Poll and Discussion regarding RNs in the OR. (for research paper )

[KC CHICK]

I am currently in Eng 102 doing research for my paper. The subject I have chosen has some personal interest for me, and others on this board.

The issue is regarding RNs as circulators in the OR. Should UAPs be allowed to circulate under the direct supervision of an RN??

"

The issue of UAP in the circulating role is controversial. In some instances, an institution may loosely interpret the Health Care Financing Administration (HCFA) and Joint Commission on Accreditation of Healthcare Organizations (JCAHO) rules, which require an RN to be "immediately available."7 Based on their interpretations, these institutions may have an RN supervise several ORs simultaneously and have UAP function in the scrub and circulator roles."

Surprisingly, there is no federal statute governing the circulating role within the OR.

"The current HCFA rule governing surgical services, 482.51, states that

ORs must be supervised by an experienced RN or a doctor of medicine or osteopathy;

licensed practical nurses (LPNs) and surgical technologists may serve in the scrub role under the supervision of a RN;

a qualified RN may perform circulating duties in the OR, and, in accordance with applicable state laws and approved medical staff policies and procedures, LPNs and surgical technologists may assist in circulatory duties under the supervision of a qualified RN, who is immediately available to respond to emergencies; and

surgical privileges for all practitioners performing surgery must be delineated and specified in a roster, in accordance with the competencies of each practitioner.10"

Another fact I came across is that only 20 states in the US require RNs to circulate. Therefore, in those states that aren't regulated, the hospitals can interpret guidlines any way they see fit. RNs are required in 37 other states, but the RN is allowed to function in a purely supervisory role. This allows a hospital to implement a UAP in the circulating role. 7 states have no RN staffing requirements regarding the OR.

What is your opinion regarding this issue? Is this safe? Do you agree or disagree with the cost-saving measure of hiring UAPs to perform a role that used to be performed only by a licensed RN?

Thank you in advance for your replies,

Anne (eternal student-seems like it anyway)

For access to the entire article that I quoted from: http://www.aorn.org/journal/2001/mayhpi.htm

[canoehead, BSN, RN]

OK, I'm not an OR nurse so I didn't vote, but I have been the baby catcher at a C section so have seen the OR in action. In my opinion you need someone to take ultimate responsibility for everything that goes on in the room. Right now I see the circulator doing that as far as equipment, sterility etc. If the doc was willing to do it (not sure if he/she would want to concentrate on the surgery and watch what everyone else was doing) then fine- UAPs could be used although I predict poorer outcomes the surgeries would get done and probably be less expensive to perform.

Historically RN's have been the coordinators of care, keeping in mind everything that is going on inside and outside the OR (scheduling, skills, technical duties). RN's do that job in the OR and on the floors, and are trained to watch out for everyone to give the pt the very best final outcome we can offer them. So no, I don't think that UAPs could perform equally as well.

The thought of having one RN overseeing 4 ORs is insane because an emergency can happen any time. Most importantly the RN watches over the final product and intervenes to prevent the emergency. He/she also have the knowledge and skills to problem solve and call in what is needed. (knowing that if Xproblem happens then we have Y doc in house and the equipment is in that cupboard, and so'n so out in room 3 had this same thing happen twice before so if the 1st thing doesn't work he/she can be covered by Joe and come in and be my helper) Tell me a UAP, not trained in anything but THIS type of surgery with THIS doc will know all this, and be ready...

Sure the surgery will be cheaper, it will get done, but the outcomes will be worse, and pt stays will go up. If you are judging success by money you might get by, but by pt outcomes the idea is a clunker.

[Audreyfay]

I worked in the OR for 3 years, and loved it. I was trained to circulate, but not to scrub (they needed more circulators at the time, and never "got around" to scrubbing.) As I circulator, I used my nursing knowledge to look at everything in the room, including preparing the patient, answering their questions, watching the positioning, and leg placement, helped start IVs, sometimes helped bag pts, sign out narcotics for the anesthetist, and overall watched to make sure the patient was safe and sterile technique was maintained. While some of the tasks a UAP could do, some of the others would be impossible (or illegal) for a UAP to do. I would prefer, and ask, that an RN be the circulator. It's amazing how much they can do in an emergency. What if there's a code? Could the UAP help like an RN could? What if the pt. needed another IV started. How about foleys? I did many of those as well. Again, I would not feel safe supervising 2 rooms of UAPs. I'd rather be responsible for what I am seeing and doing.

[jodie84124]

I was a circulator for 2 years. We had CORT's to scrub. I often felt like a 'handmaiden'. We also covered in PACU in the afternoons and I felt I was using more nursing skills there. What I hated the VERY MOST: Holding retractors! I am not familiar with the term "UAP", but I'm guess it's like a 'certified technician' (CT) that was talked about years ago to augment ICU nursing. This actually supports one MD's opinion that a 'monkey could be trained to do what nurses do'. Only when we act professionally and manifest critical thinking, do we show what nurses are meant to do. I voted 'don't know enough', but I also think UAP's could function in less complex surgeries....with supervision. Really complicated cases need the mulitidimensional observations of an RN. My opinion....Jodie

[KC CHICK]

UAP means 'Unlicensed Assistive Personnel'. There is no certification earned in their training. In my research, the only documented training I could locate was a month long. It consisted of 1 week of classroom time and 3 weeks of clinical time with a preceptor. Of course, this training was for UAP's that were not left alone in the OR to circulate on their own. But that is all I could find. There is no standard out there, that I could find, by which to train the UAP to circulate in the OR. It is left up to the individual hospitals to develop their own training program.

Anne

[kmchugh]

I voted that patient safety was not at risk provided one RN supervises a limited number (2?, 3?, 5?) rooms where UAP's are circulating. As a CRNA, I say this for a number of reasons:

1. For most general surgery, the role of the circulator is primarily a technical role. Counting sponges, needles, and sharps, handing instruments into the field, taking items no longer needed from the field, packing and sending specimens, etc, do not require the specific knowledge of an RN.

2. Many of the things circulators claim require the knowledge of an RN may not be their responsibility. Positioning, for example. Ultimately (as I have been taught) everything that happens to the patient in the OR outside of the surgical field is the responsiblity of the anesthesia provider. If a patient ends up with a nerve injury as a result of positioning, who gets sued? Not the circulator, but the CRNA or MDA. (Not belittling circulators, but lawsuits filed against parties not responsible for an injury are usually dismissed.)

3. Handing off drugs: See above. Additionally, most circulators I know who have been circulators for a number of years will, in moments of absolute honesty and clarity, admit their knowledge of drugs is extremely limited. They rely on the surgeon and anesthesia to provide that knowledge.

All the debate may be moot, at any rate. I have seen hospitals decrease the number of open OR's because of a shortage of RN's and tech's to run those OR's. If the nursing shortage continues to worsen at present rates, five years from now, having one RN supervise UAP's circulating five rooms may be seen as a luxury.

Kevin McHugh, CRNA

[KC CHICK]

Kevin, thanks for your reply.

I have, until this point kept my personal opinion to myself. You raise some very good points.

I agree that anesthesia must bear the majority of responsibility for the patient, along with the Doc. However, when I circulated, there were times that I was alone with the patient in the room....CRNA had not gotten to the room yet-or had to go back to the anesthesia workroom to grab something else, doc had not been called in, and the surgical tech was out at the sink scrubbing in. This time period could last anywhere from 5 to 15 minutes. (15 minutes was rare....but did happen on occasion.)

Who would be responsible for the patient then? The RN that is alone in the room with the patient.

If this were, perhaps, a pacemaker/defib implant patient for example....the patient could have problems at any moment that could require the assistance of an RN when no one else is in the room. What would a UAP do in that case...if the supervising RN were not able to immediately respond in an emergency?

You mentioned that positioning was the ultimate responsibility of the CRNA. Yet, there were times that I positioned the pt. on my own without the input of the CRNA present. In regards to mixing drugs. No, we didn't use many and I felt that was indeed a weak area of mine. However, it is still important to mix them correctly regardless of the number of drugs used.

I agree, there are alot of things a circulator does that do not require a nursing license. I felt that same way at times.

In my opinion, it's the unexpected situations that arise that require the presense of an RN. Which one, RN or UAP, would you want help from if you needed it in your practice?

Anne:D

[spineCNOR]

Kevin, yes the anesthesia provider plays a crucial role in patient positioning. BUT in my experience anesthesia is responsible for the patient's head and arms. What about the heels, the genitals for prone patients, the dependent knee and ankle for lateral cases??? In my experience this is the circulator's responsibility, not anesthesia. (Where I work the surgeons DO NOT assist with postioning--they are not what you would call team players, for the most part).

Just one woman's opinion....

And another thing--if someone that you care about were having, say, a retina procedure done--who do you want to be handling the eye drugs--a licensed nurse or a UAP?

[kmchugh]

Just a quick note on positioning. Yes, the RN or whoever in the room often positions parts of the body, prior to the patient being asleep. But, responsibility to ensure that positioning is correct falls to whoever is doing the anesthetic. Remember, s/he who gets sued is responsible.

More later, but am putting in a new kitchen floor with my father in law. We're having a ball.

Kevin McHugh

[spineCNOR]

I hate to argue with the "argumentative member"--BUT-for shoulder scopes and other lateral cases, spines and other prone cases, etc, etc--the circulator is responsible (with the help of anesthesia and nursing assistants) for positioning AFTER the patient is asleep--at least where I work.

[semstr]

positioning is anaesthesia PLUS the surgeon doing the operation, she/ he has to make sure patient is on the table the way it schould be.

This is a federal law here, so you can bet your license the great-gods- of-cutting, check it.

Take care, Renee

[KC CHICK]

Who, then, is responsible when the CRNA is not there for a local only procedure? At my hospital, if only local is used, there is no anesthesia person present....only 2 RNs (one to circulate and one to local monitor), surgical tech, and surgeon.

**Good Luck on those floors. Yuck! What a way to spend a weekend.***

Anne:D

[semstr]

the surgeon