Reducing Sharps Injuries in the Operating Rooms of an Academic Tertiary Care Center.

BACKGROUND: Data on the prevalence and distribution of operating room (OR) sterile field sharps injuries sustained by attending surgeons, residents, scrub nurses, and surgical technologists are limited. The goal of this study is to understand current practices, injuries, and reporting behavior at an academic center, implement interventions, and assess their effect on sharps safety and reporting. METHODS: An electronic survey with questions pertaining to sharps handling practices, injuries, and reporting was e-mailed to 864 staff between July and September 2014. Adjusted analyses for risk of injury were performed. A follow-up survey was sent in January 2018, following the implementation of a shorter injury reporting form and a neutral zone. RESULTS: The overall response rate was 49.3%, with 363 completed surveys. Of respondents, 44.9% reported injuries occurring in the preceding three years. Physicians comprised 65.1% of injured staff and sustained 68.8% of the total injuries. Compared to attending surgeons, residents had a similar likelihood of injury (odds ratio 0.9, 95% confidence interval [CI] 0.37-2.2), whereas scrub nurses (odds ratio 0.3, 95% CI 0.17-0.54) and technologists (odds ratio 0.3, 95% CI 0.14-0.76) had a lower likelihood. Half of those injured reported to Occupational Health Services. Of those who did not report, 46.4% stated that time was a limiting factor. Following the interventions, the incidence of injuries among survey respondents remained unchanged. However, 54.0% of respondents stated that it was easier to report injuries. CONCLUSION: Attending surgeons and residents sustain the majority of OR sterile field sharps injuries and are the least likely to report them. Shorter reports made it easier to report the injuries.

Adding a Visual Communication Tool to the Electronic Health Record to Prevent Pressure Injuries.

Health care organizations no longer receive reimbursement for stage 3, stage 4, and unstageable hospital-acquired pressure injuries, which are never events that require interdisciplinary collaboration to treat and prevent. Perioperative patients are at risk for developing pressure injuries that may not manifest until five or more days after surgery. This quality improvement project aimed to inform inpatient nursing and health care professionals of the potential areas of skin breakdown after surgery using an annotated image (AI) depicting intraoperative patient positioning. To gauge OR nurses' use of the AI, we tracked image addition to the patient records weekly from May 2018 to May 2019 and found an overall average participation rate of 80% to 90%. Adding the AI of surgical positioning and pressure points raised awareness of the potential for skin breakdown and became a valuable communication tool for the inpatient nurses who were providing postoperative care to prevent pressure injuries.

Analysis of Nursing Clinical Decision Support Requests and Strategic Plan in a Large Academic Health System.

OBJECTIVES: To understand requests for nursing Clinical Decision Support (CDS) interventions at a large integrated health system undergoing vendor-based EHR implementation. In addition, to establish a process to guide both short-term implementation and long-term strategic goals to meet nursing CDS needs. MATERIALS AND METHODS: We conducted an environmental scan to understand current state of nursing CDS over three months. The environmental scan consisted of a literature review and an analysis of CDS requests received from across our health system. We identified existing high priority CDS and paper-based tools used in nursing practice at our health system that guide decision-making. RESULTS: A total of 46 nursing CDS requests were received. Fifty-six percent (n=26) were specific to a clinical specialty; 22 percent (n=10) were focused on facilitating clinical consults in the inpatient setting. "Risk Assessments/Risk Reduction/Promotion of Healthy Habits" (n=23) was the most requested High Priority Category received for nursing CDS. A continuum of types of nursing CDS needs emerged using the Data-Information-Knowledge-Wisdom Conceptual Framework: 1) facilitating data capture, 2) meeting information needs, 3) guiding knowledge-based decision making, and 4) exposing analytics for wisdom-based clinical interpretation by the nurse. CONCLUSION: Identifying and prioritizing paper-based tools that can be modified into electronic CDS is a challenge. CDS strategy is an evolving process that relies on close collaboration and engagement with clinical sites for short-term implementation and should be incorporated into a long-term strategic plan that can be optimized and achieved overtime. The Data-Information-Knowledge-Wisdom Conceptual Framework in conjunction with the High Priority Categories established may be a useful tool to guide a strategic approach for meeting short-term nursing CDS needs and aligning with the organizational strategic plan.

Clinical Decision Support and Perioperative Peripheral Nerve Injury: A Quality Improvement Project.

Decision support at the point of care has been demonstrated to be an effective tool in providing a safe environment and improving patient outcomes. The operating room is typically an area where advanced technology is introduced to nurses on a regular basis. This quality improvement project focused on preventing a peripheral nerve injury, which is an example of a postoperative adverse event that is considered preventable. Injury of a peripheral nerve is the result of compression, hyperextension, flexion, or ischemia surrounding the nerve. The goals for this project were to improve the knowledge of peripheral nerve injury of the operating room nurses, design and implement a peripheral nerve injury assessment screen that could provide decision support within the operating room record, improve the nursing documentation of peripheral nerve injury interventions, and (long term) decrease the incidence of peripheral nerve injury. A decision support screen within the operating room record was designed to supplement the operating room nurse's risk assessment for peripheral nerve injury. The components of this project involved a preliminary and postproject surveys on peripheral nerve injury knowledge, an educational presentation, and a retrospective random review of nursing documentation in the operating room electronic health records. Project results demonstrated a significant increase in nursing documentation of peripheral nerve injury interventions (63%-92%) and a positive attitude toward their exposure to basic decision support (P = .046). Recommendations for future studies and establishing a standardized coding system for peripheral nerve injury identification were identified.

Modeling decision support rule interactions in a clinical setting.

Traditionally, rule interactions are handled at implementation time through rule task properties that control the order in which rules are executed. By doing so, knowledge about the behavior and interactions of decision rules is not captured at modeling time. We argue that this is important knowledge that should be integrated in the modeling phase. In this project, we build upon current work on a conceptual schema to represent clinical knowledge for decision support in the form of if then rules. This schema currently captures provenance of the clinical content, context where such content is actionable (i.e. constraints) and the logic of the rule itself. For this project, we borrowed concepts from both the Semantic Web (i.e., Ontologies) and Complex Adaptive Systems (CAS), to explore a conceptual approach for modeling rule interactions in an enterprise-wide clinical setting. We expect that a more comprehensive modeling will facilitate knowledge authoring, editing and update; foster consistency in rules implementation and maintenance; and develop authoritative knowledge repositories to promote quality, safety and efficacy of healthcare.

Preventing perioperative peripheral nerve injuries.

Peripheral nerve injuries are largely preventable injuries that can result from incorrect patient positioning during surgery. Patients who are diabetic, are extremely thin or obese, use tobacco, or undergo surgery lasting more than four hours are at increased risk for developing these injuries. When peripheral nerve injuries occur, patients may experience numbness, burning, or tingling and may have difficulty getting out of bed, walking, gripping objects, or raising their arms. These symptoms can interrupt activities of daily living and impede recovery. Signs and symptoms of peripheral nerve injury may appear within 24 to 48 hours of surgery or may take as long as a week to appear. Careful attention to body alignment and proper padding of bony prominences when positioning patients for surgery is necessary to prevent peripheral nerve injury. The use of a preoperative assessment tool to identify at-risk patients, collaboration between physical therapy and OR staff members regarding patient positioning, and neurophysiological monitoring can help prevent peripheral nerve injuries.