February 2009 - Operating Room

INSIDE THE CURRENT ISSUE

February 2009

Infection Connection

Outpatient Connection

Study finds failure to include nurses in process of admitting errors to patients, families

Even though nurses routinely disclose nursing errors to their patients, a new study published in the January 2009 issue of The Joint Commission Journal on Quality and Patient Safety shows that nurses often are not included when physicians tell patients about more serious mistakes.

Nurses play such a hands-on role at the bedside of their patients that the study’s authors conclude that the absence of nurses from discussions to plan for or disclose errors can diminish the quality of the disclosure experienced by the patient or their family. For example, when nurses are not involved in the planning for disclosure, they may seem evasive in answering patients’ questions or stall by encouraging families to write down their questions or set up a meeting with doctors. The study, "Disclosing Errors to Patients: Perspectives of Registered Nurses," systematically explores nurses’ attitudes toward and experiences with error disclosure to patients.

"Improving the quality of error disclosure to patients is a top priority in healthcare," says Sarah E. Shannon, Ph.D., R.N., vice associate dean for academic services in the University of Washington School of Nursing, associate professor of behavioral nursing and health systems at the University of Washington, and lead author of the study. "Error disclosure needs to be a team sport. This means quickly sharing information among the team about the error: what happened, why it occurred, what is being done to mitigate potential harm and prevent future errors, and what the patient has been told, will be told, and when."

The study of nearly 100 nurses reports that nurses say they talk with patients about errors that are within their control, such as late or missed medications or treatments. But nurses in the study said they hesitate to independently disclose errors that involved serious harm or actions of other members of the healthcare team. In these situations, the nurses said the responsibility fell to the patient’s attending physician. The nurses said, however, that they would like a role in the disclosure process as a way to both communicate directly with the patient about nursing’s role in the event and to avoid being blamed for the event. The study also found low awareness of institutional disclosure policies.

The study’s authors — three nurses and one physician — conclude that a team disclosure process is best and recommend that healthcare organizations establish policies that permit nurses and other caregivers to participate in and raise concerns about the disclosure process.

Outfitting the inner sanctum:
Trends in surgical suites

by Susan Cantrell, ELS

The operating room (OR) has experienced a tremendous transformation in recent years. Technology reigns, and technology needs its space. In fact, some experts say that size is one of the main differences between ORs now and a few years ago.

An HD360° integtrated surgical suite, STERIS Corporation

Bigger is better

Kevin Gilroy, senior director of business development, MAQUET, Bridgewater, NJ, believes that size has become a major element in the current OR: "The biggest difference in ORs now and 5 or 10 years ago is size. The ORs are being built larger to accommodate the new imaging and robotic technology, because the equipment in the ORs is changing, too."

"While some ORs are gaining larger dimensions, they are being filled with more and more equipment," noted Stephen Heniges, vice president, sales and marketing, CompView Medical, Beaverton, OR, "so, consequently they feel smaller."

Gilroy noted that ORs once were an average of 400 square feet, which is Lilliputian by today’s standards. Randy Tomaszewski, RN/BSN, MBA, vice president, marketing, Skytron, Grand Rapids, MI, told Healthcare Purchasing News (HPN) that he now sees "overall square footage of 2,400 square feet and greater," and "ceiling heights of 10’ to handle today’s advancements in integrated room design, taking advantage of booms, lighting, and high-definition (HD) flat-panel display systems." Tomaszewski also noted that it’s common to see "at least four monitors in the most advanced ORs, to support advances made in minimally invasive surgery (MIS) and because rooms are not being dedicated, as they once were, but are being designed to be multifunctional, capable of handling a variety of surgical procedures to enhance overall flexibility, throughput, start times, and efficiencies of each and every room."

Advances in OR equipment have spawned other trends, too. Whereas the square footage of the OR is growing, much of the equipment is decreasing in size. "Equipment today and in the future must maintain a small footprint and be multifunctional," observed Heniges.

Tomaszewski expounded: "Equipment is getting smaller and lighter, from MIS equipment to the HD flat-panel displays these images are projected upon, not only for surgeons but also for anesthesia, perfusionists, and surgical teams on the whole. Monitors are getting larger, to handle advances in increasing precise formatting capabilities and the quality of images surgeons require for MIS, picture archiving communication systems (PACS), fluoroscopic images, and more. Flat-panel technology has kept much of the weight issue down to a minimum to support the larger screens. If the screens become too large, they can be mounted on a wall and still be seen. Multiple image inputs and outputs have also become very important to support digital, PACS, 3-D navigation, physiological, fluoroscopic, hospital information systems, electronic medical record (EMR), internet, C-arms, microscopes, robotics, ultrasound, video streaming, digital-image capture, video conferencing, and more."

NuBOOM,
CompView Medical,
delivers more space
to your OR in 48 hours.

Industries’ answers to enhancing efficiency

Larger space and more technological equipment beg for streamlined efficiency and organization. Chad Bittner, product manager, equipment management systems, STERIS Corporation, Mentor, OH, talked to HPN about where equipment in ORs is headed and what has fueled these changes. "Trends are consistently focused on improving OR flexibility and efficiency. This is important to facility staff, but it also has a great impact on manufacturers as we design future product solutions. We frequently hear from doctors about the need to continue improving circulating nurse efficiency and response time. Circulating nurses are tasked with multiple OR responsibilities and many times are stationed in a remote corner of the OR without a direct line of sight to the surgical field."

STERIS’s answer to improved patient safety and room efficiency is the Harmony EMS Circulating Nurse Station. "This solution uses a ceiling suspension system to provide a work station that has the flexibility to be positioned in multiple locations around the surgical field, in the same way as an equipment boom. This solution improves the line of sight to the doctor and patient, while also closing the workspace distance between the circulating nurse and the surgical field. Nurses can monitor patients more closely and anticipate the doctor’s needs better, which improves total room efficiency. The Harmony EMS Circulating Nurse Station also centralizes all patient information and room controls to one location, which maximizes functionality."

At CompView Medical, the focus is on improved imaging, safety, and efficient use of space. "NuBOOM is a revolutionary equipment and visualization management system complemented by the DOCS Touch Panel control system," said Heniges, "which enables simple-to-use connectivity to all interoperative imaging modalities: PACS, radiology information systems (RIS), EMR, internet, and video conferencing to remotely located meeting participants. NuBOOM is an HD, open-architecture platform that comes in a two-monitor or four-monitor configuration and can be installed in 48 hours. By removing cords and clutter off the floor to improve safety, allowing the ergonomic positioning of up to six monitors and offering a touch-screen panel that requires minimal staff training, the NuBOOM creates more usable space in the same OR."

Skytron also focuses on improved space and workflow. "Skytron provides leadership with innovative efficiencies for the OR and turn-key solutions for state-of-the-art light-emitting diode surgical lighting and small, efficient surgical booms that are easy to move, providing maximum flexibility with fewer mounting structures," said Tomaszewski. "Additionally, Skytron provides OR integration via our hybrid SkyVision system, which provides multi-level routing and networking control within and outside the OR; in-room and room-to-room communication; bi-
directional teleconferencing for teaching, education, and training; and remote diagnostics. The SkyVision system’s modular design delivers flexibility to meet the clinical imaging needs of present and future technologies with the easiest-to-use touch-screen control on the market."

MAQUET has a solution for the OR that’s a horse of a different color. Their system, VARIOP, is a prefabricated modular wall system that has been used in Europe for over 25 years. It recently was launched in the United States. "An advantage to the modular wall system is that it can accommodate changes without major disruption to the OR, while also allowing for quick and easy access to utility lines and electronics," said Gilroy. "Panels are removed from the walls or ceiling to make modifications or upgrades as newer technology becomes available. Using the system cuts down on the need for remodeling, because the OR doesn’t have to be taken down to make changes," noted Gilroy. "The walls are constructed similar to standard construction using a tubular stainless steel support system. The room can be built in as little as 6 months and, once delivered, can be installed in as little as 2 weeks."

MAQUET’s prefabricated VARIOP operating suites offer easy installation and flexibility.

The rooms are built in MAQUET’s factory in Germany, shipped to the United States in wooden crates, and assembled onsite. "There is less cost, less waste, and less clean up," claimed Gilroy. "The walls are sealed for improved infection control. The cabinets and nurses’ stations are built-in and all are completely sealed, so it’s easier to clean the rooms. The system allows for more natural daylight, and the window blinds are motorized. Sliding doors produce less air turbulence than swinging doors and, when closed, create a perfect seal. The doors open only half-way for staff but fully for patients, to reduce the amount of contaminants entering the OR."

Spending money to make money

Some of the newer equipment is pretty pricey. What arguments can be made to justify the purchasing expense as a cost-effective move? As Heniges, CompView, commented, "Given the current economic climate, it is imperative to demonstrate a clear return on investment for each hospital acquisition."

Tomaszewski added: "That’s a very interesting question that requires both a dollar-and-cents analysis as well as consideration of present and future increased revenue generation and support for growth for surgical programs to better meet the needs of the community and to remain competitive with other hospitals within their region. Much is squandered in the way of costs with inefficient ORs that are outdated and ill-equipped to perform the surgical techniques available today. Hospitals must consider several factors in their purchase decisions, inclusive of immediate cost savings, increased revenues, life-cycle savings, improving quality, improving patient outcomes, retention and recruitment of skilled surgeons and staff, patient safety, and more."

Tomaszewski offered an illustration: Imagine that a hospital could save $50,000 off the purchase price of an equipment package, but the package is ill-equipped, by limited function or room design, and cannot drive more cases or improve program growth. Compare it to a hospital that spends $50,000 to equip the OR with the necessary technology needed to be optimally flexible, to generate more surgical cases per day, with a resulting increase in case load that increases cash flow, producing more revenue per year. "For example, if a hospital’s efficiency could add a case per day and drive a net positive cash flow of $3,000 per day, over a year’s time (52 weeks times 5 days/week), the hospital would have generated $780,000 of additional income per year (260 times $3,000/day). Which is the better financial decision to make, $50,000 in initial purchase savings or $780,000 in additional income per year in OR efficiency? Let’s be conservative and reduce additional revenue by 50%, $50,000 versus $390,000. Which is the smarter investment?"

Integrated operating room, Skytron

David E. Johnson, product manager, Harmony OR Integration Systems, STERIS Corporation, also believes "the purchasing expense can be justified if the new OR technologies can demonstrate an increase in overall productivity, quality, and safety in the perioperative environment. For example, equipment booms and flat-panel monitor arms help to minimize OR turnaround times by eliminating the need to wheel equipment and monitors into and out of the OR. Cables are not lying on the floor, causing a potential safety hazard, because the equipment boom provides power and video connectors near the surgical field. Touch-panel control of all the various audio, video, and data sources in today’s OR can be accomplished from the traditional nurse station or one mounted on a motorized arm. This gives a central point of control and assures quick, easy, and ergonomic access to anything that might be needed during the surgical procedure, including easy access to the patient."

Gilroy explained how MAQUET’s pre-fab system compares cost-wise to more traditional approaches to updating the OR: "It is cost-effective compared to remodeling or new construction. Initially, it could be an investment of 10% to 15% more, but, when changes in the OR environment need to be made, there is less down time; new technology can be added quicker. Some changes can be made overnight or on weekends; so, there is less disruption and less revenue lost. Down the road, it actually saves costs in remodeling. The panels are easily removed and are taken elsewhere to make the changes; so, no dust or soil is introduced into the OR. When the changes have been made, the panels are brought back in and screwed into the wall. There is minimal waste compared to a construction site."

Looking to the future

The OR continues to evolve. The experts weighed in on what we may look forward to in the OR of the future.

“There will be a continual need for more data to be available directly to the surgical team,” said Heniges. “As more equipment and technology enter the OR, it is imperative that boom systems assist in accommodating the growing need for more space. CompView Medical is developing innovative methods to improve the usable space in the OR and avoid expensive construction costs.”

Johnson, STERIS Corporation, added: “The future of any surgical suite includes some level of integration, which makes ceiling-mounted, open-architecture arms, flat-panel displays, and equipment booms a necessity. This equipment optimizes the ease of use of integration systems and assures a good return on investment for expensive integration technology and cabling. Also, operating suites are becoming more complex and multipurpose; for example, hybrid ORs that can accommodate both interventional radiology and general surgery or surgical robotics and emergency open surgery. These new spaces require a new level of collaboration among key vendors, who must integrate many technologies into a seamless workspace for surgeons and nursing staff. Hospital planners who are considering building hybrid ORs are wise to consult with companies like STERIS, who have the expertise to design these highly complex rooms in synchrony with other vendors.

More specifically, said Johnson, is that STERIS is “continually looking to make all of our ceiling-mounted equipment and integration systems smaller, lighter, and easier to use. We also look for ways to increase video quality for all equipment in the OR, since C-arms, PACS, and videoscopes all must look their best, although each has different display characteristics. More than just aesthetics, we are looking to use these more compact, more versatile, higher quality products to increase the safety, productivity, and quality of care in today’s ORs. STERIS’s HD360? Suites are great examples of such focus and expertise.”

At Skytron, “Advances in booms, lighting, integration, communications, and equipment will continue to require more equipment to support ever-increasing technological needs and capabilities. Equipment will continue to get smaller and lighter. Integration technologies will become more standardized. We will eventually see blue-tooth and wireless systems used within the OR, which will further reduce the necessary amount of equipment surrounding the surgical field.”

“Patients are growing older and heavier,” continued Tomaszewski. “Greater imaging capabilities and support platforms to adapt flexibly to an increasingly aging population with greater imaging needs continues to evolve, with surgical tables that provide top slide, weight capacities in the 600-pound to 1,200-pound range, to safely handle patients.”

“Green technologies will continue to be developed and advanced, with products requiring less energy to power, as well as with products that are kinder to the environment.” In general, noted Tomaszewski, the focus will be on “products that are easy-to-use, safe and reliable, maintaining day-to-day, high-quality, long-term performance that provides value and durability and that deliver lower life-cycle costs and lowest cost of ownership long term.”