Meeting OR Standards in the Evolving Interventional Procedure Room and Cardiac Catheterization Laboratory

Interventional radiological suites meet the definition of interventional perioperative centers based on the Association of periOperative Registered Nurses (AORNs). The demands for meeting the AORN perioperative standards and recommendations for practice impact every radiological interventional suite in the nation. The evolution of the procedure room to interventional perioperative suite requires physicians, staff, and administrators to embrace this changing arena of patient care to meet the recognized and expected level of staff knowledge and skills, staffing levels, and patient safety. Evaluation of staffing needs and mix determines the orientation needs to be applied to all present staff and new staff that will work in these areas. Interventional perioperative centers are found in (1) angiographic suites, (2) cardiac catheterization laboratories, (3) computed tomography procedural areas, (4) ultrasonography procedural areas, and (5) magnetic resonance procedural areas as well as others. Staff, managers, and administrators are challenged to meet the interventional perioperative standards and recommendations for patient care delivery through comprehensive orientation and skills validation.     

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.     

Improving Associate Degree Nursing Students' Perioperative Clinical Observation Experiences

For associate degree nursing students at Eastern Kentucky University, Richmond, the perioperative nursing clinical experience typically included a one-day observation of a surgical procedure, with students entering the OR suite after the surgery started and having to leave before the surgery was completed. An associate professor of nursing and a perioperative staff education coordinator partnered to address this lack of a complete perioperative experience for students and offer a more formal OR experience. The clinical experience was altered to provide relevant didactic perioperative nursing content in class before the clinical day, a group orientation, and observation in the preoperative, intraoperative, and postoperative areas. Reactions of students and perioperative staff members to these changes were positive.     

Family presence during cardiopulmonary resuscitation and invasive procedures: practices of critical care and emergency nurses.

BACKGROUND: Increasingly, patients' families are remaining with them during cardiopulmonary resuscitation and invasive procedures, but this practice remains controversial and little is known about the practices of critical care and emergency nurses related to family presence. OBJECTIVE: To identify the policies, preferences, and practices of critical care and emergency nurses for having patients' families present during resuscitation and invasive procedures. METHODS: A 30-item survey was mailed to a random sample of 1500 members of the American Association of Critical-Care Nurses and 1500 members of the Emergency Nurses Association. RESULTS: Among the 984 respondents, 5% worked on units with written policies allowing family presence during both resuscitation and invasive procedures and 45% and 51%, respectively, worked on units that allowed it without written policies during resuscitation or during invasive procedures. Some respondents preferred written policies allowing family presence (37% for resuscitation, 35% for invasive procedures), whereas others preferred unwritten policies allowing it (39% for resuscitation, 41% for invasive procedures), Many respondents had taken family members to the bedside (36% for resuscitation, 44% for invasive procedure) or would do so in the future (21% for resuscitation, 18% for invasive procedures), and family members often asked to be present (31% for resuscitation, 61% for invasive procedures). CONCLUSIONS: Nearly all respondents have no written policies for family presence yet most have done (or would do) it, prefer it be allowed, and are confronted with requests from family members to be present. Written policies or guidelines for family presence during resuscitation and invasive procedures are recommended.     

Surveyors scrutinize patient rights compliance

EDs have several areas where they can fail to comply with patient rights standards. Include pain assessment on the delayed nurse report, and reassess for pain. A patient rights statement must be given to all patients, whether they are admitted. Have admission criteria. They may be included in your scope of service document. Ensure your staff members know who obtains consent for emergency procedures such as catheterization. Blanket policies can address cases that don't have consent. Give patients information on advance directives, and find out if the patient is a no code.     

Family presence during cardiopulmonary resuscitation and invasive procedures: practices of critical care and emergency nurses.

BACKGROUND: Increasingly, patients' families are remaining with them during cardiopulmonary resuscitation and invasive procedures, but this practice remains controversial and little is known about the practices of critical care and emergency nurses related to family presence. OBJECTIVE: To identify the policies, preferences, and practices of critical care and emergency nurses for having patients' families present during resuscitation and invasive procedures. METHODS: A 30-item survey was mailed to a random sample of 1500 members of the American Association Of Critical-Care Nurses and 1500 members of the Emergency Nurses Association. RESULTS: Among the 984 respondents, 5% worked on units with written policies allowing family presence during both resuscitation and invasive procedures and 45% and 51%, respectively, worked on units that allowed it without written policies during resuscitation or during invasive procedures. Some respondents preferred written policies allowing family presence (37% for resuscitation, 35% for invasive procedures), whereas others preferred unwritten policies allowing it (39% for resuscitation, 41% for invasive procedures). Many respondents had taken family members to the bedside (36% for resuscitation, 44% for invasive procedures) or would do so in the future (21% for resuscitation, 18% for invasive procedures), and family members often asked to be present (31% for resuscitation, 61% for invasive procedures). CONCLUSIONS: Nearly all respondents have no written policies for family presence yet most have done (or would do) it, prefer it be allowed, and are confronted with requests from family members to be present. Written policies or guidelines for family presence during resuscitation and invasive procedures are recommended.     

Surgical fires--learn not to burn

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CONSEQUENCES OF A SURGICAL FIRE can be deadly. Fires can occur in any setting where invasive procedures are performed. The basic principle to remember is that people start most fires, and people can prevent them.

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FIRE SAFETY TRAINING IS ESSENTIAL so that staff members recognize the elements of the fire triangle and how these elements come together every day in their practice.

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FIRE DRILLS ARE AN IMPORTANT ASPECT of this training. Education also must include review of written policies and procedures on fire safety and prevention. Staff members must learn how to respond to and fight fires on or in the patient. Fire safety and prevention must be a priority for managers and staff members. AORN J 80 (July 2004) 24-36.

     

Adherence to a Medication Safety Protocol: Current Practice for Labeling Medications and Solutions on the Sterile Field

Medication labeling omissions in the OR and the adverse events that result from them remain a challenge in health care facilities. Standardization of protocols based on guidance from the Joint Commission, AORN, the Institute for Safe Medication Practices, and other organizations is important to ensure that patients do not mistakenly receive the wrong medication. A clinical nurse specialist and a perioperative education coordinator at the Cleveland Clinic, Cleveland, Ohio, undertook a direct observation quality improvement project to assess the adherence of 21 nurses and 19 surgical technologists to a revised medication and solution labeling protocol implemented in February 2008. Results showed that overall, 70% of staff members adhered to the medication and solution labeling protocol but adherence varied among specialty areas. There was increased adherence to the protocol by junior staff members compared with more experienced staff members.     

Developing best practice in arterial sheath removal for registered nurses

The purpose of this study was to evaluate the consistency of nursing practice in the discontinuation of sheaths on designating nursing units. The sample population was randomly selected based on interventional cardiac procedures where sheaths remained in place after leaving the catheterization lab. The data collected demonstrated inconsistencies in current practice of sheath removal and specific device preference by the nursing staff. Changes to the policies and physician order set were revised to best practice standards. Annual competency training was developed for the staff as was written and visual education. The changes that were implemented throughout the project provided for a positive change in patient outcome, revenue savings, and patient satisfaction.     

Getting ready for JCAHO--just meeting the standards or really improving pain management

The Joint Commission on Accreditation of Healthcare Organizations' revised standards include new standards regarding pain assessment and management. These standards need to be incorporated into patterns of daily practice in healthcare institutions. Documentation systems, policies and procedures, standards of practice, staff education, and quality-improvement programs will need to reflect integration of these standards. Using evidence based consensus statements, guidelines, and other resources on pain management along with a step-wise implementation process will not only enhance success for incorporating the revised standards but also will promote achievement of another goal-optimal assessment and management of pain experienced by other patients with cancer.     

Conversion of school nurse policy and procedure manual to electronic format.

Policy and procedure manuals are essential to establishing standards of practice and ensuring quality of care to students and families. The Olathe District Schools (Kansas) Technology Department created the Virtual File Cabinet to provide online access to employee policies, school board policies, forms, and other documents. A task force of school nurses was formed to convert the nursing department's policies, procedures, protocols, and forms from hard copy to electronic format and make them available on the district's Virtual File Cabinet. Having the policy and procedure manuals in electronic format allows for quick access and ease in updating information, thereby guaranteeing the school nurses have access to the most current information. Cost savings were realized by reducing the amount of paper and staff time needed to copy, collate, and assemble materials.     

Surviving OR computerization

In 2007, a steering committee at West Virginia University Hospitals, Morgantown, began a three-year, accelerated design, computer implementation project to institute an automated perioperative record. The process included budgeting, selecting a vendor, designing and building the system, educating perioperative staff members, implementing the system, and re-evaluating the system for upgrades. Important steps in designing and building the system included mapping patient care and documentation processes, assessing software and hardware needs, and creating a new preference card system and surgical scheduling system. Staff members were educated to use the new computer applications via contests, inservice programs, hands-on learning modules, and a preimplementation rehearsal. Role-based security ensures that staff members are granted access to the computer applications they need to perform the work defined by their scope of practice. Planning ensures that the computer system will be maintained and enhanced over time.     

Suicide and self-harm in inpatient psychiatric units: a national survey of observation policies

There is little empirical literature on observation as a psychiatric nursing procedure to prevent patients from harming themselves or others. National guidelines for this practice do not exist, with a consequence that local policies might be variable in content and quality. This paper reports a national survey of observation policies and usage based upon a stratified random sample of 27 psychiatric inpatient service providers in England and Wales. Extreme variation in terminology and practice was encountered. The terminological confusion is likely to reduce nurses' clarity about their responsibilities and increase risks to patients. Further variation exists from place to place as to whether, and to what extent, student nurses and family members should be entrusted with the responsibility to observe patients. More than one in 10 services of the sample still have no written observation policy, and four in 10 have no clinical recording system of the procedure in place. Nurses commonly amend the procedure and terminology on an ad hoc basis. The results of this survey confirm that the Department of Health should set national standards for the policies and procedures for patient observation and that as an interim step practice guidance should be issued to all nurses (and other mental health workers) involved in this procedure.     

Robotic-assisted surgery and the need for standardized pathways and clinical guidelines

Robotic surgical techniques are revolutionizing the way surgery is performed in an effort to improve patient outcomes. Although current literature is limited, studies have shown that patients who undergo robotic-assisted procedures experience reduced surgical time, scarring, blood loss, pain, infection rates, and lengths of stay compared with patients who undergo open or laparoscopic procedures. Currently, start-up costs for robotic systems are high and include the major equipment purchase as well as supplemental equipment purchases and staff member training. There is a need to develop standardized perioperative procedures or clinical guidelines that define optimal application of robotic-assisted surgery to ensure a standard of care that is consistent across procedures and operators. Implementing a clinical pathway or guideline that is guided by evidence-based practice will involve change. Lewin's 1947 basic change theory and the Marker umbrella model may be of use to help facilitate change.     

AORN guidance statement: safe on-call practices in perioperative practice settings. Association of periOperative Registered Nurses

Call staffing and the associated long work hours can be challenging for both perioperative staff members and the health care organization. A change in culture is needed to recognize exhaustion as an unacceptable risk to patients and perioperative personnel safety. Perioperative health care providers have a personal responsibility to arrive at work fully rested. Health care organizations have a responsibility to create work and call schedules that consider the effect of long work hours on patient safety as well as perioperative staff members' welfare. The development of standardized safe work hours and call practices should reflect current recommendations emerging from authoritative sources, legislation, and empirical data. Prolonged work periods without adequate rest may contribute to diminished performance by perioperative personnel, placing both patients and workers at risk. This guidance statement may assist managers and clinicians in developing policies and procedures for safe call practices.     

AORN guidance statement: creating a patient safety culture

AORN believes all health care organizations must strive to create a culture of safety. Such a culture will provide an atmosphere where all members of the perioperative team can openly discuss errors, process improvements, or system issues without fear of reprisal. A culture of safety places an emphasis on flexibility and learning as a means of improving safety and reducing errors. Characteristics of a culture of safety include the following: communication is open and honest; the emphasis is on the team rather than the individual; standards and practices are developed in a multidisciplinary framework; staff members are helpful and supportive of each other; staff members trust each other; surgical team members have a friendly, open relationship emphasizing credibility and attentiveness; the environment is resilient, encourages creativity, and is patient outcomes-driven; the focus is on work flow and process; and these attributes are supported by an informed culture that learns from incidents and near misses. A commitment to safety must be articulated at all levels of the organization. Safety must be valued as the top priority, even at the expense of efficiency. Health care organizations must allocate an appropriate amount of resources and provide the necessary incentives or rewards to promote a robust patient safety culture. AORN recognizes that most patient safety initiatives will fail in the absence of a viable safety culture.     

Tracking medical devices to ensure patient safety

Registered nurses in perioperative settings and managers of perioperative departments must work together to implement policies and procedures to ensure compliance with these very important federal regulations. If the information is not recorded in the proper manner and shared with the manufacturer, patients' safety is at risk. Without the ability to contact physicians and patients, manufacturers cannot alert individuals appropriately if problems arise with a certain device. Tracking devices in the correct manner ensures that patients can be notified expediently. Nurses and managers should examine their current practices to ensure that they are consistent with federal regulations. A regular assessment should be conducted to ensure that tracking forms are completed in an accurate, timely manner, that permission to release a patient's social security number is obtained, and that the hospital is compliant with the FDA's most up-to-date list of devices that must be tracked. All perioperative staff members must receive education about the tracking process in their particular institution and receive updates when the process or FDA regulations change. Maintain patient safety by ensuring that the medical device tracking process is followed accurately and meets federal regulations.     

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.     

AORN guidance statement: sharps injury prevention in the perioperative setting

Occupational exposure to bloodborne pathogens via percutaneous injuries is one of the most serious dangers perioperative team members face on a daily basis. The risk of sustaining a percutaneous injury can be decreased through employee education, clear communication, device engineering, and focused work practice controls. Risk reduction strategies should include specific practices aimed at reducing the unique risks of percutaneous injuries encountered in the perioperative environment. AORN recognizes the various settings in which perioperative RNs practice, and the suggested risk reduction strategies in this guidance statement are intended to be adaptable to any setting where surgical or other invasive procedures are performed.     

探讨5例布-加氏综合症介入围手术期护理重点

目的：探讨布-加氏综合症介入围手术期的护理重点,以保证介入治疗护理的有效性和安全性。方法：对5例布-加氏综合症患者介入围手术期实施重点护理,如：饮食护理,对患者、家属心理支持,准确评估病情,有效控制腹水、出血等并发症及防治复发。结果：5例布-加氏综合症介入术后2-3 d腹壁静脉及双下肢静脉曲张基本消失,X片显示支架位置正常,扩张良好;进食及生命体征正常,无心累,双下肢水肿减退,无并发症发生。住院时间10-13 d,患者满意。结论：通过对布-加氏综合症介入围手术期实施重点护理,提高了护理质量,防治了并发症,保证了介入治疗效果。