- © 2007 Canadian Medical Association
Wait times and waiting lists are becoming so lengthy that the health care system must look to new staffing and procedural solutions so it can efficiently move more patients through operating rooms, says Dr. Gaétan Barrette, president of the Federation of Medical Specialists of Quebec.
But Barrette's proposals for reform — including the creation of a new position in the operating room, called “instrumentalist” (for handing tools to surgeons), and asking anesthesiologists to consider going back to working 2 minor operations simultaneously — are drawing decidedly mixed reviews from health care professionals.
![Figure](https://www.cmaj.ca/content/cmaj/177/5/445/F1.medium.gif)
An “instrumentalist” would pass instruments to surgeons, thus freeing up nurses to perform other duties. Photo by: Corbis/Magma
Barrette says that instrumentalists would free up at least 1 nurse from the duty of passing instruments to a surgeon and thus help redress the severe shortage of nurses in the province, which the Quebec Ministry of Health estimates now stands at around 1500. “We believe nurses are overqualified to do that part of the job in the [operating room],” Barrette says. “Sometimes we have to cancel surgeries because we don't have enough nurses passing instruments — that's ridiculous! We will not have a shortage of instrumentalists.”
Barrette says that instrumentalists could be easily recruited, because they wouldn't require any specific health care education and could be trained within a hospital. “It doesn't take a PhD or any medical training. If you can place a tray in a sterilizer, you can pass instruments to the surgeon. Nurses should be at the side of the patients who need them.”
However, both the Canadian Nurses Association and l'Ordre des infirmières et infirmiers du Québec are concerned about accountability, particularly given that such instrumentalists wouldn't be subject to any professional laws or regulations. Marlene Smadu, president of the Canadian Nurses Association, argues that it's vital to have a registered nurse in the circulating nurse role. “That is really the role that has the oversight in terms of holistic patient care in the operating room.”
In a crisis, Smadu adds, scrub nurses and circulating nurses are interchangeable. “That wouldn't be the case if you've got a different kind of practitioner doing the instrumentalist role. Everyone needs to know how that person fits in.”
And although Smadu believes there may be some more routine work that wouldn't require registered nurse training, she wonders about the future for instrumentalists. “I'm always concerned that we are creating these little pieces of work that are dead-end jobs for the people in them. If a person can only be an instrumentalist in 1 institution in Quebec, is that the kind of approach we want for a health team for the future?”
Perhaps more controversial is Barrette's suggestion that anesthesiologists simultaneously work 2 operations. “This is a much more delicate issue,” Barrette stresses. “It would be absolutely unthinkable and unreasonable to go back 20 years.” At that time, working 2 rooms was fairly common, but Canadian Anesthesiologists' Society guidelines now advise a 1-to-1 ratio with patients.
“The question is, would it be possible to determine specific situations where it would be safe and reasonable to supervise 2 minor surgeries at the same time?”
Canadian Anesthesiologists' Society President Shane Sheppard says anything is possible, “but how safe is it? We have national standards for a 1-to-1 ratio. That's the way it is, and that's the way it will stay.” Sheppard says anesthesia care teams in Ontario, which include anesthesiology assistants and nurses, are now working with anesthesiologists to administer anesthetic for routine cases, such as cataract surgery. Training more anesthesiologist assistants could help speed up the efficiency of larger surgeries. But in the end, he says, nurse shortages need to be addressed.
Barrette has also proposed that surgical waits could be partially alleviated through new pay incentives for intensive care unit nurses.
Such measures would go a long way to reduce wait times and waiting lists, he says. “At the end of the day, you might increase throughput by more than 10% to 20%. Reasonably, we can design a template that can be workable to everyone.”