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Cost containment increases pressure to pull OR Staff
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Cost containment increases pressure to pull OR Staff
Q With the increased emphasis on cost containment, I am feeling more pressure from my superiors to allow OR nursing staff to be pulled to other non-OR units when we are not fully utilizingthem in the OR. As the OR supervisor, I have resistedthis because I think it’s an infection control hazard. What do you say?
A Cost containment and fiscal accountability are two important issues for nursemanagers today. We must carefully evaluate the utilization of personnel in each department as well as the institution as a whole. At times it may be reasonable to pull nursing staff from the OR to perform needed functions on other units. However, this should not be done without careful evaluation and communication. The question of infection control surfaces early in a discussionof this issue. Nurses working in the OR are neither more nor less clean, generally, than nurses working in other areas. We work in a cleaner environment, and we perform according to the principlesof asepsis, but we stcl have a myriad of microorganisms with us at all times. The surgeon, who usually is in more intimate contact with the open wound, moves from surgical suite to inpatient unit to office and back without concern. Why do we, as nurses, think we should behave differently? If anyone leaves the surgicakuite for any reason, he should change clothing upon
a:
leaving and reentering the suite. Thorough hand washing before and after each patient contact is also important. This applies throughout health care and is not specific to the OR. Some have suggestedshowering on reentryto the surgical suite, but this appears to be contraindicated by research findings.’ Asepsis is not the most serious reason for reluctance to assign OR staff to other units. Two other issues come to mind. First, there must be a clear understanding by nursing and hospital administrationof the work done in the OR. Much of the legitimateactivity in our highly technological area is indirect care-getting ready for the patient. This includes the preparation of supplies, equipment, and environment based on a nursing assessment of the patient’s needs. Although some work can be delegated to technical workers, the overall supervision and judgment of the nurse are required. Also, the OR must be ready for patient emergencies. This takes additional time that might not be recognized becausethe situation you are preparing for may never materialize. Understanding is necessary for evaluating availability of nurses to float to other units. A second consideration is the expertise of the OR nursingstaff. The OR nurse possesses different skills and knowledge than colleagues on the patient units. This is not to say that one is superior to the other, merely different. The OR nurse performingtasks for which she is not prepared on a unit could be as much of a hazard as the unit nurse suddenly placed in the role of circulating OR nurse without preparation. McWilliams states: “Any nurse may refuse to rotate because she believes she lacks the competence necessary to provide nursing care in given specialties. It is not only her right to refuse such work, but her professional re-
dAORN Journal, February 1979,VoE29, No 2
223
sponsibilily.” (See AORN Journal, May 1976, 1081.) Once hospital administration has been notified that a nurse does not consider herself prepared, they have two acceptable choices: not assigning the nurse to the unfamiliar situation and finding another staffing alternative or developing the nurse’s competency in this area by providing education and supervised experience. To place any nurse in a situation when there is doubt about her abilityto perform safely increases the riskof liabilityforthe nurse and the hospital.2 An additional consideration is the pattern of scheduling cases and room use. By fully utilizing ORs, the institutionmight be able to employ fewer staff. This is not a simple decision however. It may appear more efficient on paper, but the hospital must still consider the requirements of surgeons for surgery scheduling. Increasing staff productivity is a major goal of management. After carefully evaluating all these factors, if it still seems wise to pull staff from the OR, the decision should be communicated to all staff as a change in the conditions of employment.
Q AS in most hospitals, urinary tract infections are the largest single category of nosocomial infections in our institution. Since we place indwellingcatheters in many patients in the OR prior to surgery, we are evaluating our technique to minimize our contribution to the problem. We observe good aseptic technique during insertion of the catheter and do not open the drainage system except at the bottom of the collecting bag. Do you have any other suggestions?
A
One of the most frequently violated tenets of proper care of the patient with an indwelling catheter is that the drainage system should always remain below the level of the bladder.3 This is to prevent reflux of urine into the bladder from the tubing and collecting vessel, which could carry microbial flora that may have grown in the moist environment of the collecting system. Even the most scrupulously performed catheterization may introduce some bacteria from the meatus and surrounding area into the
226
bladder. Generally, these bacteria do not cause an infection because the patient’s host defense mechanisms prevaiL4 However, if these few bacteria are not in the bladder long enough to be destroyed but instead drain into the external collectingsystem with the urine or if the collecting system is contaminated in some other way, the microorganisms are likely to multiply, using the urine as a growth medium. After several hours, there could be enough bacteria to challenge and overcome the body’s defense mechanism if reflux intothe bladder were to occur. When a patientwith an indwellingcatheter is moved from OR bed to recovery room cart, the urine collecting bag and tubing should not be raised above bladder level, even momentarily. Placing the bag on the patient’s abdomen or hanging it from the upper side rail, both of which I have seen many times, exposes the patient to unnecessary risk of nosocomial infection.
Janet K Schultz, RN and the Professional Advisory Committee Notes 1. R B Roberts, “Infection and sterilization problems,” InternationalAnesthesiology Clinics 10 (1972) 33. 2. W A Regan, “Or nursing law,” AORN Journal 28 (September 1978) 526. 3. Infection Control in the Hospital, 3rd ed (Chicago: American Hospital Association, 1974) 151. 4. D R Smith, GeneralUrology, 8th ed (Los Altos, Calif: Lange Medical Publications, 1975) 103.
Clarification In the guest editorial “OR nurses’ concerns about air-powered units” in the August 1978 Journal, the time specified for sterilization is appropriate for high-speed autoclaves. If gravity displacement autoclaves are used, the time is 35 min to 55 min. References to “disassembling” the air-powered instruments concerned only those parts that are normally able to be disassembled.
AORN Journul,February 1979, Vol29, No 2
Cost containment increases pressure to pull OR Staff
Q With the increased emphasis on cost containment, I am feeling more pressure from my superiors to allow OR nursing staff to be pulled to other non-OR units when we are not fully utilizingthem in the OR. As the OR supervisor, I have resistedthis because I think it’s an infection control hazard. What do you say?
A Cost containment and fiscal accountability are two important issues for nursemanagers today. We must carefully evaluate the utilization of personnel in each department as well as the institution as a whole. At times it may be reasonable to pull nursing staff from the OR to perform needed functions on other units. However, this should not be done without careful evaluation and communication. The question of infection control surfaces early in a discussionof this issue. Nurses working in the OR are neither more nor less clean, generally, than nurses working in other areas. We work in a cleaner environment, and we perform according to the principlesof asepsis, but we stcl have a myriad of microorganisms with us at all times. The surgeon, who usually is in more intimate contact with the open wound, moves from surgical suite to inpatient unit to office and back without concern. Why do we, as nurses, think we should behave differently? If anyone leaves the surgicakuite for any reason, he should change clothing upon
a:
leaving and reentering the suite. Thorough hand washing before and after each patient contact is also important. This applies throughout health care and is not specific to the OR. Some have suggestedshowering on reentryto the surgical suite, but this appears to be contraindicated by research findings.’ Asepsis is not the most serious reason for reluctance to assign OR staff to other units. Two other issues come to mind. First, there must be a clear understanding by nursing and hospital administrationof the work done in the OR. Much of the legitimateactivity in our highly technological area is indirect care-getting ready for the patient. This includes the preparation of supplies, equipment, and environment based on a nursing assessment of the patient’s needs. Although some work can be delegated to technical workers, the overall supervision and judgment of the nurse are required. Also, the OR must be ready for patient emergencies. This takes additional time that might not be recognized becausethe situation you are preparing for may never materialize. Understanding is necessary for evaluating availability of nurses to float to other units. A second consideration is the expertise of the OR nursingstaff. The OR nurse possesses different skills and knowledge than colleagues on the patient units. This is not to say that one is superior to the other, merely different. The OR nurse performingtasks for which she is not prepared on a unit could be as much of a hazard as the unit nurse suddenly placed in the role of circulating OR nurse without preparation. McWilliams states: “Any nurse may refuse to rotate because she believes she lacks the competence necessary to provide nursing care in given specialties. It is not only her right to refuse such work, but her professional re-
dAORN Journal, February 1979,VoE29, No 2
223
sponsibilily.” (See AORN Journal, May 1976, 1081.) Once hospital administration has been notified that a nurse does not consider herself prepared, they have two acceptable choices: not assigning the nurse to the unfamiliar situation and finding another staffing alternative or developing the nurse’s competency in this area by providing education and supervised experience. To place any nurse in a situation when there is doubt about her abilityto perform safely increases the riskof liabilityforthe nurse and the hospital.2 An additional consideration is the pattern of scheduling cases and room use. By fully utilizing ORs, the institutionmight be able to employ fewer staff. This is not a simple decision however. It may appear more efficient on paper, but the hospital must still consider the requirements of surgeons for surgery scheduling. Increasing staff productivity is a major goal of management. After carefully evaluating all these factors, if it still seems wise to pull staff from the OR, the decision should be communicated to all staff as a change in the conditions of employment.
Q AS in most hospitals, urinary tract infections are the largest single category of nosocomial infections in our institution. Since we place indwellingcatheters in many patients in the OR prior to surgery, we are evaluating our technique to minimize our contribution to the problem. We observe good aseptic technique during insertion of the catheter and do not open the drainage system except at the bottom of the collecting bag. Do you have any other suggestions?
A
One of the most frequently violated tenets of proper care of the patient with an indwelling catheter is that the drainage system should always remain below the level of the bladder.3 This is to prevent reflux of urine into the bladder from the tubing and collecting vessel, which could carry microbial flora that may have grown in the moist environment of the collecting system. Even the most scrupulously performed catheterization may introduce some bacteria from the meatus and surrounding area into the
226
bladder. Generally, these bacteria do not cause an infection because the patient’s host defense mechanisms prevaiL4 However, if these few bacteria are not in the bladder long enough to be destroyed but instead drain into the external collectingsystem with the urine or if the collecting system is contaminated in some other way, the microorganisms are likely to multiply, using the urine as a growth medium. After several hours, there could be enough bacteria to challenge and overcome the body’s defense mechanism if reflux intothe bladder were to occur. When a patientwith an indwellingcatheter is moved from OR bed to recovery room cart, the urine collecting bag and tubing should not be raised above bladder level, even momentarily. Placing the bag on the patient’s abdomen or hanging it from the upper side rail, both of which I have seen many times, exposes the patient to unnecessary risk of nosocomial infection.
Janet K Schultz, RN and the Professional Advisory Committee Notes 1. R B Roberts, “Infection and sterilization problems,” InternationalAnesthesiology Clinics 10 (1972) 33. 2. W A Regan, “Or nursing law,” AORN Journal 28 (September 1978) 526. 3. Infection Control in the Hospital, 3rd ed (Chicago: American Hospital Association, 1974) 151. 4. D R Smith, GeneralUrology, 8th ed (Los Altos, Calif: Lange Medical Publications, 1975) 103.
Clarification In the guest editorial “OR nurses’ concerns about air-powered units” in the August 1978 Journal, the time specified for sterilization is appropriate for high-speed autoclaves. If gravity displacement autoclaves are used, the time is 35 min to 55 min. References to “disassembling” the air-powered instruments concerned only those parts that are normally able to be disassembled.
AORN Journul,February 1979, Vol29, No 2