Preference Cards Research Articles

VoiceMyChoice™: Facilitating Understanding of Preferences of Residents with Dementia

The purpose of this study was to develop and evaluate the effects of visual materials (labeled pictures and a preference sorting template) on the ability to increase the convergence (agreement) of responses by persons with dementia and their nursing assistants on a Preference Assessment Questionnaire that contained 25 items related to Quality of Life (QoL). A total of 33 nursing assistants participated; 54% were native English speakers and 46% were non-native English speakers. Thirty-seven residents with dementia were randomly assigned to either the treatment condition, a 10-min preference card sorting task (VoiceMyChoice?; VMC) which reflected the items and content of the Preference Assessment Questionnaire, or a control condition consisting of a 10-min card matching activity using the materials from VMC. Before and after the treatment or the control session, residents and their assigned NA were administered the Preference Assessment Questionnaire; one week later, these procedures were repeated to assess consistency in responding and improved convergence between dyad members’ responses over time. Results revealed that convergence scores between members of NA-Resident dyads increased significantly after the use of VMC for both the English and non-native English dyads, but not in the control condition. VMC has the potential to enable persons with dementia to communicate personal choices and for their caregivers of various linguistic and/or cultural backgrounds to understand them better.

Factors Disrupting the Preference Card Management Process: A Root Cause Analysis

Preference cards, the nexus of an efficient OR, help ensure that OR personnel have what they need to safely and efficiently care for surgical patients. In June 2013, a new electronic health record (EHR) was implemented in the ORs of the Duke University Health System, Durham, North Carolina. Although it was an integrated system, the EHR disrupted supply management in the OR, which affected the availability of correct resources. The project team performed a process-improvement project using root cause analysis (RCA) to identify the factors that led to the disruption in the preference card management process for orthopedic surgical procedures. Team members identified that a chief cause of resource disruption was the mistiming of interface messages that created the pick lists and requisition forms. Based on the results of the RCA, the project team developed and implemented recommendations for process improvement.

One hospital, one appendectomy: The cost effectiveness of a standardized doctor's preference card

PurposeAppendicitis in children provides a unique opportunity to explore changes that reduce variation, reduce cost, and improve value. In this study we sought to evaluate the effectiveness of standardization of surgical technique and intraoperative disposable device utilization for laparoscopic appendectomy among all surgeons at a tertiary children's hospital. MethodsAll 6 surgeons at our tertiary children's hospital agreed to standardize to a single technique of performing a laparoscopic appendectomy. We collected data on all pediatric patients who had a laparoscopic appendectomy following implementation of the uniform doctor's preference card (DPC) (March 1, 2013 to February 28, 2014) and compared them to a historical control group. ResultsImplementation of the uniform DPC decreased the device cost per appendectomy from $844.11 to $305.32. Operative times (skin incision to skin closure) were 34.8minutes prior to the uniform DPC and 37.0minutes using the uniform DPC. There were no significant differences in postappendectomy outcomes. ConclusionWe have demonstrated that implementation of a uniform DPC and technical standardization for laparoscopic appendectomy can significantly reduce cost. Furthermore, this can occur without dramatically increasing operative times, length of stay, or postoperative complications.

Improving operative flow during pediatric airway evaluation: a quality-improvement initiative.

Microlaryngoscopy and bronchoscopy procedures (MLBs) are short-duration, high-acuity procedures that carry risk. Poor case flow and communication exacerbate such potential risk. Efficient operative flow is critical for patient safety and resource expenditure. To identify areas for improvement and evaluate the effectiveness of a multidisciplinary quality-improvement (QI) initiative. A QI project using the "Plan-Do-Study-Act" (PDSA) cycle was implemented to assess MLBs performed on pediatric patients in a tertiary academic children's hospital. Forty MLBs were audited using a QI evaluation tool containing 144 fields. Each MLB was evaluated for flow, communication, and timing. Opportunities for improvement were identified. Subsequently, QI interventions were implemented in an iterative cycle, and 66 MLBs were audited after the intervention. Specific QI interventions addressed issues of personnel frequently exiting the operating room (OR) and poor preoperative preparation, identified during QI audit as areas for improvement. Interventions included (1) conducting "huddles" between surgeon and OR staff to discuss needed equipment; (2) implementing improvements to surgeon case ordering and preference cards review; (3) posting an OR door sign to limit traffic during airway procedures; and (4) discouraging personnel breaks during airway procedures. Operating room exiting behavior of OR personnel, preoperative preparation, and case timing were assessed and compared before and after the QI intervention. Personnel exiting the OR during the MLB was identified as a preintervention issue, with the surgical technologist, circulator, or surgeon exiting the room in 55% of cases (n = 22). The surgical technologist and circulator left the room to retrieve equipment in 40% of cases (n = 16), which indicated the need for increased preoperative preparation to improve case timing and operative flow. The QI interventions implemented to address these concerns included education regarding break timing, improvements in communication, and improvements in ordering and preparation of equipment. After the QI intervention, the surgical technologist exiting rate decreased from 20% (n = 8) to 8% (n = 5), and the circulator exiting rate decreased from 38% (n = 15) to 27% (n = 17). In addition, the rate of surgeon exiting decreased significantly (from 25% [n = 10 of 40] to 9% [n = 6 of 66]) (P = .03). The surgical technologist and circulating nurse remaining in the room were significantly associated with decreased operating time (1.84-minute decrease for surgical technologist [P = .04] and 1.95-minute decrease for circulating nurse [P = .001]). Gains were made in personnel exiting behavior and case timing after implementation of the QI interventions, potentially leading to decreased risk. This process is easily reproduced and is widely accepted by stakeholders.

Clinical Issues—October 2014

This MonthStanding orders for narcoticsKey words: standing medication orders, preference cards, narcotics.Reprocessing instruments when there is a question of sterilityKey words: decontamination, reprocessing, instrument trays, event‐related sterility.Inaccurate sponge counts in custom packsKey words: counts, soft goods, sponges, custom packs.Chewing gum in the ORKey words: OR food consumption, chewing gum, exposure to bloodborne pathogens.

Lessons from aviation safety: "plan your operation - and operate your plan!".

Lessons from aviation safety: "plan your operation - and operate your plan!".

Standardization of operative equipment reduces cost

BackgroundWe hypothesize that standardizing operative equipment, and reducing variability can safely achieve cost reduction. MethodsWe retrospectively measured supply costs, operative time, intra-operative complications, and length of stay in a cohort of 145 patients at a children's hospital who underwent a laparoscopic appendectomy. A standardized preference card for laparoscopic appendectomy was developed and implemented. Data were prospectively collected on 101 consecutive patients and compared to the retrospective cohort using multiple linear regression. A survey assessing the perception of surgeons, nurses and scrub technologists of the impact of standardization on patient safety, patient care, OR efficiency, and cost was conducted.Wilcoxon rank sum test was used to evaluate associations between clinical role and years of experience with the total level of agreement on the survey. ResultsA 20% average reduction was achieved in supply cost per case, with no significant change in operative time (p=0.14), total time in OR (p=0.15), or length of stay (p=0.60). No intra-operative complications were identified in either group. Survey participants agreed that standardization improves cost and safety. Nurses tended to have greater agreement that standardization improved efficiency and patient care compared to other roles (p=0.06). ConclusionsStandardization of operative equipment can result in a significant cost reduction without impacting quality or delivery of care. Based on average case number per year, a total annual cost savings of >$41,000 could be realized. Survey participants agree that standardization improves cost and patient safety, yet perceptions regarding the impact on efficiency and patient care varied by occupation.

Whole-Lung Lavage for Pediatric Patients With Pulmonary Alveolar Proteinosis

Pulmonary alveolar proteinosis (PAP) is a chronic disorder of surfactant clearance from the alveoli. Its prevalence is rare, especially in the pediatric population. Although there is no cure for this condition, symptoms of PAP are managed most effectively through whole-lung lavage (WLL). Perioperative RNs caring for children with PAP undergoing WLL in the OR should implement patient interventions to maintain vital signs and normothermia and preserve skin integrity. Additionally, perioperative RNs often are responsible for assembling closed-drainage systems for WLL. Detailed procedural preference cards, targeted education sessions, and multidisciplinary collaboration are crucial for establishing a comprehensive plan of care for the pediatric patient with PAP undergoing WLL in the OR.

Utilizing the Productivity Analysis Module

Utilizing the Productivity Analysis Module

Preference card deviations adversely impact operating room efficiency

Preference card deviations adversely impact operating room efficiency

Surviving OR Computerization

In 2007, a steering committee at West Virginia University Hospitals, Morgantown, began a three-year, accelerated design, computer implementation project to institute an automated perioperative record. The process included budgeting, selecting a vendor, designing and building the system, educating perioperative staff members, implementing the system, and re-evaluating the system for upgrades. Important steps in designing and building the system included mapping patient care and documentation processes, assessing software and hardware needs, and creating a new preference card system and surgical scheduling system. Staff members were educated to use the new computer applications via contests, inservice programs, hands-on learning modules, and a preimplementation rehearsal. Role-based security ensures that staff members are granted access to the computer applications they need to perform the work defined by their scope of practice. Planning ensures that the computer system will be maintained and enhanced over time.

Improving OR Efficiency in a University Medical Center Arthroplastic Surgery Service

Staff members in the arthroplastic surgery service at University of California San Francisco Medical Center initiated an multidisciplinary OR efficiency project at the request of the facility's chief executive officer and an arthroplastic surgeon. Elements of the program included forming a consistent team, updating preference cards, starting anesthesia care earlier in the day, working with sterile processing department personnel to improve case cart delivery, improving the turnover routine, and reducing and planning for surgery cancellations. Since the project began in 2004, the surgeon has been able to double his procedure volume in the same amount of time. The surgical team and the program have become an example for the medical center and have influenced the OR culture to focus on efficiency, quality, and accountability.

Keeping preference cards up to date, effortlessly

Keeping preference cards up to date, effortlessly

Optimizing Operating Room Time Efficiency- Additional Obstacles to Efficient Case Flow

Introduction One of the greatest resources in the operating room is time. Its conservation can both save and make capital with improvement in OR utilization, increased throughput of patients, and a reduction in wasted time by surgeons and other costly OR personnel. Potential areas of improvement have been identified in the past, including increasing on-time surgical starts, decreasing room turnover times, ensuring accuracy of surgeon preference cards, and improving multidisciplinary communication.

Right upper video-assisted thoracoscopic lobectomy for early stage lung cancer

Lobectomies are commonly performed through an open approach. The proven safety and efficacy of minimal access video-assisted thoracic surgery (VATS) is changing the way we manage this operation. We present our definition of VATS lobectomy and describe our technique for VATS right upper lobectomy in clear, easy to follow steps. Finally, we provide some operative tips and a preference card.

Taking Stock of Surgeons’ Integrity and Vitality: Why the “Three A’s” No Longer Tell the Whole Story

In her commentary ‘‘A Fire In Our Hearts: Passion and the Art of Surgery,’’ Dr. Eva Singletary calls on faculty surgeons to share our inspiration as surgeons with residents and students. Her review of the surgical trainee recruitment and retention literature discloses an attrition rate in surgery that exceeds other specialties. What deters students from choosing a career in surgery, and why do many students who have chosen surgery change their mind, rejecting not just a particular program but the specialty as a whole? Long work hours and lack of balanced lifestyle are often cited factors, but surprisingly the 80-h workweek restriction has failed to improve retention. Dr. Singletary found reports of only two interventions that helped improve surgery resident experience, and both were targeted at better management of workload. Adding physician extenders to the surgical team has been helpful in some institutions. One program described success decreasing residents’ rounding time as a result of hands-on faculty instruction to improve efficiency. Most of us, whether or not we are teachers, are passionate about surgery, but most of us would also readily admit that the hopes and expectations we held for our careers have been challenged—and sometimes pummeled—by the realities of practice. These challenges can range from the anguish of failing a patient to more mundane problems such as the perennially incorrect preference card. We weather our own disappointments, small and large, as we make our way through our own 80-h or longer weeks. We have our issues, and all too often we either have little insight into them or just ignore them. By disposition, we are a group inclined more toward action than passive contemplation. This quality is adaptive in many aspects of our profession, but it can be a liability when a good dose of introspection might serve our psyche and our relationships better. The motto in my residency was the Nike athletic wear admonition ‘‘Just do it!’’ This helped power through a scut list but did little to bridge the conceptual divide with our colleagues in the ER. It did not help us find a spouse or know what do with the feelings of inadequacy or helplessness in the face of the 7-year-old whose younger sister shot him in the chest, the depressed 80-year-old who tried to take his life jumping off a 100-ft bridge and inexplicably survived, or the conscientious, pleasant anesthesia resident who was a bit of a loner and was found dead from an overdose in his call room one morning. The prospect of a surgeon articulating passion for our work other than a little chest-thumping (‘‘Gee it’s great to be alive!’’ and ‘‘Nothing beats doing a great case!’’) is frankly a little hard to imagine for many people. If surgeons are expressive, it is much more common to overhear complaints about lousy reimbursements, lengthy operating room turnaround times, the indecipherable computerized medical record, the surgical horror story that pits the surgeon’s wits and will over patient’s poor protoplasm and bad luck, or the perceived threat to our very well-being posed first by Hillary Clinton and now by Barack Obama. How often does anyone walk in on a surgery lounge conversation in which surgeons are sharing what we value about our work or extolling our good fortune? We share our trials and tribulations, but how many times in the last 5 years has any one of us had an informal, heartfelt conversation with another surgeon that included sharing thoughts about the intrinsic rewards of our work? What does our work mean to us? How did we mature through our training to be prepared to shoulder tremendous responsibility for our patients, to be decisive and technically proficient in a crisis? How did we learn to be good listeners even for difficult patients and colleagues? When as a senior resident I had my turn to present at grand rounds

Streamlining the OR

Streamlining the OR can increase physician and staff member satisfaction and improve efficiencies. Leaders at the West Florida Division for Healthcare Corporation of America took on the task of streamlining technology and processes for 16 facilities with the goal of surgical volume growth. After assessing the current processes, the team developed a plan to streamline the OR in four major areas. For each area, they paired technology with a process to accomplish the goal. The plan included improving the virtual supply inventory set up and case picking process, coupling the procedure groups and procedure set up with the scheduling process, improving the preference card set up and maintenance system, and pairing documentation with the pre-admission and chart completion process.

A Day in the Life of a Central Processing Technician

A Day in the Life of a Central Processing Technician

Hardwiring Excellence in Long-Term Care

Hardwiring Excellence in Long-Term Care

Medication Safety—Reliability of Preference Cards

A CLINICAL ANALYSIS of surgeons' preference cards was initiated in one hospital as part of a comprehensive analysis to reduce medication-error risks by standardizing and simplifying the intraoperative medication-use process specific to the sterile field. THE PREFERENCE CARD ANALYSIS involved two subanalyses: a review of the information as it appeared on the cards and a failure mode and effects analysis of the process involved in using and maintaining the cards. THE ANALYSIS FOUND that the preference card system in use at this hospital is outdated. Variations and inconsistencies within the preference card system indicate that the use of preference cards as guides for medication selection for surgical procedures presents an opportunity for medication errors to occur.