Q. Staffing for laser lases

How do you staff for laser cases? We have been sending an extra nurse in the case to run the laser so the circulating nurse does not have competing duties. I am considering requiring the nurse to remain at the console during active use. If he/she must do something else, the laser goes on standby. Considering the procedure, this would be for vascular and urology cases only. ENT high risk would still have an additional staff in the room. What are you doing?
A: When we are able we put a second nurse in laser cases, but if not, we only have one.

A: The laser safety officer should have no responsibilities other than running the laser and ensuring staff and patient safety. We try to schedule a laser safety officer as our PRN person to give breaks and ready cases for the next day if they aren’t needed. Our specialty nurses are also laser safety officers and will break from their duties to run the laser also. It’s a better idea to staff smarter than to risk laser injury.

A: In the past, we assigned either a RN or a surgical tech to operate the laser console for the surgeon, However, laser use was definitely low volume, high risk. The staff were extremely resistant to operating the console, no matter how frequently laser training was provided.

We have a laser contract with a provider for cardiac procedures, who brings the Green Light laser; and when that contract came up for renewal, we added verbiage that the company would provide laser personnel support for all laser procedures, if requested, including CO2 and Holmium. In addition to personnel support, the company will also provide a laser, if requested, as our Co2 laser is considered obsolete (no parts or service support available).

The company provides the hospital with qualified laser staff/newer models of lasers, and the change has improved staff morale and patient safety – win win!

A: We have this as an outsourced service; they provide a certified laser tech to run the laser.

A: We have a company laser rep for many cases or a dedicated laser nurse if no rep [is provided].


Q. Immediate-use sterilization of eye trays for cataract surgery

How are facilities handling timely sterilization of eye trays for cataract surgeries with rapid turnovers? Are you purchasing 8-10 trays so you have enough to do all cases each day, are you using immediate use sterilization after you have exhausted wrapped trays for the day, or are you doing something else? Are you running a rapid B.I. and holding off using these trays until it is read out? Any information will be helpful.

A: On our busiest surgery day (usually 40-45 cataract cases), we have eight trays and always have a backup wrapped tray ready (tray No. 9) for emergency purposes (i.e. failed autoclave, dropped instruments, etc). We do spore tests before surgery starts. After all eight wrapped trays have been used, we reprocess with immediate use sterilization for the rest of our cases for the day. All of our trays are color-coded, and we keep track of which tray and instruments each patient uses for their surgery. On a consecutive surgery day, we run a rapid B.I., and we hold off using the unwrapped trays until read out. We always try and have three wrapped trays ready on the consecutive surgery day in case the B.I. read out is delayed, etc. It really depends on how many autoclaves you have, what type, and how to keep them running efficiently throughout the day versus how many cataract trays you need. We start at 7 a.m., take a 45-minute lunch break from about 11 to 11:45, and then finish our cases around 1 p.m. We have two ORs and are very efficient with our turnover time. Hope this helps.

A: We are working very hard to obtain enough trays to sterilize each tray. You are not allowed to start with wrapped trays and then switch to immediate-use sterilization. What you do for one patient must be done for all patients.

A: We are performing immediate-use sterilization. We are running a rapid BI as well.

A: We have increased our cataract tray inventory to 12 and have enough to use trays that have been through a full decontamination and wrapped sterilization cycle at all times. If we do more than 12 cases per day we have enough time to get the first trays used through the entire process and ready for the 13th and 14th cases. When we presented the risk of a TASS outbreak and the problems of providing an “inconsistent” standard of care to patients ,when some trays went through a complete sterilization cycle and some did not, to our administrators. They had no problem buying the extra equipment.

A: Do you have supporting documentation for that? Thank you.

A: Technically, that process would not meet TJC Standards. “Immediate use sterilization” should be reserved for emergent/urgent use. The reasoning behind that is each patient deserves to have the same standard of care… if one patient gets instruments that have full sterilization then all of your patients should get instruments processed in the same complete manner.

A: All trays process is the gold standard, but The Joint Commission will not give you an RFI if you use immediate flash sterilization. They understand that many organizations are under constraints both financially and operationally. However, they do expect to see a trend toward doing less flash sterilization.

What they will write you up for is if they do not see that you are working on the issue. They want to see that you have an action plan for reducing or eliminating flash sterilization. So if you are not there yet, don’t worry. Just make sure that you have a plan in place that you can demonstrate and speak to.

A: We purchased enough trays so we don’t hold up turnover. We hand clean and check and terminally sterilize.

A: We have been working on a reduction strategy for IUS of all trays but eyes are our most difficult hurdle. We have been following this and drilling down on the issues for over three years. As below, the expectation has been reduction of IUS and a Plan of Action that reflects that. We have reduced our overall rate of IUS for lack of instrumentation from >20 percent to 8 percent, and our target for IUS for lack of instrumentation is <3 percentage. Currently there are no benchmarks for this, but as many have said here, the goal is the same standard of care for all cases and NO IUS for lack of instrumentation.

These posts are from OR Nation’s listserv.