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Perspectives: A Window into the World of OR Technology
Perspectives: A Window into the World of OR Technology CARINA STANTON, MA, BSJ
T
echnology is an increasingly important part of patient care delivery within the perioperative setting. The use of electronic documentation is widespread. Scanning technologies collect procedural data. A nurse can glance at a tablet to check the status of a patient, and robots are disinfecting ORs.
Perioperative services historically has been a highly technical area advancing technology use. Understanding what technologies are being used currently in the perioperative setting and investigating how nurses perceive the value of these perioperative technologies can better position perioperative services to continue as a leader in ensuring that current and future OR technologies drive efficiency, safety, and overall value. “There is no doubt that technology can enhance the patient experiencedthink about how automated processes eliminate the human factor for error and how the integration of patient data provides a more comprehensive view of a patient’s condition,” said Janice Kelly, MS, RN-BC, a clinical informatics leader and business and operational leader for the AORN Syntegrity solution, the standardized perioperative nursing documentation solution for the electronic health record (EHR). “Yet, there is room to improve how technology supports the nursing process and how a nurse understands the full potential of technology.” As technology continues to progress, she said nurses must have the skills and the voices to ensure everything from an intraoperative documentation system to a radio-frequency identification (RFID) tag on a sponge is designed to support safe, efficient, and effective use. Kelly played a key role in shaping the AORN Technology in the OR (ATOR) tool, which was developed in 2014e2015 through collaboration between AORN and the Chamberlain College of Nursing in Downers Grove, Illinois. The tool was distributed to 20,000 AORN members in 2015; 462 nurses shared responses. The resulting data were analyzed by Carolyn Sipes, PhD, CNS,
APN, PMP, RN-BC, associate professor of specialty tracks, nursing informatics, at Chamberlain College of Nursing, and Joy Don Baker, PhD, RN-BC, CNOR, CNE, NEA-BC, clinical professor at the University of Texas at Arlington College of Nursing and Health Innovation and AORN Journal editor-in-chief. Sipes and Baker shaped the research article “Technology in the OR: AORN Members’ Perceptions of the Effects on Workflow Efficiency and Quality Patient Care.”1 The article is available online in the September 2015 issue of the AORN Journal. Kelly believes the study findings can serve as a springboard to fuel conversations and investigations that will lead to new evidence that can shape informatics curriculum and professional practice training and support a true team approach to technology in the OR.
SHAPING THE ATOR STUDY What OR technology do perioperative nurses use in their daily practice? Without any established tools or instruments to answer this question, Sipes and Baker collaborated with colleagues from AORN and the Chamberlain College of Nursing’s nursing informatics research team to create a unique tool to collect data on nursing use and perception of effectiveness related to OR technologies. AORN’s nursing informatics specialist Kelly served as a subject matter expert to identify the top technology groups used in the OR to include in the ATOR question sets. These technology categories included
RFID or barcode scanning, data collection tools, workflow or dashboard management tools, and environmental services/room decontamination technologies.
The ATOR also provided opportunity to identify the perceived effects of each technology in these groupings
http://dx.doi.org/10.1016/j.aorn.2015.07.016 ª AORN, Inc, 2015
www.aornjournal.org
AORN Journal j 233
Stanton
based on workflow efficiency (WFE) and quality patient outcomes (QPC).
QUALITATIVE INSIGHTS FROM THE STUDY In their analysis of the study data, Sipes and Baker identified a number of interesting trends and anomalies concerning how certain technologies were perceived as being more or less effective and more or less supportive of quality patient outcomes. They also observed distinct variation in use of the studied technologies. Below are some of their clinical insights from the study data: Use of technology varies and this variance does not necessarily correlate with value. For example, 87% of respondents use intraoperative nursing documentation, yet only 46% of respondents see this technology as supporting quality patient outcomes. Baker says these data points are interesting because they provide qualitative data to show what is anecdotally discussed; despite mandatory use and actions that require a significant amount of time in a nurse’s practice or workflow, nurses do not perceive electronic documentation as providing high quality patient care (QPC) value. She says the next highest-used technology (59%)d image integration: radiology equipment/C-armsdis not surprising because this technology has been a standard part of surgical care for some time. The particular item also resulted in a higher perceived effect on both WFE and QPC. She says two of the least-used technologies, ozone room system (2%) and RFID for hand hygiene compliance (5%), are newer technologies that are not in widespread use but should be investigated further for potential benefits in the perioperative setting, such as supporting reduced incidence of infection. Integration technologies have the highest perceived value to improve workflow efficiencies. Image integration technologies with the highest perceived value included radiology equipment/C-arms (71%); fiber optics, scopes, and cystoscopies (71%); and video (ie, robotics/endoscopy) (67%). Device integration: monitor/vital signs to EHR followed closely in perceived efficiency value at 66%. These technologies may be considered high-perceived WFE value because they are a common part of a nurse’s daily work and these technologies provide actionable data to support patient care, Sipes said. In contrast, technologies with a low-perceived WFE value included ozone room system (7%), which is likely because this is a new technology; personnel real-time locating system (RTLS) (16%); and count RTLS (24%). Sipes said tracking staff members and OR supplies may be beneficial
234 j AORN Journal
September 2015, Vol. 102, No. 3
Related Resources The infographic preceding this article offers an illustrated presentation of the study results. For the complete study results, read the “Technology in the OR: AORN Members’ Perceptions of the Effects on Workflow Efficiency and Quality Patient Care” article at http://www .aornjournal.org/article/S0001-2092(15)00664-X/fulltext. from an organizational standpoint depending on specific workplace settings, however nurses in the study did not seem to think these positively affected their workflow efficiencies. Technology to support blood administration is perceived to have the highest value for QPC. With 81% of survey respondents saying technology for blood administration is of high QPC value, Baker sees this percentage as a significant number that warrants further investigation in specific care settings to protect the patient. She does note that only 53% of respondents feel this technology supports workflow efficiency, which could be because it requires extra time, so this is also important to consider in accounting for barriers to implementation. Perceived value of WFE is generally lower than QPC, even if only slightly, for many technologies studied. Sipes gave the example of surgery and site verification technology, which is perceived as having a low effect on WFE (26%), but a higher QPC value (51%), indicating that nurses may interpret the technology as having an effect on patient safety. She said efforts to align efficiency and safety through OR technologies could be an important area for further investigation and encourages nursing informatics leaders to connect with technology leaders and other nurse leaders in driving this conversation.
HOW TO USE THE STUDY DATA Thought leaders at every level and area of perioperative care can examine the results of the study to begin asking the important questions around OR technologies, particularly related to the opinions, needs, and ideas of frontline nurses for how to optimize technologies in a specific setting. Below several perioperative nursing experts consider next steps in evaluating survey results and moving forward with gaining a deeper understanding of perioperative technology use and perceptions: How can OR leaders leverage the findings from this study? “If leaders are smart, they will share the infographic with data from this study at huddles or staff meetings to start
www.aornjournal.org
September 2015, Vol. 102, No. 3
conversations with staff members to understand perceived value of OR technologies relative to patient safety and efficiency within their own organizations,” said Carla Thorson, MSN, RN, CNS, CNOR, content manager for AORN’s Center for Nursing Leadership. “Your staff is your biggest resource,” Thorson said. “If they feel like you are listening and you believe in their ideas, they will bend over backwards for you to try and help in any way.” She said technology implementation and usability can be a challenging area for OR directors who have to make a strong financial case to sell a technology purchase to their C-Suite and then turn around and make the case to frontline staff members about why they need to use a technology. She suggested OR leaders take note of several key study results that show nurses believe technologies in the OR can support quality patient care, including technologies to automate blood administration (81%) and medication administration (71%). What questions can be explored from the study results to support more evidence-based research on technology in the OR? “Every technology explored in this study is a good starting point for further research,” said Lisa Spruce, DNP, RN, CNS-CP, CNOR, ACNS, ACNP, director of Evidence-Based Perioperative Practice at AORN. She suggests looking at the technologies that have low use, but high perceived value for quality patient outcomes, such as using RFID for hand hygiene compliance, which has 5% use and 37% perceived value for quality patient outcomes. Specimen tissue tracking is another technology with low use (13%) but higher overall perceived value for both WFE (52%) and QPC (57%), she explained. “If these technologies can be researched to understand their effect on specific patient outcomes, that research can be used in multiple ways,” Spruce said. She explained these potential uses, including: for OR leaders making the case to purchase and implement the technology, for manufacturers to consider in further developing the technology, and for organizations such as AORN to consider the evidence in shaping practice guidelines that include the use of adjunct technology. How can nursing informatics educators use these study data to fill the gaps in understanding and use of technology in the OR? Sipes is excited to have hard data from the study results to quantify nursing perceptions about perioperative technology in a way that previously has only been discussed anecdotally. “This study provides an important step in an overarching effort to connect IT and nursing,” she said.
www.aornjournal.org
Special Feature: Perspectives
She said there is currently disconnect between the level of technology skills an OR manager expects from nurses and the opportunities nurses are given to gain those skills. Therefore, Sipes feels that further investigation specific to the categories of technology explored in the study, such as RFID, can help to build a more in-depth understanding of how specific technologies are being used and where knowledge gaps exist. “Educators in schools of nursing and in the perioperative setting could then tailor curriculum, assessments, competencies, and performance goals specific to those gaps,” she said. What can informatics leaders in industry and the hospital setting take from these survey results? Historically, technologies that tend to get implemented first have the return on investment, according to Marion Sparks McCall, BBA, RN, CNOR, CPHIMS, a nursing informatics consultant and president of Nurse Works, LLC, who coordinates the Everyday Informatics column in the AORN Journal. “With further investigation of the findings from this study, a clearer understanding of the link between technologies and patient outcomes can provide the evidence to make technology purchasing decisions based on outcomes, not just on the hard dollar,” she said. McCall added that the study results illustrate where there is room for improvement in integrating multiple technologies, such as RFID and RTLS technologies with dashboards. “It is so important that everyone looks toward that next level of technology to integrate data capture, analysis, and decisionmaking for maximum benefit.”
CONCLUSION From a broader informatics perspective, Kelly hopes informatics nurses, OR leaders, frontline nurses, and anyone else in the perioperative setting who wants to explore technology use will use the study to start candid conversations about issues such as barriers, adverse events, and workarounds. “Tell your stories; only when questions are asked can we get to a solution,” she said. “To some degree, all perioperative nurses need to become competent and confident in speaking the language of nursing informatics so they can help shape the development and implementation of OR technologiesdfor their profession, their daily practice, and most importantly, for their patients.”
Editor’s note: AORN Syntegrity is a registered trademark of AORN, Inc, Denver, CO.
Reference 1. Sipes C, Baker JD. Technology in the OR: AORN members’ perceptions of the effects on workflow efficiency and quality patient care. AORN J. 2015;102(3):289.
AORN Journal j 235
T
echnology is an increasingly important part of patient care delivery within the perioperative setting. The use of electronic documentation is widespread. Scanning technologies collect procedural data. A nurse can glance at a tablet to check the status of a patient, and robots are disinfecting ORs.
Perioperative services historically has been a highly technical area advancing technology use. Understanding what technologies are being used currently in the perioperative setting and investigating how nurses perceive the value of these perioperative technologies can better position perioperative services to continue as a leader in ensuring that current and future OR technologies drive efficiency, safety, and overall value. “There is no doubt that technology can enhance the patient experiencedthink about how automated processes eliminate the human factor for error and how the integration of patient data provides a more comprehensive view of a patient’s condition,” said Janice Kelly, MS, RN-BC, a clinical informatics leader and business and operational leader for the AORN Syntegrity solution, the standardized perioperative nursing documentation solution for the electronic health record (EHR). “Yet, there is room to improve how technology supports the nursing process and how a nurse understands the full potential of technology.” As technology continues to progress, she said nurses must have the skills and the voices to ensure everything from an intraoperative documentation system to a radio-frequency identification (RFID) tag on a sponge is designed to support safe, efficient, and effective use. Kelly played a key role in shaping the AORN Technology in the OR (ATOR) tool, which was developed in 2014e2015 through collaboration between AORN and the Chamberlain College of Nursing in Downers Grove, Illinois. The tool was distributed to 20,000 AORN members in 2015; 462 nurses shared responses. The resulting data were analyzed by Carolyn Sipes, PhD, CNS,
APN, PMP, RN-BC, associate professor of specialty tracks, nursing informatics, at Chamberlain College of Nursing, and Joy Don Baker, PhD, RN-BC, CNOR, CNE, NEA-BC, clinical professor at the University of Texas at Arlington College of Nursing and Health Innovation and AORN Journal editor-in-chief. Sipes and Baker shaped the research article “Technology in the OR: AORN Members’ Perceptions of the Effects on Workflow Efficiency and Quality Patient Care.”1 The article is available online in the September 2015 issue of the AORN Journal. Kelly believes the study findings can serve as a springboard to fuel conversations and investigations that will lead to new evidence that can shape informatics curriculum and professional practice training and support a true team approach to technology in the OR.
SHAPING THE ATOR STUDY What OR technology do perioperative nurses use in their daily practice? Without any established tools or instruments to answer this question, Sipes and Baker collaborated with colleagues from AORN and the Chamberlain College of Nursing’s nursing informatics research team to create a unique tool to collect data on nursing use and perception of effectiveness related to OR technologies. AORN’s nursing informatics specialist Kelly served as a subject matter expert to identify the top technology groups used in the OR to include in the ATOR question sets. These technology categories included
RFID or barcode scanning, data collection tools, workflow or dashboard management tools, and environmental services/room decontamination technologies.
The ATOR also provided opportunity to identify the perceived effects of each technology in these groupings
http://dx.doi.org/10.1016/j.aorn.2015.07.016 ª AORN, Inc, 2015
www.aornjournal.org
AORN Journal j 233
Stanton
based on workflow efficiency (WFE) and quality patient outcomes (QPC).
QUALITATIVE INSIGHTS FROM THE STUDY In their analysis of the study data, Sipes and Baker identified a number of interesting trends and anomalies concerning how certain technologies were perceived as being more or less effective and more or less supportive of quality patient outcomes. They also observed distinct variation in use of the studied technologies. Below are some of their clinical insights from the study data: Use of technology varies and this variance does not necessarily correlate with value. For example, 87% of respondents use intraoperative nursing documentation, yet only 46% of respondents see this technology as supporting quality patient outcomes. Baker says these data points are interesting because they provide qualitative data to show what is anecdotally discussed; despite mandatory use and actions that require a significant amount of time in a nurse’s practice or workflow, nurses do not perceive electronic documentation as providing high quality patient care (QPC) value. She says the next highest-used technology (59%)d image integration: radiology equipment/C-armsdis not surprising because this technology has been a standard part of surgical care for some time. The particular item also resulted in a higher perceived effect on both WFE and QPC. She says two of the least-used technologies, ozone room system (2%) and RFID for hand hygiene compliance (5%), are newer technologies that are not in widespread use but should be investigated further for potential benefits in the perioperative setting, such as supporting reduced incidence of infection. Integration technologies have the highest perceived value to improve workflow efficiencies. Image integration technologies with the highest perceived value included radiology equipment/C-arms (71%); fiber optics, scopes, and cystoscopies (71%); and video (ie, robotics/endoscopy) (67%). Device integration: monitor/vital signs to EHR followed closely in perceived efficiency value at 66%. These technologies may be considered high-perceived WFE value because they are a common part of a nurse’s daily work and these technologies provide actionable data to support patient care, Sipes said. In contrast, technologies with a low-perceived WFE value included ozone room system (7%), which is likely because this is a new technology; personnel real-time locating system (RTLS) (16%); and count RTLS (24%). Sipes said tracking staff members and OR supplies may be beneficial
234 j AORN Journal
September 2015, Vol. 102, No. 3
Related Resources The infographic preceding this article offers an illustrated presentation of the study results. For the complete study results, read the “Technology in the OR: AORN Members’ Perceptions of the Effects on Workflow Efficiency and Quality Patient Care” article at http://www .aornjournal.org/article/S0001-2092(15)00664-X/fulltext. from an organizational standpoint depending on specific workplace settings, however nurses in the study did not seem to think these positively affected their workflow efficiencies. Technology to support blood administration is perceived to have the highest value for QPC. With 81% of survey respondents saying technology for blood administration is of high QPC value, Baker sees this percentage as a significant number that warrants further investigation in specific care settings to protect the patient. She does note that only 53% of respondents feel this technology supports workflow efficiency, which could be because it requires extra time, so this is also important to consider in accounting for barriers to implementation. Perceived value of WFE is generally lower than QPC, even if only slightly, for many technologies studied. Sipes gave the example of surgery and site verification technology, which is perceived as having a low effect on WFE (26%), but a higher QPC value (51%), indicating that nurses may interpret the technology as having an effect on patient safety. She said efforts to align efficiency and safety through OR technologies could be an important area for further investigation and encourages nursing informatics leaders to connect with technology leaders and other nurse leaders in driving this conversation.
HOW TO USE THE STUDY DATA Thought leaders at every level and area of perioperative care can examine the results of the study to begin asking the important questions around OR technologies, particularly related to the opinions, needs, and ideas of frontline nurses for how to optimize technologies in a specific setting. Below several perioperative nursing experts consider next steps in evaluating survey results and moving forward with gaining a deeper understanding of perioperative technology use and perceptions: How can OR leaders leverage the findings from this study? “If leaders are smart, they will share the infographic with data from this study at huddles or staff meetings to start
www.aornjournal.org
September 2015, Vol. 102, No. 3
conversations with staff members to understand perceived value of OR technologies relative to patient safety and efficiency within their own organizations,” said Carla Thorson, MSN, RN, CNS, CNOR, content manager for AORN’s Center for Nursing Leadership. “Your staff is your biggest resource,” Thorson said. “If they feel like you are listening and you believe in their ideas, they will bend over backwards for you to try and help in any way.” She said technology implementation and usability can be a challenging area for OR directors who have to make a strong financial case to sell a technology purchase to their C-Suite and then turn around and make the case to frontline staff members about why they need to use a technology. She suggested OR leaders take note of several key study results that show nurses believe technologies in the OR can support quality patient care, including technologies to automate blood administration (81%) and medication administration (71%). What questions can be explored from the study results to support more evidence-based research on technology in the OR? “Every technology explored in this study is a good starting point for further research,” said Lisa Spruce, DNP, RN, CNS-CP, CNOR, ACNS, ACNP, director of Evidence-Based Perioperative Practice at AORN. She suggests looking at the technologies that have low use, but high perceived value for quality patient outcomes, such as using RFID for hand hygiene compliance, which has 5% use and 37% perceived value for quality patient outcomes. Specimen tissue tracking is another technology with low use (13%) but higher overall perceived value for both WFE (52%) and QPC (57%), she explained. “If these technologies can be researched to understand their effect on specific patient outcomes, that research can be used in multiple ways,” Spruce said. She explained these potential uses, including: for OR leaders making the case to purchase and implement the technology, for manufacturers to consider in further developing the technology, and for organizations such as AORN to consider the evidence in shaping practice guidelines that include the use of adjunct technology. How can nursing informatics educators use these study data to fill the gaps in understanding and use of technology in the OR? Sipes is excited to have hard data from the study results to quantify nursing perceptions about perioperative technology in a way that previously has only been discussed anecdotally. “This study provides an important step in an overarching effort to connect IT and nursing,” she said.
www.aornjournal.org
Special Feature: Perspectives
She said there is currently disconnect between the level of technology skills an OR manager expects from nurses and the opportunities nurses are given to gain those skills. Therefore, Sipes feels that further investigation specific to the categories of technology explored in the study, such as RFID, can help to build a more in-depth understanding of how specific technologies are being used and where knowledge gaps exist. “Educators in schools of nursing and in the perioperative setting could then tailor curriculum, assessments, competencies, and performance goals specific to those gaps,” she said. What can informatics leaders in industry and the hospital setting take from these survey results? Historically, technologies that tend to get implemented first have the return on investment, according to Marion Sparks McCall, BBA, RN, CNOR, CPHIMS, a nursing informatics consultant and president of Nurse Works, LLC, who coordinates the Everyday Informatics column in the AORN Journal. “With further investigation of the findings from this study, a clearer understanding of the link between technologies and patient outcomes can provide the evidence to make technology purchasing decisions based on outcomes, not just on the hard dollar,” she said. McCall added that the study results illustrate where there is room for improvement in integrating multiple technologies, such as RFID and RTLS technologies with dashboards. “It is so important that everyone looks toward that next level of technology to integrate data capture, analysis, and decisionmaking for maximum benefit.”
CONCLUSION From a broader informatics perspective, Kelly hopes informatics nurses, OR leaders, frontline nurses, and anyone else in the perioperative setting who wants to explore technology use will use the study to start candid conversations about issues such as barriers, adverse events, and workarounds. “Tell your stories; only when questions are asked can we get to a solution,” she said. “To some degree, all perioperative nurses need to become competent and confident in speaking the language of nursing informatics so they can help shape the development and implementation of OR technologiesdfor their profession, their daily practice, and most importantly, for their patients.”
Editor’s note: AORN Syntegrity is a registered trademark of AORN, Inc, Denver, CO.
Reference 1. Sipes C, Baker JD. Technology in the OR: AORN members’ perceptions of the effects on workflow efficiency and quality patient care. AORN J. 2015;102(3):289.
AORN Journal j 235