Guidelines in Practice: A Safe Environment of Care

Creating a safe environment for performing surgical procedures is essential to achieve successful patient outcomes and protect the perioperative personnel who are providing care. Numerous factors challenge the provision of a safe environment of care and create a complex setting for perioperative nurses to manage. The updated AORN "Guideline for a safe environment of care" provides perioperative nurses with recommendations for establishing a safe environment for both patients and personnel. This article provides an overview of the guideline and discusses recommendations for implementing fire safety protocols, using warming cabinets, and creating a latex-safe environment. It also includes a scenario describing the care of a patient with an unidentified latex allergy who is undergoing a laparoscopic sleeve gastrectomy and hiatal hernia repair. Perioperative nurses should review the guideline in its entirety and implement recommendations as applicable in operative and other procedural settings.

A qualitative study of nurse-perceived barriers to body temperature management in postoperative patients

Although evidence-based practices exist for preventing hypothermia in patients during surgery, few studies have focused on this concern in postoperative patients. The aim of this qualitative study was to explore the most challenging issues experienced by surgical ward nurses while managing the body temperature of adult surgical patients. To address this research gap, this study used a qualitative descriptive design to document barriers to body temperature management as reported by a sample of 16 perioperative nurses. The semi-structured, face-to-face interviews were digitally recorded, transcribed verbatim and analysed using inductive content analysis. The main barriers fell into three categories: professional nursing ability limitations, unfavourable working conditions and management of human resources. The eight subcategories were disadvantageous professional views, professional knowledge limitations, low motivation to provide nursing care, non-standard treatment environment, inadequate equipment and care protocols, heavy nursing care loads, inadequate staff training and ineffective staff supervision. These findings highlighted the importance of adequate resources, proper education and evidence-based care protocols in the effective delivery of body temperature management to postoperative patients.

A Practical Guide to Performance Improvement: Tools and Tips to Sustain and Control Project Improvements

This article discusses some of the tools and tips to sustain performance improvement (PI) and explores some of the reasons why PI projects may fail. Although some PI projects seem simple and easy to implement, PI team members sometimes find it difficult to keep momentum going, maintain gains, and sustain the changes when the project is nearing completion and afterward. Team member and leader discipline, including use of multidisciplinary communication and standard work processes, can facilitate ongoing improvement. Communication may include visual displays of information and routine huddles. After reviewing this article, the reader should have a better understanding of sustaining change and promoting continuous PI. This is the fifth article of a six-part series about PI.

A Phenomenographic Approach to Understanding the Expertise of Perioperative Nurses

Understanding the ways that perioperative nurses view the acquisition of expertise may provide foundational information for perioperative nurse educators. Our study aimed to evaluate specific types of expertise exhibited by experienced perioperative nurses and identify how nurses perceived these areas of expertise. We interviewed 20 perioperative nurses working in a university hospital in Korea. We extracted six themes regarding perioperative nursing expertise: sticking to principles, using available resources in complex situations, paying close attention to details, seeing the whole picture, prioritizing actions according to patients' conditions, and organizing a team to maximize efficiency. These findings may help perioperative educators develop practical educational strategies for novice perioperative nurses by providing a common language regarding the areas of expertise exhibited by experienced perioperative nurses.

The Effect of Selected Risk Factors on Perioperative Pressure Injury Development

Patients undergoing operative and other invasive procedures are at high risk for developing pressure injuries. This study aimed to determine the incidence of perioperative pressure injuries in patients who underwent procedures lasting two hours or more in Turkey and the risk factors that affect the development of pressure injuries. Data were collected during the perioperative period. The incidence of perioperative pressure injuries was 40.4%. The results of univariate logistic regression analysis showed that intraoperative vasopressor use, skin turgor, and diastolic blood pressure less than or equal to 60 mm Hg were significantly related to the development of pressure injuries. There was no significant difference between patients who developed pressure injuries and patients who did not when comparing their preoperative Braden Scale scores. Perioperative nurses should assess each patient for pressure injury risk and perform interventions to prevent pressure injuries during each stage of the patient's perioperative course.

A Qualitative Exploratory Study of Norwegian OR Nurses' Patient Positioning Priorities

The purpose of patient positioning is to provide optimal surgical site exposure for surgical team members and prevent negative patient outcomes. This study explores perioperative nurses' experiences when positioning patients for surgery. We collected data using focus group interviews of 17 OR nurses in Norway and used qualitative content analysis to analyze the data. The study findings showed that perioperative nurses emphasized their most important priorities as concepts that can be categorized into three themes: leading and coordinating patient positioning, ensuring patient safety, and promoting efficient use of OR nurses' expertise. The study findings also identify a need to define formal responsibilities in patient positioning and processes for determining positioning outcomes. Perioperative leaders should verify OR nurse competence for patient positioning to help ensure continuity and safety in complex patient pathways.

Good Catch Campaign: Improving the Perioperative Culture of Safety

Although health care workers feel pressure to reduce adverse events in the perioperative department, a lack of education, communication, and leadership can prevent hospital personnel from reporting good catches. The purpose of this evidence-based quality improvement project was to improve the culture of safety in our perioperative department by implementing the Good Catch Campaign. An interprofessional team led staff member education after implementing a standardized electronic reporting system and debriefing process to occur after good catches. Staff members reported 391 good catches from all perioperative areas during the six-month postimplementation period. Staff members completed the Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture before and six months after implementation; scores improved in five areas: communication openness, feedback and communication about error, frequency of event reporting, nonpunitive response to error, and organizational learning and continuous improvement. The campaign was a successful strategy for improving perioperative patient safety.

Guideline Implementation: Safe Patient Handling and Movement: 1.8 www.aornjournal.org/content/cme

Physical stressors that occur with patient and equipment handling in the OR (eg, moving or lifting patients, carrying heavy instrument sets, prolonged standing) can contribute to musculoskeletal disorders for perioperative personnel. In addition to increasing patient safety, safe patient handling and movement (SPHM) programs have been shown to reduce the risk and severity of injuries, workers' compensation costs, and personnel fatigue and to increase health care workers' morale and quality of life. The AORN "Guideline for safe patient handling and movement" provides guidance for implementing an SPHM program. This article discusses key takeaways from the guideline, including forming an interdisciplinary team to oversee the SPHM program, selecting safe patient handling technologies and equipment, and assessing the unique needs of each patient to develop an individualized plan for SPHM. Perioperative RNs should review the complete guideline for additional information and for guidance when writing and updating policies and procedures.

Guideline Implementation: Team Communication: 1.8 www.aornjournal.org/content/cme

The perioperative environment is fast paced and complex. Competing responsibilities, noise and distractions, and reluctance of team members to speak up when they are aware of a potential patient safety issue are all barriers to effective communication in the perioperative setting. Communication breakdowns among health care providers can lead to medical errors and patient harm. Accurate and complete communication about the patient and the patient's care can contribute to improved efficiency, better patient outcomes, and fewer adverse events. The new AORN "Guideline for team communication" provides guidance on using standardized processes and tools to improve the quality of team communication. The key points address hand overs between phases of perioperative care; a briefing to share the surgical plan; a time out to verify the correct patient, procedure, site, and side; and a debriefing to discuss what was learned and how to improve. Perioperative RNs should review the complete guideline for additional information and for guidance when writing and updating policies and procedures.

Guideline Implementation: Sterile Technique

Establishing and maintaining a sterile field to help prevent surgical site infections requires specific knowledge and skills and is among the most important responsibilities of the perioperative RN. Perioperative RNs should remain vigilant in monitoring the sterile field, communicate when a break in sterile technique occurs, and collaborate with other surgical team members to correct the break in technique. The AORN "Guideline for sterile technique" provides guidance to perioperative personnel on the principles and processes of sterile technique. This article elaborates on key takeaways from the guideline, including using sterile technique when donning sterile gowns and gloves, delivering sterile items to the sterile field, using drapes to establish a sterile field, and maintaining the sterile field. Perioperative RNs should review the complete guideline for additional information and for guidance when writing and updating policies and procedures.

Creating Safety II in the operating theatre: The Durable Dozen!

The aviation industry calls the most frequently recurring factors that lead to incidents ‘the Dirty Dozen.’ The ‘Dirty Dozen’ includes, for example, stress, distractions and interruptions, team norms etc. The article adapts the concept of the Dirty Dozen from aviation to explore resilience in operating theatres. Taking a Safety II perspective, the article introduces the ‘Durable Dozen’: 12 regulatory, organisational, team and individual behaviours that enable theatre teams to resolve safety threats.

Peripheral Nerve Blocks and Immediate Postoperative Recovery: A Single-Institution Survey of Perianesthesia Nurses' Preferences and Opinions

PURPOSE

To ascertain the preferences of perianesthesia nurses regarding peripheral nerve blocks (PNBs) and their impact on patient recovery after total joint replacement (TJR).

DESIGN

Survey of perianesthesia nurses at a single medical center.

METHODS

Fifty-nine perianesthesia nurses completed a 23-question survey on PNBs for TJR.

FINDINGS

Most agreed PNBs improved patients' pain after knee, hip, and shoulder TJR (35 [92.1%], 35 [92.1%], and 34 [91.9%], respectively). Most felt lower extremity PNBs increased risk of falling (26 [70.3%]), whereas 7 of 35 (20.0%) felt patients fell more after spinal anesthesia than after general anesthesia. Respondents preferred a block to opioid-based analgesia if they were to have lower extremity TJR or total shoulder replacement (100% [30/30 and 33/33]).

CONCLUSIONS

The perianesthesia nurses surveyed felt PNBs improved pain control and patient recovery despite a perceived risk of falling for lower extremity TJR, and they preferred PNB when considering TJR surgery for themselves.

The Role of Electronic Documentation in Ambulatory Surgery Centers

Ambulatory surgery centers (ASCs) have been slow to adopt electronic documentation (ie, electronic health records [EHRs]) compared with other types of health care organizations. However, recent developments, including documentation requirement changes, storage and security needs, and competition for physicians and perioperative personnel, have spurred greater interest in this technology. Electronic documentation systems can help meet the clinical, financial, operational, and regulatory needs of ASCs. Perioperative nurses should be involved in ensuring their facilities choose electronic documentation systems that meet objectives for all areas of their ASCs' operations. This article examines the benefits of EHRs and their use in ASCs today and in recent history, explains significant factors that encourage the adoption of electronic documentation by ASCs, and provides guidance on how to invest in an EHR system more effectively.

Perioperative Management of the Cardiac Transplant Recipient

Management of the cardiac transplant recipient includes careful titration of inotropes and vasopressors. Recipient pulmonary hypertension and ventilatory status must be optimized to prevent allograft right ventricular failure. Vasoplegia, coagulopathy, arrhythmias, and renal dysfunction also require careful management to achieve an optimal outcome. Primary graft dysfunction (PGD) can be an ominous problem after cardiac transplantation. Although mild degrees of PGD may be managed medically, mechanical circulatory support with extracorporeal membrane oxygenation or temporary ventricular assist devices may be required. Retransplantation may be necessary in some cases.

Improving Performance Measures With Perioperative Analytics

Perioperative nurses and leadership teams across the country strive to improve outcomes, increase operational efficiency, and achieve performance improvement on key measures in the perioperative department. In today's changing health care environment, which involves increasing pressure to do more with less, it is essential for perioperative leaders to understand analytics and how to use analytics to identify, plan, and implement improvement initiatives that will provide the greatest value. This article examines key performance indicators in the OR, barriers to change, and the strategies and processes that perioperative leaders can use to achieve efficiency and performance improvement goals. It also provides an example of a tactical approach to one of the OR's greatest challenges: measuring and improving block utilization.

Blood Transfusion Vital Sign Frequency: What Does the Evidence Say?

Blood transfusion vital sign protocols do not have sufficient evi- dence to mandate surveillance frequency. The purpose of this study was to examine the relationship of vital sign changes to reaction times in an effort to determine best practice for monitoring patients receiving blood products.

Enhanced Recovery in Orthopedics: A Prospective Audit of an Enhanced Recovery Program for Patients Undergoing Hip or Knee Arthroplasty

Hip and knee arthroplasty are common 'surgical procedures. Enhanced recovery programs help reduce length of stay with good patient outcomes and satisfaction. An audit is described showing improved pain management, reduced nausea and vomiting, and quicker recovery through an interprofessional approach.

Complementary and Alternative Medicines for the Postoperative Patient

The Medical-Surgical Nursing Certification Board (MSNCB) is a professional organization whose mission is to validate excellence in medical-surgical nursing. MSNCB administers the Certified Medical-Surgical Registered Nurse (CMSRN®) and Certified in Care Coordination and Transition Management (CCCTM) certification programs because certification is the recognized path for registered nurses to build and demonstrate commitment, confidence, and credibility. Certification provides an added credential beyond licensure. It demonstrates, by examination, that the registered nurse adheres to specialized nursing standards and has acquired a core body of specialized knowledge in his or her practice or specialty. The topic of this article is part of the comprehensive examination given by MSNCB. The following scenario and questions offer an example that potential certificants may use to test their knowledge. For more information about MSNCB, visit www.msncb.org.

The perfect surgical assistant: Calm, confident, competent and courageous

Poor surgical assistance has been identified as a major stressor in surgeons, making the ability to provide effective surgical assistance an important skill which will have a lifelong impact on the surgical patient. Knowledge and technical ability are clearly important, but strong personal qualities are more so in the long run. This applies to all who provide assistance either as a surgical first assistant or surgical care practitioner. These skills and attributes are needed to provide a safe service that meets the expectations of both the professional regulatory authorities and surgical Royal Colleges. Advice is given in this article as to how non-medical practitioners may acquire these skills.

Just a routine operation: a critical discussion

This article has summarised a critical discussion of the human factors that contributed to the death of a patient from a failure to respond appropriately to a 'can't intubate, can't ventilate' scenario. The contributory factors included the clinical team's inability to communicate, prioritise tasks and demonstrate effective leadership and assertive followership. The film Just a routine operation has now been in circulation for several years. When a system is designed and introduced with the intention of making a change to clinical practice, it can quickly become just another component of an organisation's architecture and complacency around its use can develop. This article has been written specifically for perioperative practitioners to renew the debate around the human factors that contribute to patient harm. By critically discussing Just a routine operation and attempting to review why the incident occurred, this article has attempted to emphasise that some of the conditions and behaviours that contributed to the death of Elaine Bromiley may be latent within our organisations and teams, and may continue to contribute to failures that affect patient safety.

A Review of the CDC Recommendations for Prevention of HAIs in Outpatient Settings

According to the Centers for Disease Control and Prevention (CDC), most health care-associated infections (HAIs) are caused by contamination from the hands of health care providers or patients, contamination from the environment, and contamination from the patient's own skin. To mitigate common sources of infection transmission, frontline health care providers must be compliant with basic infection-prevention interventions, including hand hygiene, environmental cleaning and disinfection, safe injection practices, and designation of a trained health care professional to be responsible for the infection prevention and control program. Integration of CDC recommendations should incorporate a bundled approach to these interventions and should be part of a comprehensive approach to infection prevention and control. Effective infection-prevention practices in outpatient settings are critical for reducing the risk of infection transmission, improving patient safety and patient outcomes, and reducing costs associated with health care delivery.

Management of 'Do Not Attempt Cardiopulmonary Resuscitation' (DNACPR) decisions in the perioperative period

It is increasingly common for patients to be scheduled for anaesthesia and surgery with a 'Do Not Attempt Cardiopulmonary Resuscitation' (DNACPR) decision in place. Updated guidelines for the implementation and management of DNACPR decisions were published jointly by the British Medical Association (BMA), the Resuscitation Council (UK) and the Royal College of Nursing (RCN) in 2014 (BMA, RC(UK), RCN 2014). The Association of Anaesthetists of Great Britain and Ireland (AAGBI) published specific guidelines in 2009 to guide the perioperative management of such patients (AAGBI 2009). In this article, we explain these guidelines with a focus on how DNACPR decisions are made and how they can be modified in order to permit appropriate surgery to take place.

Recognizing Signs of Prescription Drug Abuse and Addiction, Part I

Prescription drug abuse/misuse is increasing. Nonmedical use of prescription medications, especially opioid analgesics, now is considered an epidemic in the United States. Medical-surgical nurses are in a strategic position to help address substance abuse problems in patients.

Surgical care practitioners: regulation and revalidation: a discussion

The regulation of healthcare professionals is far from new. It continues to evolve, responsive to changes in the professional workforce and the needs of society.

Back to basics: environmental cleaning

The need for a clean perioperative environment is a basic principle for all perioperative team members. Recent evidence suggests that the environment plays a role in the occurrence of health care-associated infections (HAIs), including surgical site infections. Frequently cleaning high-touch surfaces helps prevent the spread of infections, and routinely cleaning and disinfecting the patient's environment can reduce the level and frequency of contamination and the risk of HAIs. Perioperative personnel should use a bundled approach to perform a standardized cleaning routine and implement a successful monitoring program.