Unmasking the OR
Just shy of 7 a.m. the surgical tower at Southeast Alabama Medical Center is a flurry of activity.
More than 100 staff nurses, technicians and other support staff don sterile scrubs, their daily uniform for work in the Perioperative Department. Mentally, they are focused and prepared for a busy day of assisting 23 highly-skilled surgeons who will occupy one or more of SAMC's 23 operating rooms.
As it turns out, this day will be another record day in surgery. Volume is up more than 50 percent over a typical day.
"We've worked to allow our physicians to schedule more early cases, which has increased our volume," said Chris Holland, RN, CNOR, RNFA, manager of surgery. "We've watched the schedule fill up for several days. We are at capacity." As a footnote, Holland said 60 to 75 percent of all surgeries are elective.
The surgeons operating on this particularly busy May morning represent all kinds of specialties, from orthopedic to heart, urology to brain. Time spent in surgery might be 10 minutes or it might be 10 hours, depending on the procedure and the complexity of the case.
They are operating in a Joint Commission accredited facility, guaranteeing the highest standard of care is provided and rigorous protocols are followed for patient safety.
On this day, patients ages 2 to 82 enter the hospital from Outpatient Registration and are escorted to Same-Day Surgery where they are prepared or "prepped" for a surgical procedure.
Part of the prepping for surgery includes receiving sedation if they are a little bit anxious, and an IV may be started. The patient's condition is assessed, history is reviewed, the surgery site is marked and everything readied for the operation.
At this point, family members are escorted to the waiting area where they can view a monitor that keeps them informed of every stage of the operation. Telephone calls from physicians and nursing staff are patched through to family members anxiously awaiting word.
"Everything is fine," the surgeon says. Spouses and parents smile and thank the doctor.
Surgical procedures begin between 7:15 and 7:30 a.m. each day. Scheduling is important as operating rooms must be cleaned and disinfected after each procedure and stocked with the proper instruments for the next procedure. Staff is shifted from one room to the next, as are physicians.
Andrew Bullington, MD, of Southern Bone & Joint goes from an ACL knee repair in operating room 14 to a broken clavicle in 13. Another team awaits 14.
Like all their coworkers behind the O.R. doors, schedule coordinators Patsy McGowan and Janie Williamson are awash in blue. Surgery is a blue world with high beam concentrated lights that appear blue and blue drapes for sterilized instruments and high-tech equipment. Some supplies are packaged in blue. Even the rooms are blue.
Just outside the 18 primary operating rooms, McGowan and Williamson, both registered nurses and long-time employees, maintain multiple patient tracking boards. Like air traffic controllers, they follow patients, assign operating rooms, help physicians and coordinate staff and anesthesiologists.
Atop these boards, located in a high-traffic corridor, is a video feed of every operating room. This allows staff to know where everyone is and to see what everyone is doing.
There is constant movement.
"The schedulers keep the flow going," Holland said.
Schedulers are in their zone.
"It looks like Dr. (O.H. 'Skip') Chitwood (of Southern Bone & Joint) is finishing up in 12," says McGowan.
Another nurse walks by and alters the board. "We're done in four," she says.
A surgery tech makes her way into seven, where she thoroughly cleans, disinfects and sterilizes all equipment. It is a key element to patient safety. Trays containing up to 50 instruments are removed for decontamination and sterilization.
Telephones ring. One patient is late arriving. Two more cases are added to the schedule after physicians' morning rounds revealed surgery is needed.
Two, no three, surgeries come in from the Emergency Department.
One is an aneurism; a craniotomy is needed. A busy day just got busier.
"I've got to find a room for Dr. (Praful) Patel (of Women's Medical Center)," Williamson says.
McGowan nods. "We don't want a surgeon to have to wait," she explains. "And we hate for a patient to have to wait. They're all our customers."
Robert Schuyler, MD, of Urological Associates of Dothan walks through, headed to O.R. number eight for a robotics prostatectomy.
Inside Operating Room 14, Dr. Bullington is back with another knee.
Prior to beginning any surgery, certain protocols are followed. As music plays on an Ipad, PA Kent Odom, scrub techs and anesthetists gather inside a black circle painted on the floor, designating a completely sterile area. An RN circulator mans a monitor just outside this area.
The patient has already been "marked" in receiving. A physician or a designated team member identifies the surgical area and the physician signs it. Once in the O.R., staff has a "time out" where the same information is reviewed with the patient.
Anesthesia works in tandem with the O.R. team. A surgical check list is reviewed after Bullington arrives. A risk assessment is taken, allergies and medications reviewed, and soon the procedure is underway.
All but two operating rooms are in use. Holland said two rooms typically are kept empty for either an emergency C-Section or heart procedure. Three C-Section rooms are located in the Family Birth Center and two endovascular suites are adjacent to the primary O.R. These designated suites are convertible for various procedures required for complex heart cases.
If schedulers are air traffic controllers, Holland sees his job as more like a floater. He has worked behind the O.R. doors for 11 years, handles the day-to-day operations and oversees a staff of more than 100.
"I make contact with surgeons and see to their needs. If there is a decision to be made about who gets a room or what comes next, I make it," Holland said. "Sometimes it comes down to who's ready and who has the most cases."
Perioperative Services at SAMC consists of Surgery, Same-Day Surgery, Pre-Surgical Testing and the Post Anesthesia Care Unit (PACU).
"Periop has many moving, complex parts," Holland said as he makes his way down the sterile corridor where supplies are kept. "All the parts work together and they complement each other."
After surgery, 95 percent of patients go to PACU for recovery. Heart patients go to the Critical Care Unit on the fourth floor and C-Section mothers go to a room in the Family Birth Center.
Patients having less invasive procedures go to Same-Day Surgery holding for an assessment and vital signs monitoring; they are usually sent home within an hour after the procedure. For those patients being admitted, they advance from PACU and go straight to a bed on the specialized nursing floor.
Hours pass with a constant flow of O.R. patients. The surgical load dwindles as the day wears on. Team members see light at the end of the tunnel, knowing they will be back the next morning, just after sunrise, to do it all again.
"Caring for patients, knowing that we are helping somebody – that's why we're here," Holland said. "Helping our surgeons take care of our patients is an awesome responsibility and a privilege. We aim to please."
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More than 100 board-certified physicians in various
specialties utilize the 23 operating rooms at SAMC.
Types of surgery performed:
• Ear, Nose & Throat • General* • OBGYN
• Orthopedic • Neurosurgery • Eye
• Cardiology • Vascular • Plastic
* General surgery includes gall bladder, thyroid, abdomen and colon.