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CHAPTER 12
Intraoperative Care
This chapter aims to enable the reader to consider the overarching principles of intraoperative care without negating the fact that this is a very large and very complex area for discussion. As practitioners we are in a privileged position of caring for patients when they are at potentially their most vulnerable. We are educated from an early stage of training to understand that we are the patient’s advocate and have a voice that patients do not have when they are in a general anaesthetic drug-induced coma or are so anxious that perhaps they are less capable of logical consideration of issues involving their immediate care. The message to take from this chapter is that the intraoperative practitioner is the patient’s guardian. You are the person who will keep the patient safe.
Patient Safety
Safety of the patient during the operative procedure is the primary concern of every member of the surgical team in the operating theatre (Rothrock 2011). Widely accepted in healthcare is the philosophy ‘First, do no harm’ and this is the mantra for everyone to meet in intraoperative care. Overall, the intraoperative practitioner is working to help restore the patient’s health. A by-product of the patient’s surgery and intervention will be a degree of physical harm. This harm is caused via the deliberate surgical damage to the tissues being operated upon.
The Evidence Centre (2010, p. 1) states that ‘The NHS strives to make all surgery safe and effective but sometimes incidents occur.’ This is where the intraoperative care practitioner fits neatly into the process. The intraoperative care practitioner works methodically in a manner to minimise the risk that surgical care poses to patients while they remain in our care.
Teamwork
At a time of great change in the National Health Service (NHS), where all clinical staff are encouraged to participate in quality improvement (Darzi 2008), teamworking becomes more critical. Teams are described as a cooperative group working toward a collective goal (Corbett 2009). The team philosophy should be aimed at collaboration and cooperation. The focus on interaction and a unilateral outcome of very high-quality patient care for every patient must be the priority. Organisational priorities must include treating patients on operating lists. The lists must be completed effectively and efficiently which will provide the trust with monetary income to enable the continuation of this care for the community and also to invest in development of further services.
Teamwork is a critical area to consider within intraoperative care. Everything we do in perioperative care is related to another area and without the team the patient would be at much greater risk of harm. The number of different professional groups that work within intraoperative care dictates that cooperation and collaboration must occur or the risk of critical events increases. Corbett (2009) reminds us very clearly that as practitioners we do not work in isolation. Patient care would be significantly affected if we did and the quality of care would be reduced.
Within every multi-disciplinary arena, effective functioning of a team will depend on the reduction and elimination of obstacles (Gillespie et al. 2008). In operating departments there are medical staff, nursing staff, operating department practitioners and support workers who are also an important group of staff upon whom much practice depends. Each group will effectively have a separate agenda, in part shaped by the organisation’s expectation and the individual role descriptors provided. Breakdowns in team working have been described as a major cause of adverse events and errors (Rothrock 2011) within perioperative care. This is relatively easy to see and a reason why many departments now prefer settled teams even if that only includes core staff. Working in teams has also been considered positive for work morale and a sense of mutual trust and cooperation, which again was described as enhancing safety (Alfredsdottir and Bjornsdottir 2007).
The key message here is collaboration, cooperation, trust and appreciation that individual disciplines bring a variety of knowledge and skills which all help to produce high-quality safe intraoperative care.
Communication
Within operating departments communication is crucial to the effective, safe and efficient provision of quality care (Wicker and O’Neill 2006). Communication remains the basis for all interaction including verbalising and listening and allows rapport to be developed between practitioners, patients and the multi-disciplinary team. Communication not only involves the verbal exchange of information but can also be in written form. Consideration to body language and the overall perception that the receiver of the information gains is important as rapport is built on two-way interaction.
Communication must enable the intraoperative practitioner to provide holistic, individualised patient care throughout the patient’s perioperative journey. The theatre environment is very changeable. As such, accurate communication is crucial within perioperative practice. Communication between practitioners, medical staff and patients is essential (Woodhead and Wicker 2005, Spry 2009) and must not be considered simply verbal. Completion of documentation with accuracy is equally important. A number of examples in intraoperative care are preoperative patient checking, instrument checks, documentation of histology specimens, reporting and documenting the swab, needle and instrument counts and handover reports to postoperative recovery practitioners.
Wicker (2011) suggests that the challenge of improving communication in the context of patient safety and the World Health Organization Checklist is essentially within the control of the theatre staff, who are the people who will begin the process with introductions in theatre during the often referred to ‘time out’. The key message is that inappropriate or inaccurate communication could potentially lead to catastrophe (Gillespie et al. 2008). Interaction between disciplines and individuals can be clouded by previous experience and may lead to potential breakdown in the efficiency and coherence of the team. The other extreme is that good communication will lead to greater satisfaction as the quality of patient care will improve, staff will feel more comfortable within the multi-disciplinary team and as such perform at a higher and more cohesive level.
Care and Dignity
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