- Email: [email protected]
AORN and University of Michigan School of Nursing Research Alliance
AORN and University of Michigan School of Nursing Research Alliance AKKENEEL TALSMA, PhD, RN; ROBIN CHARD, PhD, RN, CNOR; CATHERINE KLEINER, PhD, RN; CHRISTINE ANDERSON, PhD, RN; HYOGEUN GEUN, MPH, RN
ABSTRACT Research related to perioperative care requires advanced training and is well suited to take place at a research-intensive university. A recent research alliance established between AORN and the University of Michigan School of Nursing, Ann Arbor, uses the strengths of both a robust perioperative professional organization and a researchintensive university to make progress toward improving patient safety and transforming the perioperative work environment. Research activities undertaken by this alliance include investigating nurse staffing characteristics and patient outcomes, as well as evaluating the congruence and definitions of data elements contained in AORN’s SYNTEGRITY™ Standardized Perioperative Framework. Disseminating the findings of the alliance is expected to facilitate the communication and application of new knowledge to nursing practice and help advance the perioperative nursing profession. AORN J 93 (June 2011) 761-766. © AORN, Inc, 2011. doi: 10.1016/j.aorn.2010.11.036 Key words: nursing research, research alliance.
S
ince the releases of the Institute of Medicine reports To Err is Human,1 Crossing the Quality Chasm,2 and Keeping Patients Safe,3 health care professionals have learned about the lapses in care delivery, the extent of patient safety events, and the effects of work environment on the quality of care and patient outcomes. In recent years, patient safety research has moved from describing the errors that can occur to focusing on the circumstances and processes of care that may have contributed to the occurrence of an error. The focus of patient safety research has converged to include both investigating pa-
tient safety events and addressing the practicebased context of how errors and safety events occur. Perioperative nurses play an important role in this investigation. Literature has shown the importance of strong surgery departments and well-run perioperative processes on positive patient outcomes.4-7 Although AORN has developed the Perioperative Standards and Recommended Practices8 to provide guidance for perioperative nurses, the perioperative practice community’s understanding of the relationship of perioperative processes to favorable outcomes is limited,6,9-11 and limited
doi: 10.1016/j.aorn.2010.11.036
© AORN, Inc, 2011
June 2011
Vol 93
No 6 ●
AORN Journal
761
June 2011
Vol 93
No 6
research exists to support the practices recommended for the OR. Finding answers to questions that perioperative nurses have will help advance the perioperative nursing profession. AORN is a professional organization that provides resources to perioperative nurses, enabling them to deliver high-quality patient care so patients are able to obtain optimal outcomes. AORN’s goals include establishing a plan for participation in nursing research in partnership with research institutions. Research related to perioperative care requires advanced training and is well suited to take place at a research-intensive university. This article describes the research partnership established between AORN and the University of Michigan School of Nursing and presents an overview of the ongoing research activities conducted by this alliance.
TALSMA ET AL were invited to visit the University of Michigan School of Nursing campus and agreed to collaborate on these areas of research. To obtain funding for the proposed project, the AORN Foundation submitted an application to the 2009 Prevention Above All Discoveries Grant Program from Medline Industries. The pilot study, “Evaluation of perioperative processes of care and patient outcomes,” was accepted on March 25, 2009, and the University of Michigan investigative team was awarded $25,000 to conduct the pilot study.
AIMS OF THE ALLIANCE The aims of the alliance are to establish a method for supporting and conducting perioperative research. The sharing of resources—such as the clinical expertise from AORN, the research expertise from the University of Michigan School of Nursing, and the supportive environment of the University of MichiESTABLISHING THE ALLIANCE gan Health Systems The aims of the alliance are to establish a During the summer facilities— can facilmethod for supporting and conducting of 2008, AkkeNeel itate the communiperioperative research. The sharing of resources Talsma, PhD, RN, an can facilitate the communication and application cation and applicaassistant professor at tion of new knowof new knowledge to nursing practice. the University of ledge to nursing Michigan, Ann practice. This innoArbor, was awarded vative approach the Robert Wood Johnson Foundation inaugural connects practice to research. Nurse Faculty Scholar Fellowship.12 Dr Talsma The goals of the AORN and University of proposed to study the perioperative process and Michigan alliance were established early in the contextual factors that affect patient outcomes. alliance so that all of the team members would Available research focused primarily on surgeon clearly understand the expectations. AORN’s expertise, training, and age; however, little was goals included establishing a plan for participaknown about the role of staffing on patient outtion in nursing research in partnership with recomes, the effect of components of care on prosearch institutions. The University of Michilonged perioperative care, or whether adverse events gan’s goal was essentially the same—to could be reduced by an understanding of eventestablish a relationship with a professional related systems factors. nursing organization. Communication among In the fall of 2008, Catherine Kleiner, PhD, the team members was conducted via monthly RN, then vice president for research and nursing conference calls, e-mails, and electronic docuresources at AORN, and Robin Chard, PhD, RN, ment exchanges. These methods were effective CNOR, AORN perioperative nursing specialist, in moving the project forward. 762
AORN Journal
NURSING RESEARCH ALLIANCE RESEARCH PROJECT Dr Talsma and the University of Michigan team designed the pilot study, and AORN representatives reviewed it. The study was designed to further the understanding of perioperative nursing activities and clinical systems factors on adverse events that occur in the OR and how each affects surgical patient outcomes. The University of Michigan researchers investigated nurse staffing characteristics, such as years of experience, number of breaks taken during a procedure, actual patient-in to patient-out time, and the characteristics of count discrepancies, on patient outcomes. In addition, in the context of the grant we received, we conducted an evaluation comparing data fields to determine the congruence and definitions of data elements contained in AORN SYNTEGRITY™ Standardized Perioperative Framework, a commercially available format for inclusion in an electronic medical record (EMR) for the purpose of ensuring that standard content areas are captured. The purpose of the study was to investigate the various components of the perioperative process (eg, preoperative assessment, skin prepping, positioning, staffing, counts, throughput and flow) using data from EMRs. After defining these components and evaluating alignment with the Perioperative Nursing Data Set and SYNTEGRITY, we analyzed the data using American College of Surgeons (ACS) National Surgical Quality Improvement Project (NSQIP) patient characteristics and outcomes. Cases included in the ACS NSQIP data collection process were identified, and perioperative data elements were pulled from the cases that were included in the ACS NSQIP cohort. The database included patient characteristics, surgery specifics, and patient outcome data from ACS NSQIP data elements and perioperative care elements according to the project definitions. This provided a unique perspective of patient characteristics, perioperative process factors, surgical detail, and patient outcomes.
www.aornjournal.org
In addition to the previously identified variables, the pilot study investigation focused on major patient complications that developed postoperatively and whether process steps and throughput are related. Few performance measures are available for perioperative care, so we chose to evaluate processing times (eg, patient-in to patient-out time) throughout the OR. The complications included as outcome measures were acute renal failure, pulmonary embolism, deep venous thrombosis, pneumonia, sepsis, systemic inflammatory response syndrome, and cardiac arrest/shock, because these complications have previously been analyzed together.13 The pilot study forms the beginning of a research program to investigate the systems and process factors that influence patient outcomes postoperatively. Research questions aim to address whether processing time (ie, flow through the OR) affects patient outcomes and hospital interests (ie, costs, overall OR flow). Preliminary findings indicate a fair amount of variation in flow (ie, time) for similar procedures, the number of staff members involved, hand offs, and changes of all OR staff members (eg, surgeons, anesthesia care providers, nurses). This area of research has not been fully explored, especially because the amount of data necessary would be prohibitive unless the data are available via EMRs. The data used for this research project are available in existing EMR systems and can be used in future studies. We will work with participating hospitals to define the data elements, codes, and steps to extract the EMR data and evaluate accuracy, consistency of values, and overall quality. We anticipate a fair amount of effort will be dedicated to verifying the data elements and understanding how a hospital uses the EMR to appreciate the data obtained. We foresee important research and practice implications emerging as we further explore and disseminate the findings about the relationship between processes and patient outcomes. AORN Journal
763
June 2011
Vol 93
No 6
TALSMA ET AL
Future perioperareported and distive researchers and cussed for quality Research findings and insights should stimulate leaders will validate improvement opporadditional practice development and spur knowledge development to contribute to optimal tunities. Dr Talsma the standards and patient outcomes. recommended pracand colleagues contices of perioperatinue their research tive nursing to esefforts and maintain tablish the utility of our findings as well as regular communication with AORN to review performance measures of perioperative care usfindings and determine the focus for follow-up ing data from the perioperative process factors. studies. The research alliance allows the research findThe overall outcomes of the alliance are broad ings to be evaluated in a knowledge-generating and long-term, but some preliminary outcomes context and to be used by clinicians. The allihave been achieved. These include dissemination ance also allows the research findings to be of preliminary findings at several podium and appreciated and reviewed by professional poster presentations on topics including patient organizations such as AORN for merit and conrisk factors and outcomes, count discrepancies, tributions to improve patient safety and quality development and evaluation of OR nurse staffing of care outcomes. We anticipate that innovative measures and patient outcomes, and evaluation of changes in staffing and internal processes may social network analysis. Presentations on the predevelop based on this research. As we evaluate liminary findings were given at the 57th Annual OR staffing patterns, for instance, we observe AORN Congress in Denver, Colorado,14 the Midvariation in the number of staff members involved west Nursing Research Society Annual Research in similar procedures and hand offs at times that Congress,15 AcademyHealth,16 the University of might be crucial for sponge counts, for example, Michigan School of Nursing Dean’s Research and we want to determine whether consistency Day,17 the Sigma Theta Tau International Region using the same team members involved in a pro10 Annual Research Conference,18 the Council cedure may yield better outcomes. The findings for the Advancement of Nursing Science,19 and and insights from this area of study should stimuthe AORN Informatics Conference.20 late additional practice development and spur Another outcome has been that several manuknowledge development to contribute to optimal scripts were submitted to peer-reviewed journals in patient outcomes. The research mission of the 2010 and are currently under review. These manalliance will be fulfilled by presenting results at uscripts focus initially on OR staffing measures the AORN Congress, participating in the AORN and evaluation of OR flow and throughput. AddiResearch Committee, and publishing our findings. tional outcomes from the alliance include the folFurthermore, if a particular area might benefit lowing: from further knowledge development, grants can Christine Anderson, PhD, RN, clinical instrucbe submitted through the AORN Foundation as tor, University of Michigan, Ann Arbor, was well as the National Institutes of Health. appointed to the AORN Nursing Research Committee and as a subject matter expert for OUTCOMES OF THE ALLIANCE the upcoming “Recommended practices for The University of Michigan team has a series of documentation.” studies planned as a result of the alliance. The Dr Anderson and Dr Talsma submitted a secinitial pilot study investigation has turned into a ond grant, which is focused on identifying and hospital network where the identified issues are 764
AORN Journal
NURSING RESEARCH ALLIANCE developing interventions to reduce retained foreign object discrepancies, to Medline Industries through the AORN Foundation. This grant was not accepted on first submission and is in the process of resubmission. Dr Chard and Shawn Murphy, MSM, BSN, RN, CNOR, associate hospital administrator and director of nursing, adjunct lecturer in nursing, University of Michigan School of Nursing, Ann Arbor, submitted a grant through the AORN Foundation to Medline Industries that addresses errors and near misses in the perioperative environment. This grant was not accepted on first submission and is in the process of resubmission. The pilot study was completed in summer 2010. Findings from the pilot study have been submitted for publication. Work is continuing to conduct follow-up analyses. EVALUATION AND FUTURE PLANS We look forward to continuing to engage in a bold discussion about practices, processes, and solutions with the perioperative practice and research community in a variety of formats, including presentations, publications, and webinars. Future plans include establishing a link on the AORN web site to invite the perioperative community to participate in a discussion about the implications of the findings from the pilot study and to identify innovative practices for a high-quality and safe perioperative patient experience. The findings of the initial pilot study may help contribute to future research in the areas of use and implementation of EMRs, staffing and systems factors that contribute to count discrepancies, and development of OR staffing measures for use in outcomes studies. The findings of the pilot study also may help contribute to a review of perioperative process factors and how these contribute to outcomes and may affect hospital interest (eg, costs, OR process time, infections, complications, repeat surgeries).
www.aornjournal.org
The AORN–University of Michigan School of Nursing alliance provides the opportunity to start using rich perioperative data to build a safer perioperative work environment, thus contributing to high-quality care delivery and positive outcomes. Dissemination and implementation of the findings from the pilot study and subsequent research will generate new questions and the need for development of a research trajectory for larger future studies. Future researchers, such as doctoral students who are interested in the perioperative environment, may assist in the expansion of this work. We believe that this initiative uses the strengths of both a robust perioperative professional organization and a research-intensive university to make progress toward the goals of the Institute of Medicine3 to keep patients safe and transform the work environment. Editor’s note: SYNTEGRITY Standardized Perioperative Framework is a trademark of AORN, Inc, Denver, CO. Acknowledgement: The authors thank Twilla Barlow, director of the AORN Foundation, for her facilitation in the procurement of the Medline Industries 2009 Prevention Above All Discoveries Grant; Shawn Murphy, MSM, BSN, RN, CNOR, associate hospital administrator and director of nursing, adjunct lecturer in nursing, University of Michigan School of Nursing, for her assistance in securing the data for this project; and Melissa Biel, DPA, RN, Biel Consulting, for her grant writing assistance. References 1.
2.
3.
4.
Institute of Medicine. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err is Human: Building a Safer Health System. Washington, DC: National Academies Press; 2000. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press; 2001. Page A, ed. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: National Academies Press; 2004. Campbell DA Jr. Quality improvement is local. J Am Coll Surg. 2009;(1):141-143.
AORN Journal
765
June 2011
5.
6.
7.
8. 9.
10.
11.
12.
13.
14.
15.
16.
17.
766
Vol 93
Campbell DA Jr, Henderson WG, Englesbe MJ, et al. Surgical site infection prevention: The importance of operative duration and blood transfusion—results of the first American College of Surgeons-National Surgical Quality Improvement Program Best Practices Initiative. J Am Coll Surg. 2008;207(6):810-820. Baumgart A, Denz C, Bender HJ, Schleppers A. How work context affects operating room processes: using data mining and computer simulation to analyze facility and process design. Qual Manag Health Care. 2009; 18(4):305-314. Litvak E. Optimizing patient flow by managing its variability. In: Berman S, ed. From Front Office to Front Line: Essential Issues for Health Care Leaders. Oakbrook Terrace, IL: Joint Commission Resources; 2005: 91-112. Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2011. Wallner LP, Dunn RL, Sarma AV, Campbell DA Jr, Wei JT. Risk factors for prolonged length of stay after urologic surgery: the National Surgical Quality Improvement Program. J Am Coll Surg. 2008;207(6):904913. McLaughlin JC, Sarma AV, Wallner LP, et al. Preoperative and intraoperative risk factors associated with 30day morbidity following urological surgery: The National Surgical Quality Improvement Program. J Urol. 2006;176(5):2179-2186. McManus ML, Long MC, Cooper A, et al. Variability in surgical caseload and access to intensive care services. Anesthesiology. 2003;98(6):1491-1496. Nurse faculty scholars. Robert Wood Johnson Foundation. http://www.nursefacultyscholars.org. Accessed January 7, 2010. AHRQ Quality Indicators—Guide to Patient Safety Indicators. Rockville, MD: Agency for Healthcare Research and Quality; 2003. Department of Health and Human Services. AHRQ Pub. No. 03-R203. Version 2.1, Revision 2. Talsma AN, Anderson CA, Chard R, Murphy S. Perioperative nursing and patient safety: intra-operative processes, nurse staffing, and patient outcomes. Presented at: AORN 57th Annual Congress; March 13-18, 2010; Denver, CO. Talsma AN, Anderson CA, Geun HG, et al. The relationship between operating room characteristics and patient outcomes. Presented at: Midwest Nursing Research Society Annual Research Conference; April 10, 2010; Kansas City, MO. Geun HG, Talsma AN, Anderson C, Kleiner R, Murphy S. Contributing factors of count discrepancy with respect to operating room (OR) processes. Poster presented at: AcademyHealth; June 27-29, 2010; Boston, MA. Talsma AN, Anderson C, Geun HF, et al. Evaluation of patient risk factors and intra-operative processes on patient outcomes. Poster presented at: University of Michigan School of Nursing Dean’s Research Day; April 6, 2010; Ann Arbor, MI.
AORN Journal
TALSMA ET AL
No 6
18.
Talsma AN, Anderson CA, Chard R, Murphy S. Perioperative nursing and patient safety: intra-operative processes, nurse staffing, and patient outcomes. Presented at: Sigma Theta Tau International Nursing Honor Society Region 10 Annual Research Conference; April 17, 2010; Ann Arbor, MI. 19. Talsma AN, Anderson CA, Geun HG, Chard R, Murphy S, Kleiner C. Peri-operative processes and patient risk factors on patient outcomes. Presented at: Council for the Advancement of Nursing Science; September 27-29, 2010; Washington, DC. 20. Anderson C, Kleiner C, Talsma AN. The value of research: developing clinical registries. Presented at: AORN Informatics Conference; September 25, 2010; Denver, CO.
AkkeNeel Talsma, PhD, RN, is an assistant professor at the University of Michigan, Ann Arbor. Dr Talsma has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. Robin Chard, PhD, RN, CNOR, was a perioperative nursing specialist, AORN, Inc, Denver, CO at the time this article was written. Dr Chard has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. Catherine Kleiner, PhD, RN, was the vice president for research and nursing resources at AORN, Inc, Denver, CO, at the time this article was written. Dr Kleiner has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. Christine Anderson, PhD, RN, is a clinical instructor, University of Michigan, Ann Arbor. Dr Anderson has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. HyoGeun Geun, MPH, RN, is a research analyst, University of Michigan, Ann Arbor. Ms Geun has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
ABSTRACT Research related to perioperative care requires advanced training and is well suited to take place at a research-intensive university. A recent research alliance established between AORN and the University of Michigan School of Nursing, Ann Arbor, uses the strengths of both a robust perioperative professional organization and a researchintensive university to make progress toward improving patient safety and transforming the perioperative work environment. Research activities undertaken by this alliance include investigating nurse staffing characteristics and patient outcomes, as well as evaluating the congruence and definitions of data elements contained in AORN’s SYNTEGRITY™ Standardized Perioperative Framework. Disseminating the findings of the alliance is expected to facilitate the communication and application of new knowledge to nursing practice and help advance the perioperative nursing profession. AORN J 93 (June 2011) 761-766. © AORN, Inc, 2011. doi: 10.1016/j.aorn.2010.11.036 Key words: nursing research, research alliance.
S
ince the releases of the Institute of Medicine reports To Err is Human,1 Crossing the Quality Chasm,2 and Keeping Patients Safe,3 health care professionals have learned about the lapses in care delivery, the extent of patient safety events, and the effects of work environment on the quality of care and patient outcomes. In recent years, patient safety research has moved from describing the errors that can occur to focusing on the circumstances and processes of care that may have contributed to the occurrence of an error. The focus of patient safety research has converged to include both investigating pa-
tient safety events and addressing the practicebased context of how errors and safety events occur. Perioperative nurses play an important role in this investigation. Literature has shown the importance of strong surgery departments and well-run perioperative processes on positive patient outcomes.4-7 Although AORN has developed the Perioperative Standards and Recommended Practices8 to provide guidance for perioperative nurses, the perioperative practice community’s understanding of the relationship of perioperative processes to favorable outcomes is limited,6,9-11 and limited
doi: 10.1016/j.aorn.2010.11.036
© AORN, Inc, 2011
June 2011
Vol 93
No 6 ●
AORN Journal
761
June 2011
Vol 93
No 6
research exists to support the practices recommended for the OR. Finding answers to questions that perioperative nurses have will help advance the perioperative nursing profession. AORN is a professional organization that provides resources to perioperative nurses, enabling them to deliver high-quality patient care so patients are able to obtain optimal outcomes. AORN’s goals include establishing a plan for participation in nursing research in partnership with research institutions. Research related to perioperative care requires advanced training and is well suited to take place at a research-intensive university. This article describes the research partnership established between AORN and the University of Michigan School of Nursing and presents an overview of the ongoing research activities conducted by this alliance.
TALSMA ET AL were invited to visit the University of Michigan School of Nursing campus and agreed to collaborate on these areas of research. To obtain funding for the proposed project, the AORN Foundation submitted an application to the 2009 Prevention Above All Discoveries Grant Program from Medline Industries. The pilot study, “Evaluation of perioperative processes of care and patient outcomes,” was accepted on March 25, 2009, and the University of Michigan investigative team was awarded $25,000 to conduct the pilot study.
AIMS OF THE ALLIANCE The aims of the alliance are to establish a method for supporting and conducting perioperative research. The sharing of resources—such as the clinical expertise from AORN, the research expertise from the University of Michigan School of Nursing, and the supportive environment of the University of MichiESTABLISHING THE ALLIANCE gan Health Systems The aims of the alliance are to establish a During the summer facilities— can facilmethod for supporting and conducting of 2008, AkkeNeel itate the communiperioperative research. The sharing of resources Talsma, PhD, RN, an can facilitate the communication and application cation and applicaassistant professor at tion of new knowof new knowledge to nursing practice. the University of ledge to nursing Michigan, Ann practice. This innoArbor, was awarded vative approach the Robert Wood Johnson Foundation inaugural connects practice to research. Nurse Faculty Scholar Fellowship.12 Dr Talsma The goals of the AORN and University of proposed to study the perioperative process and Michigan alliance were established early in the contextual factors that affect patient outcomes. alliance so that all of the team members would Available research focused primarily on surgeon clearly understand the expectations. AORN’s expertise, training, and age; however, little was goals included establishing a plan for participaknown about the role of staffing on patient outtion in nursing research in partnership with recomes, the effect of components of care on prosearch institutions. The University of Michilonged perioperative care, or whether adverse events gan’s goal was essentially the same—to could be reduced by an understanding of eventestablish a relationship with a professional related systems factors. nursing organization. Communication among In the fall of 2008, Catherine Kleiner, PhD, the team members was conducted via monthly RN, then vice president for research and nursing conference calls, e-mails, and electronic docuresources at AORN, and Robin Chard, PhD, RN, ment exchanges. These methods were effective CNOR, AORN perioperative nursing specialist, in moving the project forward. 762
AORN Journal
NURSING RESEARCH ALLIANCE RESEARCH PROJECT Dr Talsma and the University of Michigan team designed the pilot study, and AORN representatives reviewed it. The study was designed to further the understanding of perioperative nursing activities and clinical systems factors on adverse events that occur in the OR and how each affects surgical patient outcomes. The University of Michigan researchers investigated nurse staffing characteristics, such as years of experience, number of breaks taken during a procedure, actual patient-in to patient-out time, and the characteristics of count discrepancies, on patient outcomes. In addition, in the context of the grant we received, we conducted an evaluation comparing data fields to determine the congruence and definitions of data elements contained in AORN SYNTEGRITY™ Standardized Perioperative Framework, a commercially available format for inclusion in an electronic medical record (EMR) for the purpose of ensuring that standard content areas are captured. The purpose of the study was to investigate the various components of the perioperative process (eg, preoperative assessment, skin prepping, positioning, staffing, counts, throughput and flow) using data from EMRs. After defining these components and evaluating alignment with the Perioperative Nursing Data Set and SYNTEGRITY, we analyzed the data using American College of Surgeons (ACS) National Surgical Quality Improvement Project (NSQIP) patient characteristics and outcomes. Cases included in the ACS NSQIP data collection process were identified, and perioperative data elements were pulled from the cases that were included in the ACS NSQIP cohort. The database included patient characteristics, surgery specifics, and patient outcome data from ACS NSQIP data elements and perioperative care elements according to the project definitions. This provided a unique perspective of patient characteristics, perioperative process factors, surgical detail, and patient outcomes.
www.aornjournal.org
In addition to the previously identified variables, the pilot study investigation focused on major patient complications that developed postoperatively and whether process steps and throughput are related. Few performance measures are available for perioperative care, so we chose to evaluate processing times (eg, patient-in to patient-out time) throughout the OR. The complications included as outcome measures were acute renal failure, pulmonary embolism, deep venous thrombosis, pneumonia, sepsis, systemic inflammatory response syndrome, and cardiac arrest/shock, because these complications have previously been analyzed together.13 The pilot study forms the beginning of a research program to investigate the systems and process factors that influence patient outcomes postoperatively. Research questions aim to address whether processing time (ie, flow through the OR) affects patient outcomes and hospital interests (ie, costs, overall OR flow). Preliminary findings indicate a fair amount of variation in flow (ie, time) for similar procedures, the number of staff members involved, hand offs, and changes of all OR staff members (eg, surgeons, anesthesia care providers, nurses). This area of research has not been fully explored, especially because the amount of data necessary would be prohibitive unless the data are available via EMRs. The data used for this research project are available in existing EMR systems and can be used in future studies. We will work with participating hospitals to define the data elements, codes, and steps to extract the EMR data and evaluate accuracy, consistency of values, and overall quality. We anticipate a fair amount of effort will be dedicated to verifying the data elements and understanding how a hospital uses the EMR to appreciate the data obtained. We foresee important research and practice implications emerging as we further explore and disseminate the findings about the relationship between processes and patient outcomes. AORN Journal
763
June 2011
Vol 93
No 6
TALSMA ET AL
Future perioperareported and distive researchers and cussed for quality Research findings and insights should stimulate leaders will validate improvement opporadditional practice development and spur knowledge development to contribute to optimal tunities. Dr Talsma the standards and patient outcomes. recommended pracand colleagues contices of perioperatinue their research tive nursing to esefforts and maintain tablish the utility of our findings as well as regular communication with AORN to review performance measures of perioperative care usfindings and determine the focus for follow-up ing data from the perioperative process factors. studies. The research alliance allows the research findThe overall outcomes of the alliance are broad ings to be evaluated in a knowledge-generating and long-term, but some preliminary outcomes context and to be used by clinicians. The allihave been achieved. These include dissemination ance also allows the research findings to be of preliminary findings at several podium and appreciated and reviewed by professional poster presentations on topics including patient organizations such as AORN for merit and conrisk factors and outcomes, count discrepancies, tributions to improve patient safety and quality development and evaluation of OR nurse staffing of care outcomes. We anticipate that innovative measures and patient outcomes, and evaluation of changes in staffing and internal processes may social network analysis. Presentations on the predevelop based on this research. As we evaluate liminary findings were given at the 57th Annual OR staffing patterns, for instance, we observe AORN Congress in Denver, Colorado,14 the Midvariation in the number of staff members involved west Nursing Research Society Annual Research in similar procedures and hand offs at times that Congress,15 AcademyHealth,16 the University of might be crucial for sponge counts, for example, Michigan School of Nursing Dean’s Research and we want to determine whether consistency Day,17 the Sigma Theta Tau International Region using the same team members involved in a pro10 Annual Research Conference,18 the Council cedure may yield better outcomes. The findings for the Advancement of Nursing Science,19 and and insights from this area of study should stimuthe AORN Informatics Conference.20 late additional practice development and spur Another outcome has been that several manuknowledge development to contribute to optimal scripts were submitted to peer-reviewed journals in patient outcomes. The research mission of the 2010 and are currently under review. These manalliance will be fulfilled by presenting results at uscripts focus initially on OR staffing measures the AORN Congress, participating in the AORN and evaluation of OR flow and throughput. AddiResearch Committee, and publishing our findings. tional outcomes from the alliance include the folFurthermore, if a particular area might benefit lowing: from further knowledge development, grants can Christine Anderson, PhD, RN, clinical instrucbe submitted through the AORN Foundation as tor, University of Michigan, Ann Arbor, was well as the National Institutes of Health. appointed to the AORN Nursing Research Committee and as a subject matter expert for OUTCOMES OF THE ALLIANCE the upcoming “Recommended practices for The University of Michigan team has a series of documentation.” studies planned as a result of the alliance. The Dr Anderson and Dr Talsma submitted a secinitial pilot study investigation has turned into a ond grant, which is focused on identifying and hospital network where the identified issues are 764
AORN Journal
NURSING RESEARCH ALLIANCE developing interventions to reduce retained foreign object discrepancies, to Medline Industries through the AORN Foundation. This grant was not accepted on first submission and is in the process of resubmission. Dr Chard and Shawn Murphy, MSM, BSN, RN, CNOR, associate hospital administrator and director of nursing, adjunct lecturer in nursing, University of Michigan School of Nursing, Ann Arbor, submitted a grant through the AORN Foundation to Medline Industries that addresses errors and near misses in the perioperative environment. This grant was not accepted on first submission and is in the process of resubmission. The pilot study was completed in summer 2010. Findings from the pilot study have been submitted for publication. Work is continuing to conduct follow-up analyses. EVALUATION AND FUTURE PLANS We look forward to continuing to engage in a bold discussion about practices, processes, and solutions with the perioperative practice and research community in a variety of formats, including presentations, publications, and webinars. Future plans include establishing a link on the AORN web site to invite the perioperative community to participate in a discussion about the implications of the findings from the pilot study and to identify innovative practices for a high-quality and safe perioperative patient experience. The findings of the initial pilot study may help contribute to future research in the areas of use and implementation of EMRs, staffing and systems factors that contribute to count discrepancies, and development of OR staffing measures for use in outcomes studies. The findings of the pilot study also may help contribute to a review of perioperative process factors and how these contribute to outcomes and may affect hospital interest (eg, costs, OR process time, infections, complications, repeat surgeries).
www.aornjournal.org
The AORN–University of Michigan School of Nursing alliance provides the opportunity to start using rich perioperative data to build a safer perioperative work environment, thus contributing to high-quality care delivery and positive outcomes. Dissemination and implementation of the findings from the pilot study and subsequent research will generate new questions and the need for development of a research trajectory for larger future studies. Future researchers, such as doctoral students who are interested in the perioperative environment, may assist in the expansion of this work. We believe that this initiative uses the strengths of both a robust perioperative professional organization and a research-intensive university to make progress toward the goals of the Institute of Medicine3 to keep patients safe and transform the work environment. Editor’s note: SYNTEGRITY Standardized Perioperative Framework is a trademark of AORN, Inc, Denver, CO. Acknowledgement: The authors thank Twilla Barlow, director of the AORN Foundation, for her facilitation in the procurement of the Medline Industries 2009 Prevention Above All Discoveries Grant; Shawn Murphy, MSM, BSN, RN, CNOR, associate hospital administrator and director of nursing, adjunct lecturer in nursing, University of Michigan School of Nursing, for her assistance in securing the data for this project; and Melissa Biel, DPA, RN, Biel Consulting, for her grant writing assistance. References 1.
2.
3.
4.
Institute of Medicine. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err is Human: Building a Safer Health System. Washington, DC: National Academies Press; 2000. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press; 2001. Page A, ed. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: National Academies Press; 2004. Campbell DA Jr. Quality improvement is local. J Am Coll Surg. 2009;(1):141-143.
AORN Journal
765
June 2011
5.
6.
7.
8. 9.
10.
11.
12.
13.
14.
15.
16.
17.
766
Vol 93
Campbell DA Jr, Henderson WG, Englesbe MJ, et al. Surgical site infection prevention: The importance of operative duration and blood transfusion—results of the first American College of Surgeons-National Surgical Quality Improvement Program Best Practices Initiative. J Am Coll Surg. 2008;207(6):810-820. Baumgart A, Denz C, Bender HJ, Schleppers A. How work context affects operating room processes: using data mining and computer simulation to analyze facility and process design. Qual Manag Health Care. 2009; 18(4):305-314. Litvak E. Optimizing patient flow by managing its variability. In: Berman S, ed. From Front Office to Front Line: Essential Issues for Health Care Leaders. Oakbrook Terrace, IL: Joint Commission Resources; 2005: 91-112. Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2011. Wallner LP, Dunn RL, Sarma AV, Campbell DA Jr, Wei JT. Risk factors for prolonged length of stay after urologic surgery: the National Surgical Quality Improvement Program. J Am Coll Surg. 2008;207(6):904913. McLaughlin JC, Sarma AV, Wallner LP, et al. Preoperative and intraoperative risk factors associated with 30day morbidity following urological surgery: The National Surgical Quality Improvement Program. J Urol. 2006;176(5):2179-2186. McManus ML, Long MC, Cooper A, et al. Variability in surgical caseload and access to intensive care services. Anesthesiology. 2003;98(6):1491-1496. Nurse faculty scholars. Robert Wood Johnson Foundation. http://www.nursefacultyscholars.org. Accessed January 7, 2010. AHRQ Quality Indicators—Guide to Patient Safety Indicators. Rockville, MD: Agency for Healthcare Research and Quality; 2003. Department of Health and Human Services. AHRQ Pub. No. 03-R203. Version 2.1, Revision 2. Talsma AN, Anderson CA, Chard R, Murphy S. Perioperative nursing and patient safety: intra-operative processes, nurse staffing, and patient outcomes. Presented at: AORN 57th Annual Congress; March 13-18, 2010; Denver, CO. Talsma AN, Anderson CA, Geun HG, et al. The relationship between operating room characteristics and patient outcomes. Presented at: Midwest Nursing Research Society Annual Research Conference; April 10, 2010; Kansas City, MO. Geun HG, Talsma AN, Anderson C, Kleiner R, Murphy S. Contributing factors of count discrepancy with respect to operating room (OR) processes. Poster presented at: AcademyHealth; June 27-29, 2010; Boston, MA. Talsma AN, Anderson C, Geun HF, et al. Evaluation of patient risk factors and intra-operative processes on patient outcomes. Poster presented at: University of Michigan School of Nursing Dean’s Research Day; April 6, 2010; Ann Arbor, MI.
AORN Journal
TALSMA ET AL
No 6
18.
Talsma AN, Anderson CA, Chard R, Murphy S. Perioperative nursing and patient safety: intra-operative processes, nurse staffing, and patient outcomes. Presented at: Sigma Theta Tau International Nursing Honor Society Region 10 Annual Research Conference; April 17, 2010; Ann Arbor, MI. 19. Talsma AN, Anderson CA, Geun HG, Chard R, Murphy S, Kleiner C. Peri-operative processes and patient risk factors on patient outcomes. Presented at: Council for the Advancement of Nursing Science; September 27-29, 2010; Washington, DC. 20. Anderson C, Kleiner C, Talsma AN. The value of research: developing clinical registries. Presented at: AORN Informatics Conference; September 25, 2010; Denver, CO.
AkkeNeel Talsma, PhD, RN, is an assistant professor at the University of Michigan, Ann Arbor. Dr Talsma has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. Robin Chard, PhD, RN, CNOR, was a perioperative nursing specialist, AORN, Inc, Denver, CO at the time this article was written. Dr Chard has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. Catherine Kleiner, PhD, RN, was the vice president for research and nursing resources at AORN, Inc, Denver, CO, at the time this article was written. Dr Kleiner has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. Christine Anderson, PhD, RN, is a clinical instructor, University of Michigan, Ann Arbor. Dr Anderson has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. HyoGeun Geun, MPH, RN, is a research analyst, University of Michigan, Ann Arbor. Ms Geun has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.