Grant Funds Provided ByA Continuing Nursing Education ActivitySponsored By

A Comprehensive Surgical Checklist:Using Technology to Help Optimize Preparedness, Patient Safety and Performance

(A Continuing Education Self-Study Activity)

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A COMPREHENSIVE SURGICAL CHECKLIST: Using Technology to Help Optimize

Preparedness, Patient Safety and Performance

(A Continuing Education Self-Study Activity)

CONTINUING EDUCATION INSTRUCTIONSThis educational activity is intended for use as a stand alone self-study activity. We suggest you take the following steps for successful completion:

1. Read the overview and objectives to ensure consistency with your own learning needs and objectives.

2. Review the content of the self-study activity, paying particular attention to those areas that reflect the objectives.

3. Complete the Test Questions and compare your responses with the answers provided.

4. For additional information on an issue or topic, consult the references.5. To receive credit for this activity complete the evaluation and registration form. 6. A certificate of completion will be available for you to print at the conclusion.

Pfiedler Enterprises will maintain a record of your continuing education credits and provide verification, if necessary, for 7 years.

If you have any questions, please call: 720-748-6144.

CONTACT INFORMATION:

2101 S. Blackhawk Street, Suite 220Aurora, CO 80014-1475Phone: 720-748-6144

Fax: 720-748-6196Website: www.pfiedlerenterprises.com

© Pfiedler Enterprises - all rights reserved 2011

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COMPLIANCE WITH TISSUE TRACKING(A Continuing Education Self-Study Activity)

OVERVIEWThe AORN Comprehensive Surgical Checklist1 combines the Joint Commission’s Universal Protocol Requirements and the World Health Organization’s Surgical Checklist from 2009. The goal of using the checklist is to improve patient safety and thereby avoid sentinel events. “Smart” (computerized) technology supports the use of a comprehensive surgical checklist by helping to optimize preparedness, patient safety, and performance.

OBJECTIVESAfter completing this continuing nursing education activity, the participant should be able to:

1. Describe six capabilities of smart technologies that can help optimize preparedness, patient safety and performance.

2. List three types of surgery-related items for which technology can help ensure availability and safe use.

3. Discuss three major benefits to the perioperative nurse and hospital of using smart technology in the perioperative setting.

INTENDED AUDIENCEThis continuing education activity is intended for perioperative registered nurses and surgical technologists who are interested in learning more about increasing awareness of available “smart” (computerized) technologies and relevant applications to perioperative nursing.

CREDIT/CREDIT INFORMATIONState Board Approval for NursesPfiedler Enterprises is a provider approved by the California Board of Registered Nursing, Provider Number CEP14944, for 2.0 contact hour(s).

Obtaining full credit for this offering depends upon attendance, regardless of circumstances, from beginning to end. Licensees must provide their license numbers for record keeping purposes.

The certificate of course completion issued at the conclusion of this course must be retained in the participant’s records for at least four (4) years as proof of attendance.

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IACET Credit for Allied Health ProfessionalsPfiedler Enterprises has been approved as an Authorized Provider by the International Association for Continuing Education and Training (IACET), 1760 Old Meadow Road, Suite 500, McLean, VA 22102.

CEU STATEMENTAs an IACET Authorized Provider, Pfiedler Enterprises offers CEUs for its programs that qualify under IACET guidelines. Pfiedler Enterprises is authorized by IACET to offer 0.2 CEU (2.0 contact hours) for this program.

RELEASE AND EXPIRATION DATEThis continuing education activity was planned and provided in accordance with accreditation criteria. This material was originally produced in June 2011 and can no longer be used after June 2013 without being updated; therefore, this continuing education activity expires in June 2013.

DISCLAIMERAccredited status as a provider refers only to continuing nursing education activities and does not imply endorsement of any products.

SUPPORTGrant funds for the development of this activity were provided by CareFusion.

PLANNING COMMITTEEColleen Becker, MSN, RN, CCRN St. Jacob, ILExec Director/DirectorPerioperative Services

Judith Pfister, RN, BSN, MBA Aurora, COProgram ManagerPfiedler Enterprises

EXPERT REVIEWERSJulia A. Kneedler, RN, MS, EdD Aurora, CODirector of EducationPfiedler Enterprises

Chad Edmonson, CST Lone Tree, COCertified Surgical TechnologistSky Ridge Medical Center

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FACULTYColleen Becker, MSN, RN, CCRN St. Jacob, ILExec Director/DirectorPerioperative Services

DISCLOSURE INFORMATIONAll planning committee members, expert reviewers, authors and faculty participating in continuing education activities sponsored by Pfiedler Enterprises are expected to disclose to the audience any real or apparent financial affiliations related to the content of their activities. Detailed disclosure appears below and also will be made verbally prior to those activities with live presentations.

Planning committee members, expert reviewers, authors and faculty information:

1. Have you (or your spouse/partner) had any personal financial relationship in the last 12 months with the manufacturer of the products or services that will be presented in this continuing education activity (planner/reviewer) or in your presentation (speaker/author)?

2. Type of affiliation/financial interest with name of corporate organization.3. Will your presentation include discussion of any off-label or investigational drug or

medical device?

Colleen Becker, MSN, RN, CCRN1. No2. None3. No

Judith Pfister, RN, BSN, MBA1. Yes2. Employed by company that receives funds from CareFusion.3. No

Julia A. Kneedler, RN, MS, EdD1. Yes2. Employed by company that receives funds from CareFusion.3. No

Chad Edmonson, CST1. No2. None3. No

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INTRODUCTIONStudies in industrialized countries have shown a perioperative mortality rate from inpatient surgery of 0.4% to 0.8% and a major complications rate of 3% to 17%.2,3 Data suggest that at least half of all surgical complications are avoidable. By using a checklist to follow critical steps, perioperative nurses can minimize the most common and avoidable risks endangering the lives and well-being of surgical patients.1

A perioperative nurse’s primary concern is always to care for the patient. However, supply-related tasks (searching for supplies, manually charting supply usage, manually documenting lot, serial number and expiration date, manually logging tissues and implants) can take a perioperative nurse away from patient care. A recent observational study of nurses during medication preparation and administration showed that nursing interruptions were significantly associated with the incidence of procedural failures (e.g., not using aseptic technique) and clinical errors (e.g., wrong dose).8

Without interruption the estimated risk of a nurse making a major error was 2.3%; with four interruptions, the estimated risk of major error was 4.7% (P < 0.001). Nurse experience provided no protection against making a clinical error and was associated with higher procedural failure rates.3 These findings suggest that nursing interruptions could also increase the number of errors and risk to patient safety.

Smart technology can automate tedious, time-consuming manual processes and provide safety checks. By reducing nursing interruptions, smart technology helps streamline nurses’ workflow and increase patient safety.

Key capabilities of smart technology include:

• Tracking;• Patient verification and supply-item verification;• Clinical alerts;• Automated documentation; • Compliance with Joint Commission requirements;• Actionable information; and• Improvement of charge capture and case.

Applying these capabilities in various ways can help optimize patient safety and help ensure that essential supplies and instruments are ready to go before surgery begins.

PREPAREDNESSThe AORN checklist addresses Preprocedure Check-in, Sign-in, Time-out and Sign-out. Preparedness is also essential to optimal checklist use. Missing items can delay an on-time start, interrupt a procedure, or result in the use of inappropriate instrumentation. Items that have been contaminated or incorrectly sterilized or stored can pose serious risks to the patient. Smart technology can help ensure that necessary items are ready for use when surgery begins.

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USING “SMART” TECHNOLOGY – EXAMPLESInstrument Management Today many hospitals perform more complex surgeries than in the past and manage a greater number of related surgical instruments. Having all necessary instrumentation available, properly sterilized and in good working order can be a major challenge. Regulations and recalls require accurate record-keeping.

The Joint Commission advocates tracking instruments to the patient level. AORN, the Joint Commission and major hospitals have called for reducing immediate use (flash) sterilization because of a possible increased risk for infection.

A smart instrument management system automatically tracks bar-coded instrument trays from the OR to Central Sterile and back. Secure instrument trays have indicators inside and outside to verify sterility. The countsheet that goes with the tray can be used in counting the instruments before and after surgery. Sterility indicators added to the countsheet provide additional confirmation that the proper process has been followed.

Perioperative nurses can access the system themselves to locate a particular instrument tray. When the correct instrumentation is delivered on time, there may be less risk of inappropriate instrumentation being used as backup. If a sentinel event occurs, the system allows users to track back to the cause. The real-time data automatically provided by the system can help in the instance of a possible sentinel event or instrument recall and are helpful for Joint Commission and Healthcare Facilities Accreditation Program (HFAP) surveys.

Data analysis can help identify ways to optimize tray inventory levels and usage patterns. At Ohio Health, Grant Hospital5, an instrument tracking system helped reduce the use of flash sterilization by 70%, from an average of 10 to approximately three times per day.4 Instead of running for immediate use sterilization to get equipment ready, a perioperative nurse can maintain an uninterrupted focus on patient care.

Mary Ann Cain, director of perioperative services at Doctors Hospital, OhioHealth, reports that nurses are better prepared, spend less time looking for instruments and can focus their attention on patient preparation and checking safety protocols. As Sandy Laymon, a nurse at Wesley Medical Center in Wichita puts it: “They don’t miss all those handwritten histories and paper documentation at all.”

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Using “SMART” Technology Instrument Management

Benefits

Pre-implementation – avg. 2 hr/day looking for sets.

Post-implementation – Staff– Better prepared, less time looking for instruments– Can focus on patient preparation and checking protocols

Mary Ann Cain, RN, Director, Perioperative Services, Doctors Hospital, OhioHealth, Columbus, OH

Storage–Secure, Automated Supply Dispensing CabinetsIn many hospitals OR supplies are stored on open shelves and can easily be removed. Manually documenting supply-item usage is time-consuming and often incomplete and inaccurate. The results can be an inability to track supplies, clinician dissatisfaction, decreased productivity, financial losses and poor regulatory compliance.

Automated supply dispensing cabinets at the point of use can help store surgical supply items safely and securely, while allowing staff rapid access to supplies. A nurse can chart, charge and reorder with the touch of a button. Item usage is accurately documented and sent directly to the billing system and the OR information management system, and the item is reordered promptly to avoid stock outs.

Clinical alerts help ensure that biologic tissues and implants are safe to use. The automated system also helps improve preference card accuracy, case pick and return processes, data accuracy and compliance with Joint Commission standards.

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Using “SMART” Technology Automated Supply Dispensing Cabinets

• Rapid access to supplies• Automatically chart, charge

and reorder supplies• Reduce time-consuming

supply management activities• Increase nurses’ time for

patient care• Clinical alerts• Manage Tissue and implants

Tissue and Biologic Implant Management The Joint Commission TS.03.01.01, TS.03.02.01 and TS.03.03.01 standards, as well as recommendations by the Association of Perioperative Registered Nurses (AORN), state that tissue and implants must be tracked and documented from acquisition to implantation or disposal. Specialized modules can help improve overall tissue and implant management and regulatory compliance by creating an electronic chain of custody. The modules continuously monitor temperature-sensitive tissues and implants and alert staff to product expiration and potential infection or contamination due to temperature-sensitive items being out of range. The system also provides detailed preparation instructions and facilitates 10-year data storage to help hospitals take prompt action in the event of a recall.

Using “SMART” Technology Automated Supply Dispensing Cabinets

Tissue and implants

The Joint Commission TS.03.01.01, TS.03.02.01 and TS.03.03.01 standards• Tissue and implants must be tracked and documented from

acquisition to implantation or disposal

Need• Update current tracking procedures• Establish reliable, automated practices • Reduce the risk of contamination and disease transmission

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INTEGRATION WITH OR MANAGEMENT INFORMATION SYSTEMSome smart automated supply dispensing systems can integrate supply dispensing technology data with the hospital’s OR information management system can automatically incorporate surgical supply and implant information directly into patient records. Integration allows procedure ID, physician name, and patient ID number to be relayed from the hospital system directly to the supply dispensing cabinet. Point-of-use data capture reduces error-prone manual documentation, particularly important when documenting lot and serial numbers. When these systems are integrated nursing time spent on documentation is reduced allowing perioperative nurses to spend more time on patient care and keeping the OR running efficiently. A 197-bed hospital identified opportunities for efficiencies within their perioperative area and implemented automated supply technology. They reduced the amount of time spent by nurses on documentation in the OR by an average of 10.9 minutes per case, translating into 1,000 clinician documentation hours saved annually.

AUTOMATED BAR CODE TRANSFUSION VERIFICATION CMS requires a facility to absorb all costs associated with treating blood transfusion errors.6 The Joint Commission National Patient Safety Goal.01.03.017 seeks to eliminate transfusion errors related to patient misidentification. Using two patient identifiers is crucial to ensuring accurate administration. In September 2010, the Joint Commission revised NPSG.01.03.01 to allow one-person verification accompanied by automated identification technology such as bar coding. Using bar code technology to provide the second check helps free the perioperative nurse to focus on patient care without that interruption.

Using “SMART” Technology Automated Bar Code Technology for Blood Transfusion Verification

Need

Joint Commission NPSG.01.03.01 - Elements of Performance• Before initiating a blood or blood component transfusion• Match the blood or blood component to the order• Match the patient to the blood or blood component

• Use a two-person verification process or a one-person verification process accompanied by automated identification technology, such as bar coding

Bar code enabled wireless transfusion verification technology can help hospitals significantly reduce the potential for errors during the blood transfusion process by promoting positive patient identification and positive blood product identification at the point of care. The hand-held device associated with transfusion verification smart technology can be used to display orders; track blood product release, delivery and administration; and can fully automate the transfusion documentation process. A perioperative nurse can quickly scan and confirm

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the identity of both the patient and the blood product The smart technology supports the clinical workflow of the transfusion, including entering vital signs, reviewing a pre-transfusion checklist, verifying transfusion details and starting the transfusion.

When the transfusion is completed, the transfusion record prints and is added to the patient’s chart. The rapid infusion feature is designed to accommodate workflow in emergent care situations. This allows the nurse to verify the right patient and blood product is immediately administered, allowing for documentation after the emergent situation.

Using “SMART” Technology Automated Bar Code Technology for Blood Transfusion Verification

• Track patient identification information• Display orders for patient blood product administration• Track product release, delivery and administration of blood products• Cross-check information electronically to help confirm ordered and

assigned blood products for the patient• Automate documentation of vital signs, update transfusion records• Review facility specific checklists• Verify transfusion• Use rapid infusion workflow in emergent care situations

SUPPORTING AORN CHECKLIST USEDuring Preprocedure Check-In, an instrument management system can provide an accurate countsheet to help indentify if any special equipment is needed and that instruments have gone through the proper cleaning and sterilization steps.

Using “SMART” Technology Preprocedure Check-In – In Holding Area

Patient/patient representative actively confirms with Registered Nurse (RN):

Identity Yes Procedure and procedure site Yes Consent(s) YesSite marked Yes N/A by person performing the procedure

RN confirms presence of: History and physical Yes Preanesthesia assessment Yes Diagnostic and radiologic test results Yes N/A Blood products Yes N/A - available, verified and tracked

Any special equipment, devices, implants Yes N/A Available, verified and tracked

Medications Included in Preprocedure check-in as per institutional custom: Beta blocker medication given (SCIP) □ Yes □ N/AVenous thromboembolism prophylaxis ordered (SCIP) □Yes □Given □ N/ANormothermia measures (SCIP) □ Yes □ N/A

www.aorn.org/PracticeResources/ToolKits/CorrectSiteSurgeryToolKit/Comprehensivechecklist/

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At Sign-In, the transfusion verification system can help verify the number of units and type of blood product available.

Using “SMART” Technology Sign-In – Before Induction of AnesthesiaRN and anesthesia are provider confirmed:

Confirmation of: identity, procedure, procedure site and consent(s) Yes

Site marked Yes N/A by person performing the procedure

Patient allergies Yes N/A

Difficult airway or aspiration risk? No Yes (preparation confirmed)

Risk of blood loss (> 500 ml) Yes N/A# of units available ______ Transfusion verification system confirms # of units, type, etc. Automated bar code identification technology can be used as second verification.

Anesthesia safety check completed Yes

Briefing:All members of the team have discussed care plan and addressed concerns Yes

www.aorn.org/PracticeResources/ToolKits/CorrectSiteSurgeryToolKit/Comprehensivechecklist/

During Time-out, countsheets and tracking data can help address instrument concerns. Tray markers verify sterility.

Using “SMART” Technology Time-Out – Before Skin Incision

Initiated by designated team member All other activities to be suspended (unless a life-threatening emergency) Introduction of team members Yes All:Confirmation of the following: identity, procedure, incision site, consent(s) Yes Site is marked and visible Yes N/A Relevant images properly labeled and displayed Yes N/A Any equipment concerns? Countsheet, tracking help document availability, usability

Anticipated Critical Events Surgeon: States the following:

critical or non-routine steps case duration anticipated blood loss

Anesthesia Provider: Antibiotic prophylaxis within one hour before incision Yes N/A Additional concerns?

Scrub and circulating nurse: Sterilization indicators have been confirmed Instrument trays – outside and inside indicatorsAdditional concerns? Skin preparation–incision site sterilized with CHG

www.aorn.org/PracticeResources/ToolKits/CorrectSiteSurgeryToolKit/Comprehensivechecklist/

NOTE: A checkmark could be added for the use of chlorhexidine gluconate to prep an incision site.

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During Sign-out, the countsheet helps in conducting and documenting the instrument count.

Using “SMART” Technology Sign-OutBefore the Patient Leaves the Operating Room RN confirms: Name of operative procedure Completion of sponge, sharp, and instrument counts □ Yes □ N/A Instrument Management System generates countsheet helps document instrument count

Specimens identified and labeled □ Yes □ N/A Any equipment problems to be addressed? □ Yes □ N/A

To all team members: What are the key concerns for recovery and management of this patient? ___________________________________________________________________________________________________ _________________________________

www.aorn.org/PracticeResources/ToolKits/CorrectSiteSurgeryToolKit/Comprehensivechecklist/

After surgery, smart supply dispensing technologies automatically document supplies, implants and tissue to the patient record, order supply refills, capture charges, and provide data for actionable information.

ACTIONABLE INFORMATIONSmart devices automatically log continuous quality improvement (CQI) data that can be wirelessly transmitted to a central server. Data mining (searching large amounts of data for clinically significant patterns) and business intelligence tools help turn the large amounts of data into actionable information, which is reported back to the hospital staff.

Customized reports help staff identify opportunities to further improve best practices, processes, workflow and compliance. Actionable information also helps reduce costs and justify requests for additional capital expenditures.

IMPROVING OPERATIONAL AND FINANCIAL PERFORMANCE On average, the OR accounts for 50% of a hospital’s total budget1 and generates 42% of patient revenue.2 Implants and biologics are among a hospital’s most expensive supplies.

Documentation errors, lost charges, higher-than-necessary inventory carrying costs, and stockouts negatively impact operations and finances. Conversely, avoiding one surgical site infection (SSI) or one hospital-acquired infection (HAI) can more than pay for smart technologies, even for a small hospital. System-generated data can help document the kind of positive, continuous return on investment (ROI) that has been shown at many facilities.

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Mary Ann Cain at Doctors said, “Our administration is now more willing to back our capital requests because we can more clearly demonstrate our needs.”

BENEFITS OF USING “SMART” TECHNOLOGYPerioperative NursesAfter implementation of smart technology in the perioperative setting:

• Nurses spend less time looking for instruments and other supplies.• Clinician satisfaction improves by having everything ready and available when

surgery begins.• Automated documentation means that information is sent to the patient record

electronically and helps eliminate manual errors and re-entry into multiple systems.

• Nurses can spend more time with patients and focus on patient preparation and checking safety protocols.

• Patient safety is improved by having verified sterility, reduced flashing, clinical alerts, and nurse’s increased ability to focus on patient care.

Nurse Managers, AdministratorsActionable information from smart technology can show facility performance and pinpoint areas for improvement to help:

• Ensure supply-item availability; • Minimize downtime;• Improve on-time starts, clinician satisfaction, and MD retention;• Improve regulatory compliance; • Improve operation, financial performance; • Improved throughput and staff productivity;• Fewer case delays;• Improved charge-capture and case-costing accuracy; and• Relevant reports to identify areas for process improvement.

SUMMARY Five critical capabilities of smart technology are:

• Tracking;• Patient/supply verification;• Clinical alerts;• Automated documentation; and • Actionable information.

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Three types of OR supplies for which smart technology helps improve preparedness, safety and performance are:

• Instruments/trays;• Tissue and implants; and• Blood products.

Three main benefits of using smart technology are:

• Improved preparedness;• Improved patient safety; and• Improved performance.

CONCLUSIONToday’s proven technologies provide a measurable and continuous return on investment, while helping safeguard patients, streamline workflow, improve charge capture and case costing, facilitate regulatory compliance and enhance data analysis. Most of all, using these technologies helps safeguard patients and allow perioperative nurses to do what they are educated to do; care for patients.

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REFERENCES/SUGGESTED READINGS1. World Alliance for Patient Safety. WHO surgical safety checklist and implementation

manual. Accessed February 28, 2011 from http://www.who.int/patientsafety/safesurgery/ss_checklist/en/index.html

2. AORN Comprehensive Surgical Checklist. AORN. Accessed February 28, 2011 from http://www.aorn.org/PracticeResources/ToolKits/CorrectSiteSurgeryToolKit/Comprehensivechecklist/

3. Thomas EJ, Zinner MJ, Brennan TA. The incidence and nature of surgical adverse events in Colorado and Utah in 1992. Surgery 1999;126:66-75.

4. Kable AK, Gibberd RW, Spigelman AD. Adverse events in surgical patients in Australia.

5. Data on file, Grant Hospital, Ohio Health case study, CareFusion.

6. List of All CMS-Hospital Acquired Conditions Expanded Under New Rule. ECRI Institute Special Advisory, October 2008. https://www.ecri.org/Documents/Patient_Safety_Center/CMS_New_Final_Rule.pdf

7. The Joint Commission 2010 National Patient Safety Goals: http://www.jointcommission.org/patientsafety/nationalpatientsafetygoals/

8. Westbrook JI, Woods W, Rob MI,et al. Association of interruptions with an increased risk and severity of medication administration errors. Arch Intern Med. 2010;170(8):683-90.

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