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2017 Conference Poster Winners
2017 CONFERENCE POSTER WINNERS
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ORN Global Surgical Conference & Expo 2017 attendees had the opportunity to earn up to 34 contact hours by reviewing and evaluating 53 research and 36 evidence-based practice posters in 10 poster sessions, and 227 clinical improvement/innovation posters in 24 poster sessions. If you were unable to view the posters in person, you can view the virtual posters of those poster authors who agreed to share their posters online. Go to http://www .eventscribe.com/2017/posters/aorn/home.asp or download the AORN Posters app.
RESEARCH POSTERS The top three posters in the research category were recognized with an award by members of AORN’s Nursing Research Committee. Following are the abstracts from the top three research posters.
1st Place: The “Tipping Point”: A Qualitative Exploration of Decisionmaking for Bariatric Surgery Janice A. Neil, PhD, RN, CNE; Donna W. Roberson, PhD, FNP-BC; Mary Ann Rose, EdD, RN; Mary Lisa Pories, PhD, MSW, LCSW Problem/purpose: There are more than 78 million Americans with obesity who are eligible for bariatric surgery. Little is known about the factors that lead a patient to make the final decision to undergo bariatric surgery. This study explored the impetus or “tipping point” to move forward with bariatric surgery. Literature review: Bariatric surgery, recognized as the most effective treatment for severe obesity, has been shown to result in sustained weight loss and the resolution of comorbidities. There is limited literature describing the decision to have bariatric surgery and what the final tipping point is for making their decision. Research question/hypothesis: The purpose of this study was to explore factors that brought patients to that tipping point in making their decision related to proceeding with bariatric
1st place in the research category: The “Tipping Point”: A Qualitative Exploration of Decision-making for Bariatric Surgery. Pictured: Janice A. Neil (left) and Donna W. Roberson (right). surgery. We asked: “Tell me about how you decided to have weight loss surgery.” Methodology: This qualitative descriptive study was set in a bariatric surgical clinic with a purposeful sample of patients (N ¼ 24) seen at the “decision visit” (appointment when the final decision to have surgery is made). Semistructured interviews were conducted, beginning with an open-ended question, and then refining questions explored factors contributing to their decision. Data analysis: A modification of Colaizzi’s procedural steps of analysis was used to organize the data. The research team individually and jointly analyzed the data and grouped significant statements into clusters. These clusters were distilled into two emergent themes that informed the decision to proceed with surgery. All four researchers agreed with the findings, which served as control bias. Results: Worsening health and low energy were major decision-makers. Participants also noted additional factors such as financial considerations and family influences. The two major themes that emerged were HEALTH and the JOURNEY to the tipping point. HEALTH included items such as “Sick and tired of being sick and tired,” declining health, complaints of fatigue/tiredness/energy loss, and http://dx.doi.org/10.1016/j.aorn.2017.04.001 ª AORN, Inc, 2017
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bariatric surgery as a way to reduce or remit chronic disease. The JOURNEY to the tipping point included immobility issues, desire to be active with children/grandchildren, acquisition of health insurance, and inability to fit in chairs or tight spaces. Conclusions/discussion/perioperative nursing implications: The decision to move ahead with bariatric surgery was multifaceted. Further research is warranted to fully understand this phenomenon and develop appropriate outreach and educational approaches. Understanding the key factors that crystallized the decision to move forward with surgery is significant. Perioperative nurses should understand that the decision to proceed with bariatric surgery is complex and has many facets.
2nd Place: Cooling Time for Warmed Irrigation Fluids to Safe Instillation Temperature Faye S. Baker, MSN, APRN, CCNS, CNS-CP, CPAN; Eric Cockrell, MSN, RN, CHES, CNOR; Ann Dennis, RN, CNOR Strong evidence supports warming surgical irrigation fluids to decrease the incidence of perioperative hypothermia. The ECRI Institute recommends that irrigation fluids can be safely warmed to 110 F (43.3 C) in fluid warmers. To prevent tissue burns, however, AORN guidelines recommend that irrigation fluid temperature should be between 91.4 F and 104 F (33 C and 40 C) at the time of instillation into a body cavity. AORN guidelines further recommend that the temperature of irrigation fluid be measured at the point of use with an FDA-approved device. Implementation of these guidelines can be challenging because many ORs are not equipped with the necessary temperature-measuring devices. This study examined the time needed for fluids warmed at 110 F (43.3 C) to cool to the recommended temperature range (91.4 F to 104 F [33 C to 40 C]) in different room temperature environments. The study results indicate that cooling time is dependent upon several variables, such as room temperature and fluid volume. Fluids immediately begin to cool rapidly upon removal from the warmer. Additionally, the cooling process is slowed with larger fluid volumes (such as a 3000 mL bag versus a 1000 mL bag or bottle) and higher room temperatures (such as 75 F versus 60 F [23.9 C versus 15.6 C]). Clinical implications of this study support point-of-use temperature-measuring devices or irrigation fluidewarming systems that maintain continuous warming at a set temperature.
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2nd place in the research category: Cooling Time for Warmed Irrigation Fluids to Safe Instillation Temperature. Pictured: Eric Cockrell.
3rd Place: Moderating Effects of Case-Mix on Operating Room Utilization Cheryl Elliott-Dawe, MSN, RN, CNOR The purpose of this study is to determine the impact case-mix has on the relationships between OR utilization and turnover time, late starts, idle time, cancellation rates, and delays. Perioperative services must efficiently utilize OR facilities to improve financial outcomes for the institution and quality outcomes for the patient. Hospital executives typically monitor five metrics of OR nonuse as measures of OR efficiency: late start, turnover time, idle time, cancellation rate, and delay. Although many studies have investigated the impact of one or two OR metrics, no comprehensive examination of the interrelationship of all five of them exists. Further, no research has been found on delineating the moderating role case-mix has on the relationships between OR metrics and OR utilization. Which of the OR metrics have the greatest impact on OR utilization? What role can the ratio of inpatient to outpatient play to improve OR utilization? A conceptual framework was conceived in which case-mix moderates the relationship between each OR metric and the dependent variable of OR utilization. Several years of data are being extracted from an academic medical center surgical data repository and submitted to multiple- and single-regression analyses to determine the strength and direction of the relationships among the variables. Data collection and analyses will be completed by December. Two considerations will frame the analyses and interpretations of results. First, the correlations and coefficients of determination will establish the relative impact each of the five metrics has on OR utilization. Second, the ideal case-mix ratio to maximize OR utilization will be delineated. It is anticipated that the results of this study AORN Journal j 555
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3rd place in the research category: Moderating Effects of Case-Mix on Operating Room Utilization. Pictured: Cheryl Elliott-Dawe. will help inform decisions about perioperative services process improvements.
EVIDENCE-BASED PRACTICE POSTERS The top posters in the evidence-based practice category were recognized with an award by members of AORN’s Nursing Research Committee. Following are the abstracts from the top three evidence-based practice posters.
1st Place: Temperature of Warmed Irrigation Fluids at Point-of-Care When Using Warming Cabinets Jack Stecher, MD; Linda F. Homan, BSN, RN, CIC Clinical problem/significance: Hypothermia increases the risk of surgical wound infection, blood loss, postoperative shivering, thermal discomfort, time-to-extubation, duration of postanesthesia recovery, and the incidence of morbid cardiac outcomes. Hypothermia can be prevented through the combined use of several warming measures, including warmed irrigation fluids. Background: AORN’s 2015 “Guideline for prevention of unplanned perioperative hypothermia” states that instillation of warmed irrigation fluids minimizes heat lost through radiation, that irrigation fluids should be warmed to normal body temperature (37 C [98.6 F]), and the fluid temperature verified before use (see Editor’s note). Clinical question: Are irrigation fluids that are stored in a warming cabinet, then poured into an unwarmed container prior to first use, delivered at or above 37 C (98.6 F)? 556 j AORN Journal
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1st place in the evidence-based practice category: Temperature of Warmed Irrigation Fluids at Point-ofCare When Using Warming Cabinets. Pictured: Linda F. Homan (left) and Jack Stecher (right).
Description of evidence-based protocol: The temperature of irrigation fluids delivered during nonemergent cesarean section procedures from a convenience sample of 50 private or walk-in patients was measured using an infrared thermometer at three time points: upon removal from the cabinet warmer, after pouring into a container on the surgical back table, and upon first use. The elapsed time from pouring saline into the pitcher to first use was also recorded. Implementation of evidence-based protocol: Data was collected by the anesthesiologist, anesthetist, OR nurse, or OR technician over an 11-month period. Liter bottles of saline solution were stored in a warming cabinet located inside the OR suite. Just prior to anticipated use, saline was retrieved from the warming cabinet and poured into a roomtemperature plastic pitcher on the surgical back table. The elapsed time from pouring into the pitcher to the point of use was recorded. The temperature of the fluid was measured as described above. Results: The average temperature of saline upon removal from the cabinet warmer was 35 C (95 F) (range ¼ 37.50 C to 31.94 C [96.26 F to 89.49 F]). The average temperature of saline after pouring into the unwarmed pitcher was 33.02 C (91.43 F) (range ¼ 25.00 C to 36.39 C [77 F to 97.5 F]). The average temperature of the saline at the time of first use was 27.76 C (81.97 F) (range ¼ 19.44 C to 32.61 C [66.99 F to 90.7 F]). The average time to first use of saline once poured into the container was 16 minutes (range ¼ 3 to
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39 minutes). The average temperature decrease from removal from the cabinet to first use was 7.24 C (13.03 F). Conclusions/discussion: In this study, irrigation fluids that were stored in a warming cabinet inside the perioperative suite and then poured into an unwarmed container prior to use were consistently delivered to the patient below 37 C (98.6 F). Perioperative nursing implications: The combined use of a cabinet warmer and unwarmed containers as a method to provide warmed irrigation fluids resulted in 100% of those fluids being delivered below the temperature recommended to help maintain normothermia. Editor’s note: The AORN “Guideline for prevention of unplanned patient hypothermia” was updated in 2016. The updated guideline no longer specifically recommends that irrigation solutions be warmed to normal body temperature, 37 C (98.6 F). The updated guideline recommends that irrigation solutions should be warmed to between 33 C and 40 C (91.4 F and 104 F). For the most current recommendations, see the “Guideline for prevention of unplanned patient hypothermia.” In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2017:567-590.
2nd Place: Decreasing Surgical Site Infections in Coronary Artery Bypass Surgery Ann Marie Cooney, RN, BSN; Frances Edwards, RN, SNP, CIC; John Karapatis, PA-C, MBA; Julie Martusciello, RN, MSN; John J. McCabe, RN, CNOR; Kristen Rojas, RN, MS, NE-BC; Alan R. Hartman, MD Purpose: In coronary artery bypass graft (CABG) surgery, postoperative wound infections are one of the most costly and dangerous complications that can occur. Our 2014 facility data showed an increased rate of postoperative surgical site infections (SSIs) in CABG patients, greater than the New York state average benchmark of 2.24%. Methods: In 2015, Southside Hospital set out to lower its sternal wound SSIs by instituting OR protocol changes and standardized protocol for incision care, including the use of silver-impregnated dressings. Beginning January 2015, all CABG patients had silver dressings applied to the sternal and vein harvest sites under sterile conditions in the OR. Additionally, the use of the irrigation gun was eliminated and sternal wires were not opened until ready for use. Postoperatively, the dressings were maintained without interruption until postoperative day 5, except if
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2nd place in the evidence-based practice category: Decreasing Surgical Site Infections in Coronary Artery Bypass Surgery. Pictured (from left to right): John J. McCabe, Ann Marie Cooney, Kristen Rojas, and Julie Martusciello. the day of discharge was before postoperative day 5, or the dressing was 75% saturated and needed replacing. In this case, the dressing was replaced by the medical staff using aseptic technique. Postoperatively, patients received daily baths with chlorhexidine wipes for five days, or the day of discharge if less than five days. Following the dressing removal and incision(s) assessments, the patients showered before discharge. Results: The 2014 CABG SSI rate was 3.5 and the 2015 rate was 0.5 per 100 procedures, demonstrating a 75.5% reduction in SSIs. Conclusion: The aforementioned operating procedural changes and standardized incision care may be valuable in decreasing the incidence of sternal wound infections.
3rd Place: It’s an Open and Shut Case: Airflow and Ventilation in the Operating Room Rachel Wisner, BSN, RN, CNOR Purpose: Patient safety in the OR is a multifactorial approach when caring for surgical patients. One important aspect commonly overlooked is the functionality and effectiveness of the ventilation system and airflow. These components work to provide the purest air within the OR suite by decreasing the bacterial air contamination and reducing the risk for a surgical site infection. At an academic, community, Magnet-designated Level I trauma center, an evidence-based practice project was conducted to determine if educating OR staff, contracted staff, AORN Journal j 557
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CLINICAL IMPROVEMENT/INNOVATION POSTERS This year, posters were again judged online using the virtual gallery. Only posters that were uploaded were judged, and the top 10% of those posters received an Award of Excellence (Sidebar 1). The posters were judged by the AORN Global Surgical Conference & Expo 2017 Task Force. The top poster is listed below.
1st Place: Heart Liver TransplantationdInnovative Multi-disciplinary Approach 3rd place in the evidence-based practice category: It’s an Open and Shut Case: Airflow and Ventilation in the Operating Room. Pictured: Rachel Wisner. and outside vendors on airflow, ventilation, and the effects of door openings leads to a decrease of unnecessary OR door openings between the time sterile supplies are opened and when the patient leaves the OR. Methodology: Digital door counters were used to track the number of door openings from the time sterile supplies were opened to the time the patient left the OR suite. Other data collected included the time supplies were opened, procedure start, procedure closure, and out-of-room time, along with the type of procedure and the number and role of staff present in the room. After initial data collection, education explaining positive and negative air pressure, conventional ventilation, laminar air flow ventilation, and the effect door openings have on air pressure and room ventilation was provided to the multidisciplinary staff of the OR. Results: A posteducation data collection was conducted using the same methods as the initial data collection. Upon conclusion of the posteducation data collection and a complete data analysis, actions to reinforce education and facilitate a change in clinical practice to better care for the surgical patient will be determined. Perioperative nursing implications: Providing OR staff with airflow and ventilation education and evidence-based practice recommendations will create a cultural shift, thus limiting door openings to provide the highest quality of care and a lowered risk for a surgical site infection to the surgical patient. Editor’s note: ANCC Magnet Recognition is a registered trademark of the American Nurses Credentialing Center, Silver Spring, MD. 558 j AORN Journal
Ella Echavez, MBA, RN, BSN, CNOR; Christen M. Meyers, BSN, RN, CNOR; Elizabeth M. Thorne, BSN, RN; Amy Lu, MD, MPH, MBA Organ transplantation already requires a dedicated multidisciplinary team. Simultaneous multi-organ transplantation presents a unique set of clinical challenges. Dedicated OR teams for abdominal and cardiothoracic transplantation exist in parallel and do not cross over because the perioperative management of these two groups is very distinct and different. However, in the clinical scenario of a simultaneous combined heart-liver transplant, there needs to be an integration of the two teams. We will present a singlecenter experience of the interdisciplinary approach and integration process for simultaneous en bloc heart-liver transplantation. In both liver and cardiac transplantation, a dedicated team of anesthesiologists, surgeons, perfusion specialists, and OR nurses are involved. For cardiac transplantation, there are specific considerations of the cardiopulmonary bypass, fluid status, as well as systemic blood pressure and pulmonary pressures. The patient is fully heparinized on the bypass machine. In liver transplantation, there are considerations of bleeding function, fluid management, and volume status. In preparation for combined en bloc transplantation, the differing needs of the teams were recognized and had to be addressed. Organized meetings were held with members of each team to discuss the relevant issues for the surgeons, the anesthesiologists, and nurses. Given the special circumstance of simultaneous en bloc transplantation, two teams of nurses, surgeons, and anesthesiologists are involved, as well as all of the equipment required for the surgeries. The intraoperative nursing plan of care and these special considerations were paramount to the success of the transplant. The assessment of the operative room, equipment, and surgical needs were considered, as
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Sidebar 1. Clinical Improvement/Innovation Poster Award of Excellence Winners A Quality Improvement Project: How Increased Communication and Collaboration Improved the Care of Perioperative Patients Catherine Jennings, BSN, RN, CNOR; Tierney PalmerKlein, BSN, RN; Heather Smith, BSN, RN, CMSRN; Rebecca T. Gilbert, DNP, RN, CCRN
1st place in the clinical improvement/innovation category: Heart Liver TransplantationdInnovative Multidisciplinary Approach. Pictured: Ella Echavez (left) and Elizabeth M. Thorne (right). well as the most basic process of where the scrub nurse would stand for each primary surgeon (cardiac versus abdominal). Planning involved discussions, meetings, and diagrams of the equipment and positioning of the patient and room choice. Planning for implementation included consolidation and adoption of clinical pathways, conceptual dry runs, and protocol development. From the planning and preparation, utilizing an integrated interdisciplinary approach and having two completely separate teams work in conjunction led to a successful en bloc transplantation of a heart-liver patient. The implications of understanding the needs and to develop a clear process utilizing dry runs and team meetings can be extrapolated to other areas in developing cutting-edge programs for an institution.
Assessing Nursing Knowledge and Confidence of Operating Room Standards for Emergency Trauma Operations Mary Jeskey, BSN, RN, CNOR; Elizabeth Card, MSN, APRN, FNP-BC, CPAN, CCRP; Lily Bell Durias, BSN, RN, CNOR; Oscar Guillamondegui, MD, MPH; Mayur Patel, MD, MPH, FACS; Travis Hamilton, DO; Cynthia Townsend, MTHS, BSN, RN, CNOR; Karen Ferris, BS, RN, CNOR; Nancy Wells, DNSc, RN Clinical Innovation: Developing a Wide Awake Hand Surgery (WALANT) Protocol Jodi Pelkey, BSN, RN, CNOR; Catherine Riedel, RN, MSN, ACNS-BC, CCNS, CCRN Creating a Culture of Courtesy and Respect by Thanking Our Patients AnneMarie O’Toole, RN Identification & Prevention of Pressure Ulcers Acquired During Perioperative Care Cam Felisimino, RN, MSN; Tyler French Immediate Use Steam Sterilization: It’s Everyone’s Business Renee Lawrence, MNSc, RN, ACNS-BC; CNOR, APRN; Lori Berry, BSN, RN, CNOR; Kenny Worley, ADN, CNOR Implementation of a Cardiac Skills Program Maureen Hemingway, DNP, RN, CNOR; Mildred Mannion, BSN, RN, CNOR Implementing Count Boards to Improve Team Communication and Increase Patient Safety in a Community Hospital Carol B. Leon, MS, BSN, RN, CNOR; Maryellen Rowley, BSN, RNFA, CNOR
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Intra-professional Collaboration for Safe Chemotherapy Administration Lauren Fujihara, MN, RN, CNOR, CNS; Stephanie Jackson, MSN, RN, AOCNS, BMTCN; Joecelyn Densing, MSN, RN It Takes a Village: A Team Approach to Lower SSI Rates Megan Lamoreux, BSN, RN, CNOR; Stella Gebhardt, BSN, RN; Diane Hady, BSN, RN Nurse Patient Advocate: Reducing Surgical Site Infections in Neuro Surgical and Spine Patients Cecil Chan, RN, BSN, CNOR
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Reducing the Incidence of Spinal Fusion SSIs Sharon M. Rossi, MS, RNC; Mary Beth Riegel, BSN, RN, CNOR; Sylve Masih, RN, MS, CNOR Reduction of Operating Room Holds by Multidisciplinary Influence Mary Korte, MSN, MHA, RN, CNOR What Goes In, Must Come Out! An Approach to Monitoring Therapeutic Packing Paula Marentay, RN, CNOR; Jane Thomson, MPH, BSN, RN, CNOR Working Together: An Interdisciplinary Approach to Decreasing Instrumentation Issues Leah Goldberg, BSN, RN, CNOR
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ORN Global Surgical Conference & Expo 2017 attendees had the opportunity to earn up to 34 contact hours by reviewing and evaluating 53 research and 36 evidence-based practice posters in 10 poster sessions, and 227 clinical improvement/innovation posters in 24 poster sessions. If you were unable to view the posters in person, you can view the virtual posters of those poster authors who agreed to share their posters online. Go to http://www .eventscribe.com/2017/posters/aorn/home.asp or download the AORN Posters app.
RESEARCH POSTERS The top three posters in the research category were recognized with an award by members of AORN’s Nursing Research Committee. Following are the abstracts from the top three research posters.
1st Place: The “Tipping Point”: A Qualitative Exploration of Decisionmaking for Bariatric Surgery Janice A. Neil, PhD, RN, CNE; Donna W. Roberson, PhD, FNP-BC; Mary Ann Rose, EdD, RN; Mary Lisa Pories, PhD, MSW, LCSW Problem/purpose: There are more than 78 million Americans with obesity who are eligible for bariatric surgery. Little is known about the factors that lead a patient to make the final decision to undergo bariatric surgery. This study explored the impetus or “tipping point” to move forward with bariatric surgery. Literature review: Bariatric surgery, recognized as the most effective treatment for severe obesity, has been shown to result in sustained weight loss and the resolution of comorbidities. There is limited literature describing the decision to have bariatric surgery and what the final tipping point is for making their decision. Research question/hypothesis: The purpose of this study was to explore factors that brought patients to that tipping point in making their decision related to proceeding with bariatric
1st place in the research category: The “Tipping Point”: A Qualitative Exploration of Decision-making for Bariatric Surgery. Pictured: Janice A. Neil (left) and Donna W. Roberson (right). surgery. We asked: “Tell me about how you decided to have weight loss surgery.” Methodology: This qualitative descriptive study was set in a bariatric surgical clinic with a purposeful sample of patients (N ¼ 24) seen at the “decision visit” (appointment when the final decision to have surgery is made). Semistructured interviews were conducted, beginning with an open-ended question, and then refining questions explored factors contributing to their decision. Data analysis: A modification of Colaizzi’s procedural steps of analysis was used to organize the data. The research team individually and jointly analyzed the data and grouped significant statements into clusters. These clusters were distilled into two emergent themes that informed the decision to proceed with surgery. All four researchers agreed with the findings, which served as control bias. Results: Worsening health and low energy were major decision-makers. Participants also noted additional factors such as financial considerations and family influences. The two major themes that emerged were HEALTH and the JOURNEY to the tipping point. HEALTH included items such as “Sick and tired of being sick and tired,” declining health, complaints of fatigue/tiredness/energy loss, and http://dx.doi.org/10.1016/j.aorn.2017.04.001 ª AORN, Inc, 2017
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bariatric surgery as a way to reduce or remit chronic disease. The JOURNEY to the tipping point included immobility issues, desire to be active with children/grandchildren, acquisition of health insurance, and inability to fit in chairs or tight spaces. Conclusions/discussion/perioperative nursing implications: The decision to move ahead with bariatric surgery was multifaceted. Further research is warranted to fully understand this phenomenon and develop appropriate outreach and educational approaches. Understanding the key factors that crystallized the decision to move forward with surgery is significant. Perioperative nurses should understand that the decision to proceed with bariatric surgery is complex and has many facets.
2nd Place: Cooling Time for Warmed Irrigation Fluids to Safe Instillation Temperature Faye S. Baker, MSN, APRN, CCNS, CNS-CP, CPAN; Eric Cockrell, MSN, RN, CHES, CNOR; Ann Dennis, RN, CNOR Strong evidence supports warming surgical irrigation fluids to decrease the incidence of perioperative hypothermia. The ECRI Institute recommends that irrigation fluids can be safely warmed to 110 F (43.3 C) in fluid warmers. To prevent tissue burns, however, AORN guidelines recommend that irrigation fluid temperature should be between 91.4 F and 104 F (33 C and 40 C) at the time of instillation into a body cavity. AORN guidelines further recommend that the temperature of irrigation fluid be measured at the point of use with an FDA-approved device. Implementation of these guidelines can be challenging because many ORs are not equipped with the necessary temperature-measuring devices. This study examined the time needed for fluids warmed at 110 F (43.3 C) to cool to the recommended temperature range (91.4 F to 104 F [33 C to 40 C]) in different room temperature environments. The study results indicate that cooling time is dependent upon several variables, such as room temperature and fluid volume. Fluids immediately begin to cool rapidly upon removal from the warmer. Additionally, the cooling process is slowed with larger fluid volumes (such as a 3000 mL bag versus a 1000 mL bag or bottle) and higher room temperatures (such as 75 F versus 60 F [23.9 C versus 15.6 C]). Clinical implications of this study support point-of-use temperature-measuring devices or irrigation fluidewarming systems that maintain continuous warming at a set temperature.
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2nd place in the research category: Cooling Time for Warmed Irrigation Fluids to Safe Instillation Temperature. Pictured: Eric Cockrell.
3rd Place: Moderating Effects of Case-Mix on Operating Room Utilization Cheryl Elliott-Dawe, MSN, RN, CNOR The purpose of this study is to determine the impact case-mix has on the relationships between OR utilization and turnover time, late starts, idle time, cancellation rates, and delays. Perioperative services must efficiently utilize OR facilities to improve financial outcomes for the institution and quality outcomes for the patient. Hospital executives typically monitor five metrics of OR nonuse as measures of OR efficiency: late start, turnover time, idle time, cancellation rate, and delay. Although many studies have investigated the impact of one or two OR metrics, no comprehensive examination of the interrelationship of all five of them exists. Further, no research has been found on delineating the moderating role case-mix has on the relationships between OR metrics and OR utilization. Which of the OR metrics have the greatest impact on OR utilization? What role can the ratio of inpatient to outpatient play to improve OR utilization? A conceptual framework was conceived in which case-mix moderates the relationship between each OR metric and the dependent variable of OR utilization. Several years of data are being extracted from an academic medical center surgical data repository and submitted to multiple- and single-regression analyses to determine the strength and direction of the relationships among the variables. Data collection and analyses will be completed by December. Two considerations will frame the analyses and interpretations of results. First, the correlations and coefficients of determination will establish the relative impact each of the five metrics has on OR utilization. Second, the ideal case-mix ratio to maximize OR utilization will be delineated. It is anticipated that the results of this study AORN Journal j 555
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3rd place in the research category: Moderating Effects of Case-Mix on Operating Room Utilization. Pictured: Cheryl Elliott-Dawe. will help inform decisions about perioperative services process improvements.
EVIDENCE-BASED PRACTICE POSTERS The top posters in the evidence-based practice category were recognized with an award by members of AORN’s Nursing Research Committee. Following are the abstracts from the top three evidence-based practice posters.
1st Place: Temperature of Warmed Irrigation Fluids at Point-of-Care When Using Warming Cabinets Jack Stecher, MD; Linda F. Homan, BSN, RN, CIC Clinical problem/significance: Hypothermia increases the risk of surgical wound infection, blood loss, postoperative shivering, thermal discomfort, time-to-extubation, duration of postanesthesia recovery, and the incidence of morbid cardiac outcomes. Hypothermia can be prevented through the combined use of several warming measures, including warmed irrigation fluids. Background: AORN’s 2015 “Guideline for prevention of unplanned perioperative hypothermia” states that instillation of warmed irrigation fluids minimizes heat lost through radiation, that irrigation fluids should be warmed to normal body temperature (37 C [98.6 F]), and the fluid temperature verified before use (see Editor’s note). Clinical question: Are irrigation fluids that are stored in a warming cabinet, then poured into an unwarmed container prior to first use, delivered at or above 37 C (98.6 F)? 556 j AORN Journal
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1st place in the evidence-based practice category: Temperature of Warmed Irrigation Fluids at Point-ofCare When Using Warming Cabinets. Pictured: Linda F. Homan (left) and Jack Stecher (right).
Description of evidence-based protocol: The temperature of irrigation fluids delivered during nonemergent cesarean section procedures from a convenience sample of 50 private or walk-in patients was measured using an infrared thermometer at three time points: upon removal from the cabinet warmer, after pouring into a container on the surgical back table, and upon first use. The elapsed time from pouring saline into the pitcher to first use was also recorded. Implementation of evidence-based protocol: Data was collected by the anesthesiologist, anesthetist, OR nurse, or OR technician over an 11-month period. Liter bottles of saline solution were stored in a warming cabinet located inside the OR suite. Just prior to anticipated use, saline was retrieved from the warming cabinet and poured into a roomtemperature plastic pitcher on the surgical back table. The elapsed time from pouring into the pitcher to the point of use was recorded. The temperature of the fluid was measured as described above. Results: The average temperature of saline upon removal from the cabinet warmer was 35 C (95 F) (range ¼ 37.50 C to 31.94 C [96.26 F to 89.49 F]). The average temperature of saline after pouring into the unwarmed pitcher was 33.02 C (91.43 F) (range ¼ 25.00 C to 36.39 C [77 F to 97.5 F]). The average temperature of the saline at the time of first use was 27.76 C (81.97 F) (range ¼ 19.44 C to 32.61 C [66.99 F to 90.7 F]). The average time to first use of saline once poured into the container was 16 minutes (range ¼ 3 to
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39 minutes). The average temperature decrease from removal from the cabinet to first use was 7.24 C (13.03 F). Conclusions/discussion: In this study, irrigation fluids that were stored in a warming cabinet inside the perioperative suite and then poured into an unwarmed container prior to use were consistently delivered to the patient below 37 C (98.6 F). Perioperative nursing implications: The combined use of a cabinet warmer and unwarmed containers as a method to provide warmed irrigation fluids resulted in 100% of those fluids being delivered below the temperature recommended to help maintain normothermia. Editor’s note: The AORN “Guideline for prevention of unplanned patient hypothermia” was updated in 2016. The updated guideline no longer specifically recommends that irrigation solutions be warmed to normal body temperature, 37 C (98.6 F). The updated guideline recommends that irrigation solutions should be warmed to between 33 C and 40 C (91.4 F and 104 F). For the most current recommendations, see the “Guideline for prevention of unplanned patient hypothermia.” In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2017:567-590.
2nd Place: Decreasing Surgical Site Infections in Coronary Artery Bypass Surgery Ann Marie Cooney, RN, BSN; Frances Edwards, RN, SNP, CIC; John Karapatis, PA-C, MBA; Julie Martusciello, RN, MSN; John J. McCabe, RN, CNOR; Kristen Rojas, RN, MS, NE-BC; Alan R. Hartman, MD Purpose: In coronary artery bypass graft (CABG) surgery, postoperative wound infections are one of the most costly and dangerous complications that can occur. Our 2014 facility data showed an increased rate of postoperative surgical site infections (SSIs) in CABG patients, greater than the New York state average benchmark of 2.24%. Methods: In 2015, Southside Hospital set out to lower its sternal wound SSIs by instituting OR protocol changes and standardized protocol for incision care, including the use of silver-impregnated dressings. Beginning January 2015, all CABG patients had silver dressings applied to the sternal and vein harvest sites under sterile conditions in the OR. Additionally, the use of the irrigation gun was eliminated and sternal wires were not opened until ready for use. Postoperatively, the dressings were maintained without interruption until postoperative day 5, except if
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2nd place in the evidence-based practice category: Decreasing Surgical Site Infections in Coronary Artery Bypass Surgery. Pictured (from left to right): John J. McCabe, Ann Marie Cooney, Kristen Rojas, and Julie Martusciello. the day of discharge was before postoperative day 5, or the dressing was 75% saturated and needed replacing. In this case, the dressing was replaced by the medical staff using aseptic technique. Postoperatively, patients received daily baths with chlorhexidine wipes for five days, or the day of discharge if less than five days. Following the dressing removal and incision(s) assessments, the patients showered before discharge. Results: The 2014 CABG SSI rate was 3.5 and the 2015 rate was 0.5 per 100 procedures, demonstrating a 75.5% reduction in SSIs. Conclusion: The aforementioned operating procedural changes and standardized incision care may be valuable in decreasing the incidence of sternal wound infections.
3rd Place: It’s an Open and Shut Case: Airflow and Ventilation in the Operating Room Rachel Wisner, BSN, RN, CNOR Purpose: Patient safety in the OR is a multifactorial approach when caring for surgical patients. One important aspect commonly overlooked is the functionality and effectiveness of the ventilation system and airflow. These components work to provide the purest air within the OR suite by decreasing the bacterial air contamination and reducing the risk for a surgical site infection. At an academic, community, Magnet-designated Level I trauma center, an evidence-based practice project was conducted to determine if educating OR staff, contracted staff, AORN Journal j 557
2017 Conference Poster Winners
June 2017, Vol. 105, No. 6
CLINICAL IMPROVEMENT/INNOVATION POSTERS This year, posters were again judged online using the virtual gallery. Only posters that were uploaded were judged, and the top 10% of those posters received an Award of Excellence (Sidebar 1). The posters were judged by the AORN Global Surgical Conference & Expo 2017 Task Force. The top poster is listed below.
1st Place: Heart Liver TransplantationdInnovative Multi-disciplinary Approach 3rd place in the evidence-based practice category: It’s an Open and Shut Case: Airflow and Ventilation in the Operating Room. Pictured: Rachel Wisner. and outside vendors on airflow, ventilation, and the effects of door openings leads to a decrease of unnecessary OR door openings between the time sterile supplies are opened and when the patient leaves the OR. Methodology: Digital door counters were used to track the number of door openings from the time sterile supplies were opened to the time the patient left the OR suite. Other data collected included the time supplies were opened, procedure start, procedure closure, and out-of-room time, along with the type of procedure and the number and role of staff present in the room. After initial data collection, education explaining positive and negative air pressure, conventional ventilation, laminar air flow ventilation, and the effect door openings have on air pressure and room ventilation was provided to the multidisciplinary staff of the OR. Results: A posteducation data collection was conducted using the same methods as the initial data collection. Upon conclusion of the posteducation data collection and a complete data analysis, actions to reinforce education and facilitate a change in clinical practice to better care for the surgical patient will be determined. Perioperative nursing implications: Providing OR staff with airflow and ventilation education and evidence-based practice recommendations will create a cultural shift, thus limiting door openings to provide the highest quality of care and a lowered risk for a surgical site infection to the surgical patient. Editor’s note: ANCC Magnet Recognition is a registered trademark of the American Nurses Credentialing Center, Silver Spring, MD. 558 j AORN Journal
Ella Echavez, MBA, RN, BSN, CNOR; Christen M. Meyers, BSN, RN, CNOR; Elizabeth M. Thorne, BSN, RN; Amy Lu, MD, MPH, MBA Organ transplantation already requires a dedicated multidisciplinary team. Simultaneous multi-organ transplantation presents a unique set of clinical challenges. Dedicated OR teams for abdominal and cardiothoracic transplantation exist in parallel and do not cross over because the perioperative management of these two groups is very distinct and different. However, in the clinical scenario of a simultaneous combined heart-liver transplant, there needs to be an integration of the two teams. We will present a singlecenter experience of the interdisciplinary approach and integration process for simultaneous en bloc heart-liver transplantation. In both liver and cardiac transplantation, a dedicated team of anesthesiologists, surgeons, perfusion specialists, and OR nurses are involved. For cardiac transplantation, there are specific considerations of the cardiopulmonary bypass, fluid status, as well as systemic blood pressure and pulmonary pressures. The patient is fully heparinized on the bypass machine. In liver transplantation, there are considerations of bleeding function, fluid management, and volume status. In preparation for combined en bloc transplantation, the differing needs of the teams were recognized and had to be addressed. Organized meetings were held with members of each team to discuss the relevant issues for the surgeons, the anesthesiologists, and nurses. Given the special circumstance of simultaneous en bloc transplantation, two teams of nurses, surgeons, and anesthesiologists are involved, as well as all of the equipment required for the surgeries. The intraoperative nursing plan of care and these special considerations were paramount to the success of the transplant. The assessment of the operative room, equipment, and surgical needs were considered, as
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June 2017, Vol. 105, No. 6
2017 Conference Poster Winners
Sidebar 1. Clinical Improvement/Innovation Poster Award of Excellence Winners A Quality Improvement Project: How Increased Communication and Collaboration Improved the Care of Perioperative Patients Catherine Jennings, BSN, RN, CNOR; Tierney PalmerKlein, BSN, RN; Heather Smith, BSN, RN, CMSRN; Rebecca T. Gilbert, DNP, RN, CCRN
1st place in the clinical improvement/innovation category: Heart Liver TransplantationdInnovative Multidisciplinary Approach. Pictured: Ella Echavez (left) and Elizabeth M. Thorne (right). well as the most basic process of where the scrub nurse would stand for each primary surgeon (cardiac versus abdominal). Planning involved discussions, meetings, and diagrams of the equipment and positioning of the patient and room choice. Planning for implementation included consolidation and adoption of clinical pathways, conceptual dry runs, and protocol development. From the planning and preparation, utilizing an integrated interdisciplinary approach and having two completely separate teams work in conjunction led to a successful en bloc transplantation of a heart-liver patient. The implications of understanding the needs and to develop a clear process utilizing dry runs and team meetings can be extrapolated to other areas in developing cutting-edge programs for an institution.
Assessing Nursing Knowledge and Confidence of Operating Room Standards for Emergency Trauma Operations Mary Jeskey, BSN, RN, CNOR; Elizabeth Card, MSN, APRN, FNP-BC, CPAN, CCRP; Lily Bell Durias, BSN, RN, CNOR; Oscar Guillamondegui, MD, MPH; Mayur Patel, MD, MPH, FACS; Travis Hamilton, DO; Cynthia Townsend, MTHS, BSN, RN, CNOR; Karen Ferris, BS, RN, CNOR; Nancy Wells, DNSc, RN Clinical Innovation: Developing a Wide Awake Hand Surgery (WALANT) Protocol Jodi Pelkey, BSN, RN, CNOR; Catherine Riedel, RN, MSN, ACNS-BC, CCNS, CCRN Creating a Culture of Courtesy and Respect by Thanking Our Patients AnneMarie O’Toole, RN Identification & Prevention of Pressure Ulcers Acquired During Perioperative Care Cam Felisimino, RN, MSN; Tyler French Immediate Use Steam Sterilization: It’s Everyone’s Business Renee Lawrence, MNSc, RN, ACNS-BC; CNOR, APRN; Lori Berry, BSN, RN, CNOR; Kenny Worley, ADN, CNOR Implementation of a Cardiac Skills Program Maureen Hemingway, DNP, RN, CNOR; Mildred Mannion, BSN, RN, CNOR Implementing Count Boards to Improve Team Communication and Increase Patient Safety in a Community Hospital Carol B. Leon, MS, BSN, RN, CNOR; Maryellen Rowley, BSN, RNFA, CNOR
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2017 Conference Poster Winners
Intra-professional Collaboration for Safe Chemotherapy Administration Lauren Fujihara, MN, RN, CNOR, CNS; Stephanie Jackson, MSN, RN, AOCNS, BMTCN; Joecelyn Densing, MSN, RN It Takes a Village: A Team Approach to Lower SSI Rates Megan Lamoreux, BSN, RN, CNOR; Stella Gebhardt, BSN, RN; Diane Hady, BSN, RN Nurse Patient Advocate: Reducing Surgical Site Infections in Neuro Surgical and Spine Patients Cecil Chan, RN, BSN, CNOR
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June 2017, Vol. 105, No. 6
Reducing the Incidence of Spinal Fusion SSIs Sharon M. Rossi, MS, RNC; Mary Beth Riegel, BSN, RN, CNOR; Sylve Masih, RN, MS, CNOR Reduction of Operating Room Holds by Multidisciplinary Influence Mary Korte, MSN, MHA, RN, CNOR What Goes In, Must Come Out! An Approach to Monitoring Therapeutic Packing Paula Marentay, RN, CNOR; Jane Thomson, MPH, BSN, RN, CNOR Working Together: An Interdisciplinary Approach to Decreasing Instrumentation Issues Leah Goldberg, BSN, RN, CNOR
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