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The RN First Assistant: An Expert Resource for Surgical Site Infection Prevention
The RN First Assistant:
An Expert Resource for Surgical
Site Infection Prevention
SUZANNE M. PEAR, RN, PHD; THERESA H. WILLIAMSON, RN, BSN
The expanded role of the RN firstassistant (RNFA) is one of a num-ber of physician-extender posi-
tions that have evolved during the past
three decades to fill clinical resource
shortages of a financial or staffing
nature.1,2 Cu
ent and anticipated fac-
tors in health care, including the pres-
ent economic downturn and surgeon
shortages, may increase the demand fo
nurses in the RNFA role.3 This article
discusses the relevant factors and
eports the results of a surgical site
infection (SSI) out
eak intervention
using RNFAs, detailing the benefits of
this expanded perioperative nursing
practice position for SSI reduction in
cardiac surgery. These results may be
generalizable to other surgical special-
ties as well.
CURRENT HEALTH CARE
REIMBURSEMENT ISSUES
In addition to the increasingly capitat-
ed reimbursements that often undercom-
pensate US health care institutions and
practitioners for their services, the Cen-
ters for Medicare and Medicaid Servic-
es (CMS) has begun its initial foray
into non-payment for certain medical
and surgical health care-associated
conditions which have been deemed
“never events.” Never events are con-
sidered adverse conditions that are
preventable and therefore should neve
happen.4 Since October 1, 2008, a num-
er of SSIs, including cardiac surgery
mediastinitis, certain orthopedic joint
surgery infections, and bariatric gastric
procedure infections, have been placed
on that list of non-reimbursable condi-
tions.5 The list of CMS never events is
expected to grow annually as addition-
al SSIs and postoperative adverse
developments that are considered pre-
ventable are added.
THE IMPORTANCE OF EXPERTISE IN
ADVERSE CONSEQUENCE AVOIDANCE
Surgical experience matters. A num-
er of studies researching the effect of
expertise on surgical outcomes have
produced similar conclusions—that
surgeons who perform large volumes
of certain surgeries have better patient
outcomes than surgeons with lowe
surgical volumes.6-10 These findings
have a direct co
elation with the use of
RNFAs in surgery. Through their edu-
cation and experience, RNFAs are qual-
ified to assist in a number of different
types of surgical procedures. In short,
they become ex perts in the procedures
that they repeatedly perform.
Many institutions have come to rely
on RNFAs to support surgical programs
ecause the number of available sur-
geons has not increased significantly,
© AORN, Inc, 2009 JUNE 2009, VOL 89, NO 6 • AORN JOURNAL • 1093
The role of the RN first assistant (RNFA) has expanded
and evolved during the past three decades. Studies that
have examined patient care outcomes relative to RNFAs
substituting for surgeons as first assistants have noted
no resulting adverse consequences, and the use of
RNFAs in surgery may improve patient outcomes.
This article reports on an intervention to improve surgi-
cal outcomes in patients undergoing cardiac surgery that
involved replacing surgical residents with RNFAs for the
harvesting of saphenous vein grafts. The resulting bene-
fits were a significant decrease in surgical times as well
as improvement in surgical site infection rates.
Key words: registered nurse first assistant, surgical site
infection, coronary artery bypass graft surgery, infection
prevention, expert practice, RNFA, CRNFA. AORN J 89
(June 2009) 1093-1097. © AORN, Inc, 2009.
ABSTRACT
p1093-1097_06_09:Layout 1 5/13/2009 2:52 PM Page 1093
JUNE 2009, VOL 89, NO 6 Pear—Williamson
1094 • AORN JOURNAL
whereas, the number of programs and patients
served has increased almost exponentially.3
Depending on the setting and degree of
administrative support, RNFAs may perform
the surgical first assistant role daily or cross-
functionally, having also to perform the role of
circulating or scrub nurse as staffing permits o
demands.
One study examined the consequence of
substituting RNFAs for surgeons as first assis-
tants by comparing the influence of a board-
certified surgeon as first assistant to an RN as
first assistant with regard to surgical patient
outcomes of abdominal aortic aneurysm
(AAA) repair. Researchers found that “the
mo
idity and mortality rates were independ-
ent of the type of assistant, as were the opera-
tive time, blood loss, and adjusted blood
transfusion volume” for patients undergoing
AAA repair, regardless of patient criticality o
other extenuating factors.11(p4)
Not only have nurses in the expanded
RNFA role been found not to put patients at
increased risk, they may actually improve
patient safety. We found that the expanded use
of RNFAs to standardize saphenous vein har-
vesting during coronary artery bypass graft
(CABG) surgery decreased an adverse patient
event—cardiac surgery harvest site surgical
site infections (SSIs).
USING RNFAS TO REDUCE CARDIAC
SURGERY HARVEST SITE INFECTIONS
Beginning in 1997, an out
eak of CABG
saphenous vein harvest SSIs occu
ed at a
southwestern federal medical center that is
affiliated with a university medicine and sur-
gery resident and fellowship trainee program.
During that year, the mean annual cardiotho-
acic clean surgical site infection rate...