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Communication is the key.

With 191 nurse delegates, 35 medical medical product supply companies and a total of 259 participants from around the country, the 45th Perioperative Nurses College Conference in Nelson was a great success.

Held at the Rutherford Hotel from October 11-13, the conference was run on the theme of 'Communication is the key'.

In the perioperative environment, we are the unconscious patient advocates. An integrated team approach involving open communication and respect for our patients and colleagues is paramount. An overview of the presentations is provided for those members who were unable to attend.

Surgico Free Paper Session

Registration on Thursday October 11 was followed by the Surgico Free Paper presentations.

Jenny Green was the first presenter and discussed the preparation of undergraduate students at Massey University prior to their perioperative clinical placement and how to help overcome the fear of the unknown and facilitate students' involvement and comfort in the setting.

Kathryn Skadiang presented an audit of paediatric fasting times at Manukau Surgery Centre. The audit produced results of variable and long waits for children. Kathryn recommended that fasting times of clear fluids be reduced to one hour for paediatric elective surgery.

Tracey Lee discussed how staff recruitment and retention needed to work hand-in-hand. Filling one position without plugging the other leaves you with a constant drain or not enough to begin with. Tracey outlined the teamwork-based approach used at Auckland City Hospital involving all stakeholders to identify what drives the workforce and what can be done to support them meet their goals.

Debbie Booth Travel Award

There were four papers presented in the Debbie Booth Travel Award, sponsored by Obex Medical with the runner-up award sponsored by Boston Scientific.

Stephen Cotterell from Christchurch Hospital discussed advancements in Central Venous Access Device (CVAD) placement and care. In particular the insertion of tunnelled catheters in the upper arm and chest veins where Peripheral Inserted Central Catheters (PICC) are not recommended. Stephen has completed the required education, competences and supervision to insert these lines, offering another option for patients.

Shona Matthews from Auckland-Northland region drew on the conference theme to discuss communicating and rapport-building with patients in the outpatient medical imaging setting. She outlined strategies to quickly establish rapport with patients, put them at ease and ensure they understand their pending procedure.

Gillian Martin from Auckland-Northland looked at the evolution and role of the nurse, from Florence Nightingale's time to the current care of patients in a rapidly developing medical imaging setting.

Andrea Walford from Hawkes Bay talked about dealing with patients with difficult intravenous access (DIVA). She outlined the development of their ultrasound-guided IV access service utilising their PICC insertion skills. She offered pointers and video footage for those wishing to start such a service.

A welcome reception with refreshments and canapes followed, along with the opening of the trade stands. It is important to acknowledge the contribution of partner sponsor REM Systems, leading sponsor BSN Medical along with Stryker sponsorship of the breakfast session, Manuka Street Hospital the very welcome coffee cart and supporting sponsors Hallmark Surgical, BOC Limited and Southern Cross Hospitals Limited.

Trade support is critical to running our annual conference.

KEYNOTES & PLENARY SPEAKERS

The Friday programme opened with a mihi whakatau (welcoming speech) led by Tui Lister. This was quite beautiful and set the tone for the conference to follow over the next two days.

What's your prison?

Dr Paul Wood is an expert in helping individuals and organisations turn adversity to their advantage and ensure change leads to growth. Paul's passion for transformational change comes from his personal journey from 'delinquent to doctor' which he discussed in depth. He was quite simply inspirational.

Paul's mother died when he was 18 and with her declining health and death, any softness went out of his life. His father was a stern man who brought him up hard but fair. His personal identity was battered and he felt he was not enough of a man, so he took drugs and became quite violent to overcompensate. He lived in a tough world where violence and the drug culture was everything.

After his mother's funeral, Paul met with a drug dealer for his latest fix. The man was a sexual deviant and sexually assaulted Paul, who retaliated and beat him to death. Paul was sent to prison.

"My life potential was fixed in the mental prison in my mind," he said. Where you end up in life is your choice.

On turning 20, he was transferred to the notorious B Block at maximum security Paremoremo Prison. Life was bleak but one day in the yard he met another prisoner, who changed his perspective on what he thought his reality was. This change in thinking led Paul to begin studying for a degree in psychology despite his limited educational background and the prison authorities making it difficult. His father enrolled him and paid his university fees. After eight years' study, he obtained a Doctorate.

Paul outlined what he called the 'Five Steps to Freedom.' This requires recognition that we are born free; we have no agenda, ideas or expectations. We are a blank canvas. As we grow, we acquire self-defeating beliefs that limit our potential or create our mental prison. Paul had to be in actual prison before he could recognise this.

Step two requires choosing to break out of our prison, be it mental, or in Paul's case, also physical. This depends on what our desires are and how desperate we are for change and what our limiting beliefs are. To break out there has to be a real emotional commitment to change. Often we don't want to risk failure, when we are comfortable enough with our life.

Determine where you are and where you want to be in your future and make the escape. Change may seem beyond your reach and for Paul this also required quitting marijuana. You need to have specific goals for your life right now and make change, with a focus on the present.

The fight for freedom requires grit and tenacity to overcome obstacles as well as the support of others. In Paul's case, that came from his father who visited him every week and paid for his education and his tutors at Massey University. The tutors also visited him in prison at postgraduate level where face-to-face contact was required.

Paul describes personal courage as being like a muscle; the more it is used the better it works. Finally he talked about keeping it real; acknowledge that sometimes we will slip back. Living free is about trying to be the best version of yourself with the goal of getting better.

Paul gave us so many lessons that will ensure the way we communicate with ourselves propels us towards our potential, rather than holding us back. He was an inspiration and an amazing example of what can be achieved with self-belief and support of others.

Dr Paul Wood's much viewed Auckland TED talk can be accessed at www.youtube.com/watch?v=LjjlsW1MDmc

Cyclone ITA hits Nelson! Scenario and debrief

Cyclone ITA hit Nelson on Good Friday 2014, with the wind gusts damaging the roof of Nelson Hospital. A 1000kg copper sheet was blown from its fixings and dangled precariously above the intensive care unit (ICU) roof. Code White was declared and when the severity of the situation was realised, this escalated to Code Red.

What happened next was described in the presentation from Emergency Management and Business Continuity Planning manager at Nelson-Malborough DHB, Peter Kara, along with operating theatre and post anaesthetic care unit (PACU) nurses Bronnie Ball, Pamela Millson and Isobel Heslop.

Emergency services were called, the main road outside the hospital was closed and a helicopter was brought to the road outside as the helicopter pad was in the storm damaged area.

It was decided patients in ICU had to be evacuated a soon as possible to PACU and a crane was organised to cut off the copper roof, no mean task on Good Friday. There was a great risk in doing this, as if let loose, the copper sheet would have "guillotined" into the ICU.

Assumptions were made as to who had been told. Unfortunately, theatre and PACU staff were not notified, a major 'communication breakdown'. At the same time, it was necessary to perform an acute caesarean section and two nurses were called in to work. PACU staff did not know the ICU patients were coming. In fact, the theatre manager did not find out about the emergency until after the weekend.

The move, although part of the hospital plan, had not been practised frequently but the eight ICU patients were evacuated. Was everything all right? No it was not. More research was needed and further review of procedures.

After any emergency, debriefing is absolutely critical. The question was raised 'where to from here and how do we do better'? The main issue was clear lines of communication.

Thunderstruck Scenario

Following the presentations on Cyclone ITA showing the need for Emergency Evacuation Procedures, Tim Ellena RN, (surgeon) Matt Crocker RN (Anaesthetist), Andrew Green (Anaesthetic Tech) and Peter Kara set up a practical interactive breakout session incorporating the steps leading up to an evacuation. The simulated situation was very real with only in-house smoke missing from the room.

Tim used two members from the audience to be the scrub and circulating nurse, which helped them feel the stress of the situation. The purpose of this was to familiarise conference participants with the process of practising emergency scenarios (Thunder Struck as we call it) and to see for themselves the logical steps that need to be taken for a smooth-running real-life evacuation.

Practise makes perfect and if everyone is communicating and working towards a common goal, lives will be saved. Our goal was to give other hospitals a platform to follow to help them implement their own evacuation scenarios if they so wish.

This was an idea based on experiences from hospital staff who had been in the Christchurch earthquake. Their experience showed trial evacuations had limitations and research can often lead to the simplest solutions. Hence Thunder Struck was born and showed the need to make quick decisions. Knowing the plan ahead of time makes a difference. In addition, exercises only work with engagement from all staff and if there is a defined goal, that has benefit.

Simulation exercises were begun with help of the Fire Service, including smoke-filled rooms, injured people lying on the floor and an anaesthetised patient. It was found that a patient could not be moved very far on the operating table as it was impossible to lift the table across the flooring joins between rooms. Task cards were made, and jerkins hung in "Main St" for each leader.

When it is time to leave or move into another fire cell--it is not a discussion, it is a decision. Good, quick sharp communication will save lives--so communicate and move effectively. In turn, learning needs to be converted into actions and checklists. Debriefing is important.

Invite fire service and staff from other hospitals to learn from the experience and share ideas and information. Nelson Hospital has made up a series of check sheets that can be accessed here:

https://www.dropbox.com/sh/5e0wncwjpoa5nyj/

AAAEPAPM2y8b5Wg5Hja5cMr8a?dl=0

Effective surgical teams

Claudia Teunissen is Charge Manager Operating Theatres at Nelson Hospital and has a background in change management and the introduction of the Surgical Safety Checklist in a range of settings. Claudia's review sought to identify and critically appraise the literature around the relationships between inadequate communication and teamwork within perioperative teams and in turn the barriers and challenges to achieve continuous quality improvements and reduce perioperative harm.

Dynamics within the multi-disciplinary perioperative team and deficient understanding of the respective competencies for individual professions is a barrier to collaboration. This is compounded by restricted availability of and inconsistent team training or simulation. In addition, financial influences, health targets and expenditure priorities take precedence over other developments in service organisations.

Claudia highlighted the need for consistency and permanency in the operating theatre and the importance of the manager understanding the skill mix and competencies of individual staff. There are barriers to effective surgical teams and Claudia described them as high staff turnover, team composition, and perioperative teamwork concept and organisation performance incentives.

She believes the solution is more professional education. There is also a need for incident reporting to highlight any problems.

The effective teamwork was tested in the inter-disciplinary simulation at Nelson Hospital and later Wairau Hospital. The annual exercise addressed existing barriers and challenges to achieve continuous quality improvements in reducing perioperative harm.

Claudia also participated in the Thunder Struck stimulations at the breakout sessions to further demonstrate how the model works in reality.

Rhythm Interactive

As we walked through the door for this session, looks of surprise and smiles were on our faces when we saw a drum waiting in each seat! On the stage two performers did not utter a word. Then they began to drum--and we attempted to follow, directed by actions and body language only.

We laughed! It took us a while at first to correctly mimic the drum beat as a group. The lead performer's pleasure and displeasure was obvious when the audience hit the mark and also when we did not!

Rhythm Interactive showed us the art of non-verbal communication through an interactive drumming session. There was no talking, although singing and humming was eventually incorporated. Audience participation was strong and no one was snoozing following that lovely lunch we had enjoyed. They were so good that one of our international visitors wants them to come to their country!

Communicating with your colleagues-Personality Plus

Maryanne Coyle has an extensive career in Operating Rooms throughout New Zealand and the UK. After training in Wellington as an RN, she has worked in Sydney, London and Southern Cross Christchurch. Maryanne is currently a Territory Manager for REM Systems.

Over the years Maryanne has developed her public speaking skills, utilised to speak at national health conferences. She also facilitates workshops and seminars for operating room (OR) staff. Maryanne's sessions are always funny, provocative, relevant and important. She did not disappoint in Nelson.

There is no right or wrong personality. Everyone has a different personality and each style is equally important. So how do staff members utilise their communication style to function and relate to their team?

Maryanne provided a snapshot of the four styles of personality to assist us in working out what personalities our colleagues have. This can help us to understand them better in the work place.

The four styles of communication were identified by Maryanne: analytical, driver, supportive, expressive. These four styles are characterised by their responsiveness. Responsiveness ranges from a people-orientated approach to task-orientated. All types care about people, but their focus is different.

Analytical - are more task-orientated. Their emphasis is on working conscientiously within existing circumstances to ensure quality and accuracy. They expect precision, efficiency and high standards.

Driver - their emphasis is on overcoming the opposition to accomplish results. They focus on results, efficiency and action.

Supportives are people-orientated. Their emphasis is to co-operate within existing circumstances to carry out the task. They want team stability and collegial relationships.

Expressives shape the environment by influencing or persuading others. They want challenge, excitement and relationships.

In addition to these communication styles there are varying degrees of assertiveness. They may ask--an indirect method of communicating or tell--a direct method of communicating.

Both communication styles can influence to the same degree, but their approach is different. For these communication styles to work they have established ways, which require certain environments, attributes and situations.

Maryanne presented her own experiences, giving us a better understanding of the principles of dealing with personality styles in the OR.

Communication vital in SSI prevention

The ever-changing landscape of infection--how communication is vital in preventing infection in a world of antibiotic resistance was the core of the presentation from Elsie Truter. Elsie has a background in Perioperative Nursing, a Master's degree in medical ancient history and currently works as the Infection Prevention and Control professional in a small private hospital. She delivered a fascinating presentation looking at healthcare through the ages.

The Romans had excellent public health facilities, with the first recognised hospitals built to treat soldiers and veterans. Roman medicine grew out of what military doctors learnt and demanded. Elsie showed slides of layouts of Roman military hospitals, with separate medical and surgical wards, fresh rainwater collection for dressing wounds and single rooms for patients. Many surgical instruments bear a striking resemblance to instruments used today, including duck-billed speculum!

Elsie then covered healthcare and hospitals in Europe during the Middle Ages. At this time, hospitals were called "spittle houses" and provided care for the sick, insane, and destitute. Persons of means preferred to receive care at home, with the kitchen table often used as a makeshift operating table. Cleanliness was virtually non-existent. Hospitals were crowded and rats ran amok, often over patients. Infectious diseases strongly impacted life in medieval times and bubonic plague killed about one-third of all people in Europe between 1347 and 1350. As well as plague, epidemics of smallpox, influenza, dysentery and typhus were frequent.

The final third of the presentation looked at our healthcare practice from the 1940s until today. Although there have been huge advances in medicine, surgery, including operating theatre design and microbiology, antibiotic resistance has become a problem. It is believed that contamination of surgical wounds mainly occurs at the time of surgery, eventually leading to surgical site infections.

The operating theatre is a complex system in which many risk factors are present. This includes not only the features of the structure and its fixtures, but also the management and behaviour of healthcare workers. Sub-optimal behaviour and equipment can threaten asepsis, such as eating food in theatre, poor cleaning practices, and fabric covered chairs, to name a few. Adverse surgical events may be due to poor communication, bad operative technique, malfunctioning or improperly used equipment and cognitive errors due to stress or inattention.

Communication in the operating suite is often poor and may contribute to adverse outcomes. Studies have shown that improving the physical layout of theatre and improving staff behaviour results in a reduction in contamination and, consequently, surgical site infection.

Cultural engagements

The next session was about korero mai--cultural engagements with Maori patients and their whanau and was presented by Tui Lister. She has been senior Maori health practitioner for Te Waka Haurora services at Nelson Marlborough DHB for the last ten years. Tui explained how this role provides support for Maori patients and their whanau and she feels privileged to work with patients at their most difficult times.

Tui serves as the bridge between patients and health professionals through their health journey and treatment, relaying health messages and explaining what was said as well as helping whanau access the appropriate treatment. She found one of the biggest challenges for patients is the medical jargon, which she acknowledges took her a few years to master. She will visit whanau in their home and accompany them to appointments.

One of the difficulties when encountering Maori patients is their historic fear of hospitals ("you go there to die") hence their reticence for attending follow-up appointments and treatment. Tui explained how a one-on-one discussion with these patients--taking account all their concerns, which are not always evident to non-Maori--is often all that is needed for patients to be involved in their treatment.

Cultural support is another aspect of Tui's role, such as consulting on cultural practice. Tui applauded our efforts to return body parts to all patients. Some Maori patients were unaware that this is now standard procedure and are thankful that this is an easy event to manage. Tui shared her experience coming to the operating theatre to perform a karakia prior to a procedure.

Tui has a gentle accommodating manner. She is able to reassure patients and empower them to actively participate in their own healthcare. Tui is passionate about developing programmes to improve Maori health status and actively works with both hospital and community social workers to support whanau through incidents of family violence and abuse.

POMRC: who we are and why are we important?

The Perioperative Mortality Review Committee (POMRC) was established in 2010 as an independent review committee that advises the Health Quality and Safety Commission (HQSC) on how to reduce the number of perioperative deaths in New Zealand. Its aim is to reduce these deaths and improve the quality of the health system and outcomes for patients.

Stephanie Thomson is a Rotorua-based Nurse Practitioner in adult perioperative care with a wealth of experience in critical care, surgical nursing, quality and risk management as well as medical ethics both in New Zealand and overseas. She is currently serving a three-year term on the POMRC.

Stephanie outlined the history of the POMRC and its current membership. The committee publishes an annual report and she covered some of the findings. For example, the 2012 report looked at mortality in four clinically important areas: cholecystectomy, pulmonary embolus (PE), patients aged 80 years and older following both emergency and elective surgery and elective admissions for those classified as ASA 1 or 2 (American Society of Anaesthesiologists physical status classification).

Recommendations included VTE (Venous thromboembolism) prophylaxis, use of the Surgical Safety Checklist and informed consent, ensuring patients should know their actual risk of dying and the use of non-operative care pathways when surgery is deemed too risky.

Topics covered in subsequent reports include sepsis, reasons for Maori mortality, documenting ASA, death on a weekend, abdominal aortic aneurysm (AAA) deaths and subsequent recommendation for offering endovascular surgery when possible and hip fractures.

This was a very interesting session and provided a lot of insight into why we now have some of our checklists, and processes, and how they have evolved. See the full reports on the POMRC website.

www.hqsc.govt.nz/search?q="Perioperative+Mortality+Review+Committee"&start=25

More is not always better

Ophthalmologist Dr Derek Sherwood, Chairman of the Council of Medical Colleges and clinical leader of 'Choosing Wisely', delivered a thought-provoking presentation on "over treatment" of the patient.

As clinical leader of the Choosing Wisely campaign, Dr Sherwood informed his audience of how groups of health professionals are facilitating a culture change to stop unnecessary tests and treatments for patients and promote better decision making. "The care they need and no less, the care they want and no more."

Growing evidence suggests assessment of risk versus benefit of treatment is essential with fad treatments found to be of little or no value, with 3040 per cent of patients not benefitting from this.

Dr Sherwood highlighted attitudes that needed to change in a culture of overuse, for example 'because it has always been done that way, 'patients want it', 'community want it', poor patient understanding of risk or benefit and the 'referring Doctor wants it.'

He emphasised that Choosing Wisely promotes a culture of shared decision making between health professionals and patients by having well informed conversations around treatment options.

The presentation concluded with four areas of discussion required between health professional and patients to improve decision making and quality of care for all patients. These were 'do I really need this procedure, what are the risks, are there simpler safer options, what if we don't do anything?

Visit the Choosing Wisely website for further information: choosingwisely.org.nz/

Stress management in high pressure environments

Dave Nicholls provided an informative and hilarious presentation on how to deal with stress in the hospital. Here are some facts about stress:

Stress levels take about 10 days to come back to normal. Two weeks of holiday every six months is recommended.

Food can impact on stress. Sugar-loaded diets are contraindicated. Over-indulgence in alcohol can detract from the balance. Having a meal within two hours of bedtime can also have a detrimental effect.

Stress and sleep: Studies have shown people age 45 plus who are having less than six hours sleep are 200 per cent more likely to suffer heart attack. Less than five hours of sleep can lower killer T-cells and compromise the immune system by 70 per cent.

Health supplements: four-six squares of 70 per cent plus dark chocolate per day can lessen the risk of heart disease and stroke. Oral vitamin C shows no apparent benefit, but intravenous administration has shown some benefit. The use of multi-vitamins it would seem causes a drastic increase in the incidence of head, neck, skin and breast cancers. Vitamin D is helpful to reduce the risk of cancer occurrence. Sun exposure is the source of vitamin D production and the use of sun screens interferes with this, hence 30 minutes of sun exposure each day is advised.

To conclude, we can manage our stress by managing our leave, taking vitamin D supplements, eating a little dark chocolate, and getting some sleep.

BREAKOUT SESSIONS

Working in Haiti

Dr Alex Rutherford is head of Orthopaedics in Nelson and Wairau where he has worked for the last 30 years. His presentation provided valuable insight into his work in Haiti as a member of Medecins Sans Frontieres (Doctors Without Borders).

Dr Rutherford became a member of Medecins San Frontieres, an organisation providing international humanitarian medical nongovernmental aid.

Following the 2010 earthquake in Haiti, Dr Rutherford was sent to provide surgical assistance at a 120-bed hospital in Port-au-Prince. His workload for two months consisted mostly of trauma surgery. He faced many challenges during his time there, predominantly around communication. Fortunately, he was provided with two interpreters (Haitian people speak only Creole or French). Haiti is a poverty-stricken country with poor infrastructure and is unable to cope with the frequent cholera outbreaks, earthquakes, hurricanes and political unrest.

Dr Rutherford shared photos of his time in Haiti via Power Point presentation, introducing the people he worked with, his living environment and graphic images related to the surgical work he performed. Many of the injuries he displayed were from motor vehicle accidents, gunshot and machete wounds. Other images showed infected wounds he had surgically treated and the on-going problems patients develop from these infections. He commented on how rewarding volunteer medical assistance can be to save lives and ease suffering of people in crisis situations.

ACC injury treatment

Addressing a full breakout session room, Charles Smith provided a succinct presentation around the Accident Compensation Commission (ACC) Treatment Injury: When to lodge a claim, surgical mesh-related claim insights.

Charles explained how ACC's focus had shifted since 2005 from 'medical misadventure' to 'treatment injury,' taking the blame and fault out of the equation and allowing for a more transparent system of assessing claims.

He presented several examples of ACC claims that were either rejected or accepted and explained why. There are links and flyers with information on how to know when to encourage a patient to make a claim, how to step through the process and even if some of the information is lacking, the role ACC plays in investigating this further.

Charles also encouraged any group--hospital or community-based--to contact ACC if similar a presentation on the system and claims process would be helpful. At the end of the session Charles covered outcomes of the ACC research regarding surgical mesh-related claims. Follow this link for more mesh data: www.acc.co.nz/surgical-mesh-claims

Difficult conversation

Biddi Hoskin is a registered nurse with over 20 years' experience working in operating rooms and currently as a Johnson & Johnson product specialist based in Wellington. She has had significant exposure to different teams, team dynamics and personalities. Her 30 minute presentation/workshop was from a book called 'Crucial Conversation by Kerry Patterson. The presentation and workshop focussed on keeping dialogue going during difficult conversations.

Biddi detailed how it is important to focus on "facts" and not the "stories" we may already have in our heads as we enter a conversation. Stories are the experiences we bring; some facts can be a number of stories.

Remember to suspend judgement and use the facts we have to avoid emotion. It is stories that bring emotion, not facts.

When emotions are heightened, voices are raised, and participants may leave. If this situation occurs it is time to pause, take a breath and stick to the facts. We act our worst when it matters most. Dialogue is not about winning but if you go back to the facts you are winning.

The workshop involved teams coming up with true, false, or unknown responses to a series of questions related to a situation both read to them and displayed on a whiteboard for 30 seconds.

The exercise was done to make the point that we cannot assume and always need to return to the facts.

There was good engagement in the workshop and it was interesting to see the team dynamics after the other material presented on communication styles. The take home messages was: always stick to the facts and not the stories--and suspend judgements.

Surgical plume safety

Kay Ball is a Professor of Nursing at Otterbein University in Ohio, USA, a past President of the Association of Peroperative Registered Nurses (AORN) and earlier this year published 'Lasers the Perioperative Challenge'. (See book review, page 38).

More than 500,000 healthcare workers are exposed to surgical plume every year, with staff experiencing headaches, watery eyes, nausea, fatigue and respiratory problems. This is a workplace safety issue.

Cases documented included a 44-year-old laser surgeon and a 28-year-old gynaecology theatre nurse who repeatedly assisted, presenting with laryngeal papillomatosis; a gynaecology surgeon presenting with cancer of the tonsils and another with tongue cancer. Operating theatre personnel have presented with bladder cancer, commonly found in cigarette smokers, despite never smoking.

Research (Tomita et al., 1989) shows that the amount of smoke condensate from one gram of tissue was the equivalent of three unfiltered cigarettes in 15 minutes from laser plume, and six unfiltered cigarettes in 15 minutes from electro-surgical unit (ESU) plume. The mean activation time of ESU plume was 12 minutes 43 seconds. This equates to 27-30 unfiltered cigarettes being smoked in the operating theatre on a daily basis in order to generate a passive air pollution with an equivalent mutagenicity.

The hazards of surgical plume include toxic gases of more than 150 chemical compounds, some of which are carcinogenic and have a cumulative effect. Particulate matter--77 per cent of which is greater than 1.1 microns in size--ends up in the lung alveoli and is potentially damaging. It also decreases visibility of the surgical site.

Papilloma virus remains active post laser excision, potentially causing subsequent infection elsewhere. In addition, laparoscopic plume from low temperature devices is absorbed by the patient and is known to cause post-operative nausea and vomiting, headaches, and double vision.

AORN, the International Federation of Perioperative Nurses (IFPN) and other professional organisations in the USA recommend the use of plume evacuation systems while Denmark prohibits the use of energy devices without plume evacuation systems. The best solution is protection with good room ventilation, workplace practice controls using plume evacuators and adherence to written policy and procedures.

Smoke evacuation equipment collects and filters large amounts of plume and these devices should be quiet, easy to use, readily moveable and effective. Education of both medical and nursing staff is very important as this will create 'buy in' from those using the equipment that creates plume.

Create a sense of urgency--your lungs are NOT the place to filter plume.

PACU--implementing 'protective pause'

Cath Greep spoke on the journey the Nelson Hospital Post-Anaesthetic Care Unit (PACU) team has been on, working to introduce a 'protective pause' at the time of patient handover from theatre team to the PACU nurse.

Cath discussed the timeline of how this eventuated for the Nelson Hospital PACU team. It resulted from three of the Nelson Hospital PACU nurses attending an education day and presentation by Dr Adam Hollingworth on a project he had done on improving PACU handovers.

She presented the adapted format that has been developed to suit the Nelson Hospital PACU unit, described how the idea was introduced and adopted by the Anaesthetic department and how all the team members, including theatre nurses, have got on board with it. She discussed some of the blocks they had when starting to use the handover tool and how it has improved the care of the patient at handover time.

Out-of-Hospital STEMI pathway

Kris Gagliardi, an intensive care paramedic and National Patient Pathway Manager for St John's NZ, presented 'the NZ Out-of-Hospital STEMI Pathway: why do we need it?'

This in-depth presentation of the development of critical time-dependant out-of-hospital cardiac reperfusion therapy related completely to this year's conference theme. Kris laid out the rationale for the collaborative effort between his team at St John and specifically Dr Tammy Pegg at Nelson Marlborough DHB. Together they created an expeditious pathway to reduce the time getting lifesaving treatment to those in the community suffering a heart attack--in particular a ST-segment elevation myocardial infarction (STEMI).

The crux of the effort is direct communication via an ECG transmission application and phone conversations between those treating the patient "out in the paddock" and an on-call cardiologist.

Instead of waiting until the patient arrives in the emergency department--potentially an hour or more away in the rural setting--St John staff in Nelson-Marlborough DHB are able to administer clot-dissolving medication by following the STEMI Pathway, while under the direction of the cardiologist. The on-call cardiologist then makes the decision to direct St John staff where to take the patient. Sometimes this would be airlifting the patient directly to Nelson Hospital. After hours, the patient will be transferred to Wellington where a waiting team would have been assembled to take the patient to a cardiac catheterization lab for emergency cardiac angiogram and percutaneous cardiac intervention (PCI) care.

During the question and answer time following the presentation, Kris was asked about the "medical staff only" Facebook page set up to aid further communication and learning opportunities. Through this venue, the national roll-out of the STEMI Pathway, along with episodes of pre and intra hospital care, is discussed. This collegial process has led to improved communication and to improved timelines, providing even better cardiac service to the people of New Zealand.

Planning complex revision hip surgery

Vicki Smith, a registered nurse working as a Clinical Support Representative for Zimmer-Biomet, has many years' experience in orthopaedic nursing. During her travels around New Zealand operating theatres, she witnesses the frustration from both nurses and surgeons in the organisation of revision joint surgery. The poor communication between joint revision surgery booking, theatre preparation and staff information sharing is apparent.

Vicki reflected on her first-hand experience as an RN and the lack of information available for the theatre prior to revision surgery. Confronted with limited details at the beginning of a theatre list--for example MR X Hip Revision Surgery--only created a number of questions. What equipment is needed? Do we have the equipment? Is it a total hip revision, the cup or the femoral component we are removing? What are we inserting?

These frustrating circumstances motivated Vicki to develop a revision hip booking form to improve communication in the theatre environment so staff were better informed prior to the start of a theatre list. The booking form covered important information: the procedure, operative side, surgery date, reasons for revision, implants to be removed, implants insitu, replacement equipment required, and extra equipment needed.

Vicki stressed the importance of communication with joint revision surgery because of the many types of revision, each requiring specialised equipment, and the many people involved from booking surgery to implanting the new joint. Deciding factors when planning each revision case centred around the questions, why are we doing the surgery? Is it for infection, dislocation, wear or fracture, and is partial revision or total revision required and is it cemented or uncemented?

Vicki gave a very good overview of the amount of communication required for planning joint revision surgery. She also provided essential information and encouraged hospitals to develop and use planning charts to ensure better preparation and management of a joint revision surgery theatre.

Dermal fillers and botulinum toxin

Juliet Asbery, is a nurse practitioner (Acute Care) in the plastics and reconstructive surgery specialty, member of the Preoperative Nurses College (PNC) Professional Practice Committee and Vice Chair of PNC presented a session entitled 'Dermal Fillers and Botulinum Toxin-a reconstructive or cosmetic tool?'

Botulinum Toxin is a neurotoxin produced by Clostridium Botulinum and while eight types exist, only A and B are used medically. Dermal fillers include collagen, synthetic and hyaluronic acid fillers. Dermal fillers are usually used to correct creases and lines, to plump up the lips and cheeks, and to enhance facial contours. They are all commonly used in cosmetic and reconstructive treatment.

Juliet acknowledged the billion-dollar industry behind these products but encouraged us to look beyond the initial assumption of purely cosmetic applications and showed the products as treatment options for cosmesis and moderate or severe disorders like Frey's syndrome or hyperhidrosis or excessive sweating, strabismus and blepharospasm.

She also advised a non-judgemental approach in the products' use for cosmetic treatment and consideration that what might be perceived as purely cosmetic by the practitioner could be perceived as very detrimental for the body image and identity of the client. She encouraged us to consider different concepts of beauty - rounder and softer facial features are often seen as more feminine and socially acceptable in females. For example, in some Asian countries an asymmetric or square face may be seen as an undesirable characteristic and socially limiting. Juliet highlighted that a comprehensive and professional client assessment, good communication skills and informed consent are crucial.

The skill of the injector combined with their clinical knowledge of facial anatomy and pharmacokinetics can be used to treat patients safely and effectively.

Find your leadership style

Laura Jordan is a registered nurse currently working in a casual post anaesthetic care unit, perioperative role at Nelson-Marlborough DHB.

Her presentation, 'Find Your Leadership Style (No--Doze Leadership)', focused on learning how your specific leadership style can bolster your approach to team leading, management, direction and delegation in the perioperative environment.

She spoke of her experience working at the National Outdoor Leadership School and of the correlation between this environment and nursing. We have to work as a team every day, be able to face new things but always with safety in mind, and be able to adapt as we go.

This was a good session to have after lunch as Laura had an interactive component to her talk. We all had to choose half of the room depending on whether we related our personality to Laura's description of 'water' or 'wind' and then 'hot tamale' or 'cool cucumber'. She then explained how the four different personality types might react in the perioperative environment and how our different personality types cope in leadership roles.

Masquerade Dinner

After a full-on Friday of serious and more lighted-hearted presentations on ways of communicating, stretching our personal boundaries and discovering what personality types we were, we headed down to the newly rebuilt Trafalgar Centre for the conference dinner.

The dinner theme was "Masquerade," which gave people licence to dress up as much or as little as they liked. There were some wonderful outfits on display. Juliet Asbery won the prize for the best female costume and Andrew won the best male costume.

The Challenge quiz tested people's knowledge about wines and the winemaking history and was great fun. It was a close call between Nelson-Marlborough and Hawke's Bay, with Hawke's Bay winning the 'Percy the Peacock' trophy in the end.

It was a great night with a great band, food, entertainment and fun with everyone mixing and mingling, even a touch of 'break dancing' with the Caterpillar being done.

The organising committee hopes everyone enjoyed it as much as they did.
COPYRIGHT 2018 New Zealand Nurses' Organisation, Perioperative Nurses College
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Title Annotation:pnc conference; 45th Perioperative Nurses College Conference
Publication:The Dissector: Journal of the Perioperative Nurses College of the New Zealand Nurses Organisation
Article Type:Conference news
Geographic Code:8NEWZ
Date:Dec 1, 2018
Words:6642
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Next Article:2018 ACORN 2018 Conference: Examining the Perioperative Nurse Surgical Assistant role.
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