The Hierarchy of Priority: Patient, People, & Paperwork

This blog is cross-posted on The Circulating Life

The operating room can be more than a little overwhelming at times. There's a constant flurry of activity as the team prepares for and then performs surgical procedures. Every case seems to have equipment and supplies for days, there's a million people, and every instruments has at least two different names, if not three. The chaos is enough to make a new person question their career choice.

For those of us that are used to the chaos and busyness, we tend to use the word "dance" to describe everything that happens in the OR. All of us have our part to play, we perform our part while others perform theirs at the same time, and together we pull off a solid, flawless performance with each successful surgery that we move through our department.

And while that all sounds very lofty and poetic, if you're looking at it through eyes that are new to the OR, it's just looks like chaos - organized chaos, sure, but chaos all the same.

What is going on?!

As you're learning, it's easy to feel pulled in different directions - help the scrub tech, plug in equipment, open extra items, answer the surgeon's phone, grab a medication for anesthesia, and hey! Where's the music? - but remember, while everything matters, not everything is equally urgent.

So, If you find yourself staring into the chaos, wondering, “Where do I even start? What should I focus on first?” I have some advice for you today that will help you as you learn to navigate the operating room and its multitude of needs.

Where do I even start?

This is where learning to prioritize will help you navigate the plethora of requests and demands for your attention. And the easiest way to think about prioritization in the operating room is to break everything down into the 3 P's: Patient, People, & Paperwork.

The Patient

The patient is, at all times, your number one priority. From the time you interview them in Pre-Op, until the time you drop them off in PACU, they will be your primary focus.

Everything that you do within the case can be see through the lens of patient care and patient safety: positioning the patient, the surgical skin prep, counting instruments and soft goods accurately, safe medication administration, confirming the correct surgical site, performing the timeout, etc. All of these tasks, and more, have a direct impact on the patient and their care, so when it's time for one of these to be done, they take priority over other tasks like grabbing extra supplies or charting.

Now, all of this is nuanced with the fact that you have to be aware of the patient, their condition, and their needs at all times. If the patient is crashing, or we're in an emergency situation, and something outside the room is needed, the best course of action is to run grab it so that the team has what they need to save the patient.

Whether it's a standard procedure or an emergency situation, everything we do is focused on the patient, and our activity is based on their level of need.

The People

There are A LOT of people in the OR, right? Who do you focus on? Who's request do you deal with first?

Anytime anesthesia has an immediate need, they always get my attention, because they are actively working to keep my patient alive. And since they're dealing with the patient, I address their needs first.

Following anything urgent from anesthesia, the scrub tech is my biggest priority. They're scrubbed in, setting up their sterile field and getting ready for the case. They can't just break scrub every time they need something, so it's up to me to ensure that their needs are met. And I want to set them up for success because we don't need any delays in starting the procedure or providing care. A delay negatively affects the patient, therefore, I'm going to make sure that I give them whatever supplies or instruments are needed.

I'm going to stay alert to the needs of everyone who is scrubbed in throughout the case, while also paying attention to anything anesthesia might need. Everything isn't urgent, but I have to be paying attention so that I can sift through everything that's being thrown at me and hopefully address the most important needs first.

It's difficult to describe the "filtering" of requests that goes on as the case progresses, but here are a few examples:

• Music? I'll get to that as soon as every other urgent task is completed.

• Closing suture? The case just started, I'll grab that once the case gets going and everything is settled.

• Missing instrument? Lemme grab it, I'll be right back.

• More irrigation? Sure thing.

• Open another blade? I'm on it.

The Paperwork

Finally, it's time to chart... Well, maybe. At any moment, someone at the field may ask for something, and the paperwork just isn't as important right now as the people doing the case.

It's so easy to lose sight of our priorities when we have so much pressure to get the charting done, and when there's this enormous mountain of paperwork screaming for our attention. Yes, the charting is important, it must be accurate, thorough, and complete. The burden of documentation is a very heavy one, for sure. And yet, we can always chart later. We can't take care of the patient later.

So remember to get the most important details like room times, staff in the room, and any implant information, because you can always fill your chart in after the patient gets to PACU. And if you have those key pieces of information, you won't have to go hunting for anything when you finally sit down to chart.

Clarity in Chaos

Learning to prioritize the needs of the patient and the room is a skill that you will develop over time and with experience. You're not going to be perfect at prioritization - there will be times when you choose to do a less important task first, and that's ok. You'll realize very quickly what the order should have been. But if you use the 3 P's as a filter for your decision making, they will help you as you learn to prioritize your tasks in the organized chaos of the operating room.

Until next time,

Melanie