for ricky adams only!

Research, Evidence-Based Practice, and Clinical Improvement/Innovation Posters

A ORN Surgical Conference & Expo 2014

attendees had the opportunity to earn up to

31 contact hours by reviewing the poster

book and evaluating 34 research and 37 evidence-

based practice posters in eight poster sessions, and

211 clinical improvement/innovation posters in 23

poster sessions. Posters are available online, for

those poster authors who agreed to share their

posters online, at http://www.eventscribe.com/2014/

posters/aorn/home.asp.

RESEARCH POSTERS

The top three posters were recognized with an award

in the research category by members of AORN’s

Nursing Research Committee. Following are the

abstracts from the three winning research posters.

1st Place: Factors Associated With RN Turnover in Perioperative Units

Catima Potter, MPH; JiSun Choi, PhD, RN

Retention of younger perioperative nurses is an

issue. This may create additional problems as the

nursing workforce continues to age and retire. The

research study’s aim was to examine nursing work

context and RN characteristics associated with

perioperative RN turnover. The sample consisted of

565 perioperative units in 260 US hospitals. Linked

2012 data on RN turnover and RN survey work

context items from a national nursing quality data-

base were used. Unit-level annualized turnover (ie,

separation) rates were calculated for RNs. Hierar-

chical Poisson regression analysis was performed at

the unit level. The mean unit level perioperative

RN turnover rate was 1.92%. Nearly 18% of all RN

separations had less than two years of experience

at the hospital. More influence over schedule and a

higher percentage of RNs with specialty certification

were associated with lower perioperative RN unit

turnover. Perioperative units with longer RN unit

tenure reported lower RN turnover. Overall, the

model had a moderate fit (R2 ¼ 0.68). Although the perioperative turnover rate was low, findings indi-

cated that factors such as scheduling influence,

specialty certification, and RN unit tenure were

associated with turnover among perioperative RNs.

Nurse leadership personnel should assess workforce

characteristics in addition to work context when

developing retention strategies.

2nd Place: A Focused Ethnography: Experiences of RNs Transitioning to the OR

Mary A. Brinkman, PhD, RN, CNOR

The OR is a unique setting and specialty area of

nursing practice that requires optimal orientation

and education to render safe and efficient patient

care. Unfortunately, there will be a significant

shortage of nurses in the OR in the next five to

10 years. The need for new nurses in the OR is

essential because many OR nurses in the workforce

1st Place in the research category: Factors Associated With RN Turnover in Perioperative Units. Pictured: Catima Potter

http://dx.doi.org/10.1016/j.aorn.2014.04.011

� AORN, Inc, 2014 June 2014 Vol 99 No 6 � AORN Journal j 713

will retire within the next five years. Currently,

most nursing programs no longer offer periopera-

tive courses in their curriculum. Subsequently, this

trend has led to the need for hospitals to educate

and orient new nurses to their ORs. As hospitals

educate their own OR nurses, retention after ori-

entation becomes a priority.

The purpose of this study was to explore nurses’

experiences as they transition to a new area of

nursing practice, the OR. A qualitative focused

ethnography was conducted. Fourteen RNs tran-

sitioning to the OR agreed to participate in this

study. The OR was a first-time experience for the

RNs. The setting was a large teaching hospital

located in an urban area. Observations and in-

terviews were conducted with the RNs to explore

their experiences as they transitioned in the OR.

The transition included learning the didactics of

OR nursing through the web-based AORN Nursing

101 online computer course, practicing learned skills

in a simulation laboratory, and rotating through

surgical specialty areas under the supervision of an

RN preceptor. Influences that facilitated the RNs’

transition to the OR were the positive learning

experience, their perception of belonging and

acceptance into the OR culture, the stimulating

environment, supportive personnel, collegiality

among peers, and presence of nursing in the OR.

Influences that hindered the RNs’ transition to the

OR were inconsistency in precepting, being in a

hostile environment, limited exposure to the OR

before the transition, and an overwhelming envi-

ronment. Meleis’ Situational Transition model

emerged in the RNs’ experiences transitioning to

the OR. The need to educate nurses in the OR is

essential to assure safety and positive outcomes for

the surgical patient. Structured perioperative cour-

ses implemented by hospitals or with partnerships

with nursing programs can enhance the education,

transition, and retention of nurses new to the OR.

The importance of a nurse educator having an

advanced degree with experience in the OR spe-

cialty was essential in coordinating and mentoring

nurses transitioning to this new practice area. The

RNs who are prepared to precept were vital in the

education and retention of RNs transitioning to

the OR. The need for consistent preceptors was

recognized as an essential factor to the RNs’ suc-

cessful transition. The findings contribute to

evidence-base practice for the design and imple-

mentation of perioperative courses for new nurses.

3rd Place: Transient Hypothermia Post-Cardiopulmonary Bypass: When Cold ISN’T COOL

Patrel B. Nobles, BSN, RN; Cathy D. Jennings,

DNP, RN, ACNS-BC; Sarah E. Frazier, BSN, BS, RN

Background: Cardiopulmonary bypass (CPB)

is an essential component for most cardiac surgical

procedures. Using CPB-induced hypothermia can

decrease the patient’s metabolic demand, protect

the brain and other vital organs, and increase

tolerance for cardiac ischemia during surgery.

Yet, afterdrop, the unintentional decrease in body

temperature between separation from CPB and

arrival in the cardiac surgery intensive care unit

(CSICU), can be problematic for cardiac surgery

patients. This unintentional transient hypothermia

is defined as a core temperature of less than 36� C (96.8� F) lasting less than 24 hours after CPB. Transient hypothermia is associated with increased

perioperative blood loss, mechanical ventilation

time, and CSICU and overall length of hospital stay.

2nd place in the research category: A Focused Ethnography: Experiences of RNs Transitioning to the OR. Pictured: Mary A. Brinkman

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Methods: This quality improvement project had

two phases. Phase 1 was a retrospective review

of patient records to determine the incidence of

transient hypothermia in this group (n ¼ 73) and to assess the following postoperative patient out-

comes: number of units of packed red blood cell

transfusions, hours on the ventilator, hours spent in

the CSICU, and hours spent in the hospital after

surgery. This group also served as the control group.

In phase 2, sterile forced-air warming blankets

were applied on all patients in the cardiac surgery

OR during the rewarming phase of CPB and left in

place through transfer to the CSICU. The same

outcomes were evaluated for this group (n ¼ 57). Outcomes: Results revealed that patients re-

ceiving the forced-air warming blankets (Phase 2)

had a statistically significant higher core temperature

on admission to CSICU (P ¼ .018). Although not statistically significant, patients in the forced-air

warming blanket group also

n received fewer red blood cell transfusions (0.67

units versus 0.85 units, a difference of 0.18 units),

n required fewer hours of mechanical ventilation

(13.9 hours versus 19.3 hours, a difference of

5.4 hours),

n had shorter lengths of stay in CSICU (86.5

hours versus 102.1 hours, a difference of 15.6

hours), and

n had shorter lengths of stay in the hospital

(170.2 hours versus 195.7 hours, a difference

of 25.5 hours).

Conclusion: Potential for clinical benefit from

prevention of transient hypothermia is evidence-

based and has resulted in a change in practice to

include forced-air warming after CPB for all patients

undergoing a cardiac surgical procedure.

EVIDENCE-BASED PRACTICE POSTERS

The top three posters were recognized with an

award in the evidence-based practice category by

members of AORN’s Nursing Research Commit-

tee. Following are the abstracts from the three

winning evidence-based practice posters.

1st Place: Engaging Staff in LEAN Methodology Results in Increased Efficiency, Satisfaction, and Decreased Turnover Times

Dawna L. Willsey, MSN, RN, CNOR; Coleen L.

Lutz, RN; Kimberly A. McEvoy-Dodson, MBA,

BSN, RN, CNOR, FACHE; Wendy Lin, MPH

As health care and surgical procedures become

more complex, the demand and optimization of

resources increase as well. Expedient turnover

time, as defined by a surgical patient “wheels out”

of the OR to “wheels in,” has plagued surgery

leaders. The increased complexity of technology

and resources erode and disrupt efficient perfor-

mance. Turnover time improvement efforts had

been attempted by several services and could not

be sustained. Orthopedics had fallen to the bottom

quartile compared with nationally benchmarked

turnover statistics. Patient and surgeon satisfac-

tion were issues as wait times increased and

surgery utilization decreased. Spinal fusion pro-

cedures, performed by a single surgeon, were

chosen as the focus for implementation of Lean

methodology processes. Team members were

interdisciplinary, representing all phases of spinal

surgery: preoperative, intraoperative, and post-

operative. Although the focus of this project was

on surgical procedure turnover, all processes

3rd place in the research category: Transient Hypo- thermia Post-Cardiopulmonary Bypass: When Cold ISN’T COOL. Pictured: Patrel B. Nobles and Sarah E. Frazier

AORN Journal j 715

AORN CONFERENCE POSTERS www.aornjournal.org

related to surgical spinal fusion were evaluated.

Several Lean tools were taught and used during

this process, including process and value stream

mapping, Kaizen events, development of standard

operating procedures, 30-60-90 day audits, and

huddles. The overall turnover time was measurably

decreased for spinal fusion procedures, as well as

an increase in OR efficiency. Process improvement

measures and cultural learning were applied depart-

ment wide. Patient, surgeon, and personnel satis-

faction increased through the innovations of new

processes. Ongoing audit and accountability tracking

has demonstrated that the outcomes have been sus-

tained. The initial membership of this team was

designed to have at least one member who could

lead the next focused improvement team effort.

Next steps will be to apply lessons learned from

this project to teams across departments and ser-

vice lines.

2nd Place: Focus on Quality Care

Hugo Xi, MD, MBA; Lena Pearson, MS, BSN,

RN, CNOR

Annually in the United States, 1.7 million patients

develop a health careeassociated infection (HAI)

and nearly 100,000 will die from one; system-wide,

the cost of HAIs is $35 billion. Recent studies dem-

onstrate that at least 50% of HAIs are preventable

and that evidence-based interventions can sub-

stantially reduce the incidence of HAIs. The Pa-

tient Protection and Affordable Care Act will

place up to 9.5% of Centers for Medicare &

Medicaid Services (CMS) payments “at risk” for

hospitals in fiscal year 2017. Quality and pay-

for-performance incentives can be implemented to

help offset this loss. The Focus on Quality Care Pro-

gram helps hospitals to eliminate variability in pro-

cesses that will result in less waste, fewer errors,

and better outcomes. The program implements a

process from start to finish, including identification

of evidence-based best practices, an action plan,

training, support tools, and optimization of the

product portfolio. The program includes an auto-

mated tablet computer-based OR audit tool, which

helps ensure consistency and standardize data

collection from audits across hospitals. In more

than 100 audits, aggregate data collected by the

audit tool demonstrated significant variability

in surgical skin preparation procedures within

and between facilities. The variability could

have significant implications to costs and pa-

tient outcomes.

3rd Place: Count Twice Scan Once: Zero Tolerance for Retained Surgical Sponges

Deborah G. Shealy, ADN, RN; Cynthia Shealy,

BSN, RN; William H. McRae III, MD

2nd place in the evidence-based practice category: Focus on Quality Care. Pictured: Hugo Xi and Lena Pearson

1st place in the evidence-based practice category: Engaging Staff in LEAN Methodology Results in Increased Efficiency, Satisfaction, and Decreased Turnover Times. Pictured: Coleen L. Lutz and Dawna L. Willsey

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The unintentionally retained surgical item is a

devastating experience for every patient and sur-

gical team. Surgical sponges account for 70% of

retained surgical items. The first line of defense to

prevent these events is manual counting, according

to AORN standards and recommended practices. At

Memorial, root cause analysis performed on every

retained surgical item between 2005 and 2009

yielded opportunities for system improvement,

except for human error. The root cause was deter-

mined to be human error at an undetermined time

during the count process, resulting in an inaccurate

initial count or inaccurate closing counts. The sur-

gical team believed their counts were correct, all

policy and procedures had been followed, and that

neither the patient nor procedure met risk factors

for a precautionary x-ray. It was time to explore

other safeguards to prevent these events from

occurring by leveraging technology to include

barcoding and radiofrequency (RF) detection

systems. The surgical team trialed two systems.

A radiofrequency detection system was chosen and

implemented in July 2011. With two years of data

now available (ie, approximately 30,000 procedures),

there have been zero occurrences of retained sur-

gical sponges. Policy and protocols were developed

for using the RF system for surgical patients. The

implications for perioperative nursing are signifi-

cant. Tangible benefits include reduction of patient

morbidity (eg, infection, returns to the OR, mor-

tality) and associated costs as well as improved OR

efficiency. Intangible benefits include increased

patient and team satisfaction. So, count twice;

scan once.

CLINICAL IMPROVEMENT/INNOVATION POSTERS

This is the first year that posters were judged online

using the virtual gallery. Only posters that were

uploaded were judged and the top 10% of those

posters received an Award of Excellence. The

posters were judged by the AORN Surgical Con-

ference & Expo Task Force. The following award

winners are presented in order by poster number.

Put Your Hands Up: Best Practice For Healthy Hands of Operating Room Personnel

Robin C. Salzbach, RN, CNOR; Gloria Y. Hinkle,

BSN, RN, CNOR

Clinical Issue: An increase in the occurrence of

skin disorders of the hands of OR personnel at

Carilion facilities was noted after a change was

made in the surgical hand rub for the ORs.

Preparation and Planning: The objective of

this project was to define evidence-based practice

for surgical hand antisepsis and hygiene, including

products, accessibility, and methodology. The plan

was to research hand hygiene and make recom-

mendations for best practice and plan interventions.

Implementation: The surgical hand rub was

changed to adhere to the recommendation of 61%

alcohol, 1% chlorhexidine, and humectants, which

is less irritating than the previously used product.

Redundant products were removed from the scrub

sinks. There were different kinds of hand soap, and

the one with the most chemicals in its content was

removed. Education was provided via inservice

programs regarding the changes. More hospital-

approved moisturizing lotions were installed

around high areas of need. Evidence supported that

the surgical hand rub can be used as the first scrub

of the day, but must be completed with a nail

3rd place in the evidence-based practice category: Count Twice Scan Once: Zero Tolerance for Retained Surgical Sponges. Pictured: Deborah G. Shealy

AORN Journal j 717

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cleaner; therefore, nail cleaners were added to the

scrub sinks.

Conclusions/Implications for Practice: A

study by McCormick and Colleagues showed that

an increase in the use of lotion led to a 50% increase

in hand cleaning frequency. It would be reasonable

to conclude that the increase of hand lotions, better

products, and education would increase hand hy-

giene compliance and decrease patient infection

in the OR and warrants further study.

Multidisciplinary Fire/Evacuation Drill: Planning & Execution

Karin Underberg, MEd, BSN, RN, CNOR; Gee Mei

Tan, MMED; Debnath Chattergee

Clinical Issue: Fires in the OR are relatively

rare, but can result in potentially devastating

complications.

Description of the Team: A multidisciplinary

planning team was assembled with personnel from

the anesthesia, perioperative nursing, surgery, and

safety departments.

Preparation and Planning: The AORN Fire

Safety Tool Kit scenarios were adapted to cover

a variety of pediatric procedures, resulting in 10

fire simulation scenarios. Ten simulation-trained

facilitators were identified and briefed on the plan.

Assessment: Nursing personnel have partici-

pated in fire and evacuation drills on an annual ba-

sis. This was the first time the entire team rehearsed

what to do in the event of a fire or mass evacuation.

Implementation: Ten simultaneous fire sce-

narios were conducted, each with a complete sur-

gical team participating. Observers from the

anesthesia, perioperative nursing, and safety de-

partments evaluated the event. One team’s fire

response and evacuation drill were videotaped.

Outcome: Post-event surveys indicated that all

team members had a positive experience; all re-

spondents agreed or strongly agreed that the fire

simulation was educational and time spent was

worthwhile.

Implications for Perioperative

Nursing: Teamwork and training are essential in

the OR environment; therefore, we can no longer

train in silos when we operate in a team environ-

ment. Annual education is essential to respond

effectively in the event of an OR fire.

The Response Time of MGH OR Nursing Evening Trauma Team to Emergent Craniotomies

Rener Venico, BSN, RN, CNOR; Breanna Dunne,

BSN, RN; Susan Aguiar, MBA, RN, CNOR; Therese

A. Merriman, BSN, RN

Multidisciplinary Fire/Evacuation Drill: Planning & Execution. Pictured: Karin Underberg

Put Your Hands Up: Best Practice For Healthy Hands of Operating Room Personnel. Pictured: Robin C. Salzbach

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Our team is called the MGH OR nursing evening

trauma team. The team is composed of expert,

advanced, and novice RNs, certified surgical tech-

nicians, instrument and equipment technicians, a

nurse manager, and a charge nurse. The team takes

over all the surgical procedures in the OR after 3

PM, including waitlist procedures, urgent procedures,

and, more importantly, emergent procedures. Our

personnel are trained in all surgical services and

specialties. As a level 1 trauma center, MGH Boston

caters to referrals and emergent procedures from all

over New England. Our ORs have more than 70 ORs.

Within the newly opened Lunder building, Lunder 4

boasts 12 state of the art ORs designed for neuro-

logical and vascular surgery. On the evening shift,

neurosurgery is a high-volume service. At the be-

ginning of the shift, a room in the Lunder 4 is des-

ignated as the “neuro crunch room.” This room is

prepared for any emergent neurosurgery pro-

cedures, more importantly, for craniotomies. This

poster presents the response time needed by nursing

personnel in collaboration with surgical and anesthesia

teams to start a procedure from the time it was booked

until initial skin incision. We used data collected from

spring 2013 to summer 2013. This presentation may be

used for future process improvement.

Innovative Adaption to Declining Reimbursement

Kimberly Valentine, BSN, RN, CNOR; Lynn

Scalise, MBA, BSN, RN

A decline in reimbursement for orthopedic sur-

geries led personnel at Mayo Clinic to develop

innovative strategies to reduce procedure costs

while simultaneously adhering to our high stan-

dards for quality. A collaborative approach be-

tween orthopedic surgeons, orthopedic team

leaders, surgical team members, and supply chain

personnel led to the standardization of orthopedic

implants and supplies. The objective was to achieve

a reduction in overall procedure costs to meet

reimbursement. Our methodology was fostered by

a team approach to decrease waste, standardize

custom packs and supplies, standardize implants,

and ensure compliance with contracts for cost

containment. An analysis of cost per procedure

identified several opportunities for improvement.

Comparing supplies and implants used per surgeon

on similar procedures confirmed the need for

standardization. Evaluating the necessity of all

supplies opened for each surgeon’s most frequent

procedures resulted in an elimination of excess

supplies. Reports were generated from the data

collected and shared with our surgeons. Imple-

mentation was accomplished by achieving stake-

holder buy-in, physician and employee education,

and execution of process changes to achieve waste

reduction. The cost/case data provided the rationale

to drive practice change without compromising

quality patient care. One outcome of the project

The Response Time of MGH OR Nursing Evening Trauma Team to Emergent Craniotomies.

Innovative Adaption to Declining Reimbursement. Pictured: Kimberly Valentine

AORN Journal j 719

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showed a decrease in the cost/procedure of total

knee arthroplasty by $525.00.

A Staff Driven Collaborative Vacation Process

Shokjean Yee, MA, RN, CNOR; Carole M. Cass,

MSN, RN, CNOR; Elizabeth S. Pincus, MSN, MBA,

RN, CNOR, ACNS-BC; Kristen Crookes, BSN, RN;

Dawn Parnas, RN

Clinical Issue: Vacation selection is a subject

that is difficult to manage in many institutions.

Finding the balance between flexibility and insti-

tutional coverage at the workplace is challenging.

The possibility of denied requests around popular

weeks may cause employee dissatisfaction.

Description of Team: The vacation committee

was formed with representation of all employees,

services, and shifts.

Preparation and Planning: The vacation com-

mittee determined issues and proposed amendments

to the existing guidelines. Polls were conducted to

address concern regarding vacations. To determine

solutions, the committee used breakout sessions

and selective brainstorming groups, and conducted

a personnel survey.

Assessment: Survey administered:

n How the selection process should be deter-

mined (eg, annually, biannually, first-come

first-served)?

n Should vacations be open across the OR or

determined by individual service lines?

n Should vacations be determined by shift

days and evenings or events (eg, weddings,

graduations)?

Implementation: Results from the survey re-

sponses were evaluated by the Shared Governance

Council and a collaborative guideline was forged

by majority voting. Rules were established and

allocation of vacation was divided into services

and shifts, and slot allotments were determined

with use of a random generator.

Outcome: Results were presented during de-

partments meetings. A collaborative guideline is

now used to determine vacation selection.

Implications for Perioperative Nursing: The

strategies implemented are driven by personnel,

are creative, and provide a unit fit. Feedback is

collected yearly, and new guidelines are added by

majority vote. This vacation initiative is a personnel

directed, collaborative effort complementing unit

need while strengthening personnel satisfaction.

Safety Checklist: Improving Patient Safety

Yessenia Valentin-Salgado, MS, RN, CNOR; Lystra

M. Swift, MA, RN, CNOR; Mary May Saulan, MPA,

BSN, CNOR

Increased complexity of surgical procedures coupled

with multitudes of competing priorities can lead to

opportunities for disasters. At Memorial Sloan

Kettering Cancer Center, we routinely perform

procedures of varying complexities, some involving

up to six surgical specialties. We have recognized

that even experts are fallible. A safety summit was

held to evaluate existing practices and develop new

processes for rare but potentially catastrophic sur-

gical events. Emergency checklists were developed

to eliminate reliance on inherently imperfect

human memory and provide a systematic way to

explore options. This empowers all members of

A Staff Driven Collaborative Vacation Process. Pictured: Kristen Crookes, Carole M. Cass, and Shokjean Yee

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the perioperative team to respond assertively and

efficiently to emergency situations, such as:

n air embolism,

n anaphylaxis,

n bleeding,

n bradycardia,

n cardiac arrest,

n failed airway,

n fire,

n hypotension,

n hypoxia,

n malignant hypothermia,

n tachycardia,

n incorrect count,

n robotic to open procedure,

n robot malfunction, or

n sharps injury.

Multidisciplinary simulations are performed to

train all surgeons, anesthesia professionals, and

nursing personnel regarding how to function during

critical events. Checklist simulations have now been

incorporated into our annual mandatory competency

program. As a prerequisite, all anesthesia professionals

and surgical providers are certified in advanced

cardiac life support. Preliminary feedback regarding

checklist use indicates that the emergency checklists

provide standardization, increase personnel satis-

faction, and improve proficiency in handling in-

traoperative emergencies.

Let’s Clear the Air: There is No Such Thing as Safe Surgical Smoke

Sherry L. Chavis, RN, CNOR; Melanie I. Becker,

BSN, RN, CNOR; Vicki L. Wagner, MSN, RN,

CNOR; Mercelita I. Bowerman, BSN, RN, CNOR;

Mary Shirley Jamias, RN, CNOR

Clinical Issue: Evidence of the harmful effects

of surgical smoke is prevalent in literature and

recognized by organizations like AORN, The Joint

Commission, and the National Institute for Occu-

pational Safety and Health. In the absence of

consistent and effective management, surgical

smoke continues to permeate the perioperative

environment potentially causing harm to patients

and personnel.

Description of the Team: Our team consisted

of perioperative nurses, team leaders, educators,

and managers.

Preparation and Planning: Articles from

professional publications, AORN recommended

practices, the AORN Management of Surgical

Smoke Tool Kit, and organizational policies and

procedures were reviewed.

Assessment: A pre-education personnel survey

was conducted to assess existing surgical smoke

management practices. Quantitative data was re-

viewed to determine pre-education smoke evac-

uator usage.

Implementation: A three-part, multimedia

education program was implemented for OR

personnel. Additional implementation strategies

maintained momentum to include

n an “everyone is a champion” initiative,

n updated preference cards,

n updated OR cores with appropriate supply

items,

n provision of practical personnel resources, and

n a “Look Who is NOT Smoking” initiative.

Outcome: A posteducation personnel survey

was conducted and comparison data demonstrated

improvement. Postimplementation quantitativeSafety Checklist: Improving Patient Safety.

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data demonstrated an increase in smoke evacuator

usage.

Implications for Perioperative Nursing: The

success of this initiative reduced the presence of

surgical smoke plume in the perioperative envi-

ronment, resulting in a safer environment for pa-

tients and personnel.

Fast Track to OR for Trauma/Emergency/ Unstable Patients

Lydia E. McQuinn, BSN, RN; Betty A. McGee,

ADN, RN, CNOR

Clinical Issue: Problems identified included

n a need to improve efficiencies of care provided

to pediatric trauma patients to enhance the

medical coordination between physician leaders;

n lack of consistent communication between the

emergency department (ED) and OR, which

resulted in patients being transported to the OR

when perioperative personnel or the anesthesia

professional were not immediately available;

and

n lack of a face-to-face hand-over between OR

nurses and ED physicians.

Purpose: Improve the efficiency of care and

outcomes for unstable pediatric trauma patients

from the ED to the OR with coordination of surgical

care between medical personnel (eg, surgeons, ED

physicians, anesthesia professional, OR personnel).

Planning and Implementation: A failure mode

and effects analysis (FMEA) was conducted, which

addressed the need to form a trauma quality com-

mittee for surgical services to help identify areas of

opportunity in our trauma service. A trauma and

surgical vision statement was created to identify

needs for the ED/trauma service line. Collabora-

tive efforts and communication were established

between the ED Physicians/nursing and respira-

tory therapy to facilitate transport of the trauma

patient to the OR. The need was identified to have

ED physician and personnel remain with the pa-

tient to continue to monitor and support the patient

until the OR RN and anesthesia professional were

present to receive the hand-over report safely from

ED personnel.

Outcomes: There now exists a medical con-

sensus of ED physicians for how to handle emer-

gent needs of the OR and team for unstable pediatric

patients. This includes timely communication be-

tween the ED and OR of when to expect trauma

patient. Trauma patients are transported, moni-

tored, and supported by ED personnel in the

OR until the hand-over can be completed to OR

personnel. A cart containing surgical attire for ED

personnel to don to enter the OR suite was created

Fast Track to OR for Trauma/Emergency/Unstable Patients. Pictured: Betty A. McGee and Lydia E. McQuinn

Let’s Clear the Air: There is No Such Thing as Safe Surgical Smoke. Pictured: Sherry L. Chavis, Vicki L. Wagner, and Mercelita I. Bowerman

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and placed by the elevator for ease of access. An

OR RN completes a trauma review sheet for every

trauma patient received in the OR. The statistics

are tabulated and reviewed monthly by members of

the trauma quality committee to identify processes

in need of improvement.

Conclusion: Our goal ultimately is to save lives

and improve patient outcomes. With the imple-

mentation of fast track to the OR, we have decreased

the wait time, established a collaboration between

surgical and ED personnel, expedited safe care

for unstable trauma patients during transport to

the OR from the ED, and facilitated a thorough

face-to-face hand-over in the OR between the ED

personnel, anesthesia professionals, and OR per-

sonnel. The trauma quality committee meets

monthly to review each procedure for any pro-

cess improvements needed.

Standardized Back Table and Mayo Setup

Monica L. Heyn, BSN, RN, CNOR; Debra L. Rode,

RN, CNOR; Stacy E. Lyons Weatherly, BSN, RN,

CNOR; Linda L. Pinkston, MSN, RN, CNOR

Scottsdale Healthcare, consisting of four hospitals

and one outpatient surgery center, is a leader in

surgical services in the Phoenix metropolitan area.

Among its five surgery departments, considerable

variations were discovered in the setup of back

tables and Mayo stands in surgical procedures. A

multidisciplinary team of executive sponsors,

managers, front-line personnel, and physician

champions worked together on a system-wide rapid

process improvement (RPI) project to design a

“standardized best setup” for general surgery pro-

cedures with the intent to expand into all service

lines. Our objectives in standardizing the process

were to improve safety and quality, and to reduce

waste using LEAN methodologies and best prac-

tices. In simulating what the standardized best

setup would look like, the workgroup exhibited

innovation through active discussion of using setup

zones; refined the process through collaboration

across areas; and developed educational, training,

communication, and implementation plans.

Diagramming and vector graphics of the stan-

dardized best setups were also created as refer-

ence documents for education and training. An

audit tool was developed to ensure compliance

and to provide feedback. The standardized setups

were applied system wide and project commu-

nication posters were created and displayed in

all surgical departments.

Suture Inventory Control Project

Katharine Zegler, RN, CNOR

During the move to the new University Hospital,

we discovered many sutures in inventory and noted

a number about to expire. This is an avoidable

waste of resources. The objective of the project

was to streamline suture inventory. This was ap-

proached two ways: cost-saving methods and

educational programs. For cost savings, 12-month

and four-month order history and June inventory

were requested from suture representatives. New

par levels and suggested deletions were determined

from this data. A list of sutures ordered zero to two

times in 12 months was given to the clinical co-

ordinators of each service for suggested deletion.

They approved 43 sutures for deletion for a one-

time cost saving of $9,292.03. New par levels

were determined, resulting in 184 boxes removed

Standardized Back Table and Mayo Setup. Pictured: Debra L. Rode and Monica L. Heyn

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from shelves and $32,129.81 less being carried

in inventory. Suture for return or exchange was

valued at $34,000 and we were able to receive a

one-time order of 184 boxes of our most frequently

used sutures with the exchange. Total cost savings

equaled $75,421.84. Education programs were

provided using a suture cross-reference chart so

personnel unfamiliar with all kinds of suture could

suggest an appropriate substitute. A “Did You

Know” poster was created with suture factoids.

The project outcome identified opportunities to

reduce cost and refocus ordering to need based.

Nursing efficiency was increased with education.

Clinical Pathology Specimens: Operating Rooms to Results

Renee A. Prince, MHA, BSN, RN

Clinical pathology (CP) specimens collected in

ORs are sent to the specimen processing area for a

variety of clinical reasons that are important or vital

to the care of the patient. The OR and specimen

processing area have observed that the current

process for the delivery of these specimens to the

specimen processing area does not assure 100%

delivery. As a result, specimens have been lost,

delayed in transport, or are delivered too late to

render accurate results. We observed that the pro-

cess has too many gaps to ensure that the speci-

mens are delivered to the designated laboratory

on time. The team comprised nursing administration

personnel, staff RNs, a perioperative technologist

supervisor, and personnel from the clinical pathol-

ogy and pathology quality assurance departments.

The implementation of a new delivery process

effectively decreased specimen defects, increased

speed in delivery times, and allowed the perioper-

ative nurses to remain uninterrupted at the pa-

tient’s bedside.

Creating Partnerships for Tissue Management Excellence

Kimberly Cheuvront, PhD, MBA, MT(ASCP,

AMT); Georgiana L. Grove, BSN, RN, CNOR;

Jacqueline A. Sions, MSN, RN, CNOR, NE-BC;

Myra J. Beach, MBA, BSN, RN, CNOR; J. W.

Bowers, BSN, RN, CNOR, TNCC; Cinthia R.

Cendana, BSN, RN, C NOR; Jesse R. Hixson,

RN; Mary C. Wilson, BSN, RN, CNOR

Clinical Issue: Tissue management at WVU

Healthcare was very labor intensive because of

the eight locations throughout the operative suites

and a cumbersome tracking system. To enhance

nursing satisfaction, partnerships were formed to

achieve tissue management excellence.

Team: The implementation team consisted of

an RN, a perioperative quality coordinator, and

personnel from materials management and infor-

mation technology.

Preparation/Planning/Assessment: Facility

managers coordinated construction of the tissue

Suture Inventory Control Project. Pictured: Katharine Zegler

Clinical Pathology Specimens: Operating Rooms to Results. Pictured: Renee A. Prince

724 j AORN Journal

June 2014 Vol 99 No 6 AORN CONFERENCE POSTERS

room and tracking programs were evaluated. We

used various transport containers for tissues on a

trial basis. Inventory personnel needed to achieve

24-hour coverage and the square footage necessary

to house tissue in one centrally located space were

determined. Careful review of all biological prod-

ucts, including shelf life, redundancy of product,

and regulatory requirements, occurred.

Implementation: Tissue inventory room con-

struction was completed in August 2012. Tracking

software went live January 2013.

Outcome: With implementation of new tracking

software and centralized tissue storage, compliance

requirements for the US Food and Drug Adminis-

tration and The Joint Commission are easily ach-

ieved and tissue management is improved.

Implications for Perioperative Nursing: OR

nurses are able to focus on patient care and are not

leaving the OR for extended periods of time to access

individual tissue storage units throughout the OR.

The Culture of Lateral Violence in Nursing

Kelly C. Nader, DNP, RN, CNOR; Karen M.

O’Connell, PhD, RN, CEN; Linda J. Wanzer, DNP,

RN, CNOR, COL(Ret)

Problem: Lateral violence is becoming a crisis

in the profession of nursing. Behaviors include

disruptive, demeaning, and uncivil acts that are

affecting our ability to communicate, learn, retain

nurses, and provide safe patient care. Lack of

awareness and the tolerance demonstrated by lead-

ership personnel towards this disruptive behavior

is allowing this to become a normative culture

throughout our profession.

Purpose: The purpose of this evidence-based

project was to analyze the literature for content to

include in a policy code of conduct to minimize

lateral violence and maintain effective commu-

nication among nurses.

Method: A descriptive integrative review of the

literature framed by Purpora and Blegen’s Hori-

zontal Violence and the Quality and Safety of

Patient Care conceptual model was conducted us-

ing the Bibb-Wanzer Identifying, Organizing, and

Synthesizing (IOS) strategy to guide the procedural

phase of the study. Searches of PubMed, Cumulative

Index to Nursing and Allied Health Literature,

references, and the World Wide Web were con-

ducted and resulted in 41 articles.

Results: After the literature synthesis, six trends

with targeted interventions were identified that

should be incorporated into the creation of an

organizational policy code of conduct to minimize

lateral violence and enhance communication in

nursing. Formal implementation should include

a zero-tolerance policy code of conduct that

is created using shared governance. Synergistic

interventions include educational initiatives,

Creating Partnerships for Tissue Management Excellence. Pictured: Mary C. Wilson, Jacqueline A. Sions, and Georgiana L. Grove

The Culture of Lateral Violence in Nursing.

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communication skills, supportive leadership, and

establishment of healthy organizational values

and ethics.

Perioperative Nursing Implications: A zero-

tolerance policy is only the first step toward

creating a healthy work culture. The evidence

obtained in this literature review supports the need

for a synergistic, multipronged, zero-tolerance

program that is strongly supported by leadership

personnel. The organizational culture has a massive

effect on tolerance and awareness of lateral violence.

Lack of action on the part of leadership personnel

endorses negative behavior and will lead to pro-

gram failure.

Implementing Postanesthesia Discharge Criteria in a Pediatric Setting

Julie A. Martin, MBA, BSN, CNOR; Lori

McDaniel, BSN, RN, CPN; Amber Riordan,

BSN, RN, CPN; Lee-Anne Waterman, RN, CPN

Several discharge criteria scales exist for use in the

perioperative setting. The phase-one postanesthesia

care unit uses one scale in our hospital, but the

criteria were not clearly defined for discharge from

phase two to home. This resulted in variations in

practice when nurses relied on individual judgment

and experience. A team of RNs collaborated with

the department of anesthesiology to create phase-

two discharge criteria that could be used in a pe-

diatric setting and provided general guidelines to

discharge a child home safely. The team conducted

a literature search and survey of similar pediatric

hospitals and identified three primary discharge

criteria scales being used. A discharge criteria

scoring tool and guidelines relevant to pediatrics

was proposed to the anesthesia and nursing de-

partments, and implemented in 2013. Clearly

defined phase-two discharge criteria resulted in a

higher nursing satisfaction rate and more consistent

practice. Based on the literature search, the team

changed practice to not require consumption of

fluids by mouth as a discharge criterion, except for

select patients. Perianesthesia nurses collaborated

with the department of anesthesiology to develop

discharge criteria for pediatric surgical patients,

which provided consistency in practice (standardiza-

tion of care) and increased nursing confidence of

when it is safe to discharge the patient to home.

Editor’s note: AORN is currently soliciting sub- missions for poster presentations for the AORN

Surgical Conference & Expo 2015. The deadline is

October 3, 2014. Interested authors can find more

information at http://www.aorn.org/Events/CallFor

Proposals/Poster_Guidelines.aspx.

Implementing Postanesthesia Discharge Criteria in a Pediatric Setting. Pictured: Lee-Anne Waterman and Julie A. Martin

726 j AORN Journal

June 2014 Vol 99 No 6 AORN CONFERENCE POSTERS

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