Home Study Program

JULY 2004, VOL 80, NO 1

Home Study Program

The RN first assistant as OR concierge

This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements. A minimum score of 70% on the multiple-choice examination is necessary to earn 1.9 contact hours for this independent study. Purpose/Goal: To educate perioperative nurses about the role of the RN first assistant as OR concierge.

he article The RN first assistant as OR concierge, is the basis for this AORN Journal independent study. The behavioral objectives and examination for this program were prepared by Rebecca Holm, RN, MSN, CNOR, clinical editor, with consultation from Susan Bakewell, RN, MS, BC, education program professional, Center for Perioperative Education. Participants receive feedback on incorrect answers. Each applicant who successfully completes this study will receive a certificate of completion. The deadline for submitting this study is July 31, 2007. Complete the examination answer sheet and learner evaluation found on pages 99-100 and mail with appropriate fee to

AORN Customer Service

c/o Home Study Program 2170 S Parker Rd, Suite 300 Denver, CO 80231-5711 or fax the information with a credit card number to (303) 750-3212. You also may access this Home Study via AORN Online at http://www.aorn.org/journal/homestudy/default.htm.

BEHAVIORAL OBJECTIVES
After reading and studying the article on the role of the RN first assistant (RNFA) as OR concierge, nurses will be able to

1. explain problems encountered by the obstetrics and gynecology department

at the facility described in this Home Study,

2. discuss options that facility members considered to resolve these problems, 3. identify methods used by the RNFA to solve these problems, and 4. describe skills that an RNFA may possess that would put him or her in an
ideal position to act as OR concierge.

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Home Study Program

The RN first assistant as OR concierge
Kathie Robbins, RN; William J. Mann, Jr, MD found itself plagued by physician complaints about delayed procedures, inadequate or incorrect equipment, and problems with individuals assisting on complex procedures. Perioperative staff members compiled lists of procedures in which problems occurred, and a review of these lists indicated that problems were widespread and not associated with a specific OR team or physician. Some of the ongoing problems reported by perioperative staff members included incorrectly scheduled procedures, physicians requesting instruments that were not on their preference cards, novel patient positioning requirements, and requests for a large variety of unfamiliar instruments. Frequent lengthy and frustrating discussions were held during the monthly OB/GYN department meetings, but no appreciable improvement was noted. During this time, several physicians decided to perform their procedures in other, smaller facilities where they perceived that fewer problems occurred during surgery. Jersey Shores volume of gynecology procedures remained stable because of the addition of new surgeons, but individual physicians began to perform fewer procedures as they transferred procedures to other facilities. Additionally, gynecology case volume in the attached same day surgery center (ie, surgicenter) was noted to be very low. A decision was made to place a nurse in charge of the gynecology service. This individual was instructed to meet with OB/GYN physicians frequently to address their concerns. Unfortunately, because of staffing limitations, this nurse also was responsible for urology and general surgery. In addition, many problems occurred during the evening and

fficiency in health care is a paramount concern as profit margins lessen and budget constraints place harsh demands on surgical services departments. In addition, competition between hospitals for physicians and OR staff members has increased, and unhappy physicians and staff members are quick to move to other facilities. Maintaining adequate OR staffing levels is becoming more difficult because of the nurse shortage, and a projected physician shortage in five to seven years will only aggravate the situation.1 In this stressful environment, teamwork, which is the backbone of perioperative patient care,2 (p 372) is even more vital to successful functioning.

DIAGNOSING

THE

PROBLEM

At Jersey Shore University Medical Center, Neptune, NJ, the obstetrics and gynecology (OB/GYN) department

ABSTRACT

MANAGERS AND STAFF MEMBERS in the department of obstetrics and gynecology at Jersey Shore University Medical Center, Neptune, NJ, determined that surgeon and OR staff member problems were impeding their ability to function as a team.

AN RN FIRST ASSISTANT was hired to act as OR concierge. Her primary role was to ensure smooth functioning of procedures performed in the facility.

PHYSICIAN COMPLAINTS DISAPPEARED, OR staff members found the concierge supportive and adept at problem solving, and surgical volume increased significantly. AORN J 80 (July 2004) 84-94.

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on weekends when this nurse was not available; therefore, no improvement occurred, and the nurse overseeing gynecology services became frustrated and transferred to another hospital. While these problems were occurring in the OR and the surgicenter, a different set of issues began to develop in the obstetrical suite. Jersey Shore University Medical Center serves as a regional referral center for high-risk obstetric As the comReimbursement procedures. plexity of patient conditions increased, more and hospital complicated and extended surgical procedures resource were being performed in allocation make the labor and delivery (L&D) department, including hysterectomies, orthopedic, arterial ligations, and extended procedures intrauma, and volving the bladder or ureters. Staff members in cardiovascular the L&D department had considerable expertise in procedures a assisting in cesarean secpriority, so it is tions (C-sections) but were unprepared for not feasible to more complicated procedures, which usually create a team were emergent and unscheduled. consisting only Significant deficits were noted in instrument of gynecology trays, particularly because they were not staff members. intended to be used for more extensive procedures. Expense prohibited adding needed instruments to every tray, so separate instrument trays were created for more extensive procedures. Identifying these trays and ensuring that they were stocked properly , available, and easy to find and open, however, became a source of concern for L&D staff members and physicians. In addi-

tion, physician instrument and supply preferences varied. A staff member was assigned to address these issues, but problems still were encountered in nearly every extensive procedure.

LOOKING

FOR A

SOLUTION

Gynecological procedures at Jersey Shore University Medical Center often are scheduled to run concurrently in two or even three separate rooms; on other days there are very few or no procedures scheduled. The reality of reimbursement and hospital resource allocation make orthopedic, trauma, and cardiovascular procedures a priority. In this environment, it is not feasible to create a team consisting only of gynecology staff members. In addition, it clearly was not possible to create a separate perioperative team for the OR, the L&D department, and the surgicenter. Hospital administrators were aware of the problems and asked the vice president of nursing to clarify and resolve the problems. The vice president of nursing and the new OB/GYN department chair worked together on a thorough review of the problems. The goal was not to determine who was at fault but to devise the means and methods needed to ensure that procedures were performed smoothly, quickly, and efficiently while also eliminating physician and staff member complaints. The chair spoke with division directors, department physicians, and the OR nurse manager. In addition, the vice president and the chair held several brainstorming sessions in which they discussed budgetary constraints. The novel approach that evolved from these brainstorming sessions was to create a position for a concierge or facilitator whose role would be to optimize procedure performance for the OB/GYN department. This person would be responsible for solving problems in the OR, surgicenter, and L&D

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department. These three areas have separate organizational and administrative structures. The concierge, therefore, administratively would be part of the OB/GYN department, and costs would be shared by the departments of nursing and OB/GYN. The concierge would report directly to the OB/GYN department chair.

other units. Requiring that the new position be filled by an RNFA obviated any possibility of nurses leaving an OR, L&D, or surgicenter budgeted position to apply for the new position. In addition, the RNFA was credentialed and qualified to work in each area.

IMPLEMENTATION
An experienced RNFA A concierge or with an interest in gynecologic surgery and past facilitator role experience as an independent practitioner in was created to the hospital was recruited and introduced to the optimize departments physicians in her new role. She iniprocedure tially spent several days observing procedures in performance in the OR, L&D department, and surgicenter to identithe obstetrics fy departmental and process problems rather and gynecology than focusing on individual staff members. Addepartment and ditionally, she met with OR staff members and to solve supply processing department employees who problems in the cleaned and packaged gynecologic instrument OR, labor and trays. She reviewed her findings with the chair delivery and drew up a list of specific issues to address. department, and Several problems were identified immediately. surgicenter. For example, physician preference cards were not kept up to date, and previously created standardized instrument trays were either outdated or lacked so many additional instruments that they were useless. In particular, previous efforts to create a standardized laparoscopy tray that would serve both general surgeons and gynecologic surgeons resulted in a situation in which
AORN JOURNAL

THE RN FIRST ASSISTANT AS CONCIERGE

Most RN first assistants (RNFAs) possess unique skills they have developed during nursing school, their perioperative nursing experience, and additional specialized didactic and clinical education and by serving as first assistants.3 The experience of first assisting exposes an RNFA to hands-on contact with problems encountered during procedures, and previous perioperative nursing experience allows an RNFA to appreciate the hurt, disappointment, and frustration of perioperative team members trying to perform well but receiving unexpected requests and demands for which they are unprepared. An RNFA also is accustomed to being present in the OR suite and physically involved with procedures. This provides a level of management experience within the OR suite itself. This experience indicated that an RNFA would be an ideal choice for the new position. All staff members in the OR, L&D department, and surgicenter actively participated in staff member recruitment. The facilities vacancy rates of approximately 3% meant that no budget had been allocated to staff the new position. Partially budgeted dollars were allocated for the proposed RNFA position by the nursing department; this later was transferred into the OB/GYN department budget. This prevented the new position from being perceived as competition for nurse recruiting by

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neither specialtys needs were met. Often three or more full trays had to be opened to obtain all the needed equipment. This was due in part to evolving surgical skills or methods and to the addition of new physicians who requested different instruments. Hysteroscopic surgery had become more complex, and surgeons were performing new endometrial ablation procedures. Additionally, busy urogynecology and gynecologic oncology services had developed, which reThe RN first quired not only new instruments but also assistant met brought in new patient populations (eg, patients with each who are morbidly obese and who require different physician to surgical equipment and special positioning). Adreview and ditionally, research protocols were instituted that update required special handling of many oncology speciindividual mens. Finally, the OB/ preference cards GYN department had seen a remarkable growth and to identify in the number of patients with complicated obstetric problems, which reand highlight quired that surgical proeach surgeons cedures and C-sections be performed simultaneousspecific needs. ly in separate rooms and areas. This required more equipment than was available on standard obstetrical instrument trays and placed greater demands on scrub personnel and circulating nurses in the L&D department.

SYSTEM CHANGES
The RNFA met with each physician to review and update individual preference cards. She identified and highlighted surgeons specific needs (eg, latex-

free gloves, special separately wrapped instruments, extra-long instruments or equipment, vascular clips) by putting those items in bold typeface on the card. The RNFA created uniform laparoscopy towers with identical light sources, power supply, and rapid insufflation equipment. She also assembled a basic, gynecological laparoscopic instrument tray that included a high-volume irrigation system, multiple scissors and grasping tools, monopolar and bipolar attachments, and a videotape camera and light cord. She ensured that staff members from the supply processing department wrapped unique laparoscopic tools used by individual surgeons separately. She put three sizes of trocars (ie, 5 mm, 10 mm, 12 mm) in each tower to be opened as needed. Before patients were brought into the room, the RNFA helped the circulating nurse and scrub person test light cables and cameras and confirm that air tanks were full. The RNFA then created a basic hysteroscopy tray, as well as an endometrial ablation device tray. She purchased enough extra-long instruments and retractors to have two sets of instruments assembled to accommodate procedures performed on patients who are morbidly obese. Additionally, the RNFA created a modified hysterectomy tray and sent it to the supply processing department to be sterilized in red wrapping for the L&D department. She also ensured that vascular clips were stocked. The RNFA then provided inservice programs for all circulating nurses and assistants on the obstetrical service. Although these specific changes were important, the actual presence and input of the RNFA played a greater role in improving services provided. She reviewed all OR schedules in advance and identified potential problems or

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physicians with specific needs. This ensured availability of equipment, and any questions OR team members might have were addressed before the surgeons arrival. Furthermore, she was available physically during procedures to troubleshoot any problems that arose. After the procedure, she would review with the surgeon how the procedure had gone and what could have been improved. She scrubbed and assisted on many of the more difficult procedures to ensure they went well and to lend moral support to new scrub personnel. Almost immediately, surgeons began to include the RNFA in the scheduling process to ensure her presence during procedures they felt might be difficult. The RNFA continued to attend department meetings and meet with physicians to seek opportunities to provide better service. In addition, she remained in close contact with the department chair to ensure that issues related to the teaching program were addressed, develop new services, and welcome new physicians. She asked new physicians about any specific needs they might have related to OR equipment or procedures and was present during the first few procedures they performed to ensure a positive first impression. On several occasions, urgent or pressing procedures had to be added to the usual busy OR schedule. To facilitate this, the RNFA helped provide nursing support to staff members and thus minimized disruption of the OR schedule. Occasionally, equipment malfunctions would occur. When a rapid insufflator failed to deliver adequate gas volumes, the RNFA identified the problem, contacted the appropriate vendor, and quickly arranged for loaned equipment until the device could be repaired. When retractors were not being re-

assembled properly by supply processing department personnel, the RNFA met with the individuals involved to correct the problem and then monitored the next few procedures to ensure that the problem did not reoccur. The RNFAs support in the L&D department was particularly well received. Obstetrical team members were very proficient in caring for pregnant patients with complex medical problems. Pro- When equipment cedures such as cesarean malfunctions hysterectomy, bladder or ureter surgery, or ligation occurred, the RN of hypogastric arteries were uncommon, howevfirst assistant er, so L&D staff members were uncomfortable paridentified ticipating in these procedures. Consequently, the the problem, RNFA scrubbed in on several of these procecontacted the dures and was present in the room for other proceappropriate dures. The newly assembled red-wrapped instruvendor, and ment tray was used, with good surgeon and nurse quickly arranged acceptance.

OUTCOME

Within two to three months, it was apparent to physicians and OR staff members that their complaints were being taken seriously and addressed in a manner that focused on getting procedures done. There were fewer episodes of surgeons not having needed equipment, and laparoscopic procedures went more smoothly. The new L&D instruments meant that emergency cesarean hysterectomies and hypogastric artery ligation procedures progressed much more easily with

for loaner equipment until the device could be repaired.

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good outcomes. The RNFAs presence during these procedures improved staff member morale and confidence. During the next year, gynecology surgical volumes increased in both the OR and the surgicenter, and urogynecology and gynecologic oncology services grew remarkably, requiring that more physicians be added to the department. Surgical volume for the OB/GYN rose more Surgical volume department than 20%. Surgeons performing more rose more than began complex laparoscopic and hysteroscopic proce20%, and dures in the surgicenter, use of surgisurgeons began optimizing center staff members and up OR time for performing more freeing oncology and urogynecology. Additional phycomplex sicians were added to the and several laparoscopic and department, commented on how much they appreciated hysteroscopic the RNFA helping them procedures in the adjust to the hospital. The RNFAs relationship with OR and L&D surgicenter. staff members became one of a mentor. She used special competencies to encourage mutual learning and help develop self-confidence, respect, and commitment. This was successful because the RNFA provided positive support and demonstrated behavior worthy of imitation.4 Additionally, the RNFA had an excellent understanding of the departments equipment needs, which facilitated annual equipment budgeting. The RNFA also noted that equipment and draping supplies were wasted on minor gynecologic procedures because standardization of draping setups failed to differentiate clean from sterile procedures. For example, a vulvar biopsy

requires different equipment and draping than does a vulvectomy. This created potential budgetary savings and improved efficiency. Medical students rotate through the department at six-week intervals. Many of these students have not had previous surgical rotations and do not understand the most basic aspects of OR procedures and techniques. The RNFA volunteered to create a short educational session to teach proper scrubbing, gowning, and gloving techniques. This is followed by a review of commonly used instruments. The program has been a tremendous success and has helped medical students feel less intimidated by surgery. Their presence no longer is disruptive, and they seem to be more relaxed and able to focus on learning. Finally, because the RNFA was comfortable with preoperative patient preparation, she worked on ensuring that research consents were administered properly and that staff members adhered to departmental policy regarding administration of prophylactic antibiotics for all hysterectomy patients. In many respects, the concierge position heavily depended on the RNFA acting as a troubleshooter and problem solver because RNFAs often have these types of skills. In addition, the position required professionalism and sensitivity to others perceptions and identities. This prevented hostility and ensured that the RNFA was seen as a resource, not a threat or competitor.

CONCLUSION
The unique training and skill sets RNFAs have allow them to function well as OR concierges, facilitating optimal use of OR time and minimizing physician and staff member problems with equipment, changing technology and procedures, and the introduction of new services. This role provides an alternative to creating a specialty team,

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which may be cost prohibitive. In this model, the RNFA is a resource to the OR, the L&D department, and the surgicenter. She is able to function in all three arenas, so common problems can be solved with less effort and better information exchange. The RNFA also can help budget, save resources, and teach OR staff members and students. Additionally, the RNFA provides surgical assistance to surgeons when needed. Kathie Robbins, RN, CNOR, CRNFA, is an RNFA in the department of obstetrics and gynecology at Jersey Shore University Medical Center, Neptune, NJ.

William J. Mann, Jr, MD, MBA, FACOG, FACS, is chair of the department of obstetrics and gynecology at Jersey Shore University Medical Center, Neptune, NJ.

NOTES 1. R A Cooper, T E Getzen, The coming physician shortage, Health Affairs (Millwood) 21 (March/April 2002) 296-299. 2. B S Gregory Dawes, Building teams, synergy, and your resource, (Editorial) AORN Journal 72 (September 2000) 372. 3. T Homan, A Dunscombe, Marketing the RN first assistant role, AORN Journal 72 (August 2000) 234-240. 4. S L Allen, MentoringThe essential connection, (Presidents Message) AORN Journal 75 (March 2002) 440-444.

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Examination

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Examination
The RN first assistant as OR concierge
1. At the facility reported on in this Home Study, some of the ongoing problems reported by perioperative staff members included 1. inadequately oriented staff members. 2. incorrectly scheduled procedures. 3. inexperienced resident surgeons. 4. novel patient positioning requirements. 5. physicians requesting instruments that were not on their preference cards. 6. requests for a large range of instruments. a. 1, 3, and 6 b. 2, 4, and 5 c. 2, 4, 5, and 6 d. 1, 2, 3, 4, 5, and 6 2. Issues that began to develop simultaneously in the labor and delivery (L&D) suite at the facility reported on in this Home Study included 1. increasing complexity of patient conditions. 2. instrument tray deficits because the trays were not intended for more extensive procedures. 3. more complicated and extended surgical procedures being performed in the L&D department. 4. staff members unprepared for more complicated procedures, which usually were emergent and unscheduled. a. 1 and 3 b. 2 and 4 c. 1, 2, and 3 d. 1, 2, 3, and 4 3. Reimbursement and hospital resource allocation prevented creation of a team consisting only of gynecology staff members. a. true b. false 4. The concierges role was to optimize procedure performance for the OB/GYN department by a. developing separate teams for the OR, L&D, and surgicenter. b. reporting directly to the OR manager. c. resolving problems in the OR, surgicenter, and L&D department. 5. An OR concierge would benefit from the unique skills that many RN first assistants (RNFAs) possess, such as 1. financial and staffing experience. 2. hands-on contact when first assisting. 3. previous perioperative nursing experience that provides insight into team member frustration. 4. opportunities for management experience in the OR suite itself. a. 1 and 4 b. 2 and 3 c. 2, 3, and 4 d. 1, 2, 3, and 4 6. The RNFA initially spent several days observing procedures in the OR, L&D department, and surgicenter to identify problems with staff members. a. true b. false
AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Centers Commission on Accreditation. AORN recognizes these activities as continuing education for RNs. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity. AORN is providerapproved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure.

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Examination

7. After meeting with each physician, the RNFA instituted system changes that included 1. assembling a basic, gynecologic laparoscopic instrument tray. 2. creating uniform laparoscopy towers. 3. identifying and highlighting surgeons specific needs. 4. identifying new purchasing requirements that remain within budgetary constraints. 5. updating individual preference cards. a. 1, 3, and 4 b. 2, 4, and 5 c. 1, 2, 3, and 5 d. 1, 2, 3, 4, and 5 8. The presence and input of the RNFA played a greater role in improving services provided because she reviewed all OR schedules in advance and identified

potential problems or physicians with specific needs. a. true b. false 9. The RNFA scrubbed and assisted in all difficult procedures to help identify problems. a. true b. false 10. The RNFA continued to work with the department chair to 1. develop new services. 2. ensure that issues related to to the teaching program were addressed. 3. participate in personnel hiring and firing issues. 4. welcome new physicians. a. 1 and 2 b. 3 and 4 c. 1, 2, and 3 d. 1, 2, and 4

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Answer Sheet

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Answer Sheet

CH02

The RN first assistant as OR concierge

Event #04070 Session #8173 Contact hours: 1.9 Fee: Members $9.50 Nonmembers $19 Program offered July 2004 The deadline for this program is July 31, 2007 A score of 70% correct on the examination is required for credit.

lease fill out the application and answer form on this page and the evaluation form on the back of this page. Tear the page out of the Journal or make photocopies and mail to:

AORN Customer Service

c/o Home Study Program 2170 S Parker Rd, Suite 300 Denver, CO 80231-5711 or fax with credit card information to (303) 750-3212.
Additionally, please verify by signature that you have reviewed the objectives and read the article, or you will not receive credit.

Signature ________________________
1. Record your AORN member identification number in the appropriate section below. (See your member card.) 2. Completely darken the spaces that indicate your answers to examination questions one through 10. Use blue or black ink only. 3. Our accrediting body requires that we verify the amount of time you required to complete this 1.9 contact hour (95minute) program._________ 4. Enclose fee if information is mailed.

AORN (ID) # _______________________________ Name _____________________________________ Address ___________________________________ City_______________________________________ State __________ Zip ____________ Phone number______________________________ RN license #________________________________ State __________________________ Fee enclosed _______________________________ or bill the credit card indicated MC Visa American Express Discover Card # ____________________________________ Expiration date Signature _________________________________________________
(for credit card authorization)

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Learner Evaluation

Learner Evaluation
The RN first assistant as OR concierge
Objectives
To what extent were the following objectives of this Home Study Program achieved? 1. Explain problems encountered by the obstetrics and gynecology department at the facility described in this Home Study. 2. Discuss options that facility members considered to resolve these problems. 3. Identify methods used by the RN first assistant (RNFA) to solve these problems. 4. Describe skills that an RNFA may possess that would put him or her in an ideal position to act as OR concierge.
This evaluation is used to determine the extent to which this Home Study Program met your learning needs. Rate these items on a scale of 1 to 5. Purpose/Goal: To educate perioperative nurses about the role of the RN first assistant as OR concierge.

Content
5. Did this article increase your knowledge of the subject matter? 6. Was the content clear and organized? 7. Did this article facilitate learning? 8. Were your individual objectives met? 9. How well did the objectives relate to the overall purpose/goal?

Test Questions/Answers
10. Were they reflective of the content? 11. Were they easy to understand? 12. Did they address important points?

Learner Input
13. Will you be able to use the information from this Home Study in your work setting? a. yes b. no 14. I learned of this Home Study via a. the Journal I receive as an AORN member. b. a Journal I obtained elsewhere. c. the AORN web site.

d. SSM Online. 15. What factor most affects whether you take an AORN Journal Home Study? a. need for contact hours b. price c. subject matter relevant to current position d. number of contact hours offered What other topics would you like to see addressed in a future Home Study Program? Would you be interested or do you know someone who would be interested in writing an article on this topic? Topic(s): ___________________________ ___________________________________ Author names and addresses: ________ ___________________________________ ___________________________________

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