ASC Efficiency: Using Your Perioperative RNs to Their Fullest Potential

When it comes to efficiency in the operating room, a few obvious components come to mind. Having top-quality equipment and instruments, for example, are a given. But to truly keep your surgical flow humming, the people you have in your OR are just as important as the devices.

Unfortunately, as many surgery centers attempt to downsize staffing costs, they miss out on a crucial OR asset—perioperative nurses. This feature includes perspectives from surgeons, administrators and nurses on why these trusty staffers are worth the extra dollars.

What Exactly Can RNs Do?

When the Texas Senate passed a bill that required certified surgical technicians, many centers panicked—surgical techs aren't exactly easy to find. Lucky for the San Antonio Eye SurgiCenter, there was a convenient alternative. A trained RN could stand in for a tech, and the ASC already had three.

Albert Castillo, San Antonio Eye's administrator, says that from his standpoint, RNs are far more efficient than technicians. While laws vary from state to state, in Texas, an RN is licensed to handle any procedure or responsibility that is delegated by the physician, though the physician still takes full liability for anything that goes wrong. Technicians, on the other hand, can't be assigned any additional responsibilities.

“Sometimes doctors don't want to pay for a nurse with an RN degree when the standards only require having one nurse available. Yes, you're taking a hit from hiring an RN, but you're able to use them in a lot of areas because of their greater level of education. RNs understand a lot more when it comes to surgical needs, not just bedside care,” says Sandi Roegelein, RN, the ASC lead nurse and director of San Antonio Eye.

Because of their training, RNs can step in at many points. She explains that at San Antonio, the RNs can do everything from preparing the OR suite for a busy day of surgery to working as first assist. The one-operating-room surgery center usually has one RN in the OR and one in the induction and recovery area. If a surgical day is particularly busy, a third will come in to circulate. Each nurse is trained to function in all areas so she can step in whenever necessary. “You're paying RNs to be the thinkers when you need them,” says Ms. Roegelein.

Preoperatively, Ms. Roegelein explains, her nurses will take care of calling patients to make sure they have taken any necessary antibiotics and offer reassurance, set up the surgical schedule and ensure that everything is ready for when the patient comes in. Nurses do skin prep and IVs upon patient arrival. During surgery, the RN makes sure that all instrumentation is present and correct, assists any anesthesiologist or surgeon needs and keeps track of all documentation and chart work. Once the patient is in recovery, an RN takes care of the postop assessment and ensures he or she is ready for discharge.

The center usually has a registered medical assistant do the postoperative follow-up calls, but during busy times or if a patient has extensive questions, the RNs will step in to field the calls.

Devoted Discussions

Sandy Roberts, MD, a surgeon at the San Antonio Eye Center, says that encouraging openness from every member of his team—whether it's the doctor, nurses or subordinates—about what needs to be improved ensures that no detail of the OR experience is overlooked. He explains that his head nurse, Ms. Roegelein, has input at the center's quarterly meetings, which has led to a great deal of fine-tuning, especially with postoperative control. For example, thanks to nurse input, the center now has a printout of the different kinds of eye drops and a picture of the bottle with exact instructions. That way, if a patient is confused after the procedure, the paper can be handed to a family member who will then know exactly what to do—much safer than giving explanations to someone who is just waking up from surgery.

Mr. Castillo says that all staff members are involved in committees so they can participate in efficiency improvements. “Our group is very involved. It's not just any one physician or nurse,” he says. For example, when analyzing the cost per surgical case per physician, everyone had input for how to streamline and create a specific surgical protocol that is applicable to everyone. The group found that turnaround time was significantly slowed down because instruments weren't being sterilized quickly enough. “We had actually gotten to the point where we were standing there waiting for instruments for the next case,” he says. To remedy the situation, smaller, more efficient sterilizers were brought in so the RNs could turn over instruments faster.

Within the OR, Dr. Roberts says to “encourage teamwork, a positive work environment and professionalism. Make sure each individual knows their job, but feels comfortable enough to speak up if there is a question. You don't want to create pressure to proceed if something isn't quite right.”

Cross-Training for Success

Extensive, proper training of staff is without a doubt the number one way to keep your operating room in tip-top shape. At San Antonio Eye, Mr. Castillo says that training takes four to six weeks. Because the training is difficult, he says that productivity takes a definite hit when a seasoned nurse leaves—especially since it can take a long time to find a replacement. Like many single-specialty ASCs, his center isn't open five days a week, meaning a two-day-a-week job is a tough sell.

While it is always unfortunate when an established member of any staff moves or retires, Satish Modi, MD, of Poughkeepsie, NY, says that he appreciates the energy the greener nurses bring to the operating room. At his multi-specialty ASC, the nurses have a wide range of responsibilities and must be willing to be flexible with their day-to-day tasks. The RNs start IVs, check H&Ps, put drops and anesthetics in the eyes, set up instrumentation and circulate. In addition to managing patients, his nurses also look at quality control compliance because the center is privately owned.

The training for all this? It takes ages, says Dr. Modi, and involves both the nurse manager and physicians. He recommends hiring both technicians and RNs and cross-training them to circulate the OR and set up preop. He likes to be active in their training, by showing videos and breaking down each step of a procedure and the coordinating instruments. He encourages each nurse to make a flowchart of the process to help keep track. When first starting out, the nurses also have a photograph of how instrumentation should be arranged in the OR from left to right.

Monitors are set up in the OR, so that all staff can watch exactly what the surgeon is doing. Not only is this a great training tool, but Dr. Modi also says it increases synergy in the OR and allows nurses to notice if something isn't quite right and make suggestions as they become more comfortable in the environment. “If the RNs see that I'm getting a little slow, they can say, ‘Hey doctor, do you need this?’ We are a true team. I teach them what all the steps are so their input is helpful.”

Constant teaching and talking, he says, helps boost his OR efficiency and most importantly, creates a better patient experience for each step of the surgical experience. “The patients are incredibly comfortable. There's no point in having efficiency if you don't have happy patients.” OM