Growing Novice Nurses to Perianesthesia Care: Formation of a Post-Anesthesia Care Unit (PACU) Fellowship.

PURPOSE: To provide a proof of concept of a structured, replicable perianesthesia fellowship program for nurses with less than 2 years of experience and new graduate nurses. DESIGN: An immersive learning experience was implemented as a pilot quality improvement project using the Plan-Do-Study-Act method. METHODS: This 24-week fellowship program used blended learning approaches and the Tiered Skill Acquisition Model (TSAM) to develop foundational Post Anesthesia Care Unit (PACU) skills. Nurse Fellows (4) acquired knowledge in stages, with each week in the program reinforcing and building upon the prior week's learnings. Settings included an initial 10 weeks in the ambulatory PACU, then the acute care PACU (weeks 11-20), and the final 4 weeks were spent in the primary unit where the Fellow would transition into a PACU Staff RN. Through each phase, the Professional Practice Department's Clinical Mentor Nurse promoted preceptor development, facilitated learning experiences and provided bimonthly evaluations of the Nurse Fellow's progress via our institution's clinical rounding tool. We used the Nursing Anxiety and Self-Confidence Associated with Clinical Decision Making (NASC-CDM) scale to assess novice nurses' anxiety and self-confidence associated with making clinical decisions at designated intervals. FINDINGS: All Nurse Fellows completed the program and remained in PACU positions 2 years post-fellowship. They reported discomfort and increased stress transitioning to different PACUs; however, they later indicated reduced anxiety and greater confidence in clinical decision-making, as noted in subsequent evaluations of the NASC-CDM scale. CONCLUSIONS: Perianesthesia fellowship programs incorporating blended learning, skill reinforcement, and formal mentoring on a primary PACU unit build confidence and competence in the novice nurse, making this once-excluded population of nurses a viable option for recruitment directly into the PACU environment.

A Nurse-Led Implementation Science Specialist Program.

ABSTRACT: A well-known challenge in health care is integrating evidence into practice. Implementation science (IS) is a growing field that promotes the sustainable application of evidence-based practice (EBP) to clinical care. Health care organizations have an opportunity to support sustainable change by creating robust IS infrastructures that engage nurses in the clinical environment. Integrating IS into a nursing shared governance model is an ideal vehicle to empower direct care nurses to sustain EBP. Importantly, an IS infrastructure may also promote nurse retention and increase interdisciplinary collaboration. This article, the first in a series on applying IS, describes how a multisite health care organization developed a systemwide nurse-led IS Specialist program within a shared governance model.

Thoracic enhanced recovery with ambulation after surgery: a 6-year experience.

OBJECTIVES: Our institution implemented a protocol known as thoracic enhanced recovery with ambulation after surgery (T-ERAS) in thoracic operations. The objective was early ambulation starting in the postoperative ambulatory care unit. METHODS: Video-assisted thoracoscopic surgery lobectomy patients are placed on a chair in the preoperative area and then walked to the operating room. Postoperatively, patients are placed on a chair as soon as possible. Our target ambulation goal was 250 feet within 1 h of extubation. Patients then walk to their hospital room. T-ERAS adoption and outcomes were compared to a pre-T-ERAS period, in addition to the comparing early and late T-ERAS cohorts. RESULTS: Over 6 years, 304 patients on T-ERAS underwent a planned video-assisted thoracoscopic surgery lobectomy. Median age was 67 years (range 41-87 years). The target goal was achieved in 187 of 304 (61.5%) patients and 277 of 304 (91.1%) patients ambulated 250 feet at any time in the postoperative ambulatory care unit. The T-ERAS period had a median length of stay of 1 day vs 2 days in the pre-T-ERAS period (P < 0.001). There were low rates of pneumonia (2/304, 0.7%), atrial fibrillation (12/304, 4.0%) and no postoperative mortalities for T-ERAS. The target goal was achieved at a greater rate in the late (92/132, 72.0%) versus early (28/75, 37%) T-ERAS cohort. The mean time to ambulation was reduced in the late cohort (46-81 min). CONCLUSIONS: Early postoperative ambulation was feasible and considered key in achieving low morbidity after video-assisted thoracoscopic surgery lobectomy. Adoption of T-ERAS improved over time. Further studies will help define adoptability at other sites and validate impact on improving outcomes.

Surgical Fire Safety: An Ambulatory Surgical Center Quality Improvement Project.

Surgical team members use fire risk assessment tools to determine the risk of a surgical fire occurring and facilitate communication to reduce risk. The purposes of this quality improvement project were to improve knowledge and awareness of surgical fire risk and increase practitioners' use of a fire risk assessment tool during the surgical safety communication process. We recruited a purposive sample of participants that included all surgical team members of a metropolitan ambulatory surgical center. We based the educational intervention on published evidence and findings of a preintervention knowledge, attitude, and practice (KAP) survey. We assessed knowledge, current practice, and practice intent using a 10-item pretest and posttest, and used a follow-up posttest to assess knowledge retention and practice change. The findings suggest that a brief educational intervention regarding fire risk assessment contributes to improving staff member knowledge and use of prevention strategies.

Two-Year Experience Implementing a Curriculum to Improve Residents' Patient-Centered Communication Skills.

OBJECTIVES: Surgery milestones from The Accreditation Council for Graduate Medical Education have encouraged a focus on training and assessment of residents' nontechnical skills, including communication. We describe our 2-year experience implementing a simulation-based curriculum, results of annual communication performance assessments, and resident evaluations. DESIGN: Eight quarterly modules were conducted on various communication topics. Former patient volunteers served as simulation participants (SP) who completed annual assessments using the Communication Assessment Tool (CAT). During these 2 modules, communication skills were assessed in the following standardized scenarios: (1) delivering bad news to a caregiver of a patient with postoperative intracerebral hemorrhage and (2) primary care gallstone referral with contraindications for cholecystectomy. SP-CAT ratings were evaluated for correlations by individual and associations with trainee and SP characteristics. Surgical patient experience surveys are evaluated during the curriculum. SETTING: Independent academic medical center surgical simulation center. PARTICIPANTS: Twenty-five surgery residents per year in 2015 to 2017. RESULTS: Residents have practiced skills in a variety of scenarios including bad news delivery, medical error disclosure, empathic communication, and end-of-life conversations. Residents report positive learning experiences from the curriculum (90% graded all modules A/A+). Confidence ratings rose following each module (p < 0.001) and in the second year (p < 0.001). Annual assessments yielded insights into skills level, and relationships to resident confidence levels and traits. Communication scores were not associated with resident gender or postgraduate year. Over the course of the curriculum implementation, surgical patients have reported that doctors provided explanations with improved clarity (p = 0.042). CONCLUSIONS: The simulation-based SP-CAT has shown initial evidence of usability, content validity, relationships to observed communication behaviors and residents' skills confidence. Evaluations of different scenarios may not be correlated for individuals over time. The communication curriculum paralleled improvements in patient experience concerning surgeons' clear explanations. An ongoing surgery resident communication curriculum has numerous educational, assessment, and institutional benefits.

Interrater Reliability of Hospital Readmission Evaluations for Surgical Patients.

Value-based purchasing initiatives have helped shift attention to the accuracy of hospital readmission information at the most clinically detailed level. The purpose of this study was to determine the interrater reliability (IRR) of surgical experts in assessing surgical inpatient readmissions for categorical causes, relation to index procedure, and potential preventability. Cases were selected from the American College of Surgeons National Surgical Quality Improvement Program local database. Of 1840 cases, 156 patients (8.5%) were readmitted within 30 days of the procedure. Surgical site infection was the most common readmission cause (32%), followed by obstruction or ileus (17%). IRR was moderate for readmission cause (60% agreement, κ = 0.51), substantial for readmission in relation to surgical procedure (92%, κ = 0.70), and lowest for potential preventability of readmissions (57%, κ = 0.18). Results suggest that readmission cause and relation to surgical procedure can be determined with moderate to high degree of IRR, while preventability of readmissions may require stricter definitions to improve IRR.

Talk the Talk: Implementing a Communication Curriculum for Surgical Residents.

OBJECTIVES: The Accreditation Council for Graduate Medical Education milestones provide a framework of specific interpersonal and communication skills that surgical trainees should aim to master. However, training and assessment of resident nontechnical skills remains challenging. We aimed to develop and implement a curriculum incorporating interactive learning principles such as group discussion and simulation-based scenarios to formalize instruction in patient-centered communication skills, and to identify best practices when building such a program. DESIGN: The curriculum is presented in quarterly modules over a 2-year cycle. Using our surgical simulation center for the training, we focused on proven strategies for interacting with patients and other providers. We trained and used former patients as standardized participants (SPs) in communication scenarios. SETTING: Surgical simulation center in a 900-bed tertiary care hospital. PARTICIPANTS: Program learners were general surgery residents (postgraduate year 1-5). Trauma Survivors Network volunteers served as SPs in simulation scenarios. RESULTS: We identified several important lessons: (1) designing and implementing a new curriculum is a challenging process with multiple barriers and complexities; (2) several readily available facilitators can ease the implementation process; (3) with the right approach, learners, faculty, and colleagues are enthusiastic and engaged participants; (4) learners increasingly agree that communication skills can be improved with practice and appreciate the curriculum value; (5) patient SPs can be valuable members of the team; and importantly (6) the culture of patient-physician communication appears to shift with the implementation of such a curriculum. CONCLUSIONS: Our approach using Trauma Survivors Network volunteers as SPs could be reproduced in other institutions with similar programs. Faculty enthusiasm and support is strong, and learner participation is active. Continued focus on patient and family communication skills would enhance patient care for institutions providing such education as well as for institutions where residents continue on in fellowships or begin their surgical practice.

Assessment of Surgery Residents' Interpersonal Communication Skills: Validation Evidence for the Communication Assessment Tool in a Simulation Environment.

OBJECTIVES: Although development of trainees' competency in interpersonal communication is essential to high-quality patient-centered surgical care, nontechnical skills present assessment challenges for residency program directors. The Communication Assessment Tool (CAT) demonstrated internal reliability and content validity for general surgery residents, though the tool has not yet been applied in simulation. The study provides validation evidence for using the CAT to assess surgical residents' interpersonal communication skills in simulation scenarios. DESIGN: Simulations of delivering bad news were completed by 21 general surgery residents during a mandatory communication curriculum. Upon completion of the 10-minute scenario, standardized participants (SPs) assessed performance using the 14-item CAT rating scale and individually provided feedback to residents. Discrete communication behaviors were recorded on video review by a trained blinded observer. The traits emotional intelligence questionnaire short form (TEIQue-SF) was completed by the residents 6 months later. SP-CAT ratings are evaluated with respect to learner characteristics, observed behaviors, and TEIQue results. SETTING: Surgical simulation center in a 900-bed tertiary care hospital. PARTICIPANTS: General surgery residents were targeted learners. Trauma survivors network volunteers served as SPs, acting as a family member of a patient who developed an intracerebral hemorrhage following a small bowel procedure. RESULTS: Discrete communication behaviors were reliably assessed by the observer (interrater reliability with trainer: 89% agreement, κ = 0.77). SP-CAT ratings ranged from 34 to 61. Higher SP-CAT ratings were correlated with positive communication behaviors (Spearman ρ = 0.42, p = 0.056). Total TEIQue was positively related to SP-CAT ratings (ρ = 0.42, p = 0.061). The TEIQue emotionality factor was strongly correlated with SP-CAT ratings (ρ = 0.52, p = 0.016). CONCLUSIONS: The CAT demonstrates content validity in a simulation environment with former patients acting as SPs. This study provides validation evidence relating the SP-CAT to discrete observations of communication behaviors by a trained, reliable observer as well as residents' self-reported emotional intelligence traits.

Top 10 patient safety issues: what more can we do?

A 2012 survey of AORN members identified the top 10 safety issues reported by perioperative nurses. These nurses are in a unique position to understand the errors and the unreported near misses that occur in the OR. For each of the top-rated safety issues that RNs identified, we discuss the evidence of risk and contributing factors and make targeted recommendations for further improvement in perioperative safety with the goal of mitigating risk and improving patient outcomes.

Effectiveness of 2% CHG cloth bathing for reducing surgical site infections.

We conducted a prospective cohort study on the effectiveness of preoperative bathing with chlorhexidine gluconate (CHG) cloths for reducing surgical site infections. We hypothesized that use of CHG cloths as an adjunct to surgical prep would significantly reduce the endogenous flora of surgical patients and therefore reduce surgical site infections. Data from a control group of patients who had undergone general, vascular, and orthopedic surgery were used for comparison. Results indicated an overall reduction of infection in the group that received a 2% CHG bath before surgery. There also was a possible reduction in postoperative organ space infection, although the sample numbers were extremely small. To reduce surgical site infections, we suggest a nursing protocol of preoperative bathing with a 2% CHG cloth for patients undergoing general and vascular surgery, and an additional trial to investigate the use of preoperative CHG cloth baths in all surgical patient populations.

Priority patient safety issues identified by perioperative nurses.

Much of the work done by perioperative nurses focuses on patient safety. Perioperative nurses are aware that unreported near misses occur every day, and they use that knowledge to prioritize activities to protect the patient. The purpose of this study was to identify the highest priority patient safety issues reported by perioperative RNs. We sent a link to an anonymous electronic survey to all AORN members who had e-mail addresses in AORN's member database. The survey asked respondents to identify top perioperative patient safety issues. We received 3,137 usable responses and identified the 10 highest priority safety issues, including wrong site/procedure/patient surgery, retained surgical items, medication errors, failures in instrument reprocessing, pressure injuries, specimen management errors, surgical fires, perioperative hypothermia, burns from energy devices, and difficult intubation/airway emergencies. Differences were found among practice settings. The information from this study can be used to inform the development of educational programs and the allocation of resources to enhance safe perioperative patient care.

Selection of a method to rate the strength of scientific evidence for AORN recommendations.

The use of scientific evidence to support national recommendations about clinical decisions has become an expectation of multidisciplinary health care organizations. The objectives of this project were to identify the most applicable evidence-rating method for perioperative nursing practice, evaluate the reliability of this method for perioperative nursing recommendations, and identify barriers and facilitators to adoption of this method for AORN recommendations. A panel of perioperative nurse experts evaluated 46 evidence-rating systems for quality, quantity, and consistency. We rated the methods that fully covered all three domains on five aspects of applicability to perioperative nursing practice recommendations. The Oncology Nursing Society's method was rated highest for all five aspects of applicability, and interrater reliability of this method for perioperative recommendations was 100%. Potential barriers to implementation of the rating method include knowledge deficit, staff resources, resistance to change, and fear of showing that lower levels of evidence support some recommendations. Facilitators included education, resource allocation, and starting small. Barriers and facilitators will be considered by the implementation team that will develop a plan to achieve integration of evidence rating into AORN documents. The AORN Board of Directors approved adoption of this method in June 2010.