From the slopes to surgery: tiered scrub orientation underway at UCH

December 2nd, 2015

Think about hospital operating rooms, and images of surgeries and scrubbing probably spring immediately to mind. Skiing and slaloms? Not so much. But OR procedures and ski slopes have at least one important thing in common: degree of difficulty.

That concept underlies a pilot now underway in the inpatient ORs at UCHealth Metro Denver (University of Colorado Hospital). The idea is to assign cases to scrub tech and scrub nurse orientees that match their skill levels and experience and help them prepare for progressively challenging procedures.

Cases are designated in a way familiar to those who take to the ski slopes: green for beginners, blue for those in the intermediate stages, and black for experts. All orientees begin with “green” procedures. These cases require appropriate gowning, awareness of sharps safety, assembling retractors and instruments, and maintaining a sterile field.

At the blue level, the orientee sets the case up independently, handles the instrumentation, and understands the appropriate pace of the surgery. For black cases, the orientee demonstrates an understanding of specialty equipment, plans for anticipated surgical outcomes, and offers suggestions that might improve case efficiency and outcomes.

An individual can progress from green to blue by meeting evaluation requirements for specific skills on three cases from his or her service line leader, preceptors, and surgeons. The same applies to orientees who want to move from blue to black cases and for those seeking to work on black cases.

The plan currently is aimed at cases in general surgery, gynecologic and surgical oncology, plastics, and burn.

Entering the green zone

The pilot idea was initiated by Shandra Wilson, MD, associate professor of urologic surgery at the University of Colorado School of Medicine and medical director for the Urologic Oncology Clinic at UCH.

“We’ve all been in situations where the experience of the orientee doesn’t match the case,” Wilson said.

To measure the potential short-term benefits of the approach, Wilson administered a survey to orientees that asked them to rate the appropriateness of their assignments for their skill level and their comfort in handling cases they had been assigned. Surgeons were asked to assess how appropriately orientees were matched to cases and whether or not they had ever asked a scrub orientee to step aside because they were concerned about his or her skill level. Wilson said she plans to resurvey and evaluate the results.

“I want to see movement,” she said.

At the very least, the skills checklist and evaluation process increase the likelihood that orientees have the basic skills in place to handle a variety of surgical procedures, Wilson said. That, in turn, could have longer-term benefits, such as improving patient safety, avoiding unnecessary delays, minimizing blood loss, and managing costs, she added.

The most important pay-off of the initiative, will be developing cohesive teams that protect patients, said Richard Schulick, MD, chair of the Department of Surgery at UCH.

Surgical technologist Stephanie Azeltine (right) and orientee Kozmo Flores, RN, scrub for a reconstructive urologic procedure, which is a “green” case.

Orientees at the green level aren’t excluded from blue or black cases, said Sara Rushman, RN, CNOR, clinical nurse educator for the inpatient OR. If the schedule demands it, they can start a case at either of those levels and continue it until a retractor is placed and the surgery itself starts. Preceptors are always in contact with orientees, Rushman added, and will step in if the procedure demands it.

“We are trying to avoid putting the orientee in a difficult situation,” Rushman said.

That’s a sometimes overlooked consideration, Schulick added. “We often look at cases from the surgeon’s perspective,” he said “For difficult cases, we want the scrub with the greatest experience. But from the scrub’s perspective, he or she doesn’t want a case where things don’t smoothly.”

Training trials

Blue caseIndeed, as straightforward as the approach sounds, it’s been challenging to implement, said Jenny Ward, RN, CNOR, genitourinary/gynecology service line specialist for the inpatient OR. For one thing, as the lone academic medical center in the Rocky Mountain region, UCH might not get a large number of green cases on any given day. That means that even orientees at the beginning of their six-month orientation may have to spend a fair amount of time working more complex cases. They therefore don’t move smoothly and predictably from one level to the next, Ward said.

“We might not have many green cases, but the orientees still need education,” Ward said.

It’s also difficult to match cases and orientees perfectly on a staff with a combined total of 135 scrub techs and scrub nurses working with orientees who constantly rotate through different services, Ward said. That makes it a challenge for charge nurses to know the progress of each orientee and assign cases on the basis of their skill level.

To address that, Wilson created a binder with information about each orientee’s demonstrated skills that charge nurses can use as a reference to make assignments.

But the environment of a teaching hospital can turn the categories of green, blue, and black to shades of gray, Ward said. The pilot calls for “green” orientees to stop at the point of placing retractors, but not all learners progress at the same rate, she pointed out.

Shandra Wilson, MDLuda Zeldin, surgical technologist (near right) and orientee, Kelsey Nida, RN, scrubbing for a robotic prostatectomy, a “blue” case.

“What about the one who is doing well?” Ward asked. “Why not let her keep going? In practice, we’re finding that there is a lot more of a gray zone. Sometimes I let them go.” The engaged preceptor, Ward said, will know when to make that call.

The pilot aims to make orientees happier with their work experience by sparing them from uncomfortable situations, Rushman added, but others might chafe at missed opportunities to work on the most challenging cases.

“They all need to learn, but how do you learn if you aren’t given the opportunity to do those harder cases?” she asked.

Even acknowledging these nuances, however, the rapid growth of UCH’s surgical service, which has added six new inpatient ORs since 2013, together with the volume of complex cases, demands a tiered system, Rushman said. Surgeons performing cases with large amounts of expected blood loss or tumors with vascular involvement, for example, “need someone who can stay on top of it,” she said.

“We’ve acknowledged that there is sometimes a mismatch between cases,” Schulick added. “We anticipate some things and not others, which is a natural consequence of our growth.” It takes time, he noted, to assess and understand the skills a new staff member possesses.

Urologic surgeon Shandra Wilson, MD, spearheaded the scrub orientation initiative at UCH.

A tiered system, however imperfect, is also important if the hospital is to hold onto staff, said Ward, who acknowledged that retention in the OR has been a challenging issue.

“We are finding ways to get our people to stay here,” she said. “We’re trying to take into account orientees’ skill levels so they feel better prepared for surgeries and have more confidence in the skills they are using.”