resistant gram-negative organisms (MDR-GNOs) have become more and more prevalent. Limited treatment options are available for MDR-GNO infections; thus, prevention is key. Patients who are at high risk for developing infections must be identified, and specialized prevention interventions must be developed for their care. Surgical patients are one subset of patients at high risk for developing MDR-GNOs. Advanced practice nurses must support nurses and other health care personnel in preventing MDR-GNO infections. Education should include active surveillance, contact precautions, cohorting patients and staff members, unit closures, reinforced hand hygiene practices, and environmental cleaning tailored to the care of surgical patients in regard to their preoperative, intraoperative, and postoperative care.     

Implementing AORN Recommended Practices for Prevention of Transmissible Infections

Preventing infection in the perioperative setting is a critical element of patient and health care worker safety. This article reviews the recommendations in the AORN “Recommended practices for prevention of transmissible infections in the perioperative practice setting.” The recommended practices are intended to help perioperative nurses implement standard and transmission-based precautions (ie, contact, droplet, airborne), including use of personal protective equipment as well as interventions to prevent surgical site infections and exposure to bloodborne pathogens. Additional recommendations cover vaccination programs and how to manage personnel who require work restrictions. Hospital and ambulatory patient scenarios are included to help perioperative nurses apply the recommendations in daily practice.     

The healthcare marketplace in the next millennium and nurses' roles in infection prevention and control.

For the past several years, constant changes in the health care marketplace have been dominated by the demand to manage costs. This has resulted in declining numbers of hospitals, hospital beds, and occupancy rates, along with increasing severity of illness in the patients who are hospitalized. It has long been known that infection prevention and control activities reduce risks for morbidity and mortality in patients and caregivers. Infection risk reduction activities are integral to nursing care delivery in any health care setting; however, the increasing stresses on care providers and declining staff-to-patient ratios compromise these priorities. Nurses share responsibility for infection risk reduction with other health care personnel who all need to work together with infection control professionals (ICPs) to develop and use prevention and control strategies based on scientific evidence.     

Implementing AORN Recommended Practices for Sharps Safety

Prevention of percutaneous sharps injuries in perioperative settings remains a challenge. Occupational transmission of bloodborne pathogens, not only from patients to health care providers but also from health care providers to patients, is a significant concern. Legislation and position statements geared toward ensuring the safety of patients and health care workers have not resulted in significantly reduced sharps injuries in perioperative settings. Awareness and understanding of the types of percutaneous injuries that occur in perioperative settings is fundamental to developing an effective sharps injury prevention program. The AORN “Recommended practices for sharps safety” clearly delineates evidence-based recommendations for sharps injury prevention. Perioperative RNs can lead efforts to change practice for the safety of patients and perioperative team members by promoting the elimination of sharps hazards; the use of engineering, work practice, and administrative controls; and the proper use of personal protective equipment, including double gloving.     

The implementation of intentional rounding using participatory action research

‘Intentional'/‘hourly rounding’ is defined as regular checks of individual patients carried out by health professionals at set intervals rather than a response to a summons via a call bell. Intentional rounding places patients at the heart of the ward routine including the acknowledgement of patient preferences and in anticipation of their needs. The aim of this study was to implement intentional rounding using participatory action research to increase patient care, increase staff productivity and the satisfaction of care provision from both patients and staff. Outcomes of the study revealed a drop in call bell use, no observable threats to patient safety, nursing staff and patient satisfaction with care provision. However, any future studies should consider staff skill mix issues including the needs of newly graduated nursing staff as well as the cognitive status of patients when implementing intentional rounding on acute care wards.     

The Importance of Needlestick and Sharps Safety for Nurses and Staff in the Interventional Radiology Setting

Needlestick injuries continue to be one of the most serious health and safety threats in our health care workplaces. Because of the invasive nature and unique procedural circumstances of interventional radiology (e.g., dark environment, sterile drapes, etc.), nurses and radiologists are at a high risk of accidental needlestick and sharps injuries. As a natural result of these procedural circumstances, the focus of the staff is on the patient and his or her well-being, and it is likely not on the safety of the staff during or after the procedure, when the risk of injury is greatest. Despite the fact that the majority of US acute care facilities have now largely converted to the use of safety-engineered medical devices, after the first decade of the Needlestick Safety and Prevention Act of 2000, a large number of nurses and other personnel still remain at serious risk of injury. By combining proactive measures—such as training staff on the correct use of medical safety devices, establishing injury prevention teams, and evaluating all medical safety devices thoroughly—with reactive measures like maintaining an accurate injury log, nurses will be able to come to work with a lessened risk of needlestick and sharps injuries and be able to educate one another on how to make these types of injuries a “never event” in the health care setting.     

Infection control in the community: a pragmatic approach

Infection can have a detrimental and potentially life-threatening impact on the health and wellbeing of patients. Infection control and prevention is as important in the community as it is in an acute hospital. This article summarizes the key infection and prevention issues in community nursing. It offers a pragmatic approach as community settings may be challenging to both infection control and community healthcare professionals. Patient safety is the top priority, and ensuring that safe practices are followed to reduce the risk of infection regardless of healthcare setting is paramount. There are many external factors that may impede infection control practices when delivering care in a patient's own home, and this article sets out the factors that must be considered in order to manage the risk.     

“Managing Up” Can Improve Teamwork in the OR

Holding each team member accountable for following policies and behaving professionally in the work environment should be the responsibility of all perioperative personnel, not just the department manager. A culture in which employees “manage up” is one in which they communicate with each other in respectful ways and feel comfortable correcting each other when they see negative behaviors or inconsistencies in patient care delivery. Creating a culture in which employees feel empowered to manage up requires education, support of management, and staff member assertiveness. Ultimately, individual accountability and effective teamwork can help ensure patient safety.     

Implementing AORN Recommended Practices for Medication Safety

Medication errors in the perioperative setting can result in patient morbidity and mortality. The AORN “Recommended practices for medication safety” provide guidance to perioperative nurses in developing, implementing, and evaluating safe medication use practices. These practices include recognizing risk points in the medication use process, collaborating with pharmacy staff members, conducting preoperative assessments and postoperative evaluations (eg, medication reconciliation), and handling hazardous medications and pharmaceutical waste. Strategies for successful implementation of the recommended practices include promoting a basic understanding of the nurse's role in the medication use process and developing a medication management plan as well as policies and procedures that support medication safety and activities to measure compliance with safe practices.     

Implementing AORN recommended practices for electrosurgery

Technology is constantly changing, and it is important for perioperative nurses to stay current on new products and technologies in the perioperative setting. AORN's "Recommended practices for electrosurgery" addresses safety standards that all perioperative personnel should follow to minimize risks to both patients and staff members during the use of electrosurgical devices. Recommendations include how to select electrosurgical units and accessories for purchase, how to minimize the potential for patient and staff member injuries, what precautions to take during minimally invasive surgery, and how to avoid surgical smoke hazards. The recommendations also address education/competency, documentation, policies and procedures, and quality assurance/performance improvement. Perioperative nurses should consider the use of checklists and safety posters to remind staff members of the dangers of electrosurgery and the steps to take to minimize the risks for injury.     

Ambulance Diversion and Emergency Department Offload Delay: Resource Document for the National Association of EMS Physicians Position Statement

Abstract

The emergency medical services (EMS) system is a component of a larger health care safety net and a key component of an integrated emergency health care system. EMS systems, and their patients, are significantly impacted by emergency department (ED) crowding. While protocols designed to limit ambulance diversion may be effective at limiting time on divert status, without correcting overall hospital throughput these protocols may have a negative effect on ED crowding and the EMS system. Ambulance offload delay, the time it takes to transfer a patient to an ED stretcher and for the ED staff to assume the responsibility of the care of the patient, may have more impact on ambulance turnaround time than ambulance diversion. EMS administrators and medical directors should work with hospital administrators, ED staff, and ED administrators to improve the overall efficiency of the system, focusing on the time it takes to get ambulances back into service, and therefore must monitor and address both ambulance diversions and ambulance offload delay. This paper is the resource document for the National Association of EMS Physicians position statement on ambulance diversion and ED offload time.