How ‘Pit Crews’ Achieve Faster, Safer Turnovers

Boston Children’s Hospital shaves precious minutes between cases to keep its OR schedule in the fast lane.

Boston Children’s Hospital is renowned for its exemplary care on many fronts, including surgery. In 2019, however, its data showed one performance metric that wasn’t a source of pride: OR turnover time. The facility averaged an extraordinarily long 42 minutes for its most complex cases.

“We have very sick pediatric patients and telling someone their child’s surgery is delayed because the OR isn’t ready was a reality we wanted to erase permanently,” says Andrew T. Smith, MSN, RN, NE-BC, CPN, senior director of nursing and patient care services in the hospital’s main operating room.

Tackling inefficiencies

In 2020, Boston Children’s launched an extensive Lean Six Sigma Green Belt project to evaluate room turnover. Several inefficiencies were revealed, including multiple team members cleaning different elements in the same OR space. For example, environmental services department technicians were responsible for cleaning the floor and walls surrounding the anesthesia workstation, while the anesthesia tech was tasked with cleaning the anesthesia equipment directly in between.

The investigation also found that members of the turnover team didn’t communicate among each other well and were unable to pivot if more support was needed after a complex case. Opportunities for OR staff to handle turnover activities before environmental services arrived were missed. Supplies and equipment for the turnovers were gathered at the end of the case. All these inefficiencies added up to unacceptably long turnover times. Leaders realized the hospital needed its own turnover hack that neighboring Boston hospitals had already implemented: an OR assistant (ORA) position. The new hybrid role would perform a combination of tasks previously handled by patient care techs, clinical assistants, environmental services and anesthesia techs. The new ORAs were trained to collaborate with these OR staff members to take on some of their turnover duties, such as cleaning anesthesia equipment.

Dubbed “The Pit Crew,” Boston Children’s ORAs now stand at the ready, joining nurses, techs and other OR colleagues to start room turnovers together, just as NASCAR pit crews do when servicing race cars the moment they pull off the track. A staffing note: Many ORAs at Boston Children’s transitioned from roles in environmental services.

The addition of ORAs had a statistically significant effect. Turnovers after complex surgeries were completed in 36 minutes — a 14% reduction.

Time savings were not the only improvement that came with the establishment of The Pit Crew. Leaders found a drastic reduction in dust burden during their biweekly interdisciplinary environment-of-care rounds. The workplace culture surrounding turnovers also improved. ORAs report feeling embraced as a valuable part of the OR team, particularly in terms of receiving support from OR nurses with turnovers, and appreciate that their voices are heard when sharing their ideas for improvements.

“The good thing about using an ORA model for turnovers is that it works for any case,” notes Julian Inferrera. As Boston Children’s OR flow manager, Mr. Inferrera leads a team of 19 ORAs and directly oversees their activities in the main OR.

Pit crews in action

ON A MISSION A project that investigated slow OR turnovers at Boston Children’s Hospital identified several inefficiencies, including different team members cleaning their own designated objects in the same space.

Mr. Inferrera says adaptability and interdisciplinary collaboration are keys to the OR pit crew’s success, because many cases can require a nuanced approach that must be planned before they end. Two examples of such procedures are tympanostomy tube insertions and orthopedic spinal fusions, he says.

The tube insertions are short cases that generally produce light accumulations of bioburden and waste. When the patient is wheeled out of the room, ORAs follow AORN guidance for environmental cleaning to remove debris and decontaminate anesthesia cables, the front of the anesthesia machine, the anesthesia supply cart, the IV pole, the surgical bed, lights, straps and bed controls. If the floor and walls are soiled, ORAs clean them, along with any other items used during the case.

At least three ORAs are used after the spinal fusions. Multiple OR team members assist in removing trash and bioburden from the room. Working together to fairly distribute tasks within the group, two ORAs wipe down the anesthesia cables, the front of the anesthesia machine, the anesthesia supply cart, the IV pole, the surgical bed, lights, straps, bed controls, surgical tables, chairs, booms and foot pedals. “The floors can be visibly soiled, so we encourage an initial mop around the surgical space to remove visible bioburden, followed by a thorough mop after moving all equipment to ensure the removal of all contaminants left by the previous patient,” says Mr. Inferrera.

Communication keys

Nurses and clinical assistants take the lead in declaring what needs to be decontaminated in the high-volume outpatient ORs, which streamlines the turnover process for the ORAs. “In an effort to promote high reliability, we work closely with our anesthesia tech group to ensure that the anesthesia space is decontaminated while the OR assistant group is actively working in the rooms,” adds Mr. Inferrera. “This helps expedite anesthesia techs’ turnovers and allows them to focus on more time-consuming tasks. If they are present while the ORAs are actively decontaminating, they always lend a hand.”

The collaboration between nurses, surgical techs, anesthesia techs, clinical assistants and ORAs has ultimately made the pit crew approach successful. “Sharing what’s needed ahead of time, rolling up your sleeves no matter your role, and having a shared understanding of the evidence-based practices that must be followed without cutting corners is the best approach to create a safe, clean environment of care for every surgical patient,” says Mr. Smith. OSM

EFFICIENCY HACKS

Five Ways to Reduce Turnover Time Without Sacrificing Quality

Here are some standard practices during “Pit Crew” turnovers at Boston Children’s Hospital that could work for your facility:

• Add ORAs. After comprehensive training and competency assessment, this position can handle advanced environmental cleaning activities such as decontamination of anesthesia equipment, surgical robots, electronics, consoles, booms and positioning equipment.

• Establish pre-turnover tasks. Nurses and other members of the OR team help prep the room for turnover by gathering equipment and positioning supplies for the next case.

• Assign a flow manager. This role leads the pit crew, facilitates communication among ORAs, clinical assistants and anesthesia techs, and monitors room turnover throughout the day. The flow manager also reviews turnover data to identify opportunities for ongoing improvement.

• Standardize timing of turnover workflows across all roles. Set the amounts of time each turnover task should take. This will help pit crew members assess whether they are completing their tasks on time, or whether they’re working too quickly.

• Create a standardized turnover checklist. This document should list items that need to be decontaminated and specify the disinfectants that should be used. All team members should work off this checklist to avoid duplicating or neglecting tasks.
—Carina Stanton