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Operating Room Nursing: What Does A Circulator Do?

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Employment return false;” />See results Circulating Nurses Need to Know Where to Find Everything
Getting The Operating Room Ready
Depending on the facility, the nurse’s job in getting the room ready may differ. I am going to explain how it works in a small hospital, as opposed to a large hospital and/or teaching facility.

After speaking with the patient to assess any special needs, the circulator will return to the operating room. Once there, the nurse will give the scrub personnel a report on the patient. If the room is not cleaned completely, the nurse will assist. This may require wiping down furniture and equipment or mopping the floor. We do whatever needs to be done.

Once the room is cleaned, the scrub and circulator will gather the supplies, instruments, and equipment for the next case. Sometimes we get lucky and there is a float crew who have already gathered these things together for us. Once we bring the supplies, instruments, and equipment into the room, we double check to make sure we have everything we need.

The video above shows all the different places we may have to visit to get ready for our case. The circulating nurse needs to know where to find everything shown. It’s amazing that we know exactly where to find everything.

From Lights to Microscopes, the Circulator Knows Them All
Equipment
All equipment needed for the surgery has to be brought into the room. We have many different pieces of equipment. There is the electocautery unit which is used for most procedure. We may need a special bed or positioning supplies. We may need the monitors for cases using a “camera”. Miscellaneous machines used for bipolar cautery, machines to run the cameras, pumps for fluids and more.

All of this equipment needs to be checked to ensure it is working correctly before the patient is brought to the room. This can be quite time consuming, especially if one is not working correctly and needs some troubleshooting. The OR nurse’s number one troubleshooting technique is to turn it off and turn it on. Surprisingly, this works the majority of the time.

In the video below, the gentleman reviews some of the equipment needed for surgery. It is very nicely done.

Some of the Equipment Circulators Have to Know
This is Pretty Boring, Technical Stuff. Circulators Know All This Information-And Just As Much About All Equipment
Surgeon’s Preference Cards
These “cards” tell you many things you need to know. These pages are called “cards” because, before the days of computers, they would be written on index cards. The card will list all items needed for the surgery. It will list items you may need to have on standby. Equipment that you will need. Settings for said equipment. The surgeon’s preference regarding preps. Lots of useful information. Make sure to read the cards!

Many facilities use these sheets as the charge cards also. It is very important to keep the cards current. Implants may change. Surgeons may learn a new way to do things, requiring different instrumentation. The surgeon may well tell you to change the card, because he “always does it this way.”

Some surgeons will try to change their cards every procedure. I once worked with an orthopedic surgeon who had me change his card in 5 consecutive cases. When he yelled and told me to change his card a 6th time, I told him he would have to keep this card for 1 week before I would change it again. Lol, it worked and he stopped asking me to change it.

Opening
We then proceed to “open” the case. First we need to create a sterile field where we can open sterile supplies. A sterile tablecloth, or a pack containing one, is opened on the back table. (The back table is the table the scrub personnel use to set up all the supplies and instruments.) We try to open in a logical order. The scrub personnel will need to make this mess into a coherent whole. Not always the easiest job, but miraculously they get it done.

Instruments are either wrapped in outer sheets, or in hard cases. The sheets are not sterile on the outside, but are sterile inside. The same is true with the hard cases. Often times instruments are opened on a “mayo” stand. This is a small table with 2 legs with long feet on wheels. This mayo stand will eventually hold the most used instruments needed for the surgery. It is wheeled so the table is over the patient.

The video below shows some of the items opened and explains a little on sterile technique.

Opening the OR Room Using Sterile Technique
Counting
Next we count all the “sponges”. Regular people know these “sponges” as the cloth dressings that cover the wound. The main difference is our sponges come with a radio-opaque strip so they can be seen under x-ray if needed. We count all the needles. Anything that is small enough to be left in the surgical wound will be counted. These may be electrocautery tips or anti-fog liquid and sponge. Depending on the surgery, we may count all the instruments also. For a large surgery, this can take some time.

When the scrub personnel has made some order out of the chaos of the back table, we will give them any medications and fluids needed in the surgery. Fluids usually consist of a saline solution that is isotonic to the body’s fluids.

At this point we are ready to bring the patient into the room. The nurse leaves to get the patient while the scrubbed personnel continue to “set-up” (make order out of chaos) the table and mayo stand.

Below is a good video of a count being done.

Sponge, Needle and Instrument Count
Bringing The Patient To The Operating Room
I like the facilities that have anesthesia providers help push the patient to the room. Some facilities will have you push the patient by yourself. This is very bad for your back, so try to find some help.

While going to the OR room, keep the conversation light and cheerful. As you enter the room, introduce the patient to all other team members. Always focus on the patient. Explain everything you are doing. Although you have explained this in the holding area, you cannot expect the patient to remember.

Always stay with the patient until they are asleep. Be prepared to help the anesthesia provider with the intubation. Only leave the bedside after the patient is intubated and the anesthesia provider is satisfied.

Help Pushing the Bed or Stretcher
Does your facility routinely provide the circulating nurse help pushing the bed or stretcher?

Yes, Anesthesia provider

Yes, Other Person

No
See results Try to Ensure You Have Help Pushing Beds and Stretchers
Time Out
The surgical time out can be compared to a pilot’s checklist. The time out is a checklist ensuring everyone knows the plan and everyone is ready for it. The time out needs to be done before each and every surgery. First everyone in the room needs to stop what they are doing and pay attention. At times it is hard to get everyone’s attention. Other times everyone is ready.

We introduce everyone in the room and tell their role. This is done for new staff and company representatives, to name a couple. Next we verify the patient’s identity, making sure the paperwork and wristband match. We review the patients allergies and special needs. We confirm which pre-operative antibiotic has been given.

The circulator will read the consent to make sure everyone agrees on the procedure. We verify that the correct side/site has been marked by the surgeon. We confirm we have the correct implants, positioning aids, special equipment needed. We discuss how the patient is to be positioned. The surgical team will also discuss how specimen are to be handled.

The time out is a very important part of patient advocacy. We are protecting our patients when we ensure that everyone has the same plan and is on the same page. Just as a pilot is expected to use the checklist every time so nothing is missed, so the circulator needs to follow the hospital’s procedure every time. We may think we know it, and we do, but sometimes little things can be overlooked. This is why it is so important to have a checklist to read.

The video below shows a time out being done. It is a good example.

Time Out Checklist
Does your facility have a time out checklist that is used on every case?

No
See results Time Out Procedure
A Standard Betadine Scrub and Paint Procedure
Prepping The Patient
After the time out, the circulator goes into action. The nurse must first “prep” the patient. Prepping is the cleaning of the surgical site to prevent infection. The circulator may need to clip the area if the hair is long. I have worked with surgeons who prefer that no hair is clipped. Be sure to know your surgeon’s preference.

At times, you may need help holding a limb or two. You should have planned accordingly while setting up the room, asking for help if it is not normally available. With few exceptions, we will prep beginning at incision and moving outward. The area prepped needs to be large enough to accommodate the opening in the drapes plus a few inches more to each side.

Some preps have an alcohol base. As a patient advocate, the circulator ensures that the prep is dry and has not pooled around the patient prior to the drapes being placed. Alcohol preps are a fire hazard. I have seen the prep catch fire when the electrocautery was applied. Luckily, it was just what had pooled in the belly button, there was a small flash, and that was all.

Above is a video on showing a standard iodophor scrub and paint. Below is a video showing a standard iodophor/alcohol applicator prep.

Standard Duraprep design your own shirt for fun Procedure
The Surgery
During the surgery, the circulator’s responsibilities are to deal with all non-sterile activities. We open suture (the needle and thread for sewing). We will open any additional instruments or supplies needed. We run and get necessary items that are not in the room. We also run and obtain anything the anesthesia provider needs. We are called circulators because we never sit still.

Observing and maintaining the sterile field is an important responsibility for the circulator. It is up to us to make sure everyone at the sterile field is moving correctly and not contaminating themselves or others. We also observe the surgery to help anticipate needs. It is better to be watching and already moving when something is needed, rather than sitting reading a magazine.

Circulators are also the record keepers for the facility. We need to document all activity during the surgery. We document equipment settings, implants put in or taken out, specimen, how the patient is positioned, what positioning aids were used, and the list goes on and on.

The video below is a training video showing one task of a circulator. The gentleman speaking does hit on some other topics that are good to know.

One Thing a Circulator Does
End of Surgery
At the end of surgery, we count all items again. If the count is incorrect we need to inform the surgeon and find the missing items. I cannot stress how important this is. Sometimes during an emergencies, we may not have time to count. We will take an x-ray at the end of surgery to ensure nothing is left inside the patient.

Once the counts are correct and the dressing is on, we will remove the drapes (the sterile coverings) and clean the patient. The anesthesia provider may or may not extubate the patient. At times, they prefer to extubate in the PACU (recovery room).

Reporting to PACU (Recovery Room)
When we arrive in PACU, the circulator will report to the nurse there. At this point, the patient is usually too groggy to answer questions for themselves. The patient’s name and allergies are given and double checked with the name band. Circulators tell the PACU nurse the surgery and site, what medications design your own shirt for fun and/or blood given, and check the dressings at the incision site, to name a few things.

Many facilities now have a hand-off checklist. I think this increases patient safety. Circulators are very busy people with many things going through their minds. A checklist ensures that no pertinent information is missed.

Hand-Off Checklist
Does your facility provide a checklist to use during hand-off to PACU?

Yes

No
See results Skills Needed
I am going to go over a few of the skills you will need as a circulating nurse in the operating room. First, you must be extremely efficient. Being efficient includes the ability to prioritize wisely and use critical thinking. Surgeons will ask you for several items at once during surgery. The first item they name always seems (to me) to be the one they need the least. Sift through this laundry list to ensure you bring the most critical items first.

Circulators need high energy. Nothing you do will ever be fast enough for the surgeons. Everything is needed now, not 30 seconds from now. Rooms need turning over. Supplies, equipment and instruments obtained. Circulators hit the ground running the moment they arrive on the floor. The running does not stop until their shift is done.

Rhinoceros-thick skin is necessary for circulating nurses. Almost everything that is not perfect will be blamed on circulators. I have had surgeons call my team and I, “the stupidest people on the face of the entire earth!”. I have been on the receiving end of a list of swears that would make a sailor blush. And, as a circulator, you have to just let it go. Water off a duck’s back.

Circulators need titanium spines. Confrontation skills and the ability to stand up for our patients and ourselves is critical. Remember that tirade you let go during the surgery. It is essential to confront the doctor after. You also must be able to stand your ground, politely, while the surgeon is yelling. When it is a matter of patient advocacy, you can never back down.

Circulators must be curious with an excellent memory. We remember when we see something out of place so we can put it away correctly later. We like a place for everything, and everything in it’s place. But, at times, items get misplaced. You will usually see these misplaced items while you are running to get a surgeon something. It pays to remember later and put it away correctly.

Loving a challenge and thinking outside the box are essential circulating skills. At times you may need to think up a new way to use some instrument or equipment. Time is crucial in the operating room, and anything we can do to decrease anesthesia time helps the patient.

Multi-tasking is another important circulator skill. It seems we are always doing three things at once. Circulators are multi-talented.

With all the equipment circulators work with, good technical skills are demanded. We need to troubleshoot equipment every time something is not working correctly. Good technical skills help greatly.

Circulators are active learners. We love change and are very adaptable. I can not imagine (or remember) a day as a circulator that I did not learn something new. Equipment and instrumentation are always changing. New techniques are always being introduced. As a circulator you will learn every day.

Wrap It Up
I hope you enjoyed this look into a circulator’s life. I have not hit every thing the circulator does, just the most important parts. We also do continuous quality improvement, inservices and just about any odd job that needs to be done while we are not in active surgeries.

Being a circulating nurse in an operating room takes a certain temperament. You have to be as strong as bedrock and as bendable as a straw. Adaptability is crucial. Everything is always changing in the operating room. But, if you have the temperament, you will find it is the best job in the world. Operating room nurses are a special breed. We love our jobs.

Nice Explanation of Nursing Duties in an Operating Room
© 2017 Kari Poulsen

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sendingLinda Crampton 118 minutes ago from British Columbia, Canada

This is a very detailed and impressive article, Kari! Thank you for sharing such interesting and educational information.

Jackie, I do not know how that could happen. If they took it from your hip, it means it was probably what the operation was about was getting it into the spine.

Not every surgeon is excellent at what he/she does. Not every OR crew is quite as exacting as I expect people to be. I may be able to guess if I had more information. But without being there, I could not explain this. I’m sorry if that happened to you. What did the surgeon say about it?

AuthorKari Poulsen 15 hours ago from Ohio

FlourishAnyway, I have noticed that the new surgeons have more respect for the nurses. They are more aware of what makes for a hostile environment. I put it down to a change in their training. The OR may be even better once the older guys all retire, lol.

Jackie Lynnley 26 hours ago from The Beautiful South

How could it possibly happen that with all these people in the operating room a surgeon could forget to put the bone he took from your hip into your cervical spine?

FlourishAnyway 29 hours ago from USA

With the egos of surgeons, have you seen any changes in how nurses are treated over the years? Are most of them like this? Not the career for most people to take sure belittling and just keep plugging.

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