3 Nonnegotiables for Patient Care in the OR

Production pressure—the “overt or covert pressures and incentives on personnel to place production, not safety, as their primary priority”—is one of the highest threats to your level of patient care. As an anesthesiologist, here are three nonnegotiables I prioritize in the OR, no matter the external pressures.

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It was one of those lessons early in residency I can still hear my mentor telling me: “Never be afraid to tell them, ‘No, I’m not ready.’”

In the whirlwind of residency, especially in the intense environment of the operating room (OR), the pressure to work efficiently is undeniable. An aging population means that payor mixes are getting worse, hospitals are often operating in the red, and 100 medical staff are carrying the workload of 175 providers.

Still, regardless of your phase of training or practice, it’s paramount to prioritize patient care above all else.

In this post, we’ll delve into the concept of production pressure in medicine, with a specific focus on the challenges faced in the OR and anesthesia. We’ll discuss nonnegotiable aspects of patient care and explore some strategies for patient advocacy we can practice, even while handling a never-ending stream of work that needed to be done yesterday. 

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How Production Pressure Affects Medical Care 

We want to do it all. We want to give our patients the best possible, safest care in the most efficient and cost-effective manner.

Now, despite attempts to follow every rule, there are situations where this becomes nearly impossible. I’m not suggesting that you throw in your central line with street clothes on and unwashed hands. But I will confess that when performing a high-stakes complex cardiac anesthetic as a solo provider, the time to perform hand hygiene the requisite 287 times per hour simply doesn’t exist, and I’m relegated to “doing my best.”

That said, there are certain principles that can’t be compromised without jeopardizing patient safety and well-being.

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3 Things That Can’t be Compromised in the Operating Room 

Some things can’t be compromised in the OR, regardless of how busy you are. These include the following: 

1. Informed Consent and Effective Communication

In the OR, obtaining informed consent during every pre-op can be challenging, but its importance cannot be overstated. Unfortunately, I’m often afforded only a few minutes to gather the patient’s entire pertinent medical history, devise a tailored anesthetic for them, and explain the potential risks and benefits of said anesthetic and its alternatives.

To make matters worse, it’s hard to know what I should tell them about the risks they face. Do I strike fear into their hearts, letting them know there are chances of death, anaphylaxis, laryngospasm, prolonged intubation, unexpected arrhythmias, heart attacks, and strokes? Or do I leave it closer to the catch-all, “There are some rare but serious side effects, none of which we expect.”

Despite the push to “go, go, go,” always take the time to communicate thoroughly with your patients. Explain procedures, potential risks, and expected outcomes in detail. A well-informed patient is a patient who trusts their medical team. An added benefit is the better your rapport, the less likely you are to see them in court.

2. Sterility

Sterile technique is the hallmark of good care. Many hospital infections are preventable, and taking the time to work sterilely is time well spent. As tempting as it is to cut corners to save time (i.e., forgoing an ultrasound drape, not letting chlorhexidine dry for three full minutes), this is the low-hanging fruit of infection prevention.

If you accidentally touch something with a sterile glove, don’t keep it to yourself. You’ll garner more respect by admitting it and simply changing your gloves. See someone else bump something with their glove? Speak up in the name of patient safety. 

3. Closed-Loop Communication

You wrote on your CV that you have excellent communication skills. Now it’s time to prove it. Closed-loop communication is the way to ensure that everyone on a care team is on the same page. Without it, we’re relegated to assumptions, and it’s unacceptable to rely on assumptions when we’re talking about our patient’s medical care.

I tell my students, “Unless you hear the recipient of your message repeat it back to you, consider it unheard.”

This is paramount in my day-to-day life in the cardiac ORs. I need to make sure the circulator on the other side of the giant OR hears me when I tell the world that heparin was given, or 100% of the protamine has been administered. It takes a little more time sometimes, but it feels great when you don’t have to wonder whether or not your message was communicated. Better to say it twice than not at all. 

In the Face of Pressure, Take a Second to Reset

I’ll leave you with this. Some days, nothing seems to go our way. We miss our IVs, can’t track down family members for consents, or struggle to work congenially with our counterparts. Then an emergency sets you back 15 minutes, and the phone continues to ring.

When I find myself in one of these situations, rather than continuing to go full speed and trying to make up lost time, I stop everything I’m doing, close my eyes, and take a pause. I’ll take a deep breath, have a “namaste moment” of sorts, gather myself, and reprioritize the tasks to complete.

It’s like a four-second meditation that helps pull me out of the fire, and drops me back into the driver’s seat, with a clear mind, ready to make good decisions.

Further Reading

Looking for more (free!) content to improve your patient care? Check out these other posts for physicians on the Rosh Review blog:

• Lessons from Being a Homeowner that Made Me A Better Physician
• A Physician’s Guide to Communicating with Your Medical Team
• How to Effectively Manage Stress and Burnout in Emergency Medicine

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