Questions for all Circulators

[surgeryrngirl]

I would love some feedback on how you handle these situations:

1. Being rushed between cases. Not having time to make sure everything is ready to go for the next case.

2. Do you ever go to the room before doing the count?

3. Do you count on cases where you are not entering a cavity?

4. Do you ever come back to the room after being sent to get yet another item..... to find that anesthesia has opened suture while you were gone?

5. Do you always do a "time out"?

I would love some feedback. Do all OR's have these problems?

Thanks,

Surgerygirl

[grahamcracker977]

Well, that's quite a list...
Yes to most of those questions...
I think it depends on your experience (years in the OR) and confidence...
There's always the "turnover" rush...when I worked at a major trauma center we had to scavenge for equipment like headlights, beanbags...people would steal from your room if you were not there...sabotage big time. I'm currently at a quickly expanding community hospital. Our turnovers are always 15 minutes or less, we have excellent ancillary staff (housekeeping,anesthesia techs) who care about what they do, and enough equipment so sabotage does not occur. So now, I'm not so stressed about the next case. If I were working days (not anymore), I would get to work early and get my cases situated (extra equipment, sets, suture, meds)...thus less stress during turnover.
Counting...try to do it before I bring a pt in. Not always possible due to that rush for turnover. We absolutely do a count before the surgeon gets the scalpel...same for our timeout. I don't care if it's a blase...this is john doe and we're doing a lap appy...it still works. You should always count for cavity cases...big cavities...like the belly/chest you should always do an instrument count. It also depends on the scrub nurse I'm working with. Some like to get set up and then break until the pt is ready. I'm cool with that because I'm not running like the proverbial chicken trying to deal with the pt, anesthesia...and now my scrub nurse. Others like to lounge around and scrub in at the last minute and then ask for various items they could have gotten if they had taken the time to prepare. I don't mind getting items but piss poor planning on your part does not make it my emergency.
Yes, I have anesthesia give suture when I'm out of the room. Usually they're kind enough to tell me or write it down on the grease board. If not, my scrub nurse is usually kind enough to let me know. They can be quite helpful if you're out of the room...they can also be a pain.
We always do a time out. That wasn't always the case but even before this was JACHO doctrine if it was an extremity/eye/hernia/etc I would always time out to verify site/procedure.
Again, there's always a rush to get the case started. Most anesthesia providers/charge nurses are cool and willing to give you an extra minute to catch your breath. Of course there are exceptions to the rule.

[HarleyNurse_Sue]

I must also say yes to all of those questions. I am a really new nurse(graduated a year ago) and have been in the OR since then. I do not work in a trauma hospital but when there are 65 cases scheduled for a day and most surgeons want to be done and in the office before 5pm days are very hectic. Counting and time out are hugely important things to do. Even though you feel that no one is listening to you, you at least know that you did your job. Just know that it is not just you and that you are not alone. Call for a count whenever you want, hold up the case to do a count because in the long run you are keeping yourself and the rest of the people in the room out of the courtroom.

[Rowan13]

I am a new nurse who is involved in a 16-week internship in the OR - my dream job. Sometimes I think the dream is really a nightmare. About Time Out: I find the best time to do this without causing an uproar by the surgeon (many hate time outs because they seem to think we don't think they know what they are doing) anyway the best time for me to do it is as I am securing his/her sterile gown. I am behind the surgeon and have him/her captive. It works every time.

Our hospital also requires that the surgeon mark the site to be worked on while the patient is in the holding room. A few surgeons either refuse to do it or act like a bunch of spoiled children when surgery is held up because they didn't do it. I'd like some insight from other nurses about how to best handle the surgeon brats out there. Is there a graceful way to get them to do this hospital-required act without stepping on toes?

[torah1rn]

Originally Posted by surgeryrngirl

I would love some feedback on how you handle these situations:

1. Being rushed between cases. Not having time to make sure everything is ready to go for the next case.

2. Do you ever go to the room before doing the count?

3. Do you count on cases where you are not entering a cavity?

4. Do you ever come back to the room after being sent to get yet another item..... to find that anesthesia has opened suture while you were gone?

5. Do you always do a "time out"?

I would love some feedback. Do all OR's have these problems?

Thanks,

Surgerygirl

1. There's always a rush. I always think it's funny that they want a 5 table case set up in 10 mins.... I check my case carts first thing in the AM and if I know the surgeons routine, it's a little easier in terms of supplies needed. Not as much running. This only fails if my cases get moved.

2. Constantly. I usually have a helper doing the count with the scrub while I position the patient. Gets us in the room on time and the count is still done before a cut. The only problem here is when a laparoscopic case turns into an open case and we haven't counted instruments before hand. NIGHTMARE trying to count while the surgeon is yelling for things. I've even had one surgeon say forget the count, we'll get an x-ray at the end... The patient was dying on the table and a little pressure would have delayed the bleeding, but this guy is always in a rush. No matter what he's rushing.

3. On cases where we haven't entered a cavity we don't count instruments, but we count everything else.

4. Yes anesthesia will open suture while gone. Someone usually lets me know because no one wants to sit in the room for an hour waiting for an x-ray because of a incorrect needle count. A really skilled tech sometimes will use clean instruments to open a packet and then throw the instruments off. I prefer the anesthesia person do it.

5. Yes. A time out always have to be done. The question is, is it always done prior to cut. Unfortunately, no. I try very hard. But that surgeon that's always in a rush has a huge tendency to grap the scalpel and go to town. My hospital also requires that I'm looking at the name band at the same time that I'm looking at the chart and doing the pause. So, it's hard to capture him while tying him up as one person suggested. Also the surgeons always seem to be coming into the room full of conversation and I have to beg and plead for people to do the time-out. No one really pays attention during the time out. The anesthesia people are the worst for talking through my time out. I used to try to do it as soon as the surgeon walked into the room. But the 2 or 20 anesthesia that pay attention to the pause didn't like that because sometimes the surgeon was walking in during intubation. I'm still looking for a way to do it that will work most of the time... But the people in the OR really don't care about doing the time-out.

[Marie_LPN]

Originally Posted by surgeryrngirl

I would love some feedback on how you handle these situations:

1. Being rushed between cases. Not having time to make sure everything is ready to go for the next case.

I don't get rushed anymore. One way i've solved this is if anesthesia is hellbent on getting in the room when THEY'RE ready, i'll park a bunch of things in front of the door. It takes much longer to get through the door when you have to move the cautery, suction, 3 chairs, and one long table out of the way (hey, talking didn''t work for a few, but they learned )

2. Do you ever go to the room before doing the count?

Sometimes, depends on how much there is to count.

3. Do you count on cases where you are not entering a cavity?

Small stuff gets counted on all cases, like sponges, blades, sutures needles.

4. Do you ever come back to the room after being sent to get yet another item..... to find that anesthesia has opened suture while you were gone?

Yes, and right then i'll demand a suture count. Depending on what's going on, if the suture was needed for an unexpected bleeder.

5. Do you always do a "time out"?

Yes, it's a matter of safety, it's also policy. Any doc who dares to get on their soapbox about how 'stupid' the time-out is gets my "I'm following the rules, not making them, go whine to management if you don't like it" speech.