Spectators in the OR - discussion of operating room nursing law

AORN Journal, Feb, 1997 by Susan E. Ziel

Observing surgery has become the health care industry's newest spectator sport, in which a seemingly endless stream of students, sales representatives, sports trainers, and others can gather to view surgical procedures. This trend opens a new area for the liability of hospitals and hospital personnel. The following is an example of what an OR supervisor might encounter in a typical day.

It is only 7:15 AM, and the OR supervisor already has had to speak with Dr Jones, a gynecologist, who invited three students to observe a surgical procedure today without obtaining the necessary authorizations. After learning that the three students were Dr Jones, son and his two college friends, the OR supervisor notified the chief of surgery, who promptly interrupted Dr Jones, well-intended, but not well-thought-out, plans.

The OR supervisor winds his way down the crowded hallway to relieve the circulating nurse in OR 12, and he scans the many masked, but not always identifiable, faces that hurry past him. As he approaches OR 3, he observes a nursing instructor leading what appears to be a nauseated student out of the room.

Between ORs 4 and 5, he sees a sales representative trying to sell a young thoracic surgeon on the benefits of a new chest tube as she scrubs for her next procedure. The surgeon looks gratefully at the OR supervisor as escorts the salesperson back to OR 7, where the sales representative is supposed to be observing another thoracic procedure. Peering through the window of OR 10, the OR supervisor checks on the assistant football coach and trainer as they videotape an orthopedic surgeon's efforts to repair their star fullback's injured knee.

It is another day in the life of an OR supervisor, who must depend on competent surgeons and surgical staff members to enforce policies and procedures that limit the risks associated with unauthorized access, invasion of privacy, and wrongful disclosure of confidential information.

UNAUTHORIZED ACCESS

Safety and security are significant concerns in perioperative settings because patients are vulnerable when they are induced with anesthesia or given mind-altering medications. Surgeons and surgical staff members wear many layers of masks, gowns, and other required protective garb that may make them indistinguishable from visitors in the OR, who are similarly masked.

Given these concerns, only authorized and properly supervised people who are involved in duly authorized activities should be allowed in surgical suites. As a result, the hospital must select competent surgeons and surgical staff members who take their responsibilities seriously and who monitor and control the flow of services and people within the surgical suite. Well-drafted surgical staff bylaws, rules and regulations, and surgical department policies must identify specific people, prerequisites, and limitations necessary to authorize and limit access to the surgical suite.

At a minimum, such surgical staff and department rules should address each of the following questions in detail.

* What type of person is per-limited access to the perioperative setting? Students Leg, medical, nursing, allied health, premedical, college, high school) Sales representatives? Sports trainers? Coaches? Others?

* What is the procedure for requesting access to the perioperative setting? Who makes the request? Is it in writing? What information is required? How far in advance should the request be made@ Who reviews the request and makes the final decision?

* If access is granted, what other consents keg, patient, parent) must be obtained? By whom?

* What are the specific limitations Leg, related to attire, conduct, location) on the OR visitor? What type of orientation is required? By whom? Is the person there only to observe? If so, is he or she to remain in the comer of the room or in the surgical suite's observation deck? Can he or she scrub in and assist with surgery?

* What level of supervision is required? By whom? Who ultimately is responsible for this person's behavior?

* What types of recording devices (eg, camera, videotape, computer are allowed during the procedure? Are they inspected before their use? How is the confidential information obtained by these recordings protected from wrongful disclosure to a third party?

Students in the health care professions frequently are present in surgical suites to observe, and sometimes to participate in, surgical procedures; therefore, education programs and their instructors also have a legal duty to instruct and supervise these students adequately in surgical suites. The instructors, whether they are attending physicians or nursing instructors, bear a particularly important responsibility for the actions and behaviors of the students who are present during surgical procedures.

Such obligations, in addition to student prerequisites (eg, tuberculosis testing, malpractice insurance, cardiopulmonary resuscitation certification), should be stated clearly in the underlying training agreements between hospitals and education programs. Surgeons and surgical department staff members must supervise and control the access, supervision. and behavior of all students and other visitors who may be present, properly or improperly, in perioperative settings. Controlling OR access allows people from the "outside world" to learn more about surgery while protecting the safety, privacy, and confidentiality interests of surgical patients and hospital personnel.