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Autumn 2019
Journal of Volume 32
Number 1
Perioperative Nursing Autumn 2019
NORTHERN TERRITORY PERIOPERATIVE
NURSES ASSOCIATION INC.
Colour coded labels for easy identification Enhanced stability and stack-ability Reduced storage space needs Supply chain efficiencies
Contents
Editorial3
President’s report 5
Clinical practice article – Improving antibiotic prescribing for surgical
prophylaxis – the role of nurses 7
Peer-reviewed article – The impact of improved surgical safety checklist
participation on OR efficiencies: A pretest–posttest
analysis 9
Peer-reviewed article – Perioperative nurses’ perceptions of cross-training:
A qualitative descriptive study 19
Journal Editor
Associate Professor Nicholas Ralph Peer-reviewed article – Innovations in postgraduate work integrated
journaleditor@acorn.org.au learning within the perioperative nursing
environment: A mixed method review 27
Journal of Perioperative Nursing:
The official journal of the Australian
Feature – Pressure injury risk assessment and prevention strategies in
College of Perioperative Nurses
operating room patients: Findings
ISSN 2209-1084 (print) from a study tour of novel practices in American hospitals 33
ISSN 2209-1092 (online/digital)
Grants and scholarships 39
Published quarterly by
ACORN
PO Box 899 Education report 45
Lyndoch SA 5351
www.acorn.org.au ACORN Standards update 47
Copy editor Eleanor Tan
ACORN noticeboard 49
Graphic design Savanah Design
Subscription enquiries Coming events 51
administrator@acorn.org.au
State reports 53
Advertising enquiries
Wendy Rowland
T: 0414 412 306
wendy.rowland@acorn.org.au
Booking deadline 17 April 2019
Author enquiries
Author guidelines are available at
www.acorn.org.au/journal/author- Cover photo: ACORN wishes to acknowledge Calvary St Lukes Hospital, Launceston.
guidelines. Views expressed in any article are those of the contributors and not necessarily those of the Australian College of
Perioperative Nurses (ACORN), nor are the products advertised given the official backing of the College. The College
For further enquiries email cannot accept any responsibility for the accuracy of any of the opinions, information, errors or omissions in this
journal. Articles published in the Journal of Perioperative Nursing are copyright and the copyright remains with
administrator@acorn.org.au. ACORN. Anyone wishing to reprint articles must obtain written permission directly from the editor.
Journal of Perioperative Nursing Volume 32 Number 1 Autumn 2019 acorn.org.au 1
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ACORN Editorial Associate Professor Nicholas Ralph
PhD, MClinPrac (Perioperative Nursing), RN
The Australian College of Perioperative School of Nursing & Midwifery,
Nurses (ACORN) is a registered
Australian company and health Preventing University of Southern Queensland
promotion charity. It exists to serve its
members, the perioperative profession, perioperative Jeffrey Gow
PhD, MEcon
the patient and the community to
promote the prevention and control of hypothermia is School of Commerce, University of
Southern Queensland
disease.
clinically feasible Jed Duff
ACORN’s vision is for Australian patients
to receive the safest and highest quality and cost effective PhD, BN
School of Nursing and Midwifery,
evidence-based perioperative care in University of Newcastle
the world. Inadvertent perioperative
hypothermia is associated with
serious adverse surgical outcomes blood loss, prolonged hospitalisation
ACORN Board of Directors
including increased infection rates, and thermal discomfort are just
Rebecca East a few examples of the serious
morbid cardiac events and surgical
President
bleeding1. Surgical patients are complications that are caused by
Trent Batchelor particularly at risk of hypothermia perioperative hypothermia. Enzymes
Director that regulate organ functions and
because of ‘anaesthetic-induced
Patricia Flood impairment of thermoregulatory process medications, for instance,
Director control’ and the ‘cool operating are very sensitive to the change in
Journal Committee Chair and Research body temperature and consequently
room’ temperature that create the
Committee Chair
perfect combination for developing hypothermia affects the
Karen Hay hypothermia post-surgery 1,2. pharmacodynamics of many drugs.
Director
Conference Committee Chair and Perioperative hypothermia develops Recent developments in
Professional advocacy and advisory in three characteristic phases:
liaison thermal care
1. a rapid decrease in core The United Kingdom National
Grace Loh
Director temperature in the first hour Institute for Health and Clinical
Hospital and University Collaboration due to core to peripheral Excellence (NICE) has published a
and Accreditation Committee Chair redistribution of body heat guideline ‘Perioperative hypothermia
Grants, Awards and Scholarships mediated by the use of volatile
Committee Chair (inadvertent): The management
anaesthetic agents of inadvertent perioperative
Paula Foran
2. a slow linear decrease in core hypothermia in adults’ detailing
Member Director
Membership and Local Associations temperature due to heat loss appropriate perioperative thermal
Liaison Committee Chair exceeding metabolic heat gain management to minimise the
occurrence of perioperative
Sophie Ehrlich 3. a plateau in temperature in which
Director hypothermia. The guideline is based
vasoconstriction decreases heat
Education Programs Committee Chair on a comprehensive systematic
loss from the skin3.
review including both meta-analysis
Donna Stevens
Director Perioperative hypothermia increases and cost-effectiveness analysis4.
Education Committee Chair the incidence of complications
Recommendations from the
following surgery. Reducing
Garry Stratton guideline include the requirement
Director the incidence of perioperative
for preoperative hypothermia risk
Finance, Audit and Risk Committee hypothermia through appropriate
assessment, regular temperature
Chair perioperative care can reduce
monitoring, and active and passive
the number and complexity of
warming strategies. However,
complications that arise. Sessler2
compliance with recommendations
investigated the complications that
in clinical practice is poor despite
arise from hypothermia by reviewing
their relative simplicity and cost-
the current literature and reported a
effectiveness. For example, results
dozen major health consequences.
from a large European multisite
Myocardial ischemia, coagulopathy or
Journal of Perioperative Nursing Volume 32 Number 1 Autumn 2019 acorn.org.au 3
observational study (n = 8083) with guidelines effective for With the release of this report
conducted prior to the NICE guideline reducing perioperative hypothermia. expected in the first half of 2019, we
development found that temperature They found that the total cost encourage all perioperative nurses
monitoring was not appropriately of perioperative hypothermia to to take heart in recognising the
undertaken in 81 per cent of the Australian health system is significant value they provide to the
patients5. Both the Australian and $1.26 billion and that preventing Australian health care system by
New Zealand College of Anaesthetists perioperative hypothermia has an delivering excellent perioperative
and the Royal Australasian College of annual net benefit of: care.
Surgeons clinical guidelines reflect
• $602 million to the Australian References
the recommendations of the NICE
health system
guideline3. 1. Sessler D. Perioperative
• approximately $7085 per patient for thermoregulation and heat balance.
In 2014 a thermal care bundle was Lancet 2016;387(10038):2655–2664.
major surgery (with an overnight
developed by a panel of Australian 2. Sessler D. Complications and treatment
stay) from reducing SSIs alone
expert clinicians and researchers to of mild hypothermia. Anesthesiology
improve the prevention, detection • approximately $6560 per patient for 2001;95(2):531–543.
and treatment of perioperative minor surgery (with an overnight 3. Australian and New Zealand College
stay) from reducing SSIs alone. of Anesthetists (ANZCA). Perioperative
hypothermia in adult surgical
normothermia: Clinical audit guide. ANZCA:
patients6,7. Implementing a thermal This report is of significance to all Sydney, 2013.
care bundle can help rapidly perioperative nurses in Australia as 4. National Collaborating Centre for Nursing
disseminate optimal clinical the prevention of hypothermia is and Supportive Care. The management of
guidelines for the management of often led by nurses and denotes the
inadvertent perioperative hypothermia
in adults: Prevention and management in
health care–associated illnesses value of high reliability nursing care. adults. Clinical practice guideline. NICE:
and risks. The bundle elements were Significantly, the authors recommend London, 2008.
selected from the NICE guideline on that: 5. Torossian A. Survey on intra-operative
the management of perioperative temperature management in Europe. Eur J
hypothermia in adults. • current best practice is adopted Anaesthesiol 2007;24(8):668–675.
ensuring that thermal care is 6. Duff J, Walker K, Edward K, Williams
Economics of preventing provided to ‘every patient, every R, Sutherland-Fraser S. Incidence of
perioperative inadvertent hypothermia
perioperative hypothermia time’
and compliance with evidence-based
In a report soon to be released, • a national multidisciplinary-based recommendations at four Australian
hospitals: A retrospective chart audit.
the authors will provide a detailed policy for preventing and managing
Journal of Perioperative Nursing
economic analysis on the cost- perioperative hypothermia is 2014;27(3):16–23.
effectiveness of preventing developed 7. Duff J, Walker K, Edward K, Ralph N,
inadvertent perioperative • a definitive clinical trial on Giandinoto J, Alexander K, Gow J, Stephenson
hypothermia in Australia. Using J. Effect of a thermal care bundle on the
perioperative hypothermia is prevention, detection and treatment of
rigorous up-to-date data, the conducted. perioperative inadvertent hypothermia. J
authors report findings based on a Clin Nurs 2018;27(5–6):1239–1249.
scenario of 80 per cent compliance
4 Journal of Perioperative Nursing Volume 32 Number 1 Autumn 2019 acorn.org.au
President’s report Rebecca East
President
With the start of 2019 already drifting well into the past as you
read this autumn ACORN journal I wonder if our new year’s
resolutions are still fresh in our minds?
I don’t tend to make new year’s units on how to manage fatigue. This be well rested and well supported.
resolutions but I have recently been standard indicates that it is not only We want to work with industry to
working on taking care of myself. The the responsibility of health care find ways of lightening our load and
year 2018 was a tough one – not only facilities to ensure that staff are well decreasing the occurrence of fatigue
was it tough for me personally but for rested and safe to attend to their in the perioperative environment.
many of my colleagues, family and shift, but it also indicates that it is The inaugural ACORN Leadership
friends. I think as I write we have all our own responsibility to ensure we Summit in Canberra this year will
been looking forward to a new start are safe to work during our shift1. allow our perioperative leaders
in 2019. to discuss these issues nationally
And so I have decided to make a
and allow ACORN to support them
Nursing fatigue and burnout is a promise to myself to take care of
in not only this issue but in wider
constantly growing issue not only myself in 2019 and beyond. Although
industry issues. The summit has
in perioperative units but in health our employers are responsible
limited numbers so if you are keen
care worldwide. Only recently, as I sat for providing us with a safe work
to join us in Canberra for the ACORN
quietly waiting to perform an after- environment, we too are responsible
Leadership Summit please make sure
hours case, I had a catch up with for ourselves and our colleagues.
to get your registration in soon!
a colleague. He was fatigued. The The year 2019 is shaping up to be
long weeks of call, after hours cases a fantastic year on so many levels While we work in the background to
and challenges that he consistently personally and professionally. build our voice in the industry, I ask
comes up against every day are However, I will not be able to reach you to promise that you will work on
wearing him thin. Not to mention the all of my goals without taking care of taking care of yourself too. We are
challenges he faces in the outside myself in the process. responsible for our own health, and
world, having a young family, sporting though I know it’s not always easy,
At our December board meeting the
commitments, and the list goes on. let’s be advocates for ourselves and
ACORN directors reminded ourselves
our colleagues. It will allow us to be
The literature recognises that fatigue what it is that we are here for. We
better advocates for our patients too.
in the perioperative environment now write down at the start of our
is increasing. I came away from the meetings our vision. ACORN’s vision Reference
late evening case questioning if I, as is for patients to receive the safest
1. Australian College of Perioperative Nurses
a colleague, was doing anything to and highest quality evidence-based Ltd (ACORN). Standards for Perioperative
improve my own environment, let perioperative care in the world. The Nursing in Australia 15th ed. Adelaide, South
alone that of my colleagues. ACORN board recognises that for this to Australia: ACORN; 2018.
has a standard to guide perioperative occur our perioperative staff need to
Change of director
Since the last issue of the journal we We welcome Trent Bacthelor as the
have had a change of director. South new South Australian director. Trent
Australian director, Di Hutt, has left is Perioperative Services Manager at
the board after four years – two as Burnside War Memorial Hospital. He
representative and two as director. attended the face-to-face meeting
Di was Chair of the Conference in Launceston in February where he
Committee that organised the met the other directors and, with
wonderful international conference them, participated in the ACORN
in Adelaide in 2018. We thank Di for Tasmania study day.
all the time and effort she has put
into ACORN.
Journal of Perioperative Nursing Volume 32 Number 1 Autumn 2019 acorn.org.au 5
save the date
6–7 September 2019
East Hotel, Canberra
acorn.org.au/summit2019
East Hotel
Canberra NSW
Clinical practice
Improving antibiotic prescribing Authors
Robert Herkes
for surgical prophylaxis – the MBBS FRACP FCICM
Chief Medical Officer, Australian
role of perioperative nurses
Commission on Safety and Quality in
Health Care, Sydney NSW Australia
Associate Professor Pat Nicholson
Surgical site infection is a potential The Australian Commission on
PhD, RN, FACORN
post-surgery risk that needs to Safety and Quality in Health Care School of Nursing and Midwifery, Centre
be managed effectively as part of (the Commission) coordinates the for Quality and Patient Safety Research,
good patient care. The discovery of Antimicrobial Use and Resistance Faculty of Health, Deakin University,
antibiotics in the 20th century and in Australia (AURA) Surveillance Geelong Vic Australia
their associated use as surgical System, which provides a range of
antibiotic prophylaxis, often AMR and antibiotic use surveillance particularly where the evidence base
with other interventions such as data. AURA also provides a platform for alternative practices is limited.
oxygenation, glycaemic control and for voluntary standardised audits
Process issues still account for many
surgical antisepsis, has minimised of surgical prophylaxis through the
variations from guidelines-based
this procedural burden. Hospital National Antimicrobial
practice. Improved standardisation
Prescribing Survey (NAPS).
However, the global increase in could bring practice more in line
antimicrobial resistance (AMR) Data from participating hospitals in with consistent and reliable delivery
is limiting the effectiveness of 2017 showed that 30.5 per cent of of antibiotic prophylaxis. There are
antibiotics currently available when surgical prophylaxis prescriptions many opportunities for improvement
treating infections and impacting for inpatients extended 24 hours including:
on the delivery of safe and effective beyond the time of surgery. This is
• consistency in documentation of
care for patients. As a result, many despite guidelines recommending
fixed antibiotic duration
infections are no longer responsive surgical prophylaxis durations of less
to first line antibiotic choices. The than 24 hours. Commonly, surgical • development of and adherence
overuse and misuse of antibiotics, antibiotic prophylaxis was found to to evidence or consensus-based
wherever this occurs, impacts be too broad or too narrow for the guidelines
the efficacy of surgical antibiotic organisms known to cause surgical
• optimising administration timing
prophylaxis. This, compounded by the site infections or to be inconsistent
for optimal concentration of
decreased antibiotic development with guidelines (with no indication
antibiotics during the surgical
pipeline, means that managing an of patient characteristics that would
procedure.
infection is no longer as simple as require variation), or the wrong dose
just selecting ‘another antibiotic’. was prescribed. The timing of prophylactic antibiotics
is crucial, and nurses working in
Due to AMR, complex infections are Variation in surgical antibiotic
the perioperative setting are well
now being treated with potentially prophylaxis prescription often occurs
placed to have a significant impact
more toxic, costly and complicated because of individual prophylaxis
on this aspect of surgical antibiotic
regimens than in the past. This preferences. Despite evidence to
prophylaxis. Optimal timing is
creates additional risks for patients, the contrary 1,2, the perception that
dependent on the pharmacokinetics
including potentially adverse adverse outcomes are reduced
of the antibiotic used to optimise
outcomes from the antibiotics used with longer and broader spectrum
tissue concentrations. Vancomycin
and increased length of hospital antibiotic intravenous courses still
(and antibiotics with a longer
stay due to a lack of oral therapeutic exists. Topical or deep surgical
half-life) should be commenced
choices. Patients with unnecessary site administration has also been
within 120 minutes of knife
exposure to long courses of antibiotic reported.
to skin; the infusion does not
prophylaxis are also at a higher risk
The increased health care–associated have to be completed prior to
of morbidity and mortality if they
complications of prolonged or the commencement of surgery.
develop an infection as it is more
novel intra-operative antibiotic use Vancomycin can cause red man
likely the organism will be resistant
(for example irrigations, pastes or syndrome when administered too
to commonly prescribed antibiotics.
washes) also need to be considered, quickly in an attempt to finish the
infusion prior to knife to skin.
Journal of Perioperative Nursing Volume 32 Number 1 Autumn 2019 acorn.org.au 7
The timing of antibiotic administration specialties) may also aid in more nurses with resources to assist
also requires logistic coordination of consistent administration practices3. in safe antimicrobial use. Go to
the patient’s journey from the ward to www.safetyandquality.gov.au/SAP
Under the National Safety and
the operating suite and from the Post to find out how you can improve
Quality Health Service (NSQHS)
Anaesthesia Care Unit back to the surgical antibiotic prophylaxis in your
Standards, every hospital is required
ward. Nurses can also support best organisation.
to have a local antimicrobial
practice by promoting documentation
stewardship program to optimise References
of the plan for surgical antibiotic
use of antimicrobials and improve
prophylaxis to avoid confusion 1. Harbarth S, Samore MH, Lichtenberg D,
the use of surgical antimicrobial
when the patient returns to the Carmeli Y. Prolonged antibiotic prophylaxis
prophylaxis within hospitals. Nurses after cardiovascular surgery and its effect
ward. Prolonged administration of
are extremely valuable in their on surgical site infections and antimicrobial
intravenous surgical prophylaxis can resistance. Circulation 2000;101(25):2916–
participation in multidisciplinary
also increase the risk of a cannula site 2921
efforts to facilitate audits and
infection. 2. Broom J, Broom A, Kirby E, Post JJ.
feedback procedures or drive
Improvisation versus guideline concordance
Simple changes such as promoting dedicated quality improvement in surgical antibiotic prophylaxis: A
the importance of correct surgical projects. The provision of safe and qualitative study. Infection 2018;46(4):
antimicrobial prophylaxis for every effective care to patients is the 541–548.
procedure could also increase ultimate goal. To achieve this, the 3. Charani E, Tarrant C, Moorthy K, Sevdalis
N, Brennan L, Homes AH. Understanding
consistent administration and risks and benefits of antimicrobial
antibiotic decision making in surgery – a
improve choice practices. Clarity use need to be balanced. qualitative analysis. Clin Microbiol Infect
regarding the lead in the choice of 2017;23(10):752–760.
The Commission is working with
antibiotic (anaesthetic and surgical
ACORN to provide perioperative
Photo competition
ACORN is seeking images that demonstrate best
perioperative nursing practice.
Send photos of your workplace and be
Summer 2018
in the running to win the complete set
Spring 2017
Journal of
of ACORN Practice Audit Tools!
Volume 31
Volume 30
Perioperative Nursing Number 4
rioperative
Summer 2018
Journal of Pe Australia
Number 3
Spring 2017
Nursing in
NORTHERN TERRITORY PERIOPERATIVE
Make sure personnel and practices depicted
NURSES ASSOCIATION INC.
PERIOPERATIVE
NORTHERN TERRITORY INC.
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in your photos meet current practice
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The photos must be high resolution, i.e.
taken on a camera, not a mobile phone,
and saved as 300 dpi. You can also submit Photos may be used as front covers for
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Competition closes 1 May 2019. Submissions permission from all people in the photos
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8 Journal of Perioperative Nursing Volume 32 Number 1 Autumn 2019 acorn.org.auPeer-reviewed article
Authors
Brigid M Gillespie
The impact of improved surgical
PhD, RN, FACORN
School of Nursing and Midwifery, Griffith safety checklist participation on
OR efficiencies: A pretest-post
University, Gold Coast, Queensland,
Australia. Gold Coast Hospital and Health
Service, Queensland, Australia.
National Centre of Research Excellence
in Nursing, Griffith University, Gold Coast, test analysis
Queensland, Australia.
Does improved use of a surgical safety checklist influence OR
Emma Harbeck
efficiency?
PhD, B Psych (Hons)
School of Nursing and Midwifery,
Griffith University, Mt Gravatt Campus,
Abstract
Queensland, Australia. Objective: To describe changes in day of surgery (DOS) cancellations
Joanne Lavin and procedural delays following introduction of a practice improvement
BN, RN intervention to improve team members’ participation in the surgical safety
Surgical and Procedural Services, checklist (SSC).
Gold Coast Hospital and Health
Service, Queensland, Australia. Methods: Pretest—posttest electronic audit of secondary data collected 12
Therese Gardiner months before and 12 months after implementation. A consecutive sample
BN, GcEN, RN of patients who underwent elective surgeries were included. Elective
Surgical and Procedural Services, Gold surgeries over two periods (November 2014 to September 2015, and November
Coast Hospital and Health Service, 2015 to October 2016) were included in the audit and data was collected
Queensland, Australia.
retrospectively. The practice improvement intervention coined ‘pass the baton’
Teresa K Withers was implemented over four weeks in October 2015.
MD, FRACS Neurosurgery
Surgical and Procedural Services, Gold Results: Across audit periods 33 017 surgical procedures (16 262 pretest and
Coast Hospital and Health Service, 16 755 posttest) were performed. DOS cancellations between phases totalled
Queensland, Australia. 826 with an increase of 112 in the posttest phase with the largest posttest
Andrea P Marshall increase being in suite cancellation (increase of 97). Across phases, there were
PhD, RN, FACN, FACCCN 1508 procedural delays (pretest n=737, posttest n =771), with the most frequent
School of Nursing and Midwifery, Griffith delay being due to staff availability (p=0.577). Pretest procedural delays
University, Gold Coast, Queensland,
averaged 38.7 minutes (SD 52.4) and posttest averaged 36.8 minutes (SD 43.2)
Australia. Gold Coast Hospital and Health
Service, Queensland, Australia. (p=0.428).
National Centre of Research Excellence Conclusions: These results suggest no change in clinical efficiencies when
in Nursing, Griffith University, Gold Coast,
Queensland, Australia.
the SSC is fully utilised. That is, increased participation in the checklist does
not increase delays in surgery. When considering ways to improve clinical
Corresponding author efficiency, hospital administrators need to consider skill mix, physical layout
Professor Brigid M Gillespie of the OR and additional staffing, factors not captured in routine clinical audit
b.gillespie@griffith.edu.au. data collected.
Authors’ contributions Introduction costliest departments in any hospital,
contributing to more than 40 per cent
BMG conceived of the study, assisted Perioperative services are typically
in participant recruitment and drafted of its total running costs1,3, with costs
comprised of three phases:
the manuscript. BMG and EH performed as high as USD $40 per minute1,2
preoperative, intra-operative, and
the quantitative analysis. AM and EH (2018 AUD estimates $55 per minute).
post-operative. As a department,
contributed to study conception and Therefore, efficient management of
assisted in interpretation. TG, JL and TKW perioperative services is one of the
the service is necessary to minimise
assisted in recruitment, participated in most dynamic and complex in a
increased costs. Loss of information
the study and assisted in interpretation. hospital system and generates up
during the patient journey through
All authors participated in the design and to 60 per cent of the total gross
coordination of the study and read and
the department may negatively affect
revenue1,2. Nevertheless, US estimates
approved the final manuscript. patient flow and reduce clinical
suggest that they are also one of the
efficiency.
Journal of Perioperative Nursing Volume 32 Number 1 Autumn 2019 acorn.org.au 9‘Efficiency’ is broadly defined as Despite the WHO SSC having been included. Data for the month of
performance that leads to cost implemented in over 132 countries October 2015 was excluded as at
reduction without compromising world-wide9, compliance remains a this time the process improvement
quality. Thus, efficiency relates to challenge10–12. We hypothesised that a strategy was being implemented
both productivity and quality. In theory-based practice improvement across the OR department. Over a
the operating room (OR) context, intervention aimed at changing four-week period, key stakeholders
definitions of efficiency usually focus clinician behaviour would increase implemented a process improvement
on time, whereas reductions in time checklist participation and item strategy intended to increase staffs’
related to a level of output translates use and influence OR efficiencies participation in the safety checks of
into efficiency4,5. Efficiency in the relative to day of surgery (DOS) the WHO SSC.
OR depends on minimising wasted cancellations and procedural delays.
and unused time to meet projected We chose these efficiencies because Process improvement strategy
surgical targets1. Numerous factors communication processes may affect In October 2015, a process
influence OR efficiencies e.g. surgical them, particularly during the sign-in improvement intervention coined
scheduling accuracy, on time starts, and sign-out phases of the WHO SSC. ‘pass the baton’ (PTB) was rolled
minimising case cancellations and To date, few studies have evaluated out department-wide with the goal
case turnover times4. improvements in WHO SSC use of improving team participation in
relative to longitudinal changes in the locally modified WHO SSC. PTB
Research suggests that improved
these OR efficiencies. was nurse-led and developed with
service efficiency depends on the
synchronisation of interprofessional input from key stakeholders across
Method nursing, surgery and anaesthetics.
communications in the OR
department which has a resultant We conducted a pretest—posttest Process strategies to promote
impact on patient flow6,7. The intent audit of electronic secondary behaviour changes in WHO SSC
of the World Health Organization data to describe changes in the participation were delivered over
(WHO) surgical safety checklist numbers of procedural delays four weeks and included audit
(SSC) is to improve several ‘must and DOS cancellations following and feedback, opinion leaders and
do’ critical clinical tasks and hence implementation of an intervention change champions, reminders and
improve the fluency of processes, to improve participation in the prompts and formal and informal
team communications and WHO SSC. DOS cancellations and education. A process evaluation
operations throughout the patient’s delays, regardless of the underlying of these strategies is presented
perioperative journey. Although cause(s), negatively impact on elsewhere14. The phases in which it
not intended to directly improve use and consequently on costs13. was most difficult to maximise staff
OR efficiencies, the checklist acts Retrospective audits of an electronic participation were the sign-in and
as a memory aid for passing on database of surgical information sign-out phases. Therefore, the PTB
key information or actions that maintained by the hospital occurred intervention specifically involved the
may otherwise be overlooked over two 12-month periods. allocation of nursing staff to lead
or forgotten ensuring timely the sign-in and sign-out using a
Setting and sample deliberate call-and-response format.
and consistent communications
among surgical teams8. Thus, the The study setting was a 750-bed Implementing changes that address
SSC aids interdisciplinary team tertiary hospital in Queensland team-based delivery of care have
communications and coordination specialising in all surgeries except demonstrated not only increases
of clinical activities. The checklist transplantation. The department in OR efficiencies15–17 but also
divides the operation up into has 18 commissioned ORs and improvements in patient safety 18,19.
three phases – the period before performs approximately 16 000
Data collection and coding
anaesthetic induction (sign-in), the surgeries per year. A consecutive
period after induction and before sample of patients undergoing Electronic data from the ORMIS
surgical incision (timeout), and the elective surgeries during the periods database of operative times inclusive
period during and immediately November 2014 to September 2015 of in-suite to out of OR times
after wound closure but before and November 2015 to October (i.e. in-suite, in anaesthetic, in OR,
transferring the patient out of the OR 2016, and drawn from the Operating procedure start, procedure finish,
(sign-out)8. Room Information Management out of OR), procedural delays (type
System (ORMIS) database was and reason), surgical specialty, and
10 Journal of Perioperative Nursing Volume 32 Number 1 Autumn 2019 acorn.org.aumonth and year were extracted We recoded DOS cancellations and were usually out of the control of
for cases of elective surgeries. The procedural delays according to their health care professionals and not
original ORMIS data files were given primary origin, i.e. whether they influenced by process improvements
to the lead author as an encrypted were related to the organisation/ associated with the use of the
Excel file. In the original database, department or to the patient. In WHO SSC. For instance, in relation
DOS cancellations and delays had the analysis, we excluded DOS to DOS cancellations ‘failure to
multiple codes for similar types and cancellations and procedural delays attend surgery’, ‘patient cancelled
reasons. that were patient-related as these booking’ and ‘unfit for surgery’ were
Table 1: OR efficacy indicators, their definitions and measures (where applicable)
OR efficiency
indicator Definition Measurement
First case on time Difference between actual time the patient enters OR and the Time recorded in ORMIS.
start4 scheduled time for the session.
Procedural delay4 Total delays from late starts (first case ‘In OR’ time is after the Coded according to the
scheduled session start time) and prolonged change-over times primary reason/origin.
(change-over time more than 15 minutes).
Categorical variable,
Reasons for delays relate to the availability of bed, equipment or numbers summed in
documents; staffing; and previous case over-run. each category.
In OR time5 Time the patient enters the OR, often referred to as ‘wheels in’ to Time recorded in ORMIS.
OR.
Procedure start The earlier time of either the specific positioning of the patient Time recorded in ORMIS.
time2 for surgery or commencement of the skin preparation.
In OR time (‘wheels Time the patient enters the OR from either the induction room or Measured in minutes.
in’) to procedure main reception area until the time the patient is either positioned
start time4,5 or has been prepped and draped for surgery. This period includes
anaesthetic induction process.
Procedure finish Time when all the instruments and sponge counts are completed Time recorded in ORMIS.
time5 and verified as correct, all post-operative radiological studies
to be done in the OR are completed, all dressings and drains
are secured, and the surgeon(s) have completed all procedure-
related activities on the patient.
Out of OR time5 Time the patient leaves the OR, often referred to as ‘wheels out’ Time recorded in ORMIS.
of OR.
Procedure finish Time from application of the final incision dressing, to when the Measured in minutes.
time to out of OR patient leaves the OR for transfer to the PACU.
time (‘wheels out’)4,5
Elective day Unanticipated cancellation of elective surgery due to either Coded according to the
of surgery patient or hospital-initiated factors. primary reason/origin.
cancellation4
Categorical variable,
numbers summed in
each category.
Note: OR = operating room, ORMIS = Operating Room Management Information System, PACU = Post Anaesthesia Care Unit
References:
4. NSW Agency for Clinical Innovation (ACI). Operating theatre efficiency guidelines: A guide to the efficient management of operating
theatres in New South Wales hospitals. ACI: Chatswood NSW, 2014; 1–82.
5. Healthcare Improvement Unit Queensland Health. Operating theatre efficiency. Brisbane: Queensland Health, 2017;1–82.
Journal of Perioperative Nursing Volume 32 Number 1 Autumn 2019 acorn.org.au 11excluded in the analysis. In terms of Table 2: DOS cancellations pre- and post-implementation
procedural delays, ‘patient condition’,
‘disaster plan activity’, and ‘radiology
Nov 2015 – Oct 2016
Oct 2014 – Sep 2015
unavailable’ were also excluded from
the analysis. DOS cancellations were
implementation
implementation
recoded according to type (within
24 hours or in-suite) and reason
(bed/equipment/documentation
Post-
n (%)
n (%)
unavailable, staff unavailable, list
Pre-
re-arranged). Procedural delays χ2 (p value)
were recoded relative to their Number of hospital
primary origin: bed, equipment or 16 262 (49.3) 16 755 (50.7)
cases
documentation unavailable; staff
unavailable or list re-arranged. Table Cancellation type 4.7 (0.030)
1 details the OR efficiency indicators Cancelled within 24
that guided this study, their 184 (51.5) 206 (43.9)
hours
definitions and measurement (where
applicable). Cancelled ‘in suite’ 173 (48.5) 263 (56.1)
Analysis Total DOS cancellations 357 469
We cleaned and analysed the data Total cancellations 826
using the Statistical Package for
Social Sciences (SPSS; V.24, IBM, Cancellation reason 1.2 (0.560)
NY, New York, USA), and checked
a random sample of 20 per cent Bed/equip/
for accuracy. Descriptive statistics documentation 258 (72.3) 332 (70.8)
using absolute (n) and relative unavailable
frequencies (per cent) or means Staff unavailable 31 (8.7) 35 (7.5)
and standard deviations (SD) were
used appropriate to the level of data. List re-arranged 68 (19.0) 102 (21.7)
For categorical data, comparisons
between phases relative to type Speciality 15.2 (0.076)
and reason for DOS cancellation
Obstetrics and
and procedural delay, and surgical 25 (7.0) 55 (11.7)
gynaecology
specialty were analysed using the Chi
squared (χ2) statistic. Independent Max facial/ENT/
61 (17.1) 67 (14.3)
sample t-tests were used to compare plastics^
overall time differences (in minutes) Orthopaedics 51 (14.3) 99 (21.1)
for each surgical specialty over
pretest and posttest phases. We used Urology 32 (9.0) 39 (8.3)
95 per cent confidence intervals (CI)
and considered p-values of < 0.05 General 36 (10.1) 45 (9.6)
significant.
Neurosurgery 36 (10.1) 43 (9.2)
Ethics
Ophthalmic 23 (6.4) 24 (5.1)
Ethics approval was given by Griffith
University (NRS/06/14/HREC) and Paediatrics 2 (0.6) 4 (0.9)
the Gold Coast University (HREC/13/
QGC/154) Human Research Ethics Cardiothoracic 56 (15.7) 60 (12.8)
committees. Following ethics
approval for the main study, we Vascular 35 (9.8) 33 (7.0)
sought permission to obtain
Note: ^ covers facio/maxillary, ear, nose and throat, dentistry and plastic surgery.
12 Journal of Perioperative Nursing Volume 32 Number 1 Autumn 2019 acorn.org.aude-identified ORMIS data from the most predominant reason for DOS Overall, the mean procedural delay
director-general, Queensland Health, cancellation. Over each audit period, (in minutes) pretest was 38.7 minutes
as required by the Public Health Act the highest number of cancellations (SD 52.4), and posttest was 36.8
(2005). occurred in orthopaedic surgery minutes (SD 43.2). These results
(n =150/826, 34.9 per cent; pretest were not significant (t=0.79, df 1506,
Results n=51/357, 14.2 per cent; posttest p=0.428).
Over audit periods, 33 017 surgical n=99/469, 21.1 per cent) and the
Table 3 displays the pretest–posttest
procedures were performed (16 262 fewest in paediatric surgery (n =6/826,
results relative to times from in OR
pretest, 16 755 posttest), representing 0.72 per cent; pretest n=2/357, 0.56 per
to procedure start and procedure
an increase of 493 in the posttest cent; posttest n=4/469, 0.85 per cent).
finish to out of OR. Relative to in
period. Table 2 shows results for Figure 1 illustrates longitudinally OR to procedure start, there were
DOS cancellations according to the frequencies of procedural significant pretest–posttest time
type and reason for cancellation. delays relative to bed, equipment or differences (minutes) in two out of
DOS cancellations between phases documentation availability; staffing ten specialties (maxillary facial/ENT/
totalled 826, representing an availability, and prior case over-runs plastics, paediatrics). In relation
increase of 112 in the posttest phase. for each month over pretest and to procedure finish to out of OR
However, there were significant posttest phases. Across phases, there times, there were significant pretest–
(p=0.029) differences between phases were 1508 procedural delays (pretest posttest time differences (minutes) in
relative to each type of cancellation n=737, posttest n =771), with the four out of ten specialties (obstetrics
(i.e. within 24 hours compared to most frequent delays being related and gynaecology, maxillary
in-suite). Across phases, a lack of bed, to staff availability; however, this facial/ENT/plastics, paediatrics,
equipment or documentation was the was not significant (χ2 =1.10 p=0.577). cardiothoracic).
Pre-implementation phase Post-implementation phase Delay code
45 Bed, equipment or
documentation unavailable
number of recorded procedural delays
Staff unavailable
40
Prior case ran overtime
35
30
25
20
15
10
5
0
Oc
No 201
De 201
Ja 201
Fe 201
M 201
Ap 201
M 201
Ju 201
Ju 015
Au 015
Se 201
No 201
De 201
Ja 201
Fe 201
M 201
Ap 201
M 201
Ju 201
Ju 016
Au 016
Se 201
Oc 201
ar 5
ay 5
ar 6
ay 6
n 4
n 5
n 5
l2
n 6
l2
b 5
b 6
p 5
p 6
g
g
r 5
r 6
t
t2 6
c 4
c 5
v 4
v 5
2
2
01
6
Month
Figure 1: Types of delays relative to bed/equipment/documentation, staffing and prior case over-runs in pre-
and post-implementation periods over month
Journal of Perioperative Nursing Volume 32 Number 1 Autumn 2019 acorn.org.au 13Table 3: Pretest–posttest results for times from in OR to procedure start and procedure finish to out of OR
implementation
implementation
95% confidence
interval of the
Post-
difference
Pre-
Mean Std error
Speciality n n t df difference difference Lower Upper
Time from in OR to
procedure start
Obstetrics and 1838 1882 0.18 3718 0:00:04 0:00:26 -0:00:46 0:00:55
gynaecology
Max facial/ENT/ 1931 1948 -4.36 3705.3 -0:02:38 0:00:36 -0:03:50 -0:01:27
plastics^
Orthopaedics 1971 2185 0.28 4154 0:00:06 0:00:23 -0:00:39 0:00:52
Urology 2451 2461 -0.69 4910 -0:00:12 0:00:18 -0:00:49 0:00:23
General 1152 1140 -1.46 2290 -0:01:03 0:00:43 -0:02:29 0:00:21
Neurology 359 392 1.96 683.7 0:02:55 0:01:29 -0:00:00 0:05:50
Ophthalmic 1913 1977 -0.92 3888 -0:00:13 0:00:15 -0:00:43 0:00:15
Paediatrics 400 429 -5.27 711.5 -0:04:09 0:00:47 -0:05:42 -0:02:36
Cardiothoracic 384 384 0.32 766 0:00:39 0:02:05 -0:03:26 0:04:46
Vascular 392 363 -0.54 753 -0:00:46 0:01:26 -0:03:35 0:02:03
Time from procedure
finish to out of OR
Obstetrics and 1838 1882 -2.44 3608.7 -0:01:39 0:00:40 -0:02:59 -0:00:19
gynaecology
Max facial/ENT/ 1933 1951 -3.35 3547.0 -0:04:55 0:01:28 -0:07:48 -0:02:02
plastics^
Orthopaedics 1972 2185 -2.17 3997.0 -0:01:39 0:00:46 -0:03:10 -0:00:09
Urology 2452 2462 1.42 4874.1 0:00:48 0:00:34 -0:00:18 0:01:55
General 1152 1141 -0.24 2291 -0:00:20 0:01:27 -0:03:11 0:02:30
Neurology 359 393 1.14 750 0:03:13 0:02:50 -0:02:20 0:08:47
Ophthalmic 1913 1977 1.99 3870.6 0:00:50 0:00:25 0:00:00 0:01:39
Paediatrics 400 429 -4.37 801.3 -0:02:44 0:00:37 -0:03:58 -0:01:30
Cardiothoracic 384 385 2.05 605.2 0:05:10 0:02:31 0:00:13 0:10:08
Vascular 392 364 -0.19 754 -0:00:30 0:02:35 -0:05:35 0:04:35
Notes:
Time difference is displayed in h:mm:ss.
Some degrees of freedom (df) have decimals because Levene’s test was violated so ‘equal variances not assumed’ data used.
^ covers facio/maxillary, ear, nose and throat, dentistry and plastic surgery.
14 Journal of Perioperative Nursing Volume 32 Number 1 Autumn 2019 acorn.org.auFigure 2 depicts longitudinally the Discussion improvements in using the checklist
pretest and posttest means (in do not translate into increased
Few studies have used longitudinal
minutes) for all specialties combined efficiencies. Still, our results suggest
efficiency indicators to measure
relative to time from in OR to that increased participation in the
the impact of theory-based process
procedure start. The results vary WHO SSC does not negatively impact
improvement strategies on DOS
across both phases but there is a on OR efficiency. That is, active team
cancellations and procedural delays
notable spike in the posttest period participation does not increase
across an entire OR department.
for the months of December and the time taken to complete clinical
The benefit of the checklist on
March. Figure 3 shows longitudinally, activities. Many staff were concerned
patient outcomes, safety related
the pretest and posttest means that implementation of PTB needed
practices and clinical processes
(in minutes) for all specialties extra time and would reduce their
are well researched20–23. There
combined relative to time from ability to complete elective case
were no significant differences
procedure finish to out of OR. In the lists on time25. Previous research
in clinical efficiencies despite
pre-implementation phase there suggests that improvements in
observed improvements in
were drops in February, June and interdisciplinary communication
checklist items coverage and
September. reduces procedural delays7,26,27.
participation post-implementation
Nonetheless, some of these studies
of PTB (acknowledging that the
used self-reported survey data
SCC was not fully utilised)24. Clearly,
or had short follow-up periods26,27.
Pre-implementation phase Post-implementation phase
00:20:30
00:20:00
Mean time from in OR to procedure start (minutes)
00:19:30
00:19:00
00:18:30
00:18:00
00:17:30
00:17:00
00:16:30
00:16:00
00:15:30
Oc
No 14
De 14
Ja 14
Fe 15
M 15
Ap 15
M 15
Ju
Ju 15
Au 15
Se 15
No 15
De 15
Ja 15
Fe 16
M 16
Ap 16
M 16
Ju
Ju 16
Au 16
Se 16
Oc 16
ar
ay
ar
ay
n
n
n 5
l2
n 6
l2
b
b
p
p
g
g
r2
r2
t2
t2
c
c
v
v
20
20
20
20
20
20
0
0
20
20
20
20
20
20
20
20
20
20
20
20
0
01
0
0
1
1
6
Month (Error bars +1–2 Std error)
Figure 2: Time from in OR to procedure start (in minutes) pre- and post-implementation periods over month
Journal of Perioperative Nursing Volume 32 Number 1 Autumn 2019 acorn.org.au 15Pre-implementation phase Post-implementation phase
00:18:00
00:17:00
Mean time from procedure finish to out of OR (minutes)
00:16:00
00:15:00
00:14:00
00:13:00
00:12:00
00:11:00
00:10:00
00:09:00
Oc
No 14
De 14
Ja 14
Fe 15
M 15
Ap 15
M 15
Ju
Ju 15
Au 15
Se 15
No 15
De 15
Ja 15
Fe 16
M 16
Ap 16
M 16
Ju
Ju 16
Au 16
Se 16
Oc 16
ar
ay
ar
ay
n
n
n 5
l2
n 6
l2
b
b
p
p
g
g
r2
r2
t2
t2
c
c
v
v
20
20
20
20
20
20
0
0
20
20
20
20
20
20
20
20
20
20
20
20
0
01
0
0
1
1
6
Month (Error bars +1–2 Std error)
Figure 3: Time from procedure finish to out of OR (in minutes) in pre- and post-implementation periods over
month
Therefore their findings need to at the study hospital. Priority is members are communicating the
be considered relative to these always given to emergency Caesarean necessary pre-checks and lessening
limitations. sections (categories 2–4), resulting the risk of unnecessary or prolonged
in the cancellation and rescheduling anaesthesia time thereby increasing
Our results indicate increases
of DOS elective (booked) C-sections. patient safety.
across most specialties for total DOS
Second, maxillary facial/ENT/plastics
cancellations (Table 2). The increase The duration of procedural delays
and orthopaedic cases involving
in ‘ in-suite’ cancellations during actually decreased despite an
implantable prosthetic components
the posttest period suggest that increase in the number of surgical
(e.g. total hip/knee replacement
clinical/case-related discrepancies procedures performed during the
surgeries) relies on having the
may not have been identified until posttest period. The results of other
appropriate range and sizes of
after the patient was received into research in this area also suggests
prosthetics available. The check-in
the department. The main reason modest to moderate improvements
phase of the WHO SCC has an item
for DOS cancellation related to in procedural delays following
covering equipment and instrument
bed or equipment availability. teamwork initiatives17,25,26. For instance,
availability. It may be that increased Wolf et al.26 and Nundy et al.27
We suggest there are a couple of
communication at this time identified reported reductions of 13 per cent
contributing factors. Firstly, for
a problem with availability and to 31 per cent in procedural delays
obstetric procedures, the availability
averted a situation when patients following the implementation of
of a ‘dedicated’ emergency obstetric
were anaesthetised without having briefings and debriefings. Clearly,
theatre during weekdays (8.00 am to
the equipment on hand. Plausibly improvements in communication,
5.00 pm) is not always guaranteed
this may demonstrate that team teamwork and planning are the
16 Journal of Perioperative Nursing Volume 32 Number 1 Autumn 2019 acorn.org.audrivers behind how checklist Implementation of PTB aimed where clinical activities take priority,
briefings reduce procedural delays27. to simplify the checking process potentially reducing the accuracy of
Paradoxically in our study, four out through addressing behavioural and these data. Thirdly, these analyses
of ten specialties showed increases contextual factors that contributed are based on selected factors
in time delays (Table 3). Generally, to limited use of the SSC14,24. Yet to identified at the departmental
procedures in these specialties had achieve sustainable improvements in level, thus patient-related factors
shorter operative times, were less efficiencies, structural interventions were not included and may have
technically complex and involved such as parallel processing, physical contributed to OR efficiencies.
younger patient cohorts. layout of the OR and additional Nonetheless, these factors were
staffing should be considered. At largely outside the control of
Our results suggest that staff
the intervention hospital, the the department or organisation,
availability was the most common
layout of the new state-of-the-art hence their exclusion. Fourthly,
cause of procedural delays across
OR department (commissioned departmental factors (e.g. staff
both periods (Figure 1). This result
in September 2013), which was turnover and training requirements,
is somewhat concerning. This type
spread out along two long corridors, increased workload and the
of delay is potentially disruptive to
impacted on workflow and therefore addition of new procedures) could
workflow and impinges on the quality
patient care because of the distance not be accounted for. Such factors
and work environment of surgery.
needed to travel to fetch equipment may also influence performance
Staffing issues are often associated
and instruments. In relation to but could not be captured in the
with safety because improved
staffing, with the appropriate skill audit data. Finally, while PTB was
efficiency and capacity mean that
mix it is possible to perform work implemented department-wide, not
more operations are performed
tasks in parallel to increase efficiency all teams consistently participated.
during the daytime when back up
and maximise the work capacity of Prior to analysis, it was impossible
personnel are readily available. Fewer
members29. The hospital site in this to delineate particular cases (and
surgeries are performed at night
study is a teaching facility so relies exclude them) where there was
when skeleton teams who may be
on a trainee workforce with varying patchy or limited use of PTB. Despite
unfamiliar with each other are more
degrees of clinical experience and these limitations, these longitudinal
likely to work together26,27. Changes
expertise; therefore, it is not always analyses showed trends relative to
to staffing over time are inevitable in
feasible to undertake clinical tasks the types of delays that occurred (i.e.
any health care setting. Over the two-
in this manner. Workforce issues bed, equipment or documentation
year audit period there were changes
can have a profound bearing on availability; staff availability, case
in staffing with seasonal influxes or
performance of OR efficiencies. over-run) and seasonal variations
attrition of staff occurring throughout
However, relative to clinical in wheels-in and wheels-out times
the year. Further, increases in the
performance metrics, factors such across surgical specialties. Thus,
number and complexity of surgical
as workforce and physical layout are these results may help to identify
cases in the posttest period meant
unable to be captured. areas of process efficiency and areas
that staff workloads necessarily
increased leading to additional staff Limitations for improvement.
being hired. Many of these new staff
We acknowledge some limitations, Implications for perioperative
needed training and upskilling in
so there are caveats in the nursing
unfamiliar surgical specialties and so
were often on a steep learning curve. interpretation of these results. Firstly, Our study shows no change in
the use of a single hospital site may health services performance
Saving time (as a measure of limit the extent to which results can when the surgical safety checklist
efficiency) in the OR does not be generalised. Secondly, ORMIS is fully utilised. The primary
necessarily lead to increased data may be subject to errors in intent of the checklist is to
efficiency28. PTB was implemented as coding, leading to misclassification. improve team performance vis-
a driver to enable change in practice Where there were discrepancies, the à-vis communication among
and process when executing the lead author followed up with coding surgical teams rather than clinical
checklist14,24. Yet strategies that target staff to clarify. Also, the accuracy efficiencies. Contrary to long-held
changes in practice (i.e. those that of the times entered depends on beliefs, performing the checks as
are behavioural in nature) are not the ability of staff to enter these a team-based activity does not
in themselves sufficient to achieve times in the ORMIS system as they decrease clinical efficiencies. Clearly
improvements in clinical efficiencies. occur. Clearly there will be occasions
Journal of Perioperative Nursing Volume 32 Number 1 Autumn 2019 acorn.org.au 17contextual factors have a bearing 8. World Health Organization (WHO). 20. Gillespie BM, Chaboyer W, Thalib L, John
Implementation of the surgical safety M, Fairweather N, Slater K. Effect of
on performance. Therefore, hospital
checklist. Geneva: WHO, 2008;1–28. using a safety checklist in surgery on
administrators need to also consider patient complications: A systematic
9. World Health Organization (WHO). Surgical
the interplay of environmental and safety web map [Internet]. Geneva: WHO; review and meta-analysis. Anaesthesiol
operational factors not currently 2013 (cited 2014 September 13). Available 2014;120(6):1380–1389.
measured as part of clinical from: maps.cga.harvard.edu:8080/Hospital. 21. Bergs J, Hellings J, Cleemput I, Zurel Ö, De
Troyer V, Van Hiel M et al. Systematic review
efficiencies. 10. Gillespie B, Marshall A. Implementation
of safety checklists in surgery: A realist and meta-analysis of the effect of the World
Competing interests synthesis of evidence. Implement Sci Health Organization surgical safety checklist
2015;10:137. on post-operative complications. Brit J Surg
The authors declare that they have no 2014;101(3):150–158.
11. Rydenfält C, Johansson G, Odenrick P,
competing interests. 22. Bohmer A, Wappler F, Tinschmann T,
Åkerman K, Larsson PA. Compliance with the
Funding statement WHO surgical safety checklist: Deviations Kindermann P, Rixen D, Bellendir M. The
and possible improvements. Int J Qual implementation of a perioperative checklist
BMG was supported by a National Health Care 2013;25(2):182–187. increases patients’ perioperative safety and
Health and Medical Research Council staff satisfaction. Acta Anaesthesiol Scand
12. Borchard A, Schwappach D, Barbir A, Bezzola
(NHMRC) Translation into Practice (TRIP) 2012;56(3):332–338.
P. A systematic review of the effectiveness,
Fellowship and the Australian College of compliance and critical factors for 23. Spiess B. The use of checklists as a method
Perioperative Nurses (ACORN) Research implementation of safety checklists in to reduce human error in cardiac operating
grant. surgery. Ann Surg 2012;256(6):925–933. rooms. Int Anaesthesiol Clin 2013;51(1):179–
194.
13. Martin L, Langell J. Improving on-time
References surgical starts: The impact of implementing 24. Gillespie BM, Harbeck E, Hamilton K, Lavin
pre-OR timeouts and performance pay. J J, Gardiner TM, Withers TK et al. Evaluation
1. Macario A, Vitez T, Dunn B, McDonald T. of a patient safety program on surgical
Where are the costs in perioperative care? Surg Res 2017;219:222–225.
safety checklist compliance: A prospective
Analysis of hospital costs and charges for 14. Gillespie BM, Hamilton K, Ball D, Lavin J,
longitudinal study. BMJ Open Qual
inpatient surgical care. Anesthesiology Gardiner TM, Withers TK et al. Unlocking
2018;7(3):e000362.
1995;83(6):1138–1144. the black box of practice improvement
strategies to implement surgical safety 25. Gillespie BM, Withers TK, Lavin J, Gardiner
2. Bender J, Nicolescu T, Hollingsworth S, Murer T, Marshall A. Factors that drive team
K, Wallace KR, Ertl WJ. Improving operating checklists: A process evaluation. J
Multidiscipl Healthc 2017:10;157–166. participation in surgical safety checks:
room efficiency via an interprofessional A prospective study. Patient Saf Surg
approach. Am J Surg 2015;209(3):447–450. 15. Fong AJ, Smith M, Langerman A. Efficiency
2016;10(1):3. doi:10.1186/s13037-015-0090-5.
3. Cima R, Brown M, Hebl J, Moore R, Rogers improvement in the operating room. J Surg
Res 2016;204(2):371–383. 26. Wolf FA, Way LW, Stewart L. The efficacy
JC, Kollengode AC et al. Use of lean and six of medical team training: Improved team
sigma methodology to improve operating 16. Buzink SN, van Lier L, de Hingh IH,
performance and decreased operating room
room efficiency in a high-volume tertiary- Jakimowicz JJ. Risk-sensitive events
delays: A detailed analysis of 4863 cases.
care academic medical center. J Am Coll during laparoscopic cholecystectomy: The
Ann Surg 2010;252(3):477–483.
Surg 2011;213(1):83–94. influence of the integrated operating room
and a preoperative checklist tool. 27. Nundy S, Mukherjee A, Sexton J, Pronovost
4. NSW Agency for Clinical Innovation (ACI). PJ, Knight A, Rowen LC et al. Impact of
Operating theatre efficiency guidelines: Surg Endosc 2010;24(8):1990–1995.
doi:10.1007/s00464-010-0892-6. preoperative briefings on operating room
A guide to the efficient management of delays: A preliminary report.
operating theatres in New South Wales 17. Phieffer L, Hefner JL, Rahmanian A, Swartz
Arch Surg 2008;143(11):1068–1072.
hospitals. ACI: Chatswood NSW, 2014; 1–82. J, Ellison CE, Harter R et al. Improving
doi:10.1001/archsurg.143.11.1068.
5. Healthcare Improvement Unit Queensland operating room efficiency: First case
on-time start project. J Healthc Qual 28. Dexter F, Coffin S, Tinker J. Decreases in
Health. Operating theatre efficiency. anesthesia-controlled time cannot permit
Brisbane: Queensland Health, 2017;1–82. 2017;39(5):e70–e78.
one additional surgical operation to be
6. Gillespie BM, Marshall A, Lavin J, Gardiner T, 18. Gillespie BM, Harbeck H, Kang E, Steel C,
reliably scheduled during the workday.
Withers TK. Impact of workflow on the use Fairweather N, Panuwatwanich K et al. Effect
Anesth Analg 1995;81(6):1263–1268.
of the surgical safety checklist: A qualitative of a brief team training program on surgical
teams› non-technical skills: An interrupted 29. Erebouni A, Gunningberg L, Larsson J. How
study. ANZ J Surg 2016:86(11);864–867. operating room efficiency is understood in a
doi:10.1111/ans.13433. time-series study. J Patient Saf 2017:1–7.
doi:10.1097/PTS.0000000000000361 surgical team: A qualitative study. Int J Qual
7. Overdyk F, Harvey S, Fishman R, Shippey Health Care 2011;23(1):100–106.
F. Successful strategies for improving 19. Cabral R, Eggenberger T, Keller K, Gallison BS,
operating room efficiency at academic Newman D. Use of a surgical safety checklist
institutions. Anesth Analg 1998;86(4):896– to improve team communication.
906. AORN Journal 2016:104(3);206–216.
doi: dx.doi.org/10.1016/j.aorn.2016.06.019.
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