An Inside Look at Perioperative Nursing at Cleveland Clinic

They are integral members of each surgical team

“Every time you do a transplant, it’s one of the most amazing things you can be part of,” says Meghan Glanc, MSN, RN, CNOR, a nurse manager for cardiac, thoracic and pediatric congenital heart surgery at Cleveland Clinic main campus. “Watching somebody come in gray and struggling to breathe and then giving them the gift of this new organ is so powerful. It’s such a beautiful experience.”

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Transplants are just one of a multitude of surgeries done by surgical teams at Cleveland Clinic, where more than 216,000 surgical procedures were performed in 2018. Surgeries range from appendectomies to aortic valve replacements, from lifesaving craniotomies to life-enhancing abdominoplasties. Perioperative nurses are part of the Cleveland Clinic Nursing Institute, and they are integral members of each surgical team within Cleveland Clinic’s clinical institutes, where the focus is on safety and optimal outcomes.

“Part of the secret to our success is that perioperative nurses partner closely with all members of our interprofessional team,” says Carol Pehotsky, DNP, RN, NEA-BC, ACNSBC, CPAN, Associate Chief Nursing Officer of Surgical Services for Cleveland Clinic. “Nurses who choose to work in the surgical setting are detail-oriented, energetic, technologically savvy and flexible. They have to be as they react to unanticipated emergencies every day, facing some of the most challenging cases and evolving situations.”

Pehotsky started her nursing career on a medical-surgical unit and moved to perioperative nursing in 2005. “It’s action oriented. A patient has a problem, and we’re going to do everything in our power to fix it. It’s exciting.”

Patient advocacy and surgical innovation

Cleveland Clinic’s perioperative nurses work in preoperative, operating room and post-anesthesia care units (PACU) within our hospitals and outpatient centers. They serve as the liaison with patients and families.

“We are truly patient advocates when they don’t have a voice to speak for themselves,” says Mary Szostakowski, MSN, CNOR, Nurse Manager of Urology and Gynecology operating rooms at Cleveland Clinic’s main campus. “As a surgical nurse, it’s all about giving people better function or a better life, or fixing a problem.”

“What an amazing gift to be part of patients’ lives when they are so vulnerable — to protect them and keep them safe. It’s such a special gift to be their advocates,” says Glanc.

“Sometimes patients are here for those rare and unusual surgeries that nobody else has done,” says Pehotsky. “But sometimes patients come to Cleveland Clinic for our reputation, even when they’re having a common procedure — for example, a hip replacement — or because they have comorbidities that necessitate a high level of care.”

High-profile surgical cases are not uncommon. For example, a surgical team from the Head & Neck Institute performed the first near-total face transplant in the country in 2008. Then in 2017, the Dermatology & Plastic Surgery Institute led Cleveland Clinic’s first total face transplant. In 2011, a surgical team from the Sydell and Arnold Miller Family Heart & Vascular Institute performed the nation’s first transcatheter valve replacement and repair. In 2016, a Cleveland Clinic surgical team in the Ob/Gyn & Women’s Health Institute performed the first uterus transplant. And the innovations continue.

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Every day at Cleveland Clinic’s Heart & Vascular Institute, up to 36 cases can be scheduled in 21 surgical suites at the No. 1 hospital for heart surgery since 1994 (U.S. News & World Report). “We care for the most complex heart cases in the world, and we have to be ready for anything,” says Glanc. “It keeps your adrenalin flowing.”

Robotic surgery

Last fall, OR nurses on Szostakowski’s Urology team were among the first in the country to use the da Vinci SP® single port robotic surgical system (Intuitive Surgical Inc.). Many surgical robots utilize three or four arms, but this system uses only one 2.5-centimeter cannula. The benefits to patients are tremendous. For example, a patient can have a prostatectomy with just one incision around the belly button and can often be discharged the same day.

Szostakowski sent her assistant nurse manager and robotics coordinator to specialized training on the da Vinci SP. Then, they worked alongside representatives from the company to train other Cleveland Clinic nurses at main campus to assist in procedures using the equipment.

Pehotsky says with advances in robotic surgery expected to continue, Nursing added the unique role of a perioperative robotics coordinator. This new role involves arranging schedules, coordinating equipment usage, and ensuring that nurses and surgical technicians are trained and competent to interact with the highly complex machines and surgical instruments. Looking to the future, the coordinator will ensure nurses at all Cleveland Clinic locations, along with their surgeon colleagues, have access to needed education on emerging robotic technology.

Training for the fast pace

With perioperative nursing removed in large part from most nursing school curriculums, Pehotsky says Cleveland Clinic has implemented a number of programs to enhance understanding and to provide the breadth of training necessary.

Cleveland Clinic requires both experienced nurses and new graduates to participate in its six-month Perioperative Nurse Residency. The program is tailored to new hires’ needs based on experience level and includes time in the classroom, simulation lab and live surgical suites.

Nurses learn how to circulate and scrub for a variety of procedures. “Our nurses and surgical technicians learn the types of procedures they assist in at a particular hospital, but they also learn a little bit of everything with the understanding that they may need to assist in any procedure,” Pehotsky explains. “Teaching our nurses multiprocedural skills helps our staffing to be more flexible, and provides them the hands-on experience with surgical instruments to aid in their critical thinking when they are circulating.”

Perioperative nurse associate externship — This is a subset of the successful nurse associate externship. Nursing students entering their senior year of nursing school can participate in perioperative clinical experiences to provide them with an in-depth “insider’s view” of the technical skills required, as well as the unique aspects of advocacy and safety that are core to perioperative nursing.

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Robust observational experiences — Perioperative leaders partner with nursing schools to open their doors to student observers. The program includes matching students with circulating nurses who can show them the unique roles of perioperative nurses in the OR.

Perioperative residency — The perioperative nurse residency is centralized at Cleveland Clinic to provide all perioperative RNs the opportunity to learn, and be supported, as a cohort. Offered several times a year, the nursing cohorts spend one to two days each week with the Perioperative Education. Department to learn “bite-sized” amounts of information in didactic and lab settings. Residents spend the remainder of each week with a preceptor in their own hospital setting, applying what they have learned.

What makes the program unique

Beginning in 2012, Cleveland Clinic changed the format of its residency program. Rather than front-loading classroom content followed by OR application, the program is now a blend of classroom and lab-based learning. Each week, students return to the OR to apply what they’ve learned under the watchful eye of their preceptor. Nurses build on skills. “It has accelerated their learning,” says Pehotsky. “We are able to accomplish in six months what used to take 12, and we have found that the program increases their confidence in their skills.”

Collaboration works

Surgery at Cleveland Clinic is “a well-oiled machine,” says Pehotsky. “We participate in really cool high-tech care, but we’re also pushing the envelope in terms of teamwork.” Nurses are valued members of the surgical team, given the same respect as surgeons and anesthesiologists.

Last May, surgical teams at main campus implemented interprofessional huddles as part of the enterprise development of the huddle process. Everyone who supports the patient — from surgical ops leadership to representatives from surgical supply — meets each morning to review the day’s cases and ensure they are ready to proceed. Huddle content helps the team head off problems, even small ones. For instance, at a recent huddle, a nurse mentioned that her team needed a specialized surgical table for an afternoon case. A nurse manager chimed in that she knew where to find one and she called the OR to deliver it. “Instead of making several phone calls, the problem was solved in 30 seconds,” says Pehotsky.

It’s all about providing quality care to patients for a short time and often while they are under anesthesia. “It’s different than being a clinical unit nurse,” says Pehotsky. “Nurses choose perioperative nursing knowing that they’re not going to get a chance to interact very much with patients, but at the end of the day you are doing something really special.”

Interestingly, Pehotsky notes that perioperative nurses are the fastest-aging demographic across the country, with up to 65% of all perioperative nurses retiring by 2022, based on the Association of Perioperative Registered Nurses statistics. “At Cleveland Clinic, we are working hard to make sure our perioperative nurses have a solid base of training, and we hope that the dynamic and varied environment keeps them engaged for many years to come.”