Routine identification and preparation of the surgical site
Description of the procedure
Identification and preparation of the site for surgery is normally carried out as follows:
- The preoperative nurse (surgical floor) makes a confirmation of the name and the identification number of the patient.
- The operative permit is then confirmed.
- “Surgical preparations of the skin commences by marking the surgical site with a skin marker” (Kouzes & Barry, 2006, p.9).
- Shaving of the surgical site is done especially if the skin is hairy.
- All the above steps are done in the holding area outside the operation room.
- The patient is then moved to the holding area of the operation room for nursing preoperative assessment and verification of ID, operative permit and documentation.
- Finally, the patient is taken for nursing intra-operative inside the operation room for final verification of ID, operation permit and the planned procedure for the surgery.
The change needed
I think that the above process of identification and preparation of the surgical site needs change because of the following reasons:
There is less information on how the surgical site should be identified, marked and verified from the first holding area until the surgery commences. The procedure has ignored verification of the surgical site from one nurse to the next and instead concentrated on verification of the operation permit and the ID (Blunt, 2007).
“The above procedure poses high risk for wrong site surgical errors since the patient is not involved in the process to enhance the reliability of the said identification” (Annick, 2010, p.106). This creates space for alterations by the medical practitioners. As the patient moves within the health care facilities, the consistency of the marked area may drastically change from one physician to the next.
The above procedure also needs to shade more light on the necessity, how to clean and shave the identified surgery site. This will help to reduce chances of infection and other associated complications.
Response from the hospital personnel
The basis for this practice was determined by a hospital committee comprising of various surgeons from the surgery department of the hospital. “The committee was chaired by the head of surgery department” (Renee, 2009, p.23).
Rationale for coming up with the procedure (by the committee) was as follows:
Marking, cleaning and shaving the identified site of surgery is a simple task that does not require any professional skills. There is no need for detailed procedures on how to mark, clean and shave identified surgical sites. The committee made an assumption that the person involved will apply common sense and do a credible job (Renee, 2009).
This practice is performed in this manner (in the hospital) because of the following reasons:
- There have been no complaints raised over the procedure.
- No research done on the hazards implicated in the modus operandi.
- No complaints on infections and misallocations of surgery sites.
All the above reasons have greatly contributed to continued use of the procedure with no clear reasons for change.
Literature review
APA formatted reference list:
- Annick, J. (2010). How to coordinate and perform theatre routines. Journal of medical nursing, 27(3), 101-115.
- Blunt, R. (2007). Surgical site infection: The host factor. AORN journal, 86(5), 801-814.
- Kouzes, J., & Barry, Z. (2006). Guidelines: Preoperative procedures for carrying out surgery. Nursing journal, 1(3), 1-11.
- Rank, J. (2011). Surgery today: Preoperative procedures. Web.
- Renee, A. (2009). Surgery operations: Preoperative procedures. Stansbury: University of Oregon.
Clinical implications of identification and preparation of the surgical site
Under this practice, several clinical implications may be realized. Lack of detailed information on cleaning and shaving of the identified sites of the patient to undergo the surgery may lead to serious infections. This is because some individuals involved in the cleaning and shaving process may not be able to exactly determine whether the skin area is supposed to be shaved or not. Incase the personnel decides to shave a skin area that has no substantial hair, the shaving may cause tiny cuts (by the razor) which may raise the possibility of infection. Serious infections are also likely to be caused due to carelessness during shaving. This is because of high possibility of hair fragments falling beneath the skin or near surgical incision (Kouzes & Barry, 2006).
Lack of involvement of the patient in the marking and verification of the marked site of surgery may lead to misallocation of the site. This may result due to varying interests of the medical practitioners who may decide to alter the marking for unknown reasons. Since the practice does not involve the patient, it is difficult to notice minor alterations on the site of surgery during verification. The patient appears to be the most appropriate party to verify the marked surgical site on his/her body from one medical practitioner to the next. Otherwise, the surgery may be carried out on a wrong site (Renee, 2009).
Procedural changes on the practice
Detailed information should be included in the cleaning and shaving stage of the process. The procedure for cleaning and shaving should give the following details:
The identified and marked surgery site should be cleaned aseptically using warm water, soap and appropriate disinfectants. This area should undergo further scrubbing in the operation room to enhance protection from any infections. Shaving should only be done when the surgery site contains substantial presence of hair to avoid unnecessary cuts that may cause infection. When shaving, the practitioners need to be more careful not to allow hair fragments to fall beneath the skin or move close to the surgical incision to prevent serious infections that may result after the surgery. All this information need to be included on the procedure for identification and preparation of the surgical site. The information will directly guide the medical practitioners on how to exactly carry out the cleaning and shaving process with minimal risk of infection.
The existing procedure for marking and verification of the surgical site should be changed by insisting on verification of the surgery site. The verification process must involve the patient who is less likely to allow alterations from the initial identification made. The patient will also enhance the reliability of the said identification (Schuster, 2008).
After initial identification of the surgical site, no patient should be allowed to leave the holding area of the operation room before the site is clearly marked by the surgeon, including the surgeon’s initials, on or at the anatomical site of the proposed intervention. The marking should only be done with surgical skin marker. Wrong side of the identified site may also be marked with a universal “no” sign at the surgeon’s direction. Correct side or site can be marked with the surgeon’s initials. If dressings/casts cover the site, or if there is an open wound at the site, the covering can be marked in the same fashion. If different procedures are planned for different sites during the same surgery, the appropriate site may be marked “yes” and a short abbreviation also marked on each location. To identify a digit, a dot or star should be used (Rank, 2011, p. 3).
Involvement of key stakeholders in the procedural change
In order to implement the above procedural changes, the key stakeholders of the hospital (especially those from the surgery department) need to be involved. I can involve the key stakeholders in changing the existing modus operandi and abide by the planned change in the following manner:
There is need to conclusively engage the key stakeholders in the process of identification of the two sides of the proposed change. The first side involves the benefits that are likely to be realized after adoption of the proposed change. The second side involves the limitations associated with the proposed change. After elaboration, the stake holders will be able to carry out a cost benefit analysis from an informed basis and make a verdict to transform the existing procedure as well as abide by the anticipated change (Schuster, 2008). This is because the benefits associated with the above proposed changes on the existing practice seem to overshadow or prevail over the limitations.
I will also point out and justify the risks of infection as well as misallocation of the surgery site associated with the existing procedure for the practice. This will make them realize the need to get involved in the alteration of the existing procedure. Convincing key stakeholders to accept and participate in implementation of the change process for the existing procedures for the practice will motivate other members of the hospital to also accept the changes and comply with the new procedures (Schuster, 2008).
Translation of research
The following difficulties may be encountered in translating the above changes into practice:
First, there is a likelihood of difficulties in summarizing the findings of the research (appropriate procedure for identification and preparation of the surgical site). Research reveals a lengthy process which may prove difficult and time consuming when all the contents are strictly followed. For instance, it will be difficult to synthesize this lengthy procedure into practice especially for emergency surgical incidents (Schuster, 2008).
Another difficulty is on the complexity of the proposed changes. Such complexities include accurate marking of the surgical site and determination of whether a surgical site needs shaving or not. The procedure for labeling the wanted and unwanted sides of the surgical site as explained above also seems to be complex. Therefore, making these processes simple and easy to understand may appear to be difficult in the translation of research (Rank, 2011).
Barriers to change
There are several possible obstructions that may come upon in attempt to introduce the above procedural changes. First, there is likelihood of resistance from the management and other members of the staff. Resistance from members may drastically slow down the process of instituting the necessary changes due to withdrawal or lack of commitment. For any change to be effective, it needs to be supported by most of the team members (Schuster, 2008). Elevated levels of resistance to the proposed change may lead to its failure. Resistance is likely to appear since the proposed changes are complex and time consuming. The medical practitioners who are fond of short procedures will find it difficult to accept the proposed detailed processes for identification and preparation of the surgical sites. Resistance may also be intentional as a result of hatred or unhealthy competition. Another barrier may result due to inadequate availability of resources. In order to practically synthesize the research findings into practical guidelines and procedures, there is need for enough resources. Proposed detailed procedures may call for more input of resources (additional resources) which may not be readily available. This will derail the process of adoption of the proposed changes (Rank, 2011).
The culture and traditions of the hospital may also be another barrier. “Culture and traditions make members get used to certain ways of doing things” (Schuster, 2008, p.76). It then becomes cumbersome to make such members change from the cultural and traditional way of doing their things. For instance, most of the medical practitioners are already used to the existing procedures for identification and preparation of the patients’ surgical sites. It may be difficult to convince such members and make them accept the new changes. This seems to be a barrier in instituting new proposed changes.
Strategies to overcome the barriers to change
My team can apply the following strategies to overcome the above barriers to the proposed changes:
Resistance can be minimized by proper creation of awareness on benefits associated with the proposed changes among the members. Once most of the members realize the potential benefits associated with the changes, they are likely to offer no resistance. Team members should also make good relations to earn a good reputation so that they can be trusted by the rest of the members. Team members should also avoid unnecessary collision with other members to minimize intentional resistance (Schuster, 2008).
The team members should mobilize enough resources to enable implementation of the proposed changes on identification and preparation of the patients’ surgical sites. They can do this by approaching the management and finance committee to convince them and make them approve the necessary resources for the proposed changes.
For the culture and traditions, the team members may simplify and make the changes to appear less complex so that the members can readily accept them. The team members can also introduce the changes gradually if the members are strictly attached to the existing procedures of identification and preparation of the patients’ surgical sites (Schuster, 2008).
Application of findings
Considering the findings on the importance of verification of the surgical sites and involvement of the patients in the process; the implementation process can be achieved through drafting verification forms that will ensure that the patients’ surgical sites are verified by every practitioner with confirmation from the patient. All medical practitioners involved in the surgery process have to undergo training to become familiar with the proposed changes. After training, they will be able to guide others on the implementation of the improvements to the existing procedure. All members should be made to believe in continual improvement. This will make it easy to implement procedural changes that are in form of improvements to the existing processes (Renee, 2009).
References
Annick, J. (2010). How to coordinate and perform theatre routines. Journal of medical nursing, 27(3), 101-115.
Blunt, R. (2007). Surgical site infection: The host factor. AORN journal, 86(5), 801-814.
Kouzes, J., & Barry, Z. (2006). Guidelines: Preoperative procedures for carrying out surgery. Nursing journal, 1(3), 1-11.
Rank, J. (2011). Surgery today: Preoperative procedures. Web.
Renee, A. (2009). Surgery operations: Preoperative procedures. Stansbury: University of Oregon.
Schuster, S. (2008). Surgical floor: Improving preoperative surgical procedures. Medical Journal, 2(11), 69-78.