Key Words
perioperative registered nurse, international surgical trip, operating room requirements, pre-trip planning, setting up an operating room
Synopsis
The purpose of this chapter is to help experienced perioperative registered nurses prepare for their first international surgical trip by familiarizing them with the process of establishing and running a successful operating room (OR) in an unfamiliar facility in a foreign country. This will be accomplished through discussions of pre-trip preparations, setting up the OR with limited supplies and resources, establishing professional working relationships with local staff members, planning ahead, conservation of supplies, and emergency preparedness.
Introduction
First-time participants on a surgical team trip may feel a measure of pre-trip apprehension. This is a normal reaction to an upcoming unknown experience with unfamiliar team members. Be assured that there are resources available to prepare you for your work. This chapter is one such tool. As an experienced OR nurse, you already possess a solid foundation in the basics of perioperative standards of practice. With a willingness to be flexible, an openness to becoming engaged in problem solving, and a desire to experience new people, places, and cultures, you will be well prepared to meet any challenge.
Pre-Trip Preparation
Your role is integral to the success of the trip. In addition to providing intraoperative patient care, the OR nurse establishes the OR and ensures that all equipment, instruments, and supplies are available and functioning properly during the entire trip. The responsibilities begin before departure.
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If you will be traveling to the site with an organization, contact organizing personnel pre-trip to learn as much information as possible about the facility.
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Contact previous trip participants to glean valuable information about the local staff and site resources.
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Review packing lists to familiarize yourself with the equipment and supplies being sent.
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On occasion, the bulk of the supplies will be purchased when the team arrives at the hospital. Inquire about the details of that process (e.g., Who is the local contact person? What supplies will be available?)
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If possible, visit the organization’s medical supply warehouse to learn the proper operation and care of the equipment.
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Explore opportunities at your own work site to learn how to clean, sterilize, and troubleshoot instruments and equipment.
During travel, it is imperative to keep track of all equipment and supplies. The containers should be counted as they are checked in to the airlines and every time they are back in your possession at a new destination. If applicable, arrange for safe overnight storage of the containers ( Fig. 1.2.1 ).
Establish the Surgical Suite
Upon arrival in the host country, the team travels to the facility where the surgeries will be performed during the duration of the trip. Work begins as soon as the accompanying boxes of equipment and supplies have been unloaded. The first task is to determine the perioperative space. This will be established within the limitations of the facility and in collaboration with the local staff. The team members discuss and envision the surgical suite setup as they tour the space provided ( Fig. 1.2.2 ). Patient flow patterns need to be considered. Ideally, the physical layout will enable an easy flow from pre-operative (PREOP) to OR to post-anesthesia care unit (PACU) to ward. For patient safety, the OR and PACU must be in close proximity. A small, quiet, calm space can usually be made available near the OR for patients to await their surgery. The wards are often in a more distant part of the facility.
Once the perioperative space is finalized, the OR nurse will need to assess available local resources and processes that the team may need to utilize.
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Key local staff members need to be identified (e.g., OR supervisor or head nurse, technician support staff). These colleagues will quickly become valued team members. This can be challenging if communication requires interpreter assistance. During the initial setup day, interpreters are extremely busy assisting with patient evaluations.
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Sterile saline for irrigation will be needed for all surgeries. Distilled water for the autoclave may be required. It takes time to obtain these fluids, so this should be a priority.
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Determine local facility instrument sterilization processes. Locate the hospital’s sterile processing department (SPD) or central sterilization area. Which local staff members will be responsible for sterilization of the instrument sets? What is their availability, and what are hours of operation? Negotiate the process for having the team’s instrument sets sterilized at the end of each day and retrieved the next morning ( Fig. 1.2.3 ).
FIG. 1.2.3
Local staff ready to assist with instrument sterilization.
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Locate an area to securely store team supplies. If the OR is large enough and not used by local staff during off hours, supplies may be kept in the OR itself. Often supplies will be stored in an anteroom or a room located near the OR. If necessary, obtain locks and keys for the OR and storage room.
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Determine how to locally procure needed supplies. Team supplies are limited, and some items may run out before the trip is over. Certain items may be easily obtained within the facility (e.g., gauze, syringes, disposable gloves). If sterile gowns and drapes run out, local sterile cloth gowns and drapes may be available for team use ( Fig. 1.2.4 ). Identify key local staff members who are authorized to obtain these supplies should they be required.
FIG. 1.2.4
If team supplies run out, locally supplied sterile cloth gowns and drapes are utilized.
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Inquire about facility environmental services processes.
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How are clean linen for the OR bed and positioning aids procured?
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What are the trash and soiled linen removal processes?
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What is the local system for sharps disposal?
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What is the procedure for room cleanup between cases and/or terminally at end of the surgical day?
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Creating a Functional Operating Room
The next major activity centers on setting up the OR. The first task is to determine the layout of the OR. This is accomplished in collaboration with the team anesthesia providers. The arrangement of the room and final OR bed placement will be based on the most appropriate space for setting up the anesthesia machines.
Assess Available OR Furniture and Equipment
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Beds/stretchers
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Familiarize yourself with the OR beds provided. In general, these beds are operated manually ( Fig. 1.2.5 ). Practice using the controls because some functions may not be fully operable. Critical functions for successful surgery include locking/unlocking, Trendelenburg, raising/lowering, side tilting.
FIG. 1.2.5
An example of a manually operated surgical bed.
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Be aware that transport stretchers may not raise/lower and may have no brakes or side rails.
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Lighting
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Most facilities will have at least one ceiling-mounted light. Determine whether these lights are fully functional and adequate for OR bed placement. Often additional portable lights may be required for surgeries involving multiple procedures (e.g., burn scar excision and simultaneous skin graft harvesting).
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Be prepared for power outages by having alternate light sources ready (e.g., flashlights, headlamps, or mobile phone flashlights).
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Tables
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Obtain tables as appropriate for anticipated procedures. A flat surface is required for a sterile procedural back table. A small cart with functioning wheels is ideal. Mayo stands are not always readily available.
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A larger table can be used as the OR nurse’s work space ( Fig. 1.2.6 ). The supplies used on every case can be placed here for quick access (e.g., non-sterile examination gloves, prep solutions, local medications, dressing supplies, positioning aids, tape).
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