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Journal of Perioperative Nursing - Volume 32 Number 1 Autumn 2019 - Australian Commission on ...
Autumn 2019

                          Journal of   Volume 32
                                       Number 1
              Perioperative Nursing    Autumn 2019

                                                     NORTHERN TERRITORY PERIOPERATIVE
                                                         NURSES ASSOCIATION INC.
Journal of Perioperative Nursing - Volume 32 Number 1 Autumn 2019 - Australian Commission on ...
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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
Journal of Perioperative Nursing - Volume 32 Number 1 Autumn 2019 - Australian Commission on ...
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Journal of Perioperative Nursing - Volume 32 Number 1 Autumn 2019 - Australian Commission on ...
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
Journal of Perioperative Nursing - Volume 32 Number 1 Autumn 2019 - Australian Commission on ...
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
Journal of Perioperative Nursing - Volume 32 Number 1 Autumn 2019 - Australian Commission on ...
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
Journal of Perioperative Nursing - Volume 32 Number 1 Autumn 2019 - Australian Commission on ...
save the date

         6–7 September 2019
         East Hotel, Canberra
         acorn.org.au/summit2019

East Hotel
Canberra NSW
Journal of Perioperative Nursing - Volume 32 Number 1 Autumn 2019 - Australian Commission on ...
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
Journal of Perioperative Nursing - Volume 32 Number 1 Autumn 2019 - Australian Commission on ...
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
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                                                                                                                                                PERIOPERATIVE
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      in your photos meet current practice
      standards.

      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.au
Peer-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.au
month 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                                                             11
excluded 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.au
de-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

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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                                                                                13
Table 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.au
Figure 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
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  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                                                                                               15
Pre-implementation phase                                 Post-implementation phase
                                                          00:18:00

                                                          00:17:00
 Mean time from procedure finish to out of OR (minutes)

                                                          00:16:00

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 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.au
drivers 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                                                        17
contextual 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
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18                                                  Journal of Perioperative Nursing Volume 32 Number 1 Autumn 2019 acorn.org.au
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