Same-day surgery managers cry foul: Staff cutbacks threaten patient safety
Not enough nurses, orderlies can wreak havoc on your program
At a same-day surgery program that lacked a dedicated person to handle the laser, the laser wasn't put on "standby" status. The surgeon inadvertently stepped on the laser pedal during a laparoscopic cholecystectomy, and the laser fired and hit a blood vessel.
Such threats to patient safety are not uncommon in the current environment of staff cutbacks, same-day surgery managers say. Programs are not using a dedicated registered nurse to supervise lasers, for example. Hospi tals are trying to cut and control costs, and they look at an extra laser person as unnecessary, says Kay Ball, RN, MSA, CNOR, FAAN, perioperative consultant/educator for K&D Medical in Lewis Center, OH.
When procedures are complex, same-day surgery managers would be wise to have an extra person to control the laser, handle the fiber, and prepare the equipment, says Wendy Winer, RN, BSN, endoscopy surgery specialist at the Center for Women's Care and Reproductive Surgery and Emory School of Nursing, both in Atlanta. Ball points out, however, that many same-day surgery procedures, such as cervical ablations, are noninvasive and require little responsibility by the circulation nurse. With such procedures, "having only one nurse is very appropriate," she says.
New recommended practices on laser safety from the Association of Operating Room Nurses (AORN) don't specify that a nurse has to be dedicated to the laser program. (For more information on AORN's recommended practices, see insert.)
Having a dedicated person for the laser program isn't the only potential problem staffing cutbacks may create. Same-day surgery managers need to examine their skill mix constantly to make sure they're using the right people to perform the right tasks, suggests Ramona Conner, RN, MSN, perioperative nursing specialist at the Center for Nursing Practice, Health Policy, and Research at AORN.
"Some of the facilities I'm aware of that have done some cutbacks, to try to preserve nurses, have cut back too steeply on ancillary support personnel - orderlies, technicians, and secretarial people," Conner says. "The RN ends up not only having to care for the patient but do non-nursing tasks and functions. Some are wasting RN skills on non-nursing functions."
Shortages jeopardize careThere aren't enough staff to move and position patients, same-day surgery managers complain. "If the patients begin to wake up, they have to be secured to the bed or have someone standing there with them," Winer says.
Positioning patients is particularly critical, she says. "If the legs have been in stirrups for a long time, the legs need to be brought down together," she says. "It almost always takes two people to adequately do that."
With the shortage of staff, all of these situations are potential safety hazards, Winer says. "They are accidents waiting to happen," she says.
Another growing area of concern in same-day surgery staffing is the practice of having non- specialized nursing in programs that do a broad spectrum of cases. "In many places, a couple of years ago, programs would have nurses specialize in lap general surgery, GYN laparoscopy, and other different areas," Winer says "Now there's not enough staff to do that."
Nurses should be cross-trained if they are expected to handle new responsibilities, she says. "In one day, you may be in on ENT cases, eye cases, and plastic surgery," she says. "Because of staffing shortages, these people have to be properly trained."
In some same-day surgery programs, staffing cutbacks have led to RNs being replaced with unlicensed assistive personnel (UAPs). In fact, a proposed rule change from the Health Care Financing Administration would eliminate RN supervision in the OR. (For more details, see Same-Day Surgery, April 1998, p. 49.)
"[UAPs] don't have the ability to assess patients," Ball warns. "Administrators are thinking, 'We'll put unlicensed people there.' Patients aren't getting the skilled nursing care they deserve and are paying for." (For information on AORN's stand on UAPs, see SDS, March 1998, p. 46.)
Are you rushed to open cases?Another concern is the shortage of nurses to open cases. "There's a push from administration to do as many cases as possible in as short a time as possible," Winer says. Frequently, there are only enough staff for one nurse to start the cases. "That means that something could happen." For example, in the rush to open a case, a nurse might turn on the light source when the light cable is not attached to the laparoscope; the cable could be lying on a patient drape.
"The light cable should not be turned on unless it's attached to a scope," Winer says. "Otherwise, it could start a fire."
Many same-day surgery programs have decided to use two people to open the case. "You can't sacrifice safety because you're in a hurry," she says.
What you can doSo what's the solution? No. 1: Hire the right people. Same-day surgery is a very technologically intensive area, points out Jayne Byrd, BSN, director of surgical services at Rex Healthcare, a corporation of health care providers, including a hospital and freestanding surgery center, based in Raleigh, NC.
"From my perspective, the demand for services and the subsequent broad skill mix nurses must have are our biggest problems," she explains. Having multiskilled workers is a high priority.
"We try to recruit people with strong same-day surgery experience or strong ambulatory experience. They understand the work, the intensity, the pace, and have the ability to respond quickly from the perspective of thinking on their feet."
Byrd's corporation has been proactive in this area. For example, they've hired new graduates and "grown their own" multiskilled workers. "We also worked with schools of nurses, gotten the students into our environment, and we're helping them understand that ambulatory surgery is the wave of the future. If they're not teaching it to students, they're doing them a disservice."
Byrd's ace in the hole is hiring experienced inpatient OR nurses. Often, they're anxious to work the weekday, daytime hours. It's also critical to hire staff who think about the next case, she says. Look for applicants who have out-of-the-box thinking. Some applicants may come in and say, "I'm only looking for x, y, and z.
"Health care is changing," Byrd points out. "If they don't have great tolerance for change, they're probably not the people we want."
Get applicants to talk about their background, she suggests. "If they say, 'We've always done it this way, and it works for us,'" recognize the red flag, she suggests.
"If they say, for example, 'Hasn't health care changed immensely? Cataract patients are now ambulatory,' it shows people are aware of those changes and see it as positive growth," she says. "These are the people we embrace." (Another way to avoid potential threats to patient safety is to perform a job functional analysis. See story, p. 62.)
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content