Specialty team staffing models

sandiegojames · May 8, 2008

While I understand the desire to increase efficiency, patient outcomes and turnover times; allow me to voice some concerns I would have regarding a vascular specialty team.

Keep in mind, this is coming from an OR nurse in a non-trauma, 10 OR acute facility. We do Hearts/Liver Transplant/Ortho etc.... Basically everything except trauma...

From my perspective, hearts and transplants are "specialty services", extensions on general and vascular surgery. Vascualar surgery however is a very basic core surgical skill. More often than not, unanticipated emergencies in the operating room are related to unexpected bleeding. I can recall more than a couple occasion our vascular surgeon has come to the rescue whether it be a femoral artery speared during a hip pinning or something in the abdomen during a urology or laparoscopic procedure. This can happen during the course of the day or during call hours, you just never know.

By creating a vascular team, will your other staff be addequately trained to deal with these rare emergencies? There most likely will not be time to call the vascular team in for that type of problem.

Usually surgeons are quite happy with there specialty team, however when required to operate without a core team, things can be quite stressful for both surgeon and staff when not working together often enough. You'll have to ask yourself, how often will the vascular surgeon be forced to operate without the team, do they do procedures with other surgeons such as orthopedic tumor resections, anterior lumbar fusions?

Do you have any concern with not exposing your staff to a fairly basic surgical skill with some regularity? Is it realistic to try and operate a trauma center like a out patient surgi center?

Pwarble · May 9, 2008

I certainly respect your concerns. I have been in the OR for 20 years and I agree that vascular certainly in theory should comprise a "basic" surgical skill. However, what I see happening is that the majority of our staff whether due to inexperience or rapid turnover are not even competent in many of the basic surgical techniques. Now maybe this is unique to our facility, I'm not sure. Also as technology advances with endograft procedures (we do all our aortic endograft cases in the OR), vascular is becoming more specialized. In my experience, for those vascular emergencies in non-vascular cases, a good scrub with good basic skills usually will do fine. We are more concerned with the daily operations, the emergent AAA that could be repaired endografically but because your offshift personnel are unfamiliar with the wires and equipment you must subject the patient to an open repair that increases their mortality, etc. I understand your argument that specializing in the OR may not provide a well rounded department, however our experience has been that training programs are not adequately training staff in even the basics which is even more stressful for the surgeons and dangerous for our patients. We have also found that in the rare instance when a vascular emergency occurs during a non-vascular case the surgeons are much more tolerant of the staff. We are not trying to run our service as an outpatient center, just trying to make it safer, more efficient for everyone. The debate will continue whether to specialize or not.

sandiegojames · May 9, 2008

I see your point with the endo graft stents, when we do them the IR techs come over from radiology and scrub in with the interventionalist so from an OR perspective those cases aren't very complicated. But if you have to know all wires/catheters etc etc... then it's a whole new ball game.

That said, then creating a vascualar specific team would seem to just come down to the hospital being willing to devote the resources ie extra call pay for a team. But also keep in mind how creating a new call team will effect existing ones. Will a general or trauma team be impacted by loosing members. Or will they still be expected to fulfill both responsibilities?

Does an interventionalist come in to those cases or does the vascular surgeon do all the stenting?

sheisbb · May 18, 2008

well, I do have some experience with that. i work with a spine team for past 4 years, which run similiar model like what you've decribed. However, due to staff constrain, the hospital cannot affort to spare nurses to that specific model. I'm among other 15 nurses employed under university but worked in the general hospital. That gives us a privilage not to be included in the hopsital traditional nursing rotation. In spine team, there are only two nurses included in this model. There are 3 more specialties which run similiar model but all with either 1 or 2 nurses. All of us are OR trained.

This is how we do it. The nurse will attend all the elective and emergency spine surgery. Day or night. We work as scrub nurses. The circulator still has to come from the general orp pool who works on that particular shift, which may include the orthopaedic trained orp (if that's our lucky day). Usually, it only require one assistant nurse or RN for the whole surgery. We will prepare the necessary instruements and implant and after the surgery, handling the cleaning part as well.

In this hospital, we have monday as semi-e spine or and thursday as elective spine or. when we are not in any surgery day or emergency cases, we move between the orthopaedic ward and spine clinics. Here, some extra work description comes in to make up for the less working hour in the operation room.

The important issue for this model is, however, we couldnt really exclude nurses who works in rotation. This is because the movement of spine instruemnts and implants still require all day monitoring from staff who are willing to take up that responsibility (we do not have orthopaedic sister in or). Yes, we are taught of accountability and responsiblity but thing just dont happen that way in reality.