Should nurses be allowed to perform the pre-operative surgical site marking instead of surgeons? A prospective feasibility study at a Swiss primary care teaching hospital

Abstract

Background: Surgical site marking is one important cornerstone for the principles of safe surgery suggested by the WHO. Generally it is recommended that the attending surgeon performs the surgical site marking. Particularly in the case of same day surgery, this recommendation is almost not feasible. Therefore we systematically monitored, whether surgical site marking can be performed by trained nursing staff. The aim of the study was to find out whether surgical site marking can be carried out reliably and correctly by nurses.

Methods: The prospective non-controlled interventional study took place in a single primary care hospital of Uster in Switzerland. During a pilot phase of 3 months (starting October 2012) the nursing staff of a single ward was trained and applied the surgical site marking on behalf of the responsible surgeon. After this initial phase the new concept was introduced in the entire surgical department. 12 months after the introduction of the new concept an interim evaluation was performed asking whether the new process facilitates daily routine and surgical site marking was performed correctly. 22 months after the introduction a prospective data collection monitored for one month whether the nursing staff carried out surgical site marking independently and correctly. Data were collected by a patient-accompanying checklist that was completed by the nursing staff, the staff in the operating room and the responsible surgeons.

Results: The stepwise implementation of the new concept of surgical site marking was well accepted by the entire staff. 150 patient-accompanying checklists were analyzed. 22 data sheets were excluded from the analysis. 90% (n = 115/128) of the surgical site markings were correctly performed. For the remaining 10% either a surgical site marking was not necessary or the nursing staff asked a surgeon to mark the correct surgical site. During the whole study time of almost 3 years, no wrong-site surgery occurred.

Conclusion: Surgical site marking can be performed by trained nurses. However, the attending surgeon remains fully responsible of the correct operation on the correct patient.

Keywords: Implementation; Safety; Surgery; Surgical site marking; Time-out; Wrong-site surgery.

Fig. 1

Timeline of the study with consecutive evaluations

Fig. 2

Evaluation of the nursing staff after pilot phase showing acceptance of the new process

Fig. 3

Evaluation 12 months after implementation showing a corresponding perception of the new process

Fig. 4

Prospective data collection 22 months after implementation