Do sacred cows’ still graze in your OR?
Evaluate rituals with eye to outcome, safety
(Editor’s note: In this first part of a two-part series, we discuss rituals that exist because "it’s always been done that way." In next month’s issue, we’ll discuss five infection control practices and whether they can be safely changed.)
They still graze in and around some operating rooms (ORs), but many "sacred cows" have been put out to pasture as a result of new technology, updated infection control guidelines, and the persistence of same-day surgery staff members who constantly ask the question, "Why are we doing this?"
"Sacred cows are rituals or guidelines that we have routinely followed in the operating room without questioning the origin or the necessity," explains Hilda Guevara, RN, BSN, facility administrator of Central Park Surgery Center in Austin, TX. "Because infection control issues are easy to identify and it is easy to measure outcomes of changes in infection control practices, it is always a good area in which to identify sacred cows."
Same-day surgery managers are the most likely people to find rituals routinely performed in inpatient surgery unnecessarily carried over to same-day surgery, Guevara adds. "Outpatient surgery tends to be cleaner, so some of the more traditional rituals, such as mopping the whole OR floor and wearing cover gowns and shoe covers, are not as necessary," she explains. Other sacred cows that are being shown the pasture include expiration dating on sterile packages, skin preparation techniques, timing for surgical hand scrubs, and hair removal, Guevara says.
Changing any practice within the OR needs to be approached carefully, suggests Peggi Hood, RN, BSN, administrator of Worcester (MA) Surgical Center. Conduct a literature search to see what the accepted standard is in other surgical programs, check guidelines that address the activity you are evaluating, verify accreditation standards or licensing rules, and make your decision based on information that is relevant to your same-day surgery program, Hood suggests.
You also must be prepared not to make a change if your research doesn’t support a change, Hood adds. A recent issue her staff evaluated came after an anesthesiologist suggested that parents staying with children who were being put to sleep did not need to dress in the coveralls, hats, and shoe covers. (For more information about parents in the OR, see Same-Day Surgery, December 2001.) "His reason for suggesting this change was to be more user-friendly to the patients," Hood explains.
After the literature search and guideline review, Hood then looked at the standard of care throughout her program. "We don’t let any other people into an OR without the coveralls, so we decided that even if there was no higher risk to patients, we couldn’t treat our pediatric patients with a different standard of care than our other patients," she says. For this reason, parents still wear coveralls and hats, but no shoe covers. "We realized that we didn’t require shoe covers of everyone, so we make the shoe cover decision on a case-by-case basis," she says.
Don’t follow the herd
It is important to only make changes that make sense for your same-day surgery program, Hood points out. "We perform a lot of cataract procedures and insertion of ear tubes, so there is little possibility of contamination from blood or other body fluids in most cases," she says. Until five years ago, her staff were mopping the entire OR between each of these cases. "Now, we don’t mop at all between cataract or ear-tube cases," she says. In the rooms in which other surgical procedures are performed, her staff only mop the area immediately around the patient, she adds.
Be prepared for reluctance to change, says Marimargaret Reichert, RN, MA, administrator of the Surgical Care Center at Southwest General Health Center in Middleburg Heights, OH. "Surgeons are often reluctant to change practices related to surgical hand scrubs and skin preparation, while nurses and other operating room staff are hesitant to change practices related to expiration dates, cover gowns, and mopping between cases," explains Reichert. (One surgery center was cited by the Centers for Medicare & Medicaid Services for having an "immediate jeopardy" deficiency that put patients’ lives at risk after state examiners noticed a surgeon using an alcohol-based product between cases in place of a surgical scrub. For more information, see Same-Day Surgery, July 2001.)
The best way to address any reluctance to change is to get team involvement, says Reichert. "Include representatives from infection control, risk management, anesthesia, the OR staff, and the surgeons in the evaluation of changes," she says. When discussing the issues, focus on outcomes and develop indicators for monitoring and validating changes you make, she adds.
Consult professional organizations
"We also look at a variety of guidelines and check with other same-day surgery programs in our network," says Hood. The Centers for Disease Control in Atlanta, the Association for Professionals in Infection Control and Epidemiology in Washington, DC, and the Association of periOperative Registered Nurses in Denver all are good sources of guidelines, she says.
The elimination of the shoe cover requirement is one of the hardest rituals for Guevara to let go of since she started her OR nursing career in San Antonio, near many cattle ranches. "We had one surgeon who visited his cattle every morning before he came into surgery," she explains. "Because he didn’t change shoes, we insisted that he always wear shoe covers!"
Sources
For more information about "sacred cows" in the operating room, contact:
• Hilda Guevara, RN, BSN, Facility Administrator, Central Park Surgery Center, 900 W. 38th St., Suite 200, Austin, TX 78705. Telephone: (512) 323-2061. Fax: (512) 323-2062. E-mail: [email protected].
• Peggi Hood, RN, BSN, Administrator, Worcester Surgical Center, 300 Grove St., Worcester, MA 01605. Telephone: (508) 754-0770. E-mail: [email protected].
• Marimargaret Reichert, RN, MA, Administrator, Surgical Care Center Southwest General Health Center, 18697 Bagley Road, Middleburg Heights, OH 44130. Telephone: (440) 816-2794. E-mail: [email protected].
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