Concepts of Peri-operative nursing / Organization of the OR Team

Sylvia Wong

Department Operations Manager

Operating Theatre Services ,

Queen Mary Hospital

Chairperson (2012 – 2014)

Association of Hong Kong Operating Room Nurses

History of Perioperative Nursing •  First introduced at 1873 •  Identified as nursing specialty by 1889 •  Importance of asepsis and sterilization of instruments and

supplies for invasive procedures

Scrub Person 1.  Wash hands aseptically 2.  Donned a sterile gown and

gloves 3.  Assist during surgery •  organizing instrument; and •  passing them to the surgeon

Circulator 1.  Outside the sterile surgical field 2.  Managed the OR 3.  Maintain contact with those

outside the OR

Perioperative Nusing

•  Specialty that works with patients who are having operative or other invasive procedures.

•  Work closely with surgeons, anaesthetists and / other supporting staff

•  Perform preoperative, intraoperative, and postoperative care primarily in operating theatres

Wikipedia, last read at 1 Oct 2012

Perioperative Nursing Roles

Circulator •  Provide nursing care during surgery •  Observes for breaches in surgical asepsis •  Coordinate the needs of the surgical team •  Manage the environment during surgery

Perioperative Nursing Roles

Scrub •  Works directly with the surgeon within the

sterile field •  Pass instruments, sponges and other

items needed during the procedure.

Perioperative Nursing Roles

Perianesthesia •  Providing nursing care to patients

undergoing or recovering from anaesthesia – Preoperative assessment – Post anaesthesia care unit – Ambulatory care – Pain management

Perioperative Nursing Roles (HAHO)

Nursing practices that address the needs of patients, their families, and significant others that are required during the pre-operative, intraoperative and postoperative phases.

Philosophy of Perioperative Care

•  It is a dynamic, cognitive, behavioral and technical process directed towards provision of quality patient care before, during and after surgical intervention.

•  Interactive process in building trust with patients and significant others

•  Teamwork among various health care teams to provide quality service

Philosophy of Perioperative Care

•  Distinct functions for: – Provision of safe physical environment – Protect patients from high-risk events –  Initiates continuous awareness of the dignity

of persons – Attend to patients’ physical, psychological,

spiritual and social needs.

Goal of Perioperative Nursing Practice

Ensure quality patient care

To achieve patient’s optimal level of wellness and functional status before, during and after surgical intervention.

Framework of Perioperative Nursing : The TRUST Model

Teamwork

Risk Management

Utilization

Specialty Competency

Target outcome

Teamwork

Teamwork implies both intra-departmental and interdepartmental

1.  Coordinate comprehensive care

2.  Works in collaboration with other health professionals to meet client’s need

Teamwork

Risk Management

Risk Management involves issues that have impact on the safety of client and staff

Risk Management

•  Report and investigate incidents so that lessons can be learned – Advanced Incident Reporting System (AIRS) – Near miss

•  Mistakes and error should not be replicated

•  Ensure concerned parties are “risk aware” and active in managing risks

Adverse Events

•  Patient focused –  Intrinsic to the patient with unknown

cause(s) – Reactive, manage instantly to ensure

patient survival •  Process or system error

– Extrinsic to the patient and focused on the organisation

Adverse Events

1.  Aspiration 2.  Haemorrhage 3.  Reaction to blood

transfusion 4.  Cardiac arrest 5.  Respiratory arrest

1.  Allergies (drug/ latex) 2.  Mislaid swab or

instrument 3.  Faulty medical

equipment 4.  Wrong site surgery 5.  Wound infection

Clinical Risks

•  Pressure Ulcers •  Deep Vein Thrombosis •  Hypothermia •  Wound infection •  Diathermy burn

Teamwork

Risk Management

Specialty Competency

Specialty Competency = Excellence of Client Care

Specialty Competency

•  Obtain knowledge and skills to fulfill the functions/activities of a perioperative nurse

•  Individualized assessment and care •  Initiate appropriate nursing interventions based

on the interpretation from the assessment (reference to departmental guidelines or standard of care)

•  Evaluate nursing interventions •  Documentation

Teamwork

U = Utilization of evidence-based nursing knowledge

Risk Management

Specialty Competency

Target Outcome

U U

U

Teamwork

Target Outcome includes both Service and Client Outcome

Risk Management

Specialty Competency

Target Outcome

U U

U

What do our patients want? •  Friendliness, courtesy, thoroughness, intelligence,

sense of humor and trustworthiness •  Pain management •  Temperature maintenance •  Setting up the surgical position •  Performing the anaesthesia and operation •  Skills in the recovery room •  Adequacy of information: involve in decision making

concerning their treatment, consider their personal views and opinions

•  Avoid disturbance of colleagues who are devoted to their own conversations during care

Organization of the OR Team •  Surgeon •  Anaesthetist •  Nurse

–  Anaesthetic –  Scrub –  Circulate –  Recovery

•  Supporting Staff –  Scrub technician (Theatre Assistant) –  Anaesthetic Assistant –  Internal cleansing –  Portering

RN / EN APN / NO WM DOM

NC

Fellowship for RN

Target  Outcome  

Risk  Management  

Teamwork  Specialty  Competence  

RECIPROCAL COLLABORATION

Utilization

SMART in TRUST Model

SPECIALTY COMPETENCE

TARGET OUTCOME

Specialty Competent

• Expert clinical

advise & consultation

• Expert clinical

practitioner

• Enhancement of patient need &

services

• Provision of expert Knowledge by EBP, Professional training & development • Develop corporate & hospital wide training for professional development

• Sustain the quality of patient care by governance of specialty standards & service Improvement • Change agent for service delivery • Enhance the patient safety by risk reduction strategies

Facilitation of effective & mutual communication & collaboration with different stakeholders

Mastery Ahead Reciprocal Collaboration Target Outcome

Service Efficiency • Facilitate on reducing the duration/length of stay • Streamline the pre-admission / anaesthetic assessment of ASA 1 / 2 operative patient by peri-operative /anaesthetic nurse

SMART model for Nurse Consultant in Anaesthetic Care

Quality & Safety • Maintain the post-operative patient in normothermia • Reduce the post-operative patient’s pain scale to acceptance level through pain assessment after nursing / therapeutic intervention • Prevent the occurrence of intra-operative pressure ulcer development below stage 2 • Conduct at least one risk reduction strategies yearly

Service Effectiveness • Adverse events occur in relation to anaesthesia and PACU at lowest rate • Ensure medication safety • Increase patient satisfaction rate

Team Building Team expertise by training & competency assessment

Specialty Competent

• Expert clinical

advise & consultation

• Expert clinical

practitioner

• Enhancement of patient need &

services

• Provision of expert Knowledge by EBP, Professional training & development • Develop corporate & hospital wide training for professional development

• Sustain the quality of patient care by governance of specialty standards & service Improvement • Change agent for service delivery • Enhance the patient safety by risk reduction strategies

Facilitation of effective & mutual communication & collaboration with different stakeholders

Mastery Ahead Reciprocal Collaboration Target Outcome

Quality & Safety • Overall high compliance rate for audit • Conduct at least one risk reduction strategies yearly • Adverse events occur at lowest rate • Implication of EBP Service Efficiency • Facilitate the duration /length of stay by multidisciplinary collaboration • Maintain turnover rate within 20 minutes • Reduction of surgery cancellation rate by pre-operative confirmation & education

Service Effectiveness • Maintain the theatre at international standard in item of physical parameters & aseptic technique • Ensure drug identification in sterile field • Increase patient satisfaction rate Team Building • Team expertise by training & competency assessment • Enhance cross- disciplinary collaboration

SMART model for Nurse Consultant in Peri-operative Care

Specialty Competent

• Expert clinical

advise & consultation

• Expert clinical

practitioner

• Enhancement of patient need &

services

• Change agent for service delivery

• Provision of expert Knowledge by EBP, Professional training & development

• Sustain the quality of patient care by governance of specialty standards & service Improvement • Enhance the patient safety by risk reduction strategies • Enhance the patient need & services by implementation & evaluation of different techniques, treatments, technologies and programmes

Facilitation of effective & mutual communication & collaboration with different stakeholders

Mastery Ahead Reciprocal Collaboration Target Outcome

Quality & Safety • Overall high compliance rate to audit and SOPs • Conduct risk reduction strategies for quality improvement yearly • Conduct research project for application of EBP

Service Efficiency • Reduce waiting time in specialty clinic by early intervention from nurse-led clinic • Increase discharge rate in pain clinic • Reduce medication use • Reduce repetitive AED attendance due to pain problems • Shorten the duration of hospitalization

Service Effectiveness • Adverse events occur at lowest rate • Increase patient satisfaction rate • Ensure adequate training for new staff

Team Building • Facilitate team expertise by training & assessment • Enhance cross-disciplinary collaboration to sustain the services quality & patient safety • Establish system to enhance quality improvement

SMART model for Nurse Consultant in Pain Management

Conclusion

•  TRUST is the core of perioperative nursing – Our framework of nursing care – Our core to obtain the trust from our patients,

colleagues, anaesthetist, surgeons

•  SMART is our future directions

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