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Does Your Facility Excel? Tell Us Why and Be Our Guest at OR Excellence!

If you haven't yet nominated your facility for our 2014 OR Excellence Awards, here are a few reasons why you might want to take a few minutes to shine a spotlight on your center for all the outstanding work you and your staff have done:

  • We'll feature the 7 grand prize winners in the September issue of Outpatient Surgery Magazine. Pretty cool to see your name and photo in print!
  • You'll be our guest at OR Excellence, Oct. 14 to 17 at the New Orleans Marriott. Here's the deal: If you get yourself to the Big Easy by plane, train or automobile, we'll pick up your hotel stay for 3 nights and waive the conference registration fee.
  • At our special awards luncheon, we'll present you with a cool plaque you can display in your waiting area to impress all your patients.
  • You'll probably get a big raise. (Hey, anything can happen!)

It's easy to enter, but you've got to enter to be recognized. Nominate your facility in any or all of the following categories: patient safety, pain control, patient satisfaction, financial management, employee safety, infection prevention and environmental stewardship. Tell us how your team and your center excel for OR Excellence.

Dan O'Connor

Brief and Debrief to Improve Surgical Outcomes

Thoughtfully structured briefings and debriefings have the potential to dramatically improve surgical communication and outcomes, a recent study in JAMA Surgery suggests.

The briefings, say the authors, go beyond traditional time outs in that team members introduce themselves by name and role before the time out, then conduct a formal review after the time out. It may sound extensive and time-consuming, they say, but studies show that effective briefings can be done in less than 2 minutes, and that they can reduce surgeon-reported delays by more than 80%.

Pre-operative briefings, including a discussion of information relevant to the procedure, can improve communication, decrease surgical workflow disruptions, improve compliance with antibiotic and deep vein thrombosis prophylaxis, and improve overall perceptions about the safety climate in the OR, say the authors. But, they caution, providers must be committed to the process for briefings to be effective.

Debriefings, along with addressing housekeeping points after the case, should provide an opportunity for unstructured feedback regarding process defects, and a system should be put in place to address defects that are revealed. The authors provide this example: "One of the SSI prevention interventions implemented by the team was isolation of dirty instruments used for bowel anastomosis. Nurses and technicians said this was difficult because the surgeons did not communicate when they were starting and ending the 'dirty' portion of the procedure. … The surgeons decided to include this point in the briefings as well."

Jim Burger

Would You Have Fired This Bawdy Nurse?

Her colleagues called her a bully and complained about her bawdy language and sexually charged jokes. Her superiors were annoyed by her suggestions for improving the training of nursing students. She complained about working evening hours. Still, the National Labor Relations Board recently ruled that Donna Miller, RN, was a talented surgical nurse whom Inova Fairfax Hospital had no right to fire.

The trouble began in 2005, when the supervisor of the Falls Church, Va.-based hospital's ASC decided to schedule cases after 6 p.m. This upset Ms. Miller and her colleagues, who were accustomed to working regular hours. The friction between management and the OR team escalated in early 2007, when most pediatric procedures, including inpatient cases, were moved to the ASC.

During this time, however, the head of the ASC called Ms. Miller an "excellent clinician" and "fabulous nurse" and noted she was "a tremendous asset" during an annual review conducted in September 2008. A few weeks later, Ms. Miller was promoted and praised for her clinical expertise and dedication.

But then things began to snowball. In December 2008, the ASC supervisor told Ms. Miller she had received complaints about her constant use of inappropriate language. In early 2009, 3 nurses called the health system's compliance hotline to sound off about Ms. Miller's manipulation of the surgical schedule, apparently to punish nurses she didn't like; her failure to follow proper procedures, including the adequate cleaning of instruments; her habit of taking extended breaks; and her use of profanity and sexual innuendo among co-workers. The nurses said Ms. Miller intimidated and bullied the people with whom she worked.

During the ensuing investigation by Inova's HR manager, Ms. Miller authored an e-mail (signed also by 4 colleagues) to the supervisor in charge of training nurses. It requested that they receive notification of which nursing fellows were scheduled for a rotation through the ASC, how long the rotations would last, a list of learning objectives, and a way to adequately evaluate and document the fellows' progress. They also asked for weeklong breaks between rotations. The e-mail ended with, "We are committed to giving these fellows the best possible educational experience with all of our combined experience and guidance!"

The supervisor sent the e-mail to the ASC director, noting that she was "furious" that Ms. Miller acted as spokeswoman for the group and claiming that the group was talking behind her back and ganging up on her. At the time, the HR director found nothing objectionable in the e-mail. Three days later, however, the HR director discussed the e-mail and compliance hotline complaints with the chief of surgery. The chief said he admired Ms. Miller's clinical skills, but found her vindictive and put his full support behind her termination.

Ms. Miller was informed of the accusations and denied all but one: She admitted that, when a surgeon asked her what she'd done on New Year's Eve, she told him she'd been naked in a hot tub with her husband. Ms. Miller was placed on administrative leave and instructed not to discuss the disciplinary action with her colleagues.

Several surgeons offered to speak on her behalf, but were allegedly turned down by the HR director. Ms. Miller was terminated less than a month later for "creating a hostile work environment, excessive sharing of details of her personal life and using inappropriate language," according to the NLRB.

The NLRB ruled that Ms. Miller's initiation of a discussion about how certain aspects of the nursing training program ran, her request for a week's break between rotations and her raising of concerns over the transfer of cases to the ASC were activities protected by labor law and "particularly relevant to the terms and conditions of employment of the ASC nurses."

The NLRB also noted that inappropriate language was apparently part of the culture in the hospital's ORs, and tolerated by the health system for years. According to the ruling, nurses and surgeons often shared off-color jokes, a monthly calendar that hung in the operating room depicted a cartoon penis and posters made by a pediatric surgeon featured images of a nurse's face superimposed on provocative magazine covers. Additionally, the board noted, Ms. Miller's punishment was much more severe than the 3 written warnings given to a surgical tech who shared sexually explicit photos of herself with colleagues.

Ms. Miller will receive lost wages and benefits as restitution. Her attorney, Paul Tyler, says he is pleased the board did its job and that the mistreatment of his client has been rectified. He says she has moved on from the ordeal and has not returned to work for Inova.

As for Inova, however, "Because it is possible we will appeal the decision, we have no comment at this time," says spokesperson Tracy Connell.

Daniel Cook

InstaPoll: What Matters Most to Surgeons?

Besides free lunch and prime parking spaces, what matters most to surgeons when deciding where to bring their cases? Tell us in this week's InstaPoll, then check back next week for the results.

Most of the 326 respondents to last week's poll about disasters have had to deal with unruly patients and natural disasters, although a small percentage have faced criminal activity. The results:

Which incident did you last have to handle?

  • armed intruder 2%
  • bomb threat 2%
  • natural disaster (hurricane) 26%
  • unruly patient 67%
  • robbery 3%

Dan O'Connor

News & Notes
  • Lactated Ringer's recalled One confirmed customer report of mold contamination has led manufacturer Hospira to voluntarily recall 1 lot of lactated Ringer's and 5% dextrose injection, USP, 1000mL, in flexible containers. The lot, number 35-118-JT, with an expiration date of Nov. 1, 2015, was distributed nationally between December 2013 and February 2014. The company says it has received no other reports of adverse events, and that it has implemented corrective actions.
  • A better ACL repair Anterior cruciate ligament reconstructions are more likely to fail with allografts (tissue harvested from donors) than with autografts (tissue harvested from the patient), a recent study suggests. The authors followed 99 patients, whom they described as young and athletic, for 10 years after surgery. More than 80% of the grafts remained intact, but those which used allograft material were more than 3 times as likely to fail (26.5%) as those with autografts (8.3%).
  • The trouble with new technology Rapid innovations in surgical technology invariably put patients at risk, according to the authors of a study appearing in JAMA Surgery. Researchers assessed the incidence of patient harm during the introduction of robotically assisted, minimally invasive radical prostatectomy and found that injuries increased twofold in 2006, the peak year for the technology's adoption at teaching hospitals. Noting that the technology has proven effective in experienced hands, and that the trend of technology's risks is not unique to robotic prostatectomy, the researchers call for national standardized training and credentialing programs and an independent, continuously updated tracking system for surgeons using new technologies.