If cardiac surgeons were asked to rank the key people in the OR that help create good outcomes for their cases, most would first mention their PA or the anesthesiologist.  A highly experienced surgical technician might be next.  Often further down the list of names are the circulating nurses.  In my experience, the introduction of the robot into the cardiac surgical OR changes that order dramatically.  Because of the impact that circulating nurses have on OR safety, they play a largely underappreciated but disproportionate role in the success or failure of robotic cardiac surgical programs.

The essence of what an excellent circulating nurse does in a cardiac surgical OR is choreography.  There are multiple steps that must be performed by a variety of different team members if a cardiac surgical case is to have a successful outcome.  The circulating nurse’s responsibilities is to make sure each of those steps happen correctly and at the right time so that the end result looks like a well-coordinated dance.  Their role is broader than most other OR staff and spans from the preop preparation, to intraop performance all the way to postop management.  A common but incorrect interpretation of their role is a “go-fer” who also has to fill in for any team member who fails to execute their task at any step along that continuum of care.  A more appropriate mental frame for their role is like an athletic coach.  The really good circulating nurses have the natural ability to help turn a group of individuals into a highly effective team.  An outstanding coach has a detailed understanding of every step of the entire operation and every possible “bail-out” maneuver that might be used.  Perhaps more importantly, a coach has an innate sense of what can make each of the team members work together so that their overall performance ends up being great.

People respond to coaching when they believe the coach has credibility.  In light of this basic aspect of human nature, the best method for teaching the staff is to show them, not tell them, the standards of performance that are needed in the cardiac surgical OR.  Certain tasks and responsibilities fall squarely on the shoulders of the circulating nurse.  A nurse who fulfills these tasks above and beyond the call of duty is leading by example, which builds credibility.  More importantly, conscientious performance helps build trust with the team that the nurse is someone who can be counted on to perform at a high level.  That trust is the essential ingredient of coaching.

Circulating nurses check the necessary stocks of supplies before cases.  This can be more complicated that it might first appear.  It requires clinical knowledge to understand the specific supplies that are needed for upcoming cases.  Introducing new surgical procedures like robotics always complicates this task.  The necessary supplies and acceptable substitutes can change on a case by case basis as the team struggles through the early learning phase of adapting to robotics.  The most proactive nurses that I’ve worked with take notes during the course of the case and discuss equipment issues during the debriefing session at the end of the case.  For instance, if a certain clamp or retractor was requested, they might bring up during the debriefing if the clamp should be added to the regular case cart in the future or if was just needed for that case only.  They might also discuss that certain clamps or other equipment that are included on the tray are never used and might be removed.  Their underlying goal is to work with the surgeon to make the process of setting up the OR more effective and efficient.

Experienced nurses know that how the case is going changes the needs for supplies and equipment.  That mandates that the nurse to maintain situational awareness throughout the case.  Their mindset is that of a high level chess player who thinks several steps ahead all the time.  If a minimally invasive case has a chance of needing to be emergently converted to a standard open approach, the required equipment would ideally be available in the room or opened up on the back table before it is actually needed.  In the heat of the moment, there is often no explicit communication from the physicians about an impending problem.  So, the circulating nurse is required to independently interpret the clinical data in order to realize that the initial plan may change and anticipate changing needs of the OR team.  Saving a few seconds in the reaction time to a crashing patient can make or break a good outcome.

Maintaining a well-stocked cardiac OR also requires that the nurse has a basic understanding of the supply chain at the hospital.  They must be able to evaluate how well it is functioning and how to prevent critical shortages at a time when patient care could be affected.  There will be supervisors and other administrators who can help when this is causing a problem, but the nurse must have some basic knowledge of the process in order to know when to ask for help.   They develop effective relationships with the vendors of the needed supplies so they are willing to go above and beyond to support the needs of the team.

Circulating nurses have a high level of technical skill needed to trouble shoot complicated equipment or bring in the appropriate support staff to help with this task.  The high stakes and tremendous complexity of cardiac surgery make this role quite challenging.  Robotic cardiac surgery utilizes the Intuitive robot and console.  Both are complicated to set up and give frequent error messages or have other problems that prevent their proper function.  The nurse must feel a sense of urgency to resolve these errors because it would otherwise mean the case must be converted to an open approach.  Cardiac surgery routinely uses intraoperative echocardiography.  There can be difficulties in acquiring and interpreting these images, which requires support from personnel outside the OR.  During the course of our cases at Mt View, cerebral oximetry devices, continuous EKG monitoring, IABP consoles have all posed important challenges because of the need for frequent troubleshooting and rapid scavenger hunt for replacement parts.

The nurse serves as an advocate for the patient and the family.  They are responsible for assuring safe patient positioning on the OR table.  It is particularly important that they make sure that the unique positioning requirements when using robotic equipment does not cause unforeseen harm to patients.  They enforce proper sterilization of the operating field.  They ensure that all the equipment and sponges are accounted for at the end of the case so there can be no chance that a foreign body is left within the patient.  They forge a bond with the nervous family in the ICU waiting room and provide them updates during the course of the operation.  This liaison role is particularly agonizing but even more important when the case isn’t going well.

The nurse also advocates for the team.  This is a high level behavior that takes many forms.  First of all, they speak up when financial considerations block the purchase of new equipment needed for patient safely or systems issues are identified that affect patient care yet remain unaddressed.  Secondly, they actively participate in the debriefings at the end of each case and during weekly team meetings that help identify the equipment and issues that influence safety.  They follow up on these discussions and help establish accountability to the action items.  They leverage their credibility with the administration by lobbying them directly about topics affecting patient safety or team performance.  They are proactive in trying to arrange the equipment in the room so that it doesn’t create an unsafe degree of clutter.  They anticipate problems with staffing.  A high risk case that is coming up will require the most experienced crew available.  For instance, if that case is likely to have pulmonary hypertension postop, the nurse will make sure that the respiratory therapist is present in the OR for the initial timeout so that the potential use inhaled agents are anticipate and the hardware is set up in advance. The nurse will make sure that required staff is available and let the surgeon know in advance if it isn’t.  The nurse engages in proactive communication with team members that are struggling and finds out what help they need to improve their performance.  This type of circulating nurse is obviously an indispensable component of a high performing team.

The circulating nurse can also have an important influence on the organizational response to robotic cardiac surgery.  Because nurses are often more trusted than physicians, they are a credible source of information for those outside the OR.  From the perspective of those on the outside, there is a dramatic difference in understanding what is going on inside an OR performing open vs. robotic cardiac surgery.  Open CABG is the quintessential mature, mainstream procedure. It has been vetted in hundreds of randomized clinical trials over the last 50 yrs.  The STS database now publically reports clear benchmarks for CABG program outcomes. Armed with this experience and data, every physician now knows all they need about open CABG. That allows the market to steer patients away from failing programs so that case volume ends up as an excellent proxy for a safe, high quality program.  Because OR and ICU beds are in such high demand, everyone in the hospital knows the volume of the program and therefore whether it is failing.  It open CABG were a game, it would be chess.  Like chess, all players (stakeholders) know all the possible moves. All you have to do to win is logically sort out the available information into a recognizable pattern and then act on pattern recognition.

On the other hand, robotic CABG is not chess. There is no STS database for robotic cardiac surgery. People have a much more difficult time understanding this new procedure and what represents a good move for those that are involved.  If it were a game, it would be more like poker – evidence about whether success is likely is more limited and hard to interpret until the game is over.  Available evidence suggests success with robotics is driven by a capability for rapid and effective learning.  Teams with a winning hand are able to quickly get through their learning curve while those with losing cards stagnate at a suboptimal plateau of performance.  In both poker and robotics, no one sees all the cards until the end.  Without direct evidence, we substitute intuition in order to predict those that are winning vs. those that are bluffing about a losing hand. In robotic surgery, intuition lets the team to see past the initial challenges of implementation.  It answers questions important to the long term like do team members efficiently resolve adverse events, maintain situational awareness and work in a highly choreographed and seamless manner? People outside the OR (referring physicians, patients choosing where to have their surgery, nurse managers, administration, etc) don’t have the benefit of this intuition.  They can only answer these questions by watching the team in action.  Since it isn’t practical for them to make these direct team observations, they will hesitate to act which opens the door for misjudgments.

The transition of the robotic CABG patient into the ICU is where the OR circulating nurse can play an invaluable political role. When a robotic cardiac surgical patient is transferred to the ICU, more stakeholders are able to see the patient and form their own opinions. This creates the illusion of chess but it is still poker.  Misjudgments, misinterpretations and unrealistic expectations are common for patients that have undergone robotic surgery.  The circulating nurse helps mitigate this problem by creating an open and transparent environment for the ICU nurses that come into the robotic cardiac surgical OR to obtain their hand off from the surgical team.  Here they see a safe, reproducible procedure performed by a high functioning team.  More importantly, they understand what the procedure is not – its not “noninvasive”.  The patients still endure some surgical trauma.  That helps with correct expectations.

The ideal model of a circulating nurse is nicely summarized by a short story: Herman Hesse’s “Journey to the East.”  This is a story about a group of travelers and their servant Leo. Leo was tireless in how he performed the most menial tasks for the group, always maintaining a cheerful spirit. One day, Leo suddenly disappeared.  Soon thereafter, the group was left in chaos and prematurely ended their journey. Later, it became revealed that Leo was actually assigned as the head of the group.  None of the others were aware of it at the time, but he led the group using a style called servant leadership.  This requires leaders to shift their mindset and serve first.  When that happens in the workplace, these leaders unlock purpose and ingenuity in those around them, resulting in higher performance and a more engaged team.  When that happens in cardiac surgery, it keeps things safe.