AORN J O U R N A L JULY 1985, VOL 42, NO I

Symposium on OR Environment Draws Physicians and Nurses Together

During a workshop, Patricia Daniels, RN, Arlington, Tex, and Regina Cates, RN, Nashville, Tenn, discuss their hospitals’ quality assurance programs.

re hospitals keeping two sets of records, one A for themselves and one for the Joint Commission on the Accreditation of Hospitals (JCAH)? Who do we bill for quality assurance, and are these programs really meaningful? Who should run the OR, the nurses or the physicians?

These and hundreds of other questions were discussed by surgeons, operating room nurses, anesthesiologists, hospital administrators, and other professionals who attended the Fourth Symposium on the Operating Room Environ- ment, held May 6 to 8 in New Orleans.

One of the major objectives of this sympo- sium-sponsored by the American College of Surgeons (ACS) in cooperation with AORN- was to improve the interaction between surgeons and OR nurses. Participants registered as physician-nurse, or physician-nurse-administrator teams and attended sessions together. Over 100 teams participated.

The subjects examined during the sessions were impact of JCAH standards on OR quality

OR management environmental methodology for the OR OR design, function, and regulations.

All four sessions were followed by discussion workshops. After the workshops, the participants returned to a general session where questions from the workshops were discussed by the respective panels. There was also an open forum during the 2% day program when panelists addressed questions from the symposium participants.

assurance

Session I

he first session opened with a welcome from T the symposium coordinator, Ronald Lee Nichols, MD, MS, FACS, Henderson professor and vice-chairman, department of surgery, and

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AORN J O U R N A L JULY 1985, VOL 42, N O 1

Are hospitals keeping two sets of records, one unofficial

and one for JCAH?

professor of microbiology and immunology, Tulane University School of Medicine, New Orleans; and Clifford H. Jordan, RN, EdD, FAAN, AORN executive director, Denver. Moderator Robert E. Condon, MD, MS, FACS, Ausman Foundation professor and chairman, department of surgery, the Medical College of Wisconsin, Milwaukee, introduced the speakers for the first panel.

The first to speak on the impact of JCAH standards on OR quality assurance was Linda Kay Groah, RN, CNOR, CNA, director of nursing- ORIPAR, University of California Hospitals and Clinics, San Francisco, and AORN treasurer. Groah spoke about the perioperative nursing perspective of quality assurance programs. Concern about quality patient care is not new to nursing, said Groah. Florence Nightingale was the first to express concerns about atrocious standards of care in her nursing notes written during the Crimean War. Today there are numerous quality assurance methods that can identify potential patient problems in the operating room.

For quality assurance programs to be effective, corrective action must be instituted immediately after the problem is identified, said Groah. And periodic re-evaluation must be performed to ensure that improvement is maintained.

The second member of the panel, Samuel E. Wilson, MD, FACS, professor and chairman, department of surgery, Harbor-UCLA Medical Center, Torrance, Calif, spoke about the 1985 JCAH regulations and the OR. The impact of JCAH on the OR promises to be significant, said Dr Wilson. Surgical privileges will be reviewed as part of hospital quality assurance programs, results of quality assurance activities will be used for renewal of privileges, surgical case reviews must be carried out on a regular basis, and monitoring will include occurrence reporting and generic screening for early identification of problems in

patient care. The genesis of quality assurance provisions is,

in part, due to shared concerns of surgeons, OR nurses, and hospital administrators about the growing malpractice problem, said Dr Wilson.

James S. Roberts, MD, vice president for accreditation, JCAH, Chicago, reviewed the recent developments in JCAH standards, and gave an update on the Commission’s review of the suggestion that standards be developed for the OR. An expert task force has been appointed to consider the possibility of a JCAH section addressing the OR. The most difficult problem in setting these standards is defining what an OR is, said Dr Roberts.

In the small groups following the first session, participants discussed their concerns from the session, and representatives from each group then repeated these questions to the panel. Deborah Spratt, RN, Rochester, NY, said her group was concerned that hospitals are keeping two sets of records, one unofficial and one for JCAH. Dr Roberts said that if JCAH is prompting hospitals to create records just for them, “there are serious problems that need to be addressed.” Dr Wilson said that neither quality assurance records nor anything else should be written secretly, if a factual honest job of reporting is to be done. “If you don’t report the facts, you’re part of the problem,” he said.

Brenda McKonly, RN, Boston, asked if one certified surgeon teaches other surgeons a new procedure, are surgeons so taught then certified according to JCAH? Dr Wilson answered, “if a surgeon fulfills your requirements for teaching, there is no problem.”

“Does compliance with JCAH standards assure quality patient care?“ asked Margaret Leete, RN, Nashville, Tenn. Dr Roberts answered that compliance with JCAH standards is no guarantee for quality care. He does believe JCAH standards make a difference though, because he doesn’t know

A O R N J O U R N A L ~~

JULY 1985, VOL 42, NO I

Because the source of most problems is ‘people problems,’ the key to effective OR management

is learning how to manage people.

if hospitals would change their standards without JCAH.

Gary Danos, MD, New Orleans, asked the panel a question his group had discussed “.4re quality assurance programs really meaningfil?” In response, Linda Groah said that it was up to each institution to make them meaningful.

Session II

her the first panel’s discussion of questions, A the second panel, discussing operating room management, was introduced by Ruth E. Vaiden, RN, CNOR, private neurosurgical nurse, Newo- logical Associates, PC, Richmond, Va, and AORN president.

Patricia P. Kapsar, RN, director, surgical services, St Joseph Hospital, Kirkwood, Mo, gave the panel’s first presentation on managing for change. “Never in the history of health care have we been faced with such an unstable envixon- ment,” said Kapsar. To deal with this unstable environment, management skills must be refined and incorporated into a team approach. Tradi- tionally, OR management was done by one person, but today physician collaboration is necessary, she said.

Managers will need accurate, timely, and relevant information for all areas, said Kapsar, and computerization is a valuable tool. But, she said, “if programs don’t work well manually, they won’t work well computerized.”

Thoughts for the future of operating room management were presented by Dwight G. Geha, MD, director, intensive care unit, Mount Auburn Hospital, Cambridge, Mass. “The daily problems of scheduling, turnover time, anesthesia and surgery delays, and organizational structures must be solved within the framework dictated by cost containment strategies, resource allocation, and uniform standards of care,” said Dr Geha. Professional competence, delineation of privileges,

and liability are issues that must be addressed in the OR; department chiefs are being held accountable for what goes on in their departments, and OR supervisors may become policemen.

The stresses of diminished resources and competition may intensify the daily problems of OR management, said Dr Geha; cooperation and visionary leadership by OR nurses, surgeons, and anesthesiologists is needed.

Problem management in the OR was then presented by the third speaker, David G . Ashbaugh, MD, FACS, St Luke’s Hospital, Boise, Idaho. The problems that arise in the operating room seem to be never ending; when one problem gets temporarily solved, a new one rises, said Dr Ashbaugh. Because the source of most problems are “people problems,” the key to effective OR management is learning how to manage people. The key players in problem management in the OR are the chief of anesthesia, the chief of surgery, and the operating room supervisor. These three should be selected for their management skills, as well as for their professional skills, said Dr Ashbaugh.

After the small group sessions, Dr Ashbaugh was asked who should run the OR. He responded that “the OR director of nursing” should run it. He also said that the director must be a very strong person, and that it is “generally a mistake to let the doctors run the OR.” Dr Geha agreed.

Sherry Targum, RN, Winter Haven, Ha, asked for a suggestion on how to keep OR scrub clothes from :‘wandering out” of the OR and out of the hospital. Kapsar said that her hospital had different colors for different services, and when doctors leave the department they are asked to change clothes, even if they are going to an adjacent intensive care unit. Dr Geha said that his hospital had purchased the “world‘s most uncomfortable” disposable scrub suits, and that no one would want to wear them. Some other suggestions from the groups included putting out only a small supply

d) 87

Brenda McKonly, RN, tells her group about the care of equip- ment in her OR. Michael Steer, MD, Beth Israel Hospital, Boston, accompanied her.

of scrub clothes at a time, keeping scrub clothes in locked cages, and having to hand in a dirty pair of scrub clothes in order to get clean ones.

When asked how surgeons can be made aware of cost containment in the OR, Kapsar suggested that the nurses wait until sutures are needed before putting them on the sterile field, and to put caricatures of items and their prices on the walls. Dr Ashbaugh said that “surgeons are not cost conscious,” and that nurses must really do a selling job on them. He also said that before doing this, the nurses must have their facts together.

Session 111

he second day of the symposium began with T the introduction of the third panel of speakers by John L. Glover, MD, FACS, professor of surgery, Indiana University School of Medicine, Indianapolis. This session focused on environmen- tal methodology for the OR.

Phillip J. Bendick, MS, PhD, biomedical engineer, associate professor, department of surgery, Wishard Memorial Hospital, Indiana University School of Medicine, Indianapolis, gave an engineer’s perspective on the OR environment. Dr Bendick opened his presentation with a comparison between Murphy’s Law and the use and misuse of equipment in the OR “If there is some way for someone to do something wrong,

they will.” The increased use of technology in medicine, and specifically surgery, has made the OR an exciting, but challenging place to work, said Dr Bendick.

New techniques and equipment require increased awareness and education for everyone involved. Adherence to published guidelines and strong doses of common sense go a long way toward providing safety in the OR, he said.

Margaret Huth Meeker, RN, BSN, CNOR, director of OR/RR nursing, Ohio State University Hospitals, Columbus, spoke about OR attire and aseptic barriers. One thing is known for sure, Meeker said; people are a major source of microbial contamination in the OR. A collective groan escaped from the audience when she told of a recommendation that all OR personnel wear an impermeable bunny-type scrub suit with foot attachments.

One of the most troublesome areas for many OR supervisors is to get people to keep their hair covered in the OR, said Meeker. Some people think it is unimportant because there is no current research attributing surgical wound infections to bacteria carried on hair of OR personnel.

Another area of interest to surgical personnel is draping and gowning material, said Meeker. Reusables are not cost effective if they do not survive the prescribed number of launderings. And if considering disposables, costs involved need to

AORN J O U R N A L JULY 1985, VOL 42, N O 1

Is it fair for pregnant women to have to work in the OR with inhalation

anesthetics and radiation?

be carefully analyzed, along with adequate storage space and an acceptable method of disposal.

The last speaker for this panel was David A. Kovach, MD, assistant professor of anesthesiology, Indiana University School of Medicine, Indiana- polis. Speaking on occupational exposure to inhalation anesthetics, Dr Kovach said that survey studies comparing the health of anesthetic-exposed personnel with nonexposed control groups show an association between chronic exposure to inhalation anesthetics and adverse effects on health. He listed the hazards of trace anesthetics as spontaneous abortions, congenital anomalies, carcinogenicity, hepatic disease, renal disease, neurologic disease, and psychomotor impairment.

Several measures can be taken to achieve acceptable levels of exposure to trace anesthetics, said Dr Kovach. These include anesthetic equipment designed to avoid leakage, preventive maintenance of anesthetic equipment, leakage testing procedures, low leakage work practices employed by the anesthesiologists (eg, careful fitting of face mask), scavenging of waste anesthetic gases outside the building, and air monitoring to ensure effective implementation of these measures.

Small groups discussed the difficulties of enforcing shoe covers, hair cover, and the no jewelry regulations. They concluded that the difficulties stem from lack of proof that uncovered shoes, uncovered hair, and the wearing of jewelry cause infections.

Another group discussed whether it was fair for pregnant women to have to work in the OR with inhalation anesthetics and radiation. And should they be given the option not to work in the OR? The group felt that all OR personnel should be told of the hazards when they start working in the OR and should be given the option not to work there.

Meeker was asked if there are advantages to an all RN staff. She answered that an all RN staff is cost effective because of the flexibility and

versatility of RNs. Groah answered from the audience that the ratio of sick time used by RNs compared to technicians is “one to three.” She also added that RNs offer more complexity to the job, and said they “can do everything you need.”

Open Forum

he second afternoon of the symposium offered T an open forum for questions and answers from the first three panels and workshops.

When asked by Dr Nichols to give some advice for JCAH reviews, Dr Roberts said

You must communicate with us; only 40% of hospitals write JCAH as to how their surveys go. Get your hospitals to send their evaluations in. We want your comments on proposed draft standards. Through AORN and ACS, you have direct access to JCAH and you should use it. Quality assurance is here to stay-the public demands it.

Dr Nichols then asked the audience if they thought surgery should be scheduled seven days a week. Harry J. Metropol, MD, Baptist Medical Center, Columbia, SC, answered that they operate six days per week, with urgent or semi-elective GYN and orthopedic cases on the seventh. Vaiden said they operate five days per week, with emergencies only on weekends.

Paul Friedmann, MD, Baystate Medical Center, Springfield, Mass, asked if specialized nurses and teams should be used for special cases. Kapsar answered that they rotate teams through services, because a small institution doesn’t have the flexibility for special teams. Meeker said that her hospital had 20 operating rooms and specialty teams were used because rotating “made for frustration and lower quality of care.” After six months of orientation to all 11 surgical services,

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the nurses join a team. The quality of care has improved with specialized surgical teams, she sidd.

Session I V

he final morning of the symposium opened T with introductions of the fourth panel of speakers on operating room design, function, imd regulations by Joseph A. Moylan, MD, FACS, professor of surgery, Duke University Medical Center, Durham, NC.

Kenneth C. Schneider, MD, MPH, associate regional administrator for health standards and quality, Health Care Financing Administration, Dallas, spoke about DRGs and the OR. Because of DRGs, said Dr Schneider, hospitals now have a stronger interest in making health care more cost effective. The surgical suite may expect some changes-there is an incentive to focus on high- volume procedures.

Peer Review Organizations (PROS) have set specific objectives to eliminate unnecessary operations and invasive procedures and to shift certain cases to the outpatient setting, he said.

The second speaker for this final panel was Gerry Kinworthy, RN, MS, staff specialist, division of quality control management, American Hospital Association, Chicago, on utilization management. Faced with prospective pricing, increased competition, new payment programs, and growing health care coalitions, hospitals can no longer operate isolated quality assurance and utilization review processes-“Quality muriince is the overall umbrella of everything we do,” said Kinworthy.

Hospitals can implement utilization manage- ment through internal changes, she said. Utilization management is the key to meeting future needs while maintaining the quality of patient care.

Don Eugene Detmer, MD, FACS, vice president for health sciences, University of lJtah School of Medicine, Salt Lake City, gave the panel’s third presentation on ambulatory surgery in the 1990s. Prospects for ambulatory surgery are excellent for the next five years, said Dr Detmer. The impact on hospitals, surgeons, payers, and patients will continue to expand.

Cost and quality concerns are real because of

David Bush, MD, tells his group about ambulatory surgery at Geisinger Medical Center, Danville, Pa. Anne Kleman, RN, accompanied him.

the great interest of for-profit corporations in health care, surgeon oversupply, and decentralization of facilities. “By 2005, megacompanies will be running America’s hospitals,” said Dr Detmer. The rise of a generation of free-wheeling entrepreneur- ial surgeons is possible, he added.

Ruth L. Batstone, RN, BS, surgical services director, Methodist Medical Center of Illinois, Peoria, presented the impact of OR design on inpatient and outpatient facilities. The pressure to perform surgery on an outpatient basis has challenged inpatient surgical units, and units designed specifically for outpatients, to provide high quality service that is convenient, pleasant, competitive, and cost effective, said Batstone. This is where OR design comes in.

Dr Nichols closed the program by saying, “we took up where we left off two years ago,” and that the symposium’s purpose of improving dialogue between surgeons and nurses had been accomplished.

JUDITH M. MATHIAS, RN CLINICAL EDITOR

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A O R N J O U R N A L JULY 1985, VOL 42, NO 1

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Extended-wear Contacts Causing Eye Problems Physicians are concerned with the number of patients reporting trouble with their extended- wear contact lenses, according to an article in the April 8 issue of Medical World News. Dr Michael Lemp, chairman of ophthalmology at Georgetown University Medical Center, says, “The problem is so severe as to be a serious pub- lic health hazard.”

Dr Lemp says the lenses are being marketed as “trouble-free, carefree, and simply an alternative” to eyeglasses. But, he says, “These products have a potential for problems. Extended-wear contact lenses increase your risk of serious eye infections and sight-threatening corneal ulcers.”

Most people developing eye infections are the elderly, according to Dr Lemp. And he says most should not have been fitted with the contacts in the first place for various reasons, including defi- cient tear production and being prone to recur- rent lid infections.

Dr Lemp believes the way to prevent these problems is to make sure prospective contact lens wearers have a thorough examination to “screen out those who shouldn’t get lenses.” He said, “Many people don’t realize that if the lenses aren’t well cared for, there’s a real potential for damage -some patients have suffered permanent vision loss.”

Dr Oliver Dabezies, clinical ophthalmology professor at Tulane University and executive vice president of the Contact Lens Association of Ophthalmologists, says, the people having prob- lems are “usually fitted with lenses at one of the discount stores without medical supervision or follow-up care. Today, it’s about 50-50, with half the patients being fitted at department stores or at discount centers that provide little professional supervision.”

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