Physicians and nurses share problems, solutions

Barba J Edwards, RN, led group discussions of the nonphysician as first assistant.

Physicians and nurses share problems, solutions

What are the duties and functions of an effective OR committee? What can you do about expensive equipment that is rarely used? How is computer scheduling going? Who should be involved in operating room design?

These and hundreds of other questions were addressed by surgeons and operating room nurses from across the country at the Third Symposium on Operating Room Envi- ronment held May 2 to 4 in New Orleans. The 21h-day conference was sponsored by the American College of Surgeons (ACS) in coop- eration with AORN and coordinated by the ACS Committee on Operating Room Envi- ronment (CORE). As in the past, one of the main objectives of the joint meeting is to im- prove problem-solving interaction between surgeons and nurses. Participants registered as physician-nurse teams and attended sessions together.

The program focused on four main areas: 0 quality assurance of patient care in the

operating room management 0 environmental methodology for the oper-

operating room design, function, and reg-

Interdisciplinary panels covered each of these topics. All four sessions were followed by small discussion workshops where the surgeons and nurses shared common experiences, questions, and possible solutions. Later, group leaders and recorders reported their group’s experience to the larger audience.

The first panel on quality assurance was moderated by Robert E Condon, MD, FACS, professor and chairman of the department of surgery at the Medical College of Wisconsin, Milwaukee. The viewpoints of the surgeon,

OR

ating room

ulations.

68 AORN Journal, July 1983, Vol38, No 1

nurse, and anesthesiologist were presented by Donald G McQuarrie, MD, PhD, FACS, professor of surgery, University of Minnesota Medical School, Minneapolis, and assistant chief, surgical service, Veterans Administra- tion Medical Center, Minneapolis; Sylvia A Doyle, RN, MS, director of OR services, St Joseph Hospital, Houston; and Charles J Va- canti, MD, anesthesiologist, St Mary’s Hospi- tal, Rochester, NY.

Dr McQuarrie emphasized the one goal of a quality assurance program must be improved care of the patient. “We must get beyond the endless meetings, rules, regulations, and policies on minor issues and collect meaning- ful data for making the best patient care decisions,” he said. “What we do with data col- lected by mortality conferences, incident reports, tissue review, or infection committee reports must be aimed at either maximizing or minimizing specific features of patient care,” Dr McQuarrie continued. “We want to maximize patient comfort and sense of well- being, the actual correction of disease, operating room efficiency, and staff satisfaction. At the same time, we need to minimize cost, length of stay, morbidity and mortality, and risk of litigation.”

Doyle addressed quality assurance from the infection control aspect by presenting guidelines and recommended practices for steriliza- tion of implants, laparoscopes, and skin prepa- ration for both surgical team and patient. As chairman of the Committee on Peer Review of the American Society of Anesthesiologists (ASA), Dr Vacanti recommended methods of identifying and resolving problems in anesthesia care. He suggested that accurate documentation of problems go to the institu- tion’s OR committee for evaluation and correc- tive action. In smaller hospitals where there may not be more than one anesthesiologist, the hospital can request an on-site consulta- tion from ASA to conduct peer review.

Under the umbrella of quality assurance, discussion groups tangled with issues of professional conduct within the OR, infection control, peer review, orientation programs for interns and residents, credentialing the nonsurgeon physician using the OR, and control of OR traffic. Group reports were lively and full of helpful hints.

It was generally agreed that interpersonal

Harvey Weiss, MD, answered questions about the functions of computers in the OR.

problems were best dealt with on an informal one-to-one basis. If, after an honest, assertive approach, the behavior has not changed, participants thought astrong OR committee would be the best avenue to use.

To be strong, effective, and objective, the OR committee’s members must be physicians, nurses, and hospital adminstrators who have demonstrated expertise in their fields as well as institutional authority to set and enforce policy. It is self-defeating, reported one group, to assign the surgical resident this duty just for the experience. The resident will not have the necessary clout, and the committee will be ineffective when difficult decisions need to be made.

A second panel discussed OR management. Members were Nancy L Ertl, RN, director of patient care, Mercy Health Center, Dubuque, Iowa; Stephen J Prevoznik, MD, professor of anesthesia, University of Pennsylvania School of Medicine, Philadel- phia; and Harvey A Weiss, MD, FACS, surgeon in private practice, Atlanta. Moderated by AORN President Joan Koehler, RN, the panel sparked discussion on participative management and how it can work in the OR with its territorial rights and responsibilities.

Ertl suggested the management team con- sist of the operating room supervisor and head

d- AORN Journal, July 1983, Vol38, No 1 69

nurse, the chairman and vice-chairman of de- partments of surgery and anesthesia, and senior hospital administrators. This group would be responsible for delineating indepen- dent and shared functions of each profession. Once the shared functions are identified, this committee can develop departmental objectives; guidelines for capital expenses; and policies for scheduling, safety practices, and infection control. Enforcing the committee’s rules and regulations would thus be a shared responsibility.

The approach has advantages and disadvantages for each discipline. Physicians may be viewed as “hospital policemen” and feel harassed by peers. They would be required to devote time to the committee’s work that would not be reimbursed. Nurses would be faced with additional meeting time and might feel loss of control over their work environment. In sum- mary, Ertl said the overall advantages of improved use of resources and reduced intra- professional conflicts far outweigh the disadvantages. “Concessions are far better than failure,” she concluded.

Drs Prevoznik and Weiss agreed whole- heartedly with this concept and added their own perspectives on implementation. Anes- thesia personnel must be part of the OR committee, representing their profession on decisions on professional conduct, standards of care, and scheduling policies. Dr Prevoznik

Surgeons and nurses try to determine the best method to orient newcomers to the OR. Janett Propst, RN (left), led the

discussion by asking surgeons, “How did you learn

to use the cautery?”

believes each service should set up its own rules, with the OR Committee enforcing them.

Dr Weiss was a strong advocate of using the computer for coordinating hospital bed availability, instrument availability, and surgical scheduling. He saw the OR committee making decisions about surgical supervision, the type of scheduling, down-time utilization, impaired professionals, staff morale, and policies or bylaws governing the medical staff.

Discussion groups wrestled with the pros and cons of computer scheduling. Arthur S McFee, MD, FACS, from the University of Texas Health Science Center, San Antonio, reported that his group agreed unanimously that a computer may be the answer to many scheduling problems. But they asked, how can a prepackaged program meet the needs of different OR systems? Helen Benedikter, RN, from Long Beach (Calif) Community Hospital, reported that her discussion group appreci- ated the computer‘s advantages in keeping track of operating room time by case and surgeon and storing information. At the same time, they realized the dangers of possible misuse of information.

W C Dandridge, MD, FACS, of St John’s Regional Medical Center, Joplin, Mo, reported that his group discussed computerized scheduling as an adjunct to the manual system most use quite effectively now. Most other groups expressed interest in the use of com-


Nancy Ertl, RN, and Sylvia Doyle, RN, lend their expertise to the open forum.

puters but felt the need to be educated further on their most effective use.

Another OR management issue was the acquisition of costly specialized equipment under today’s cost containment pressure. The biggest problem the nurses identified was pur- chasing equipment that is rarely used. Some solutions were (1) ask the physician request- ing the purchase to receive approval from peers, (2) post the actual cost of the equipment for everyone to see before they make their request, and (3) use the equipment on con- signment at first to ascertain actual utilization.

Attention turned to environmental methodology. An interdisciplinary team from the Uni- versity of Virginia School of Medicine, Char- lottesville, offered information on volatile anes- thetics, electrical hazards, and standards for aseptic barriers. On the panel were moderator Richard F Edlich, MD, PhD, FACS, professor of plastic surgery and biomedical engineering; William T Ross, MD, associate professor of anesthesiology; Frank P Hunter, Jr, clinical engineer and assistant professor and research director of clinical engineering; and Lawrence Noriega, RN, PhD, assistant director of nursing.

Some discussion groups contributed additional environmental problems for the panel’s consideration. Questions raised but not necessarily answered were how to teach the use of the electrocautery equipment to surgeons and the advantages and disadvantages of the needle and instrument count versus routine postoperative x-rays. Other issues were what is an adequate dress code and what

safety measures to offer the pregnant em- ployee.

During an open forum, several concerns and resolutions were raised. There was consider- able interest in discontinuing instrument and needle counts, especially in cases where the needles are under 1 cm, because it was felt they wouldn’t harm the patient. Nevertheless, the majority thought whether to do needle counts should be a matter for each hospital’s risk management policy. They decided it would be inappropriate for the group to make a recommendation. The group thought most hospitals would favor retaining the counts since, under the doctrine of res ipsa loquitur (the thing speaks for itself), the surgeon would be held liable for any retained needle.

Lyle D Pahnke, MD, FACS, from St Bernar- dine Hospital, San Bernardino, Calif, spoke of the emerging problem of diminishing pay- ments for first assistants. He asked that AORN and ACS address the issue of registered nurses performing first assistant duties in the operating room. AORN President Joan Koehler informed the audience that at AORN’s Congress in Houston in April, a resolution was passed asking that AORN define the role and scope of practice for first assisting as an inte- gral part of the perioperative role. A task force has been appointed for this purpose.

The discussion of first assistants continued, covering all nonphysician assistants. For the nurses, the issue boiled down to each state’s nurse practice act and what it allows.

The open forum also allowed time for discussion and approval of an earlier resolution

& AORN Journal, July 1983, Vol38, No 1 73

concerning nursing education introduced by Perry W Nadig, MD, FACS, from Metropolitan General Hospital, San Antonio, Tex. The resolution asked the ACS CORE to work to influ- ence nursing educators to include OR experience in their basic curriculum.

Dr Edlich presented two resolutions. The first, asking symposium participants to recommend to the CORE that a text or monograph be pre- pared outlining the contents of the symposia, was quickly and unanimously passed. His second, a recommendation that bacterial strike through and some form of stress testing be incorporated into standard criteria for studying aseptic barriers, was defeated. The group was informed that the Association for the Ad- vancement of Medical Instrumentation was studying this issue. The resolution was then modified to read that CORE and AORN, in collaboration with industry, work together to develop objective performance standards in relation to aseptic barriers. This version of the recommendation was passed.

Whatever disagreements they had among themselves, participants were united in their support of a strong OR committee to plan, set policies and procedures, and establish disci- plinary guidelines. Education for interns, residents, and nonsurgeon physicians was seen as the duty of this committee.

The final panel discussion on OR design was moderated by J Raymond Hinshaw, MD, PhD, FACS, professor of surgery, University of Rochester (NY) School of Medicine and Den- tistry, and chief of surgery at Rochester (NY) General Hospital. Operating room design,

The OR committee establishes guidelines for discipline

function, and its regulations were addressed by Edward Dunn, MD, FACS, associate clinical professor of surgery, Yale University School of Medicine, New Haven, Conn, and director of surgical services, Waterbury (Conn) Hospital Health Center; Richard A Keeler,

American Institute of Architects, director of health facilities design, Marmon Mok Partner- ship, San Antonio, Tex; Douglas K Duncan, MD, FACS, associate director, Hospital Accreditation Program, Joint Commission on Accreditation of Hospitals, Chicago; and Joseph R Radzius, JD, Chicago.

Dr Dunn reminded the audience that when planning a new OR, “form will follow function but once form is fixed, the function is hostage to it. Think of where your community is head- ed,” he advised. “For example, will you need to plan for an increase in the number of eye surgeries, prostatic surgeries, or treatment of peripheral vascular disease due to an increase in the older population? Plan for the integration of the OR suite with support services, adequate storage space, data processing capabili- ties, case cart systems or variations upon it, and adequate traffic control. This huge under- taking can only be done successfully when nurses, physicians, administrators, and architects collaborate,” he said. Keeler recommended having a dear statement of need to begin the planning. Dr Duncan and Radzius discussed JCAH requirements and a legal overview of the operating room.

On the third day, small groups met to air the common issues of legalities of physician assistant credentialing and JCAH requirements for ambulatory care.

Although the size, location, and financial status of institutions varied greatly, all groups conceded the problems were similar. Perhaps there were more questions than answers at this symposium. But physicians and nurses shared their expertise to solve past problems and anticipate the future needs of surgical services.

Ronald Lee Nichols, MD, FACS, vice- chairman of the Department of Surgery at Tulane School of Medicine, New Orleans, and coordinator of the symposium, expressed hope that this type of interaction would continue. “Nurses, surgeons, anesthesiologists, and other interested parties must continue to talk about the needs in the operating room to the betterment of patient care,” he said.

Pat Niessner Palmer, RN Nurse editor


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Physicians and nurses share problems, solutions