- Email: [email protected]
Using the cystoscopy room to increase OR space
JUNE 1993, VOL 51, NO 6
AORN JOURNAL
Practical Innovations Using the cystoscopy room to increase OR space
T
he Kaiser Foundation Hospital in Santa Clara, Calif, serves a contractual patient base of 254,000 patients. Built in 1965 and designed for a different era, the hospital must adapt to meet the health service requirements of our present community. Three years ago, statistics showed that we needed 12.5 operating rooms, but we had only eight. Although we contracted for the use of two rooms at a satellite outpatient surgery unit, we still were short of rooms and needed at least two more ORs. We made 5 PM to 9 PM hours available on the Monday-through-Thursday schedule, but we still were unable to accommodate the needs of our patients.
Addressing the Problem e formed a perioperative task force of five staff members. This group recommended two approaches to solving this problem. First, we agreed to fit emergency cases into prescheduled, canceled surgery slots. We made this choice rather than create OR downtime by trying to prepare the next prescheduled patient early. Second, we increased the OR capacity by deciding to use the cystoscopy (cysto) room for selected cases (Table 1). The task force surveyed eight hospitals in the South Bay area to learn how they dealt with a lack of OR rooms. The survey questions (Table 2) asked if other hospitals were using cysto rooms for open procedures, inquired about standards of cleaning, and inquired about the cysto room table’s reverse Trendelenburg’s
position, a key factor for anesthesia administration. The results of the telephone survey uncovered an interesting trend. Four factors were common to the hospitals that performed both open and closed procedures in traditionally closed case cysto rooms. In each of these facilities, 0 the cysto room was physically separate from the rest of the OR, the table in use was not a moveable type, the table had reverse Trendelenburg’s position capability, and 0 no special housekeeping cleaning protocols were used. The community standard for using a cysto room for open cases was tested when an emergent neurosurgery case was performed in a c y s ~ oroom at another hospital. The case went smoothly, and the patient developed no sequelae. Although one case cannot prove the merits
Cheryl S . Wright, RN, BA, CNOR, is a staff nurse in the operating room at Kaiser Foundation Hospital, Santa Clara, Calq. She earned her diploma in nursing from the Norfolk (Va)General Hospital School of Nursing and her bachelor of arts degree in health services administrationfrom St Mary’s College, Moraga, Calg The author acknowledges the statistical data contribution of Barbara Collins, scheduling office systems coordinator at the Kaiser Foundation Hospital, Santa Clara, Cali$ 1461
JUNE 1993, VOL 51,NO 6
AORN JOURNAL
Table 1
Selected Cases Scheduled for Cystoscopy Room 0 0 0
0 0 0
0
0
dilatation and curettage voluntary termination of pregnancies endoscopic procedures (eg, bronchoscopy, sigmoidoscopy, laryngoscopy, esophagoscopy, hysteroscopy) hemorrhoidectomies perirectal abscess surgery tonsillectomies. adenoidectomies, niyringotomies nonintra-abdominal lithotomies perirectal laser surgery
of cysto room use, it did indicate that our proposal to use the cysto room for nontraditional cases was not a totally new concept. We were encouraged to learn that we were not alone in contemplating a relatively new practice. We summarized our recommendations (Table 3) and the opinions of the OR staff members and presented them to the physicianadministrator of our hospital. The primary issues of concern were maintaining our standard of care, infection control, anesthesia concerns (eg, the type of OR table to be used), and professional liability. We discussed areas of concern ( e g , how we could flash sterilize instruments, the isolation of the cysto room from the OR and postanesthesia care u n i t [PACU]. access to sterile supplies, housekeeping protocols, potential liabilities). Our physician-administrator and the staff were concerned that, for example, a two-year-old child undergoing a bilateral inguinal hernia repair might not get the same standard of care in the cysto room as in a regular OR. The task force reviewed the cleaning procedures necessary for the cysto room and decided to ask environmental services personnel to clean the room each night using our total-joint protocol. We continue to use this protocol as the housekeeping cleaning standard whenever open cases are scheduled for the cysto room on the foliowing day. We also made alterations in 1462
the sinks, floor drains, and scrub area to ensure the room was usable for open procedures. The foot control sink was covered totally with a custom sliding, removable metal plate. A removable screw-in cover was installed on the floor drain located at the foot of the cystolfluoroscopy table. The configuration of our fixed fluoroscopy table did not allow its removal and restricts movement around it because a large x-ray column is affixed to the floor at the right side of the table. To do cases, we bring in an extra OR bed to have reverse Trendelenburg’s position capability and normal OR bed movement and accessibility. The extra bed occupies much of the available space in the cysto room and limits the peripheral support equipment (eg, mobile xray, cell-saver, lavage irrigator, video accessories) that can be brought into the room. A door was installed to isolate the cysto scrub sink area from the inside of the room. We agreed that the 2% glutaraldehyde solution used for disinfection of cystoscopy instruments could be left in a covered container in the room. Many staff members elect to remove the container to reduce the possibility of spillage in the crowded, limited work area. As we used the room, we became more aware of its shortcomings and
Table 2
Community Hospital Survey Questions 1 . Are you currently doing any open procedures in your cystoscopy room? 2. Is your cystoscopy room physicdly located within the sterile core of operating rooms, or is it physically separate? 3 . What type of OR table is in your cystoscopy room? Fixed? Fluoroscopymounted? Pedestal-mounted? Moveable? 4. Does the OR table in use have reverse Trendelenburg’s position capability? 5. Are any special housekeeping/cleaning procedures being used in the cystoscopy room?
advantages. We addressed and solved each issue as it arose. We addressed our need for sterile support items by using a rolling stock cart. Scheduled case supplies (eg, gloves, suture, dressings) are assembled completely on the cart. The circulating nurse, however, must run to the main OR to get unanticipated supplies. Staff members have exerted a tremendous effort to make this new plan work and take great care to “second guess” what supplies procedures will require. Innovation conquered our flash sterilization problem. Knowing that dropped or “unsterile but needed items” occur on all open cases, we devised a plan to cover that contingency. To transport sterile items from the autoclave to the cysto room (Fig l), we use a ring stand covered with a sterile disposable drape on which to transport the sterilized tray, which we cover with two sterile cloth towels. A staff member, wearing sterile gloves, pushes the ring stand to the cysto room. Once inside the room, this staff member removes the two cloth towels. The scrub nurse then can reach in and obtain the sterile instruments. The discarded drape and the two cloth towels are used later for room cleanup and containment. We realize that this flash sterilization procedure does not meet AORN’s standard (ie, AORN does not recommend covering sterile items that have been flash autoclaved), and we intend to acquire and use a commercially available, closed container system to update this practice. The nurse managers review the next day’s OR schedule to determine if appropriate surgeries are scheduled for the cystoscopy room. Nurse managers also check to ensure that surgeons are not overbooking their usual operating time just because we have the capability of doing open cases in the cysto room.
Results e have continued to use the cystoscopy room under the guidelines and protocols established by the task force in 1990. Anesthesia personnel and surgeons have endorsed this program from its inception. The
Table 3
Task Force Recommendations 0
0
0
When not in use, the cystoscopy (cysto) room should be kept ready to do a cystoscopy procedure. Limit the types of cases which could be done in the cysto room. The initial list excluded bone cases, open abdominal cases or chest cases, muscle flaps, breast implants, and major vascular cases. All local cases scheduled in the cysto room should be performed with anesthesia standby (ie, an anesthesia staff member should be present in addition to two circulating nurses). The relative isolation of the cysto room requires the presence of anesthesia standby personnel for all local cases to maintain our standard of care. Run a schedule using nine rooms (ie, eight OR, one cysto), and staff them five days a week. In the event a room is not booked, staff members can do add-on procedures.
OR staff members, however, were more reluctant to embrace the idea of doing open cases in the cysto room. Wisely, our nurse managers did not assign staff members to work in the cysto room on open procedures if they voiced reservations. Only staff members who were willing to be involved in this new program participated as members of the initial “open-cysto” team. Now that the program has a three-year track record, staff members view assignments to work in “open cysto” as simply another room, another case. This attitude does not infer complacency, but rather assurance of our continued high standard of care. Quality assurance checks early in our program failed to demonstrate any increase in postoperative infection or complications that could be attributed to performing open procedures in the cysto room. In the first year of this program, we documented Class 3 wound infections in just four patients who had undergone procedures in 1463
JUNE 1993, VOL 57, NO 6
AORN JOURhAL
Instrument processing
OR1
~
rootn
LI
J
OR3
I
iOR2
II
OR4
'
IS
I
I
Outer hall
Sterile inner core
L
H A =Autoclaves
Fig 1. The cysto room is down the hall from the autoclaves and sterile supply storage areas. The isolation of our cysto room affects flash sterilization of needed items and the time required to obtain sterile supplies and equipment not commonly found in the cystoscopy area. this room: one who had endoscopic removal of a foreign body from the esophagus, one with a sloughed skin graft, one who had anorectal sutures removed, and one who had undergone a colonoscopy. Only four patients (two from open cases) developed infections during the last year. When we compared the infection and complication rates of cysto room procedures to those of the entire OR for the same time period, we found that the cysto room infection/complication rate was within the expected norm. We believe that we have documented that the standard of care can be maintained at a high level in the open-cysto room. We have been able to perform an additional
Table 4
Cystoscopy Room Annual Usage by Specialty Closed Pediatric Plastic Obstetrics/gy necology Otolaryngology General surgery
434 120 12 5 4 1
150 c a s e s , which h a s h e l p e d r e d u c e t h e scheduling backlog. We gained a total of 107 hours of surgery through the use of our cysto room. Although we still do not have the needed 2.5 additional ORs, we have made a positive impact on the case backlog through innovative use of our existing facilities. As this is written, the number of open cases being performed in the cysto room continues to increase, and many specialties have accepted this room for open procedures (Table 4). The last hurdle was fear of potential liability. Our administration faced this issue by proceeding cautiously in the areas of staff assignment and room utilization until we obtained baseline case data to satisfy concerns. Standard of care, anesthesia issues, infection control, and professional liability are ongoing concerns that are monitored by the hospital's surgical executive committee. The OR quality assurance/improvement program at the hospital monitors the cysto rooms use f o r o p e n p r o c e d u r e s a n d subsequent case/procedure results. We have joined other area hospitals in establishing a community standard for open procedures performed in a cysto environment. The OR team at Kaiser Foundation Hospital, Santa Clara, Calif, is proud of our success in finding a solution together and doing more with less. CHERYL S. WRIGHT,RN
AORN JOURNAL
Practical Innovations Using the cystoscopy room to increase OR space
T
he Kaiser Foundation Hospital in Santa Clara, Calif, serves a contractual patient base of 254,000 patients. Built in 1965 and designed for a different era, the hospital must adapt to meet the health service requirements of our present community. Three years ago, statistics showed that we needed 12.5 operating rooms, but we had only eight. Although we contracted for the use of two rooms at a satellite outpatient surgery unit, we still were short of rooms and needed at least two more ORs. We made 5 PM to 9 PM hours available on the Monday-through-Thursday schedule, but we still were unable to accommodate the needs of our patients.
Addressing the Problem e formed a perioperative task force of five staff members. This group recommended two approaches to solving this problem. First, we agreed to fit emergency cases into prescheduled, canceled surgery slots. We made this choice rather than create OR downtime by trying to prepare the next prescheduled patient early. Second, we increased the OR capacity by deciding to use the cystoscopy (cysto) room for selected cases (Table 1). The task force surveyed eight hospitals in the South Bay area to learn how they dealt with a lack of OR rooms. The survey questions (Table 2) asked if other hospitals were using cysto rooms for open procedures, inquired about standards of cleaning, and inquired about the cysto room table’s reverse Trendelenburg’s
position, a key factor for anesthesia administration. The results of the telephone survey uncovered an interesting trend. Four factors were common to the hospitals that performed both open and closed procedures in traditionally closed case cysto rooms. In each of these facilities, 0 the cysto room was physically separate from the rest of the OR, the table in use was not a moveable type, the table had reverse Trendelenburg’s position capability, and 0 no special housekeeping cleaning protocols were used. The community standard for using a cysto room for open cases was tested when an emergent neurosurgery case was performed in a c y s ~ oroom at another hospital. The case went smoothly, and the patient developed no sequelae. Although one case cannot prove the merits
Cheryl S . Wright, RN, BA, CNOR, is a staff nurse in the operating room at Kaiser Foundation Hospital, Santa Clara, Calq. She earned her diploma in nursing from the Norfolk (Va)General Hospital School of Nursing and her bachelor of arts degree in health services administrationfrom St Mary’s College, Moraga, Calg The author acknowledges the statistical data contribution of Barbara Collins, scheduling office systems coordinator at the Kaiser Foundation Hospital, Santa Clara, Cali$ 1461
JUNE 1993, VOL 51,NO 6
AORN JOURNAL
Table 1
Selected Cases Scheduled for Cystoscopy Room 0 0 0
0 0 0
0
0
dilatation and curettage voluntary termination of pregnancies endoscopic procedures (eg, bronchoscopy, sigmoidoscopy, laryngoscopy, esophagoscopy, hysteroscopy) hemorrhoidectomies perirectal abscess surgery tonsillectomies. adenoidectomies, niyringotomies nonintra-abdominal lithotomies perirectal laser surgery
of cysto room use, it did indicate that our proposal to use the cysto room for nontraditional cases was not a totally new concept. We were encouraged to learn that we were not alone in contemplating a relatively new practice. We summarized our recommendations (Table 3) and the opinions of the OR staff members and presented them to the physicianadministrator of our hospital. The primary issues of concern were maintaining our standard of care, infection control, anesthesia concerns (eg, the type of OR table to be used), and professional liability. We discussed areas of concern ( e g , how we could flash sterilize instruments, the isolation of the cysto room from the OR and postanesthesia care u n i t [PACU]. access to sterile supplies, housekeeping protocols, potential liabilities). Our physician-administrator and the staff were concerned that, for example, a two-year-old child undergoing a bilateral inguinal hernia repair might not get the same standard of care in the cysto room as in a regular OR. The task force reviewed the cleaning procedures necessary for the cysto room and decided to ask environmental services personnel to clean the room each night using our total-joint protocol. We continue to use this protocol as the housekeeping cleaning standard whenever open cases are scheduled for the cysto room on the foliowing day. We also made alterations in 1462
the sinks, floor drains, and scrub area to ensure the room was usable for open procedures. The foot control sink was covered totally with a custom sliding, removable metal plate. A removable screw-in cover was installed on the floor drain located at the foot of the cystolfluoroscopy table. The configuration of our fixed fluoroscopy table did not allow its removal and restricts movement around it because a large x-ray column is affixed to the floor at the right side of the table. To do cases, we bring in an extra OR bed to have reverse Trendelenburg’s position capability and normal OR bed movement and accessibility. The extra bed occupies much of the available space in the cysto room and limits the peripheral support equipment (eg, mobile xray, cell-saver, lavage irrigator, video accessories) that can be brought into the room. A door was installed to isolate the cysto scrub sink area from the inside of the room. We agreed that the 2% glutaraldehyde solution used for disinfection of cystoscopy instruments could be left in a covered container in the room. Many staff members elect to remove the container to reduce the possibility of spillage in the crowded, limited work area. As we used the room, we became more aware of its shortcomings and
Table 2
Community Hospital Survey Questions 1 . Are you currently doing any open procedures in your cystoscopy room? 2. Is your cystoscopy room physicdly located within the sterile core of operating rooms, or is it physically separate? 3 . What type of OR table is in your cystoscopy room? Fixed? Fluoroscopymounted? Pedestal-mounted? Moveable? 4. Does the OR table in use have reverse Trendelenburg’s position capability? 5. Are any special housekeeping/cleaning procedures being used in the cystoscopy room?
advantages. We addressed and solved each issue as it arose. We addressed our need for sterile support items by using a rolling stock cart. Scheduled case supplies (eg, gloves, suture, dressings) are assembled completely on the cart. The circulating nurse, however, must run to the main OR to get unanticipated supplies. Staff members have exerted a tremendous effort to make this new plan work and take great care to “second guess” what supplies procedures will require. Innovation conquered our flash sterilization problem. Knowing that dropped or “unsterile but needed items” occur on all open cases, we devised a plan to cover that contingency. To transport sterile items from the autoclave to the cysto room (Fig l), we use a ring stand covered with a sterile disposable drape on which to transport the sterilized tray, which we cover with two sterile cloth towels. A staff member, wearing sterile gloves, pushes the ring stand to the cysto room. Once inside the room, this staff member removes the two cloth towels. The scrub nurse then can reach in and obtain the sterile instruments. The discarded drape and the two cloth towels are used later for room cleanup and containment. We realize that this flash sterilization procedure does not meet AORN’s standard (ie, AORN does not recommend covering sterile items that have been flash autoclaved), and we intend to acquire and use a commercially available, closed container system to update this practice. The nurse managers review the next day’s OR schedule to determine if appropriate surgeries are scheduled for the cystoscopy room. Nurse managers also check to ensure that surgeons are not overbooking their usual operating time just because we have the capability of doing open cases in the cysto room.
Results e have continued to use the cystoscopy room under the guidelines and protocols established by the task force in 1990. Anesthesia personnel and surgeons have endorsed this program from its inception. The
Table 3
Task Force Recommendations 0
0
0
When not in use, the cystoscopy (cysto) room should be kept ready to do a cystoscopy procedure. Limit the types of cases which could be done in the cysto room. The initial list excluded bone cases, open abdominal cases or chest cases, muscle flaps, breast implants, and major vascular cases. All local cases scheduled in the cysto room should be performed with anesthesia standby (ie, an anesthesia staff member should be present in addition to two circulating nurses). The relative isolation of the cysto room requires the presence of anesthesia standby personnel for all local cases to maintain our standard of care. Run a schedule using nine rooms (ie, eight OR, one cysto), and staff them five days a week. In the event a room is not booked, staff members can do add-on procedures.
OR staff members, however, were more reluctant to embrace the idea of doing open cases in the cysto room. Wisely, our nurse managers did not assign staff members to work in the cysto room on open procedures if they voiced reservations. Only staff members who were willing to be involved in this new program participated as members of the initial “open-cysto” team. Now that the program has a three-year track record, staff members view assignments to work in “open cysto” as simply another room, another case. This attitude does not infer complacency, but rather assurance of our continued high standard of care. Quality assurance checks early in our program failed to demonstrate any increase in postoperative infection or complications that could be attributed to performing open procedures in the cysto room. In the first year of this program, we documented Class 3 wound infections in just four patients who had undergone procedures in 1463
JUNE 1993, VOL 57, NO 6
AORN JOURhAL
Instrument processing
OR1
~
rootn
LI
J
OR3
I
iOR2
II
OR4
'
IS
I
I
Outer hall
Sterile inner core
L
H A =Autoclaves
Fig 1. The cysto room is down the hall from the autoclaves and sterile supply storage areas. The isolation of our cysto room affects flash sterilization of needed items and the time required to obtain sterile supplies and equipment not commonly found in the cystoscopy area. this room: one who had endoscopic removal of a foreign body from the esophagus, one with a sloughed skin graft, one who had anorectal sutures removed, and one who had undergone a colonoscopy. Only four patients (two from open cases) developed infections during the last year. When we compared the infection and complication rates of cysto room procedures to those of the entire OR for the same time period, we found that the cysto room infection/complication rate was within the expected norm. We believe that we have documented that the standard of care can be maintained at a high level in the open-cysto room. We have been able to perform an additional
Table 4
Cystoscopy Room Annual Usage by Specialty Closed Pediatric Plastic Obstetrics/gy necology Otolaryngology General surgery
434 120 12 5 4 1
150 c a s e s , which h a s h e l p e d r e d u c e t h e scheduling backlog. We gained a total of 107 hours of surgery through the use of our cysto room. Although we still do not have the needed 2.5 additional ORs, we have made a positive impact on the case backlog through innovative use of our existing facilities. As this is written, the number of open cases being performed in the cysto room continues to increase, and many specialties have accepted this room for open procedures (Table 4). The last hurdle was fear of potential liability. Our administration faced this issue by proceeding cautiously in the areas of staff assignment and room utilization until we obtained baseline case data to satisfy concerns. Standard of care, anesthesia issues, infection control, and professional liability are ongoing concerns that are monitored by the hospital's surgical executive committee. The OR quality assurance/improvement program at the hospital monitors the cysto rooms use f o r o p e n p r o c e d u r e s a n d subsequent case/procedure results. We have joined other area hospitals in establishing a community standard for open procedures performed in a cysto environment. The OR team at Kaiser Foundation Hospital, Santa Clara, Calif, is proud of our success in finding a solution together and doing more with less. CHERYL S. WRIGHT,RN