OR Manager - June 2018 - 19

Success stories
Achieving first case on-time starts (FCOTS) is a goal that
many OR leaders have difficulty meeting. This article
describes how an in-depth look at perioperative nursing
practices at Fox Chase Cancer Center led to workflow changes
and a remarkably improved FCOTS rate within a short time.
OR Manager periodically publishes success stories like this
from nurse leaders or other healthcare providers who want to
share their experience with our readers.
Other recent success stories include:
* Peer initiative cultivates a better OR culture
(January 2018, 18-19, 23)
* Improved communication tools put PACU visitors at ease
(November 2017, 21-23)
* Efficiency efforts improve staff satisfaction with turnover
time (October 2017, 21-23)
Want to share a success story from your facility? Please contact Elizabeth Wood, Editor, OR Manager, at ewood@accessintel.com;
301-354-1786. All contributed articles are reviewed and, upon acceptance, are edited for style and clarity.
More cases start on time after nurses change workflow
mong the many variables that
influence on-time starts of surgical
cases are the arrival times of
patients and staff, as well as the verifications
and documentation required
before patients are brought to the OR.
Increasing on-time starts was a key initiative
at Fox Chase Cancer Center. By
exploring the influences of nursing performance
related to first case on-time
starts (FCOTS), Fox Chase nurses identified
the barriers contributing to the
delays. Revising and implementing new
workflows increased FCOTS from 36%
to 79% within a few months.
A
Fox Chase Cancer Center, a 100bed
hospital with eight ORs, specializes
in oncology and is a member of
the Temple University Health System in
Philadelphia.
Worth getting it right-Together
When first surgical cases are late, subsequent
procedures can also fall behind,
causing dissatisfaction among
patients and their families as well as
overtime costs related to staffing and
OR case costs per minute. This is a
problem that plagues many ORs, but
it's not just the OR that is directly involved.
It all starts from the moment the
patient decides to have surgery.
The domino effect begins with preadmission
testing (PAT), the preoperative
area, and the OR. Surgeons, nurses,
aides, and staff from areas such as the
lab, blood bank, wound ostomy, nuclear
medicine, and mammography-to name
www.ormanager.com
a few-need to be involved for successful
on-time starts. Each entity is a link
in a chain that connects to the patient,
and each affects the start time, which
means it's important to understand the
bigger picture in bringing the patient to
the OR on time.
Involve staff in
decision making
to increase
compliance with
new processes.
Digging deep
We first looked at the role of the preoperative
nurse and how nurse practice
affected on-time starts. Anesthesia providers
and surgeons noticed patients
were not dressed in a timely manner,
which caused delays in starting an IV
or marking the patient prior to the procedure.
Historically,
the unit was staffed with
three nurses who were responsible for
preparing the first eight patients before
entry into the OR.
When a new surgical initiative, ERAS
(Enhanced Recovery After Surgery), was
rolled out, more time was needed to
prepare surgical patients because a
series of other preoperative steps were
added. These included default glucometer
checks and administration of ERAS
medications based on creatinine clearance
levels, which the nurses had to
calculate by obtaining real-time height
and weight.
Often, orders were confusing to new
fellows and surgeons, so additional follow-up
telephone calls were needed to
clarify the desired order. Even though
the number of first cases did not increase,
the nursing staff began to get
worn down from the added responsibilities
that contributed to delayed care.
Furthermore, the nurses were double-documenting
in the paper chart. Anesthesia
providers and surgeons looked
at their respective sections in the chart
to find information and write orders instead
of having one unified area. Each
service wanted nursing to document
information in their sections. Consequently,
there were missed orders, delaying
the overall FCOTS, and physicians
had to look for a nurse to get the information
if he or she could not document
it in time.
Essentially, each preoperative
nurse functioned not only as the primary
nurse but also as the unit secretary,
nursing assistant, transporter, if
needed (there was only one staffed on
the unit), and " chart hunter. "
Staff often walked away with charts
and did not return them to the chart
rack, which delayed signing off on the
chart. Because the preoperative nurse
is considered the last " hard stop " before
going into the OR, the nurse canContinued
on page 20
OR Manager | June 2018
19

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OR Manager - June 2018

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