Problem: Researchers, policy-makers and the national news media have shined a bright light on the problem of preventable medical errors. Among the most alarming preventable errors are those that occur in the operating room. Few have explored how common operating room policies and inadequate staffing contribute to these errors, or how these may be changed to improve patient outcomes.
Background: As a nursing student in the Netherlands in the 1980s, AkkeNeel Talsma, PhD, RN, spent her days reading the work of pioneering nurse-scientists on the other side of the globe. “The United States was on the vanguard of nursing theory at the time,” she says. “It was 10 years ahead of everyone else, and I wanted to take advantage of that.”
That she did. Talsma earned her master’s and doctorate degrees in nursing from the University of Michigan and worked for a decade on quality improvement and patient safety in the private sector. Her work caught the eye of nurse faculty at the University of Michigan, who asked her to develop and teach a course on the quality of care. Her focus has since expanded; she now teaches courses in nursing business and health systems while, with support from the Robert Wood Johnson Foundation (RWJF) Nurse Faculty Scholars program, researching inadequacies in systems that may contribute to preventable patient safety events.
Curbing preventable medical errors is now a top priority on the national health care agenda thanks to recent reports calling attention to the problem. In 1999, for example, the Institute of Medicine (IOM) released an eye-opening report asserting that the number of annual deaths caused by medical errors exceeded those attributable to motor-vehicle accidents and high-profile diseases like AIDS and breast cancer.
“We need to better understand how we go about the perioperative care processes and how that influences patient outcomes,” Talsma says.
She is particularly interested in preventing postoperative infection. “Infections are very costly to the health care system and to the patient and family,” she says. “They lead to pain and discomfort, longer hospital stays, and a greater likelihood of complications or death.”
Hospitals are seeking to reduce the nosocomial—or hospital-induced—infection rate, and Talsma believes her research may help them do that and, in doing so, improve patient outcomes and lower costs. She hopes to help hospitals reduce infections by measuring the effects of certain perioperative practices and processes as well as operating room staffing policies.
“Getting to zero may not be likely, but we think we can reduce it a lot more,” she says.
Solution: To find ways to minimize the risk of postoperative infection, Talsma and her colleagues are evaluating perioperative practices and processes using a network of Michigan hospitals.
She is currently collecting data on how nurses prepare a patient’s skin for surgery and is linking these processes with patient outcomes. She hopes to answer questions like the following: Do hospital policies help staff follow recommended practices? What is the best combination of skin preparation agents and prophylactic antibiotics to reduce infections? What factors successfully reduce traffic in and out of the operating room?
Talsma’s initial findings suggest that there is significant variation in skin preparation practices and how operating room staffing arrangements are made. She and her colleagues are currently conducting analyses to better understand the health systems or contextual factors that contribute to such practices or staffing arrangements.
Talsma began this program of research in 2008, when she was named a member of the very first cohort of RWJF Nurse Faculty Scholars. She has received annual renewable funding for the project, called Perioperative Outcomes Initiative (POI), from BlueCross BlueShield of Michigan (BCBSM) / BlueCare Network (BCN).
For the project, 18 hospitals in Michigan track data and share the results with participating hospitals to initiate local improvement projects. Talsma and her colleagues analyze the data, write baseline reports and prepare graphics that are reviewed with hospital leadership. The information is also disseminated via conference calls called “Clinical Seminars.” Hospitals are encouraged to review their own results and determine if procedural or policy changes are needed to reduce infections and improve patient outcomes. “It’s a train-the-trainer model,” she says. “Hospital representatives are encouraged to share the materials at department meetings.”
This initial phase of baseline analyses aims to establish an understanding of perioperative practices and processes that are associated with optimum patient and hospital outcomes, and to build a foundation for further research. Findings are presented nationally and submitted in manuscript form.
The novel approach allows for in-depth study and long-term evaluation of innovative practice-based interventions and both patient and hospital outcomes. “Our analyses have led to the development of two operating room staffing measures that highlighted an association with patient outcomes such as infections,” she says. ”We have established a baseline performance of perioperative practices and processes. The next phase will focus on determining the impact of specific practices on outcomes.”
Talsma currently has several papers under review by academic journals and is invited to present findings at the Association of periOperative Registered Nurses (AORN) meeting in March. Her long-term goal is to develop an optimum health care delivery system aimed at improving outcomes, which would directly benefit patients and families. “I feel that we’re scraping the surface on understanding how the perioperative process affects outcomes,” she says. “The research is developing, and we are focusing our efforts on generating new knowledge to deliver high quality and safe patient care.”
RWJF Perspective: In 2008, Talsma was one of 15 inaugural junior nurse faculty nationwide to receive a Robert Wood Johnson Foundation Nurse Faculty Scholars award. The three-year, $350,000 grant supported her research into the relationship between hospital procedures and patient outcomes from a nursing perspective. The award also supported Talsma’s participation in a training program to help prepare her for academic leadership and translating evidence into policy and practice initiatives.
The goal of the RWJF Nurse Faculty Scholars program is to develop the next generation of national leaders in academic nursing through career development awards for outstanding junior nursing faculty.