Linda K. Groah, MSN, RN, CNOR, NEA-BC, FAAN: “Historically, we have not always had the best relationship. There’s been some competition between infection preventionists and OR managers or directors. The operating room has been that secret area behind the double doors.”
Historically, perioperative nurses and infection preventionists have not gotten along all that well. That relationship had been slowly improving before the onslaught of coronavirus disease 2019 (COVID-19) and the pandemic seems to have at last forged an alliance between the two groups of professionals, says Linda K. Groah, MSN, RN, CNOR, NEA-BC, FAAN, the CEO and executive director of the Association of periOperative Registered Nurses (AORN). For example, Groah tells Infection Control Today®, “when you intubate a patient, patients will cough, and they will spread the droplet infections. Previously the OR director would have really handled this by themselves, because we took care of patients with TB and other pulmonary diseases. But COVID-19 has made this a partnership and the infection preventionist and the OR directors, managers, and the rest of the surgical team came together to develop the best methods, the best practices to keep the team as well as the patients safe during the intubation.” She adds: “Infection preventionists in many operating rooms now are part of the team and they will come through and make rounds and look at how things are being practiced and look to see if there’s anything that can be improved on how the practice is clinically being acted.”
Infection Control Today®: Let me throw a few questions at you. Historically, how well have IPs and operating room nurses worked together? Do the professions consider themselves allies in the fight against infection prevention? And has COVID made them closer allies?
Linda K. Groah, MSN, RN, CNOR, NEA-BC, FAAN: Absolutely. COVID has changed everything for us as practitioners and allies. And coming together to really make critical decisions has been a major part of how we’ve gotten through many of the of the dilemmas that we were not ready for with this pandemic.
ICT®: How did infection preventionists and operating room nurses interact historically?
Groah: That’s a really good question. Historically, we have not always had the best relationship. There’s been some competition between infection preventionists and OR managers or directors. The operating room has been that secret area behind the double doors. And they take so much ownership for that area. So, they frequently have not been the best partners. But we have seen that evolve over the years. And certainly, an experience like COVID-19 has really made that relationship and partnership much more solid. They know that they need each other to get through this critical issue.
ICT®: Can you give me a real-world example how this might happen? How it would have been handled before COVID? And how it’s handled now? I mean the relationship between infection preventionists and operating room nurses?
Groah: Certainly. I think one of the issues that I can point to very easily is that if the operating room director had a problem with something, if they had a concern about infection prevention…. Let’s take, for instance, intubating a patient. Intubating a patient is a time when there is a high probability of exposure to everybody in the operating room from that patient that’s being intubated. When you intubate a patient, patients will cough, and they will spread the droplet
infections. Previously the OR director would have really handled this by themselves, because we took care of patients with TB and other pulmonary diseases. But COVID-19 has made this a partnership and the infection preventionist and the OR directors, managers, and the rest of the surgical team came together to develop the best methods, the best practices to keep the team as well as the patients safe during the intubation. There were many practices that were put into place, some very spontaneously, and others that were well thought out and developed over time as they cared for patients. Infection preventionists in many operating rooms now are part of the team and they will come through and make rounds and look at how things are being practiced and look to see if there’s anything that can be improved on how the practice is clinically being acted.
ICT®: But while an operation is actually going on, infection preventionists will be in the OR?
Groah: That is possible. Yes, that is definitely possible that they may be there to consult and to see if there is a better way to take care of the patient than what’s currently being implemented.
ICT®: Do you this stronger alliance surviving after COVID wanes?
Groah: Yes. There’s going to be a new normal that comes out of COVID-19. And of course, as you indicated, it can’t come soon enough. But there are many things that have happened during COVID-19 that are good. And partnerships working together is one of the things that has really been strengthened. For example, the joint statement in the roadmap for maintaining essential surgery during the COVID-19 pandemic. That was with the American College of Surgeons, the American Society of Anesthesiologists, the American Hospital Association, and AORN. And infection prevention has had input into that roadmap.
ICT®: Where do the surgeons fit in?
Groah: The surgeons are a very important part of the team. And there is a shared governance model in many operating rooms in many facilities that includes the surgeon, anesthesia, infection, preventionist, and the OR director. Many hospitals on their infection control committee will have both the surgeons as well as OR directors and managers involved in those meetings.
ICT®: Tell us a little bit about AORN’s OR Excellence Conference.
Groah: OR excellence has been going on every Friday for the month of November. And we have this coming Friday and one more Friday. And that is all geared toward looking at practices and clinical improvement on caring for COVID patients as well as our regular clinical care. One of the things that is important is that in ambulatory surgery units, the OR director or the manager also has to function as the infection preventionist. And although they’re not certified, they do reach out to their infection preventionist colleagues in those situations for assistance in making decisions that impact infection control practices in the ambulatory surgery centers.
ICT®: How has COVID-19 changed the way perioperative registered nurses do their jobs?
Groah: A lot of the changes have been around telemedicine. We’re using iPads now, for instance, to do patient assessments. The assessment that happens pre-surgery is done whether it’s ambulatory surgery or inpatient, but that used to be done in person face-to-face, and now it’s been shifted to telemedicine. During the interoperative phase that has not changed. It’s still care of the patient. But certainly, the pre-op testing of the patient, if they are COVID positive or negative, is going to make a difference in how they plan the care and the room for that patient. Then postoperatively again, the care of the patient. The patients go into an area called the recovery room. And in that area, they would be cared for again. If they are COVID-19 positive, they’re going to be segregated and cared for in one area that is isolated from where the other surgical patients are cared for. So, pre-op, inter-op and post-op are the three main phases of perioperative care for the surgical patient. And how we do it has had some deviations just to meet the needs of COVID-19 patients.
ICT®: Are the questions you’re getting from members now different than what you were being asked at the beginning of the pandemic?
Groah: There are some different questions now because you know, when this started in March, we really had no playbook. We had no roadmap. And I’m sure that you’ve heard the saying that we’re flying the airplane while we’re building it. That is exactly the way we felt in the operating rooms. And we had town halls. We would work one day and one night to put together a town hall to answer a lot of the questions that we were getting. We have a clinical consult telephone line where we used those questions to build the town hall for the next day. And we had thousands of nurses call into that town hall to get some direction. When it first started, we stopped all surgery. All elective surgery was stopped. Now, we have not stopped doing surgery. But what is the guiding light there is how many beds there are in the in the facility. If you’re out of beds, they will not do surgery. They will cancel surgery or delay it because they have to keep beds in the facility for COVID patients. And so many hospitals have a quota that they will keep, like 25 beds open, or 20, or something. So, we have changed. We are using the operating rooms. We’re continuing to do surgery now. This current surge that we’re in, all the things that we learned at the beginning with the first surge are being implemented and being actually perfected. And changes are made to meet the challenges as they are occurring.
ICT®: In what circumstances would operating room nurses go to an infection preventionist?
Groah: There are several. Certainly, the airflow in the operating room. And that is regulated by code. So, they have to meet the criteria for the airflow, which usually you’re partnering with the engineering staff in the hospital. If there’s a patient that comes in that has a rash, for instance, you may need to confront or talk with an infection preventionist and collaborate with them to see is this something we should be concerned about? Or can we go ahead and use the prep solution that we were going to use? Or do we need to change? Is it OK to do surgery on this patient that has some kind of a lung pulmonary issue going on? There are several different ways that OR managers, directors, and infection preventionists work together to make sure that the environment and the care of that patient is the best that we can provide.
ICT®: Do you happen to know of any operating room nurses who have actually caught COVID in the line of duty?
Groah: Yes, I do. Yes, there have been many nurses. And as an outcome of COVID-19, there’s a lot of stress and not only for their own personal concern, but they go home to their families, and they’re concerned about their families. So not only have nurses contracted COVID-19, some have died. And some have existing issues that are lingering, that are really based on, and come from, having had COVID-19.
ICT®: One of the sadder aspects of this disease is that a lot of times people have to die alone with only the nurse in the room. But that probably wouldn’t be an OR nurse doing that, right?
Groah: No, that’s correct. Except in the cases where at the early onset of COVID-19, operating room nurses were retrained to go out and help on the nursing units. In critical care or in med-surg units. Not necessarily as the primary caregiver but as an assistant. So, some of them did experience that kind of an issue where a patient died, and they were holding the phone for the last conversation that that patient had with their family member.
ICT®: After the dust settles a little bit, do you think it’s there’s going to be a more formalized interaction between infection preventionists and operating room nurses?
Groah: I think there will be. I think that there are always positives that come out of a negative experience. And I think that relationship and the reliance that perioperative directors and infection preventionists have developed over this COVID-19 pandemic, I think that will linger and I think it will become a part of their practice going forward. There are times when there are changes in regulations that come out that have been very confusing, especially during this pandemic. And that’s another time when infection preventionists and operating room directors have had to sort through what the changes are or what the recommendations are and try to come up with the answer that’s the best for their facility and their patient population. And those are relationships that will certainly continue past the pandemic.
This interview has been edited for clarity and length.