Operating Room Staff Perceptions of Medical Students.

OBJECTIVE: While the operating room (OR) is a keystone experience, medical students often report negative experiences and intimidation in the OR. The purpose of this study is to describe the perceived role of medical students in the OR by registered nurses and certified surgical technologists to improve medical student education. DESIGN: A cross-sectional survey of select Massachusetts General Hospital perioperative staff in surgery was conducted through an anonymous survey in March 2021. Statistical analysis included inductive thematic analysis, descriptive statistics, and Mann-Whitney U tests, with a p-value of <0.05. The survey instrument characterized the perception of medical student preparedness for OR-related tasks and free-text responses on the role of medical students in the OR and opportunities for improvement. SETTING: The study was conducted at the Massachusetts General Hospital, Boston, MA. PARTICIPANTS: Participants included Massachusetts General Hospital perioperative staff in the Department of Surgery, with 262 registered nurses and 90 certified surgical technologists receiving the survey. RESULTS: There were 86 completed responses (24.4% response rate). A total of 71.23% of respondents believe medical students should be observational learners in the OR. Areas for improvement include OR etiquette (37.5%), awareness of the surgical field (26.79%), and scrubbing skills (26.79%). A total of 48.8% of staff agreed they enjoy working with medical students, followed by 20.9% who somewhat agree. A total of 27.91% of respondents somewhat agreed that medical students were knowledgeable about OR sterility and scrubbing procedures, followed by 25.58% who somewhat disagreed. CONCLUSIONS: Operating room staff enjoy working with medical students. The majority of staff believe medical students' role in the OR is that of observational learning. Areas of improvement for medical students include OR etiquette, awareness of the surgical field, scrubbing and gowning skills, and assisting staff whenever needed. Possible solutions include incorporating nursing staff as surgery clerkship stakeholders to optimize medical student experiences in the OR.

A Curriculum for Perioperative Nurse Deployment During a Pandemic.

As the coronavirus disease 2019 (COVID-19) pandemic spread around the world, the US Surgeon General called for the cancellation of elective surgeries. At a large academic medical center in the Northeast, there was a resulting surplus of perioperative nurses who were deployed to inpatient units in need of skilled nursing care for a surge of COVID-19 patients. To prepare them for deployment to inpatient units, perioperative leaders developed a core curriculum to ensure that the OR nurses possessed the skills and knowledge required to successfully care for patients outside the OR with the same level of care and compassion that they provided to perioperative patients. The leaders employed available resources at the hospital to design and implement the course in a short amount of time. This article describes the development of a curriculum for OR nurses to manage a surging patient volume on inpatient units because of the COVID-19 pandemic.

A Protocol for the Safe Use of Hazardous Drugs in the OR.

Hazardous drug (HD) use in the perioperative environment poses unique challenges and risks for exposure that can have adverse consequences for perioperative personnel. The United States Pharmacopeial Convention has implemented new standards to address the safe handling and administration of HDs by health care workers. To comply with these standards and minimize perioperative personnel's occupational exposure to HDs, a multidisciplinary team at an academic medical center in Boston that was performing an increased number and variety of operative and other invasive procedures using antineoplastic agents updated their protocol for the safe use of HDs in the OR. This article discusses HDs and the risks they pose to health care workers and outlines the new HD safety protocol for the OR that was part of a performance improvement plan to ensure compliance with new standards and staff member safety in the perioperative setting.

Prevention and Management of Operating Room Fire: An Interprofessional Operating Room Team Simulation Case.

Introduction: Operating room (OR) fire can be a devastating and costly event to patients and health care providers. Prevention and effective management of such fires may present difficulties even for experienced OR staff. Methods: This simulation involved a 52-year-old man presenting for excisional biopsy of a cervical lymph node to be performed under sedation. Participants were expected to identify and manage both contained and uncontained fires resulting from ignition by electrosurgical cautery. We conducted weekly multidisciplinary simulations in the mock OR at Massachusetts General Hospital. Participants included surgery and anesthesiology residents, certified registered nurse anesthetists, registered nurses, and surgical technicians. Participants were unaware of the scenario content. Each 90-minute session was divided into three parts: an orientation (10 minutes), the case with rapid cycle debriefing (65 minutes), and a final debriefing with course evaluations (15 minutes). Equipment consisted of a simulation OR with general surgery supplies, general anesthesia equipment, a high-fidelity Laerdal SimMan 3G simulator, a code cart, a defibrillator, dry ice for smoke effects, and a projector with a fire image. Results: From April to June 2015, 86 participants completed this simulation. Participants reported that the simulation scenario was realistic (80%), was relevant to their clinical practice (93%), changed their practice (82%), and promoted teamwork (80%). Discussion: Prevention and management of OR fire require collaboration and prompt coordination between anesthesiologists, surgeons, and nurses. This simulation case scenario was implemented to train multidisciplinary learners in the identification and crisis management of such an event.

Nurses' Perceptions of Personal Communication Devices in the Perioperative Environment.

Personal communication devices (PCDs) support reliable information sharing between clinical personnel to ease workflow processes. Perioperative leaders at a major medical center conducted a long-term quality improvement project evaluating perioperative nurse perceptions regarding PCDs. Perioperative nurses completed two surveys and the investigators conducted an independent group t test (2-tailed) to test for differences in RN perceptions of PCDs from initial use during a pilot study and after the nurses had used the technology for four years. The authors also used qualitative content analysis to assess the qualitative items on the survey. The RNs noted that the PCDs were particularly beneficial when contacting team members for assistance and that response times improved. Overhead pages decreased from 125 per six-hour period to an average of less than one per six-hour period. The perioperative nurses' perceptions of the PCDs have improved four years after implementation.

Implementing a Cardiac Skills Orientation and Simulation Program.

Patients with cardiac morbidities admitted for cardiac surgical procedures require perioperative nurses with a high level of complex nursing skills. Orienting new cardiac team members takes commitment and perseverance in light of variable staffing levels, high-acuity patient populations, an active cardiac surgical schedule, and the unpredictability of scheduling patients undergoing cardiac transplantation. At an academic medical center in Boston, these issues presented opportunities to orient new staff members to the scrub person role, but hampered efforts to provide active learning opportunities in a safe environment. As a result, facility personnel created a program to increase new staff members' skills, confidence, and proficiency, while also increasing the number of staff members who were proficient at scrubbing complex cardiac procedures. To address the safe learning requirement, personnel designed a simulation program to provide scrubbing experience, decrease orientees' supervision time, and increase staff members' confidence in performing the scrub person role.

Identifying and Managing Intraoperative Arrhythmia: A Multidisciplinary Operating Room Team Simulation Case.

Introduction: Resuscitation of a critically ill patient is challenging for both novice learners and experienced health care providers. During a critical event, not only is it important to identify the correct underlying diagnosis, it is equally crucial that the appropriate Advance Cardiac Life Support algorithm, medications, and defibrillator modality are implemented. This scenario features a 56-year-old female who presents for excisional biopsy of an inguinal lymph node to evaluate lymphadenopathy concerning for lymphoma. Intraoperatively, she goes into cardiopulmonary arrest. Participants must identify and manage three different scenarios: (1) ventricular fibrillation, (2) unstable ventricular tachycardia, and (3) bradycardia, including the use of the defibrillator. Method: Weekly simulation sessions were conducted in the in situ simulation operating room at Massachusetts General Hospital. Surgical residents, anesthesiology residents, nurses, and surgical technicians participated in a multidisciplinary operating room team. Each approximately 60-minute session included an orientation, the case, and the debriefing. Equipment included a simulation operating room with general surgery supplies, general anesthesia equipment, a high-fidelity SimMan patient simulator, a code cart, and a defibrillator. Results: Ninety-one multidisciplinary participants completed this scenario from September to December 2015. Participants reported that the scenario was applicable to their clinical practice (96%), promoted teamwork skills (88%), and encouraged interprofessional learning (94%). Discussion: Intraoperative cardiac arrest is a devastating event that can result in poor patient outcomes if the care team is not thoroughly prepared for crisis management. This simulation case scenario was implemented to train multidisciplinary learners in the identification and management of such an event.

The relationship between intraoperative teamwork and management skills in patient care.

BACKGROUND: Optimal team performance in the operating room (OR) requires a combination of interactions among OR professionals and adherence to clinical guidelines. Theoretically, it is possible that OR teams could communicate very well but fail to follow acceptable standards of patient care and vice versa. OR simulations offer an ideal research environment to study this relationship. The goal of this study was to determine the relationship between ratings of OR teamwork and communication with adherence to patient care guidelines in a simulated scenarios of malignant hyperthermia (MH). METHODS: An interprofessional research team (2 anesthesiologists, 1 surgeon, an OR nurse, and a social scientist) reviewed videos of 5 intraoperative teams managing a simulated patient who manifested MH while undergoing general anesthesia for an epigastric herniorraphy in a high-fidelity, in situ OR. Participant teams consisted of 2 residents from anesthesiology, 1 from surgery, 1 OR nurse, and 1 certified surgical technician. Teamwork and communication were assessed with 4 published tools: Anesthesiologists' Non-Technical Skills (ANTS), Scrub Practitioners List of Intra-operative Non-Technical Skills (SPLINTS), Non-Technical Skills for Surgeons (NOTSS), and Objective Teamwork Assessment System (OTAS). We developed an evidence-based MH checklist to assess overall patient care. RESULTS: Interrater agreement for teamwork tools was moderate. Average rater agreement was 0.51 For ANTS, 0.67 for SPLINTS, 0.51 for NOTSS, and 0.70 for OTAS. Observer agreement for the MH checklist was high (0.88). Correlations between teamwork and MH checklist were not significant. Teams were different in percent of the MH actions taken (range, 50-91%; P = .006). CONCLUSION: In this pilot study, intraoperative teamwork and communication were not related to overall patient care management. Separating nontechnical and technical skills when teaching OR teamwork is artificial and may even be damaging, because such an approach could produce teams with excellent communication skills as they unsuccessfully manage the patient. OR simulations offer a unique opportunity to research how to best integrate both of these domains to improve patient care.

Safety culture and care: a program to prevent surgical errors.

Surgical errors are under scrutiny in health care as part of ensuring a culture of safety in which patients receive quality care. Hospitals use safety measures to compare their performance against industry benchmarks. To understand patient safety issues, health care providers must have processes in place to analyze and evaluate the quality of the care they provide. At one facility, efforts made to improve its quality and safety led to the development of a robust safety program with resources devoted to enhancing the culture of safety in the Perioperative Services department. Improvement initiatives included changing processes for safety reporting and performance improvement plans, adding resources and nurse roles, and creating communication strategies around adverse safety events and how to improve care. One key outcome included a 54% increase in the percentage of personnel who indicated in a survey that they would speak up if they saw something negatively affecting patient care.

Relationship between physiologic and psychological measures of autonomic activation in operating room teams during a simulated airway emergency.

BACKGROUND: Emotional stability is important for individual and team performance during operating room (OR) emergencies. We compared physiologic and psychological anxiety assessments in OR teams during simulated events. METHODS: Twenty-two teams participated in a "cannot intubate/cannot ventilate" simulation. Participants completed the State-Trait Anxiety Inventory and wore a galvanic skin response (GSR) sensor. Differences in State-Trait Anxiety Inventory scores and GSR levels were analyzed. Anxiety scores were correlated with GSR levels. RESULTS: Resident physicians had significantly higher trait anxiety than the nurses, certified registered nurse anesthetists, and surgical technicians (43.9 ± 9.9 vs 38.3 ± 9.3, P < .01). Senior practitioners had significantly higher trait anxiety than junior practitioners (43.7 ± 9.6 vs 40.0 ± 9.9, P = .03). All groups showed significant increases in GSR. Psychological and physiologic data did not correlate. CONCLUSIONS: Senior practitioners and residents have higher levels of baseline trait anxiety for unclear reasons. Also, OR team training results in physiological signs of anxiety that do not correlate to self-reported psychological measurements.

Practicality of intraoperative teamwork assessments.

BACKGROUND: High-quality teamwork among operating room (OR) professionals is a key to efficient and safe practice. Quantification of teamwork facilitates feedback, assessment, and improvement. Several valid and reliable instruments are available for assessing separate OR disciplines and teams. We sought to determine the most feasible approach for routine documentation of teamwork in in-situ OR simulations. We compared rater agreement, hypothetical training costs, and feasibility ratings from five clinicians and two nonclinicians with instruments for assessment of separate OR groups and teams. MATERIALS AND METHODS: Five teams of anesthesia or surgery residents and OR nurses (RN) or surgical technicians were videotaped in simulations of an epigastric hernia repair where the patient develops malignant hyperthermia. Two anesthesiologists, one OR clinical RN specialist, one educational psychologist, one simulation specialist, and one general surgeon discussed and then independently completed Anesthesiologists' Non-Technical Skills, Non-Technical Skills for Surgeons, Scrub Practitioners' List of Intraoperative Non-Technical Skills, and Observational Teamwork Assessment for Surgery forms to rate nontechnical performance of anesthesiologists, surgeons, nurses, technicians, and the whole team. RESULTS: Intraclass correlations of agreement ranged from 0.17-0.85. Clinicians' agreements were not different from nonclinicians'. Published rater training was 4 h for Anesthesiologists' Non-Technical Skills and Scrub Practitioners' List of Intraoperative Non-Technical Skills, 2.5 h for Non-Technical Skills for Surgeons, and 15.5 h for Observational Teamwork Assessment for Surgery. Estimated costs to train one rater to use all instruments ranged from $442 for a simulation specialist to $6006 for a general surgeon. CONCLUSIONS: Additional training is needed to achieve higher levels of agreement; however, costs may be prohibitive. The most cost-effective model for real-time OR teamwork assessment may be to use a simulation technician combined with one clinical rater to allow complete documentation of all participants.

Boston bombings: response to disaster.

Disasters disrupt everyone's lives, and they can disrupt the flow and function of an OR as well as affect personnel on a professional and personal level even though perioperative departments and their personnel are used to caring for trauma patients and coping with surprises. The Boston Marathon bombing was a new experience for personnel at Massachusetts General Hospital, Boston. This article discusses the incidents surrounding the bombing and how personnel at this hospital met the challenge of caring for patients and the changes we made after the experience to be better prepared in the event a response to a similar incident is needed.

Safety planning for intraoperative magnetic resonance imaging.

An intraoperative magnetic resonance imaging (MRI) suite (ie, a type of hybrid OR) is a high-risk zone that requires well-defined safety procedures to avoid adverse events related to magnetic forces. At one facility, the opening of an MRI suite necessitated the creation of a safety plan to establish guidelines, procedures, education, and nursing care specific to the use of MRI technology in the operative environment. Formation of a steering committee enabled a multidisciplinary approach to planning and implementation. The addition of two new perioperative nursing roles (ie, MRI control room monitor, MRI safety nurse) addressed staffing challenges related to strictly enforcing MRI safety procedures and delineating duties different from those of the RN circulator. Benefits of a safe approach to an MRI-integrated operative setting included the elimination of an entire surgical experience for patients who underwent additional resection of the tumor during their initial surgical procedure instead of postoperatively or during a subsequent return to the OR.

Development of a complex orientation program for multidisciplinary training.

Providing complex orientation and multidisciplinary training for perioperative personnel of a newly constructed health care facility with new surgical suites proved both challenging and valuable to nurse leaders. Despite the need for such training, a program to teach groups across all disciplines regarding technological advances specific to the OR and to orient them to a new facility did not exist previously. To address this, we developed a multiphase educational initiative that involved orientation, technology training, and multidisciplinary simulation. The project required extensive planning, high-level collaboration, and use of the hospital's information technology systems, all while staff members continued to provide care for patients undergoing surgically complex procedures. The successful implementation of this program ensured that staff members were proficient in new OR technology and oriented to the new facility before occupancy began.

Expanding the role of nonclinical personnel in the OR.

Ideally, quality health care should be accessible, affordable, and equitable. Working toward these goals in the OR necessitates examining and redesigning work processes and nursing workflow to make better use of the education and skills of perioperative nurses and assistive personnel. This article describes a pilot project undertaken in the OR at Massachusetts General Hospital, Boston, to identify tasks that took nurses away from direct patient care and to better incorporate assistive personnel into the workflow to increase nurses' contact with patients. The pilot program resulted in an expanded role for assistive personnel and more direct patient contact for nurses.