Surgical Best Practices: Duke University Medical Center

SIP 4 Surgical Best Practices

Surgical Best Practices: Duke University Medical Center

Durham, NC

I spoke with the PACU and OR charge nurses.

PACU

PACU consists of 18 beds, not including ambulatory and peds. There is 1 charge nurse over the whole PACU and pre-op (like us) that facilitates pt. flow. They do team nursing with each team consisting of 3 team members. There are 3 team leaders, responsible for 6 patients and 3 nurses. Those 3 nurses each do direct pt. care (1 nurse: 2 patients) with an assistant( like HA). The team leader assists the pt. care nurses in her team with orders, tasks, etc and also relieves the pt. care nurses for breaks and lunches.

Staffing: All PACU nurses work 12h shifts. They staff the PACU 24h/day, 7 days/week. They do not do any call except for major holidays. Pre-op is staffed until 2000.

Leadership: There is a manager and a director for peri-op. The charge nurse said that staff are pretty satisfied overall and feel supported by the leadership.

Taking care of patients, Teamwork and Incentives: The charge nurse says their “team nursing” approach functions pretty well. Because of the “team” structure, they generally feel like they are able to take good care of their patients. They also have “flow” problems when the hospital is full and patients cannon move out of PACU.

People like working there because they get the shifts they want and they really appreciate getting their breaks on time.

OR

There are 30 operating rooms with an average of 50 cases/day. They have a separate ASU (ambulatory surgery unit) and pediatric OR.

Teamwork: There are teams based on service specialty, (sounds similar to us), who work together regularly during the day (0700-1500). Nurses and surgeons will typically work together in teams, but anesthesia floats around more. After 1500, they try to keep teams together, but nurses work where they are needed. The teams who regularly work together are generally happy in their teams.

Staffing: Nurses work staggered shifts (sounds similar to us) with the majority working 0700-1500. There is better coverage prior to 1900. There is NO call and NO rotating shifts. Cardiac is the only service that does call. Everyone has a set schedule, like Sunday-Thursday or Monday-Friday. Some nurses choose to work the weekend option. (I think they work 24h and get paid for 36h. That’s what it used to be when I worked there, but I didn’t get all the details on it). They have MANDATORY OT 1 evening/ week 1700-1900 to accommodate the cases that go over block time. The OR charge nurse that the mandatory OT is utilized about 80% of the time, usually only until 1800.

Leadership: The OR has 6 nurse managers (plus 1 currently vacant) and 2 directors. The nurse managers are divided by service specialty (similar to our RN3s). There are NO assistant nurse managers. There is 1 Clinical Director who oversees daily operations and managers. There is 1 Director for Education who oversees the secretaries, charge nurses and 5 nurses who do the OR scheduling. (All OR scheduling is coordinated through RN’s. The OR charge nurse felt like this was not really cost effective.) Because there are so many managers, OR staff is treated differently depending on the manager. Some are more flexible and more respected than others. Overall, staff feels supported by management and empowered to do their work.

Amongst the surgeons, there is an obvious “pecking order,” very hierarchical. For example, a junior surgeon would NEVER bump a senior surgeon, even for an emergent case.

Incentives: They have a clinical ladder system with requirements to achieve the next step in the ladder (which also increases pay$$). All inexperienced nurses start out as Clinical Nurse 1(CN1). To advance to CN2, you have to be proficient in 1 service, which encourages the service specialty “teams.”

I asked if surgeons and anesthesia were equally incented. She said that CRNAs are salaried and get the same pay every month. There is no additional compensation for working over. She wasn’t sure about anesthesia, but thought they were salaried as well, not based on number of cases.

Duke has started a “profit sharing” system this year where profits would be divvied out amongst all staff if certain parameters were met. For instance, pt. satisfaction scores are >89% and the profit margin is above a certain level.

Communication: Both PACU and OR nurses felt that there is mostly respectful communication, which is much better than it used to be. Apparently, a surgeon was dismissed several years ago for “bad behavior” and things are much better now. There are policies in place to support staff and encourage respectful communication.

1/1/20192