Operating Room Assessment Exam Analysis Web view01.10.2012 · The operating room...

Running head: OPERATING ROOM ASSESSMENT EXAM ANALYSIS 1

Operating Room Assessment Exam Analysis

Marialena Murphy

Grand Canyon University: NUR 665E

October 01, 2012

OPERATING ROOM ASSESSMENT EXAM ANALYSIS 2

Operating Room Assessment Exam Analysis

Assessing the learning outcomes of team members caring for patients in the operating

room(OR) presents some challenges. Often, new team members are added and receive preceptor

training and review but a formal examination of the learner’s understanding is not routinely

assessed. Knowledge provides an important base for the decisions and critical thinking skills

needed to ensure safety for patients during surgery. Many of the skills needed to be clinically

competent and to provide a safe patient environment reside in the cognitive and psychomotor

domain, but it is also important for team members to have skills and abilities in the affective

domain. The OR is a high stress environment that requires all team members to function as a

practiced unit (AHRQ, 2010). Team work, with all team members functioning with the same

basic understanding of safety standards, is an important objective to maintain in the operating

room.

At Scottsdale Healthcare a situation was identified where newly credentialed physician

assistants and nurse practitioners to our hospital system were arriving to work in our operating

rooms without a comprehensive understanding of the basic safety practices that are in use. This

situation can disrupt the team and present potential safety concerns. The purpose of this exam is

to provide a criterion-referenced evaluation tool which will assess the understanding of primary

safety practices in the operating room of newly credentialed team members. In addition this has

the potential to provide a basis of evaluation of newly hired staff members in the operating room

department and to measure ongoing staff competency. The operating room assessment exam

was developed and will be evaluated for validity and reliability. The exam, if proven to be valid

and reliable, would be a helpful evaluation tool for leaders and educators in the perioperative

specialty area.


Planning and Development

The planning and development of this exam was focused on the assessment of basic

safety practices that are fundamental to optimal team dynamics in the operating room and

maintaining patient safety. The primary safety concerns in the operating room were identified

using a variety of resources including personal experience, professional standards (AORN, 2012)

and sentinel event report statistics (The Joint Commission, 2012). The areas of focus and the

percentage of each content outcome in the operating room assessment exam included:

Prevention of Infection –28%

Surgical Site Marking – 4%

Count Safety – 20%%

Sharp Safety – 4%

Professional Conduct –4%

Patient Positioning -4%

Fire Safety -4%

Equipment Safety- 20%

Red Rules -4%

Specimen Handling – 4%

Medication Safety – 4%

Total – 100%

Since the purpose of this assessment is to focus on basic understanding and assessment of

operating room safety and team procedures, the first four cognitive levels of Bloom’s Taxomony

were utilized in the development of the multiple choice examination. These domains include

knowledge, comprehension, application, and analysis of key safety concepts. The knowledge


domain encompasses factual and procedural concepts (Billings & Halstead, 2009). The learner’s

ability to describe or explain resides with the comprehension domain while application focuses

on the learner’s ability to demonstrate or apply concepts (Billings & Halstead, 2009). The

cognitive level of analysis contains the learner’s ability to compare or differentiate concepts

(Billings & Halstead, 2009). The questions were developed to provide a balanced assessment of

the cognitive levels of the learner with 32% knowledge, 16% comprehension, 28% application,

and 24% analysis in the multiple choice question content. The table below of Cognitive Levels of

Bloom’s Taxonomy by Question details the classification and provides an outline of the

cognitive and content evaluation of the examination.

Cognitive Levels by Bloom’s Taxonomy by Question

ContentOutcomes

Knowledge Comprehension Application Analysis Totals

Prevention of Infection

3, 6 11 4, 5, 8 1, 16 7

Surgical Site Marking

2 1

Count Safety 9, 13 7, 15 5

Sharp Safety 10 1

Professional Conduct

1 1

Patient Positioning

14 1

Fire Safety 17 1

Equipment Safety

24 18, 21 19, 22 5

Red Rules 20 1

Specimen Handling

23

Medication Safety

25 1


Totals 8 4 7 6 25

(Billings & Halstead, 2009, p. 430)

Percentage of Each Cognitive Domain In the Operating Room Assessment Exam

Knowledge 32%

Comprehension 16%

Application 28%

Analysis 24%

Total 100%

Evaluation

Reliability is an important factor to consider in the development and administration of an

examination to evaluate a learner. For a test to be considered reliable, it must be dependable in

its ability to provide consistent scores (Billings & Halstead, 2009). For the purposes of

evaluation of the reliability of this examination, the identical 25 question multiple choice

question test was administered to a cohort of 10 operating room nurses with 10 or more years of

experience at Scottsdale Healthcare with a raw score of 85% and a mean and median of 94%.

Validity is considered whether the test is actually measuring the information that it was intended

to measure (Billings & Halstead, 2009).

4

3

2

1

88 92 96 100


Raw score

Number of Students 10Number of Items 100Maximum Point Value 100Highest Score 100Lowest Score 88Median 94Mean 94

Standard Deviation 1.02Test Reliability 0.94Standard Error of Measurement 0.96

The analysis of the scores for this test revealed high test reliability, 0.94, and low

standard deviation, 1.02, which would be expected when administering a basic operating safety

assessment tool to seasoned operating room nurses. This population of nurses also provided

feedback along with their answers to clarify and improve the test for the novice team member

coming into the perioperative arena. An analysis of the item difficulty in the table below,

revealed high scores for most items with the exception of question four. The difficulty for

experienced nurses answering this question correctly may reveal an issue with the question itself,

or could be pointing to an educational need in the department since half of the nurse chose the

same incorrect response.

Item Difficulty Analysis

QuestionItem

Difficulty level based

on answered correctly(P value)

1 12 13 .9


4 .55 16 17 18 19 110 .911 112 113 114 .915 116 117 118 119 120 .721 122 .823 .924 .9 25 1

Conclusion

The operating room assessment exam analysis revealed that the test is both reliable and

valid. This exam will be piloted as a tool for the appraisal of new physician assistants and nurse

practitioners to the operating room to assess their basic knowledge of safety practices. After

further evaluation with newly credentialed team members, this tool can be used to evaluate

ongoing knowledge and competency for staff nurses as well as an assessment for nurses

orienting to the department.


References

AHRQ Research Activities (2010) Simulation training in the operating room improves

competency for the entire operating room team. (355), 3.

AORN (2012). Recommended practices for surgical attire. Perioperative standards and

recommended practices, Denver: AORN.

Billings, D. M., & Halstead, J. A. (2009). Teaching in nursing: A guide for faculty (3rd ed.). St.

Louis, MO: Saunders Elsevier.

Scottsdale Healthcare Policies and Procedures (2012). http://indidge/idtracksdocs/dwnchk.aspx?

reg=Perioperative&fac=OR&dep=&fn=OR1014.$

$2.doc&dloc=Documents&docTypeRequest=PDF&uid=Guest

Scottsdale Healthcare Perioperative Services Department Operating Policies (2012).

http://intranet/template_departments.cfm?

content=content_department&department_id=34

The Joint Commission (2012). Sentinel event. Sentinel event data summary, Retrieved from

http://www.jointcommission.org/assets/1/18/Summary_1Q_20121.PDF


Operating Room Assessment Exam

NUR 655 E: Nursing Education Practicum:

Instructions: As part of my practicum requirements for NUR655E, this Operating Room Assessment Exam has been created. Please complete the following. Results will be analyzed and completed anonymously. The plan is to use this as the base for an assessment course for newly credentialed Physician Assistants and Nurse Practitioners to assess basic knowledge prior to orientation to the operating room environment at SHC. Thank you for participating in this project!

Please circle the correct answer for each question.

1. Catheter Associated Urinary Tract Infections (CAUTI) comprise more than one-third of the total number of healthcare-acquired infections. What is the most important thing that can be done in the OR to prevent CAUTI’s?

a. administer a prophylactic antibiotic for patients receiving a catheterb. use strict aseptic technique when inserting a catheterc. write the date of catheter insertion on the foley bagd. use a silver coated urinary catheter

2. Preoperative verification and confirmation of correct patient, procedure, and site should be completed and documented in a collaborative manner by the surgical team members prior to the start of every invasive procedure. All patients having an invasive procedure that involves laterality, multiple structures, (e.g., fingers and toes) or multiple levels (e.g. spinal surgery) must have their site marked. Who is the appropriate person(s) to mark a surgical site?

a. Any team member assigned to the patient’s surgical caseb. Any physician that is caring for the patient c. The surgeon or the pre-op nursed. The surgeon

3. All individuals who enter the semi restricted and restricted areas of the surgical suite should wear surgical attire intended for use only within the surgical suite and no personal clothing can be visible. Facility approved and laundered or disposable surgical attire should be donned in a designated dressing area before entry into the semi-restricted and restricted areas. What areas are included in the semi- restricted and restricted area in the surgical department?

a. the OR’s onlyb. the OR’s and sterile corec. the OR’s, sterile core, and OR hallways d. all of the surgical services department, including pre-op and post anesthesia care unit

4. When a discrepancy in the surgical count(s) is identified at the end of a case, (whether it is more or less than the count sheet indicates) the surgical team is responsible for carrying out steps to locate the missing item, and informing and receiving an acknowledgment from the surgeon as soon as a discrepancy in a surgical count is identified. If the discrepancy is not resolved what is the definitive step that must be taken to ensure no items were retained in the patient?

a. Complete an event reportb. Call the risk management officer


c. Perform an intraoperative x-ray before the final closure of the woundd. Perform an intraoperative x-ray before the patient leaves the OR

5. Changing contaminated, soiled, or wet attire reduces the potential for cross-infection and protects personnel from prolonged exposure to potentially harmful bacteria. How often should you change and exchange your surgical scrubs for fresh clean scrubs?

a. At least daily or as needed throughout the day b. Every other day or when soiledc. Weekly if they have not been contaminatedd. Only when soiled

6. Hair acts as a filter when it is uncovered and collects bacteria in proportion to its length, waviness, and oiliness. Personnel should cover all head and facial hair, including sideburns and necklines, when in the semi restricted and restricted areas of the surgical suite. What is the best way to confine all hair and reduce infection risk for patients?

a. A ponytail and a hairnetb. A bandanna, kerchief or reusable cloth hatc. A clean, disposable surgical head cover or hood that confines all hair d. Keeping hair cut as short as possible and removing all visible hair from face and body

7. A 10-0 needle popped off the suture during the case, and the team was not able to locate the needle; as a result, you have a discrepant count at the end of this patient’s surgical case. According to the SHC policy/procedure, what is the best action to take?

a. No action is needed; a 10-0 needle is too small to be seen on x-rayb. Call the risk management department immediatelyc. Inform the manager so that a performance improvement plan can be implementedd. Perform an x-ray. Needle size is not one of the exceptions listed in the policy/procedure

8. You are assisting in the draping of a surgical procedure and one of the team members tells you that your sterile glove touched the unsterile OR bed and is now contaminated. You are confident that your glove did not touch the bed because you didn’t feel anything. What is the most appropriate response to your team member?

a. Inform them that they are mistaken and continue drapingb. Thank them for their concern and assure them that you did not touch the bed, and

continue drapingc. Speak directly to the surgeon and give assurance that you did not touch the bed, and

continue drapingd. Thank them for their concern, change your glove and then continue draping

9. When performing sponge, instruments and sharps counts during a surgical case, what is the proper sequence for the count to occur?

a. sterile field, mayo stand, back table, off-fieldb. off-field, back table, mayo stand, sterile fieldc. mayo stand, sterile field, back table, off-fieldd. sterile field, back table, mayo stand, off-field

10. Use a hands-free technique whenever possible and practical instead of a hand-to-hand passing of sharp items between the surgeon and the scrubbed person. This involves creating a "neutral"


zone by the surgical/procedural team, which is an area or container where a sharp item is placed by the scrub/surgeon to be picked up by the scrub/surgeon eliminating passing hand-to-hand. What is the best location for the “neutral” zone?

a. The mayo standb. On the operative field below to the incision sitec. In a convenient location for both the surgeon and the scrubbed person that does not

interfere with draping or access to the operative sited. On the operative field above the incision site

11. AORN recommends that the application of the skin antiseptic should be applied from the incision site to the periphery. What is the rationale for this recommendation?

a. Studies have shown that less skin antiseptic is needed when using this techniqueb. Using this technique with skin antiseptic prevents introducing microorganisms from the

periphery to the surgical sitec. This technique allows the skin antiseptic solution at the incision site to begin drying firstd. This technique helps to prevent wrong site surgeries

12. Working as a team to provide the best possible care for our patients requires strong professional and congenial relationships and has been shown to increase patient safety. In order to foster relationship growth we each have a personal responsibility to approach and address situations that are questionable or cause a break-down in team dynamics. What is the preferred initial method to deal with questionable conduct or a break-down in team dynamics?

a. Address the person directlyb. Report the incident via the professional conduct icon on the computerc. Tell other staff and physicians in the department to ensure that they are aware of the

concernd. Report it to the patient safety officer and report any witnesses if applicable

13. The SHC Count Policy is based on AORN recommendations and is in place to support professional practice and patient safety. What is the only safe and acceptable method to count sponges?

a. Scrub personnel removes the paper band, separating and count each sponge individually under direct observation of the circulating RN

b. Scrub personnel lay out sponges in a way that each edge can be seen and counted by the RN when the RN has time

c. Scrub personnel hold the sponges in one hand and “page” through each one counting aloud to the RN while the RN preps the patient

d. Scrub personnel count and write down the totals on a sterile card and hand it off to the RN prior to the start of the case

14. Safety strap(s) should be used to prevent potential patient injury during surgery, and to prevent extremities from being unsupported or unsecured. Which of the following is an appropriate exception to this policy?

a. Upon surgical team member requestb. Procedures that require changes in position during the surgeryc. Procedures performed in the prone positiond. There are no appropriate exceptions to this policy


15. Sponges should be left in their original configuration and should not be cut. This is a dangerous practice and increases risk of injury to patients. What is the primary reason that this practice is a risk to patient safety?

a. Cutting a sponge can create pieces/threads of the cut sponge can cause adhesionsb. Cutting sponges has been shown to increase risk of infectionc. Altering a sponge invalidates subsequent counts and increases the risk of a portion

being retained in the woundd. This practice can increase the need for x-ray exams and expose the patient to

unnecessary radiation

16. AORN recommends that the movement of personnel and air should be kept to a minimum while invasive and noninvasive procedures are in progress. What is the best method to support this recommendation in your practice?

a. carefully assess and plan patient care needs to reduce the need for excessive movement during the procedure

b. assign one team member to monitor the traffic and air movement during proceduresc. verify and update physician preference cards to ensure accuracy prior to proceduresd. minimize talking and utilize hand gestures as the primary form of communication during

procedures

17. Fires are an inherent risk in the surgical environment as the three elements of the fire triangle (an oxidizer, fuel, and ignition source) are ever present. All procedure team members including surgeons, physician assistants, surgical technologists, registered nurses, and anesthesiologists, should participate in and perform fire safety prevention interventions prior to the start of and during every procedure. What are the specific assessments that can reduce the incidence of the disastrous event of a surgical fire?

a. Assess the locations of the fire extinguisher, fire alarm and oxygen shut off valvesb. Assess the need for supplemental oxygen, ensure skin prep is dry, verify ignition devices

on the sterile field are properly securedc. Assess the access to the emergency activation system and evacuation routesd. Assess the latest fire code changes on a regular basis

18. The patient’s exposure to radiation should be minimized and the patients should be protected from unnecessary radiation exposure in surgery. What is the best way to protect patients from injury and exposure to unnecessary radiation?

a. Take care during positioning and the procedure to keep all of the patients extraneous body parts out of the radiation beam to prevent injury

b. Wait until the just prior to the x-ray portion of the procedure to contact the x-ray techc. Identify alternative methods for the team to perform the procedure to eliminate the use

of x-rayd. Announce “x-ray” clearly for the team to heighten everyone’s awareness and decrease

the time x-ray will be used

19. You are working on a surgical case and one of the team members comments that the audible alarm on the electrosurgical unit is annoying and requests that you silence the audible warning alarms on the ESU. What is the appropriate action to take?

a. Silence the alarm using the volume control on the back of the ESU and relying on the lights on the unit to alert personnel when the ESU is activated


b. Turn up the radio so that the alarm will not seem as loud and annoying to the team and rely on the lights on the unit to alert personnel when the ESU is activated

c. Remind the team that the alarms should be present and loud enough to be heard above other sounds in the OR to alert personnel when the ESU is activated

d. Silence the alarm and submit an event report to the quality department reporting the incident

20. Red rules are rules that cannot be broken and are associated with processes that can cause serious harm to patients. At SHC, in the OR, Red Rules are as follows:

Patients are identified by two approved criteria The Surgical Time Out portion of the Surgical Safety Checklist must be completed and

documented prior to incision, and All sterile indicators must be checked and confirmed by the circulator and the scrub

person prior to the start of the surgical procedure and must remain visible until the surgical procedure is completed.

Which of the following statements is NOT true in regards to following red rules?a. Red rules must be followed exactly as specified except in rare or urgent situationsb. Every team member, regardless of role or experience in the organization, is expected to

stop the work if the red rule is violatedc. Red rules are primarily used to discipline team members who violate safety standardsd. Management always supports the work stoppage when a red rule is violated, regardless

of how inconvenient, financially costly, or disruptive it may be in the moment

21. When operating the electrosurgical unit (ESU), the operator should confirm the power settings before activation. Settings should be based upon the manufacturer’s written instructions and the intended application. The ESU should be operated at the lowest effective power setting to achieve the desired effect. If the operator requests a continual increase in power, what is the best action for personnel to take first?

a. beginning with checking the dispersive electrode, check the entire ESU and accessories circuit

b. increase the power on the ESU in increments of 5-10c. remind the operator that the power level they are requesting exceeds manufacturer

recommendationsd. call the supervisor and request a replacement ESU

22. Personnel should take special precautions when using the ESU with patients who have pacemakers, internal cardioverter-defibrillators (ICDs), or other electrical implants. Electrosurgery can interfere with both the pacemaker’s circuitry and function and create ECG artifact. Although modern pacemakers are designed to be shielded from radio frequency current, they are subject to interference during electrosurgery use.

1. Continuously monitor patients (ie, minimally, ECG, peripheral pulse) during electrosurgery use

2. Have a defibrillator immediately available for emergencies during surgery3. Keep all electrosurgical cords and cables away from the pacemaker and its leads4. Use bipolar electrosurgery whenever possible and use the lowest possible setting on the

ESUWhat are the appropriate actions to take for patients with electrical implants during surgery where an ESU will be used?


a. 2, 4b. 1, 2, 4c. 1, 3, 4d. 1, 2, 3, and 4

23. Surgical specimen handling is performed as requested by the Scottsdale Healthcare pathology department, Scottsdale Healthcare Medical Staff, and in accordance with regulatory standards. Appropriate and timely disposition and examination of specimens are multidisciplinary tasks that require vigilant attention to detail to prevent inaccurate or incomplete diagnosis or the need for additional procedures. Which of the following are the complete elements required to appropriately and safely handle patient tissue specimens?

a. patient identification, communication with surgeon and scrub person (including a “read back” verification of the specimen order by the circulating RN), containment, and labeling, and documentation

b. patient identification, specimen identification, communication with surgeon and scrub person (including a “read back” verification of the specimen order by the circulating RN), containment, labeling, and documentation

c. patient identification, specimen identification, communication with surgeon and scrub person (including a “read back” verification of the specimen order by the circulating RN), labeling, and documentation

d. specimen identification, communication with surgeon and scrub person (including a “read back” verification of the specimen order by the circulating RN), containment, and documentation

24. Because the use of tourniquets have been associated with patient injury it is important to minimize the risks of injury to patients. When selecting the appropriate size cuff to use, you should assess the size of the patient’s limb and select a cuff that will allow for the correct amount of overlap. What is the recommended overlap for a tourniquet cuff?

a. 1-3 inchesb. 2-10 inchesc. 3-6 inchesd. At least 6 inches or more

25. Medication administration in the procedural setting shall be based on the five “rights”; right patient, right medication, right dose, right time, and right route. Medications delivered to the sterile field shall be verified by two staff members, one of whom is an RN. At what point should medications be labeled by the scrub person on the sterile field?

5. Before the patient comes into the OR6. Immediately upon delivery to the sterile field7. Prior to drawing up in a syringe or asepto irrigator8. Before the RN finishes documenting the medications in the patient chart

Operating Room Assessment Exam Analysis Web view01.10.2012 · The operating room...

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