How Emory Hospital Nurses Improved Surgery Start Times

Target the Human Side to Move Metrics

Sometimes challenges in periop care snowball. This was the case in 2022 for Perioperative Nurse Educator Nicole Queen, BSN, CNOR, and OR day shift manager Karen Smith, BSN, at Emory University Orthopaedics and Spine Hospital in Tucker, GA.

They had a new electronic health record to adapt to, more travel nurses to train following post-pandemic staffing shortages, and a vacancy for their OR manager role. Meanwhile, metrics on their first case on-time starts (FCOTS) dropped from 90% of the time to 40% of the time. This drastic decrease added an estimated $300,000 per case in time delay, frustrated team members and risked a drop in patient satisfaction scores.

However, this stacked list of problems to solve did create one major win. In the process of tackling their FCOTS metrics, these nurse leaders ended up gaining the knowledge and tools to tackle other improvements along the way. How? By jumping in and helping.

Getting to the “Human-Side” of First Case Delays

“We decided to go straight to the heart of the situation to understand what was happening in the huddle, preop holding and the rooms before our first cases—really focusing on the human side of the equation with nursing processes,” Smith explained.

Talking directly with their staff was also the most expedient solution, Queen added. “Being short-staffed and stretched thin ourselves, we figured tackling the lowest hanging fruit by shoring up processes among our nurses was the smartest and most achievable approach.”

Their thinking worked.

3 Quick Fixes

Within a week of rounding and talking to staff, they identified key bottlenecks delaying first cases, which centered around communication and the need for more help.

Based on these findings they implemented these immediate fixes:

• Put a hard stop on the morning huddle to keep it from running too long.
• Scheduled to optimize skill and speed with opening a room, such as pairing a new nurse with an experienced nurse known for getting first cases ready on time.
• Created a standardized communication tool (an orange card) placed on the bed of a pre-op patient whose interview was completed to signal readiness for anesthesia.

A Capital Purchase

One longer-term fix they tackled was opening supplies for a case, which can be timely for ortho and spine cases that require anywhere from 5–25 trays. Smith and Queen coordinated with sterile processing and leadership to purchase a multiple tray sterilization solution.

It works by sterilizing instruments in trays held within a rolling container. Once processed, the rolling container is transported directly to the OR that staff access to grab needed instruments for the case. By eliminating the need for blue wrap, this rolling container eliminated extra time to remove blue wrap and has been a significant time saver for setting up a case.

Stepping in to Help

Seeing how their staffing shortage was contributing to FCOTS delays, Queen and Smith decided to join their team members side-by-side in setting up the first cases.

“Showing our staff that we were ready to be a part of the solution helped secure their trust to see we were dedicated to helping them improve our metrics,” Smith acknowledged.

They also drove changes to boost staffing through using more travel nurses and created a Perioperative Service Tech position to help streamline case set-up.

These and other changes made the difference: They bumped their first case on-time starts up to almost 100% and are sustaining this improvement.

Improving Beyond the Numbers

Getting into the trenches also helped the nurse leaders build a different level of rapport with their teams. Two years later their staffing shortage has improved, but Smith and Queen still make time to jump in and help open first cases for the day.  “Working alongside our teams at the beginning of the day gives us all a chance to talk about our weekends and families and connect on a personal level,” they shared.

This stronger connection across roles is what has proved most valuable as Queen and Smith tackle new challenges that come their way. Today they are rallying their frontline to tackle two new improvement challenges:

• reducing turnover time between cases
• adapting to a new process for pre-anesthesia Time Out

What to Ask For: Actionable Data

To colleagues looking to make similar team-led improvements, Smith and Queen stress one key suggestion:  Ask for numbers to track emerging problems and follow success once implementing solutions.

“Hard numbers from leadership on our current state and any slippage over time helps us identify problems and rally our teams to make positive changes,” Smith stressed. “Without actionable data, we are blind to really understanding there is a metric we need to improve.”

Queen added, “while much can be done at a grassroots level, nurses can’t do it alone. We need leadership support to set and succeed in achievable goals to be better for ourselves and ultimately for our patients.”

Want to learn more? Use your Virtual Pass to access Smith and Queen’s recent education session No Time to Waste, improving first case on time starts in OR.