By Victoria Stern

When Jennifer Dizon, DNP, RN-BC, began updating preference cards for a Duke University hospital in 2005, she thought the project would only last two years.

“It was just supposed to be a short project, and then I was planning to return to my job as an OR nurse,” Dr. Dizon said.

But that never happened.

“We never stopped creating and updating the cards,” said Dr. Dizon, who runs a team overseeing preference cards for the entire Duke University Health System, in North Carolina. “The health system realized it needed a group dedicated to preference card management.”

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Preference cards, which include a list of supplies and instructions for a procedure, provide the foundation for all activities in the OR.

“When the cards are accurate, cases should run smoothly,” said Erin Kyle, DNP, RN, a perioperative practice specialist at the Association of periOperative Registered Nurses. “But incorrect or incomplete information can have detrimental effects on OR efficiency and patient safety. An error could cause delays and, if not discovered and corrected before an OR patient arrives, could lead to compromise of patient safety.”

Despite their importance, preference cards appear to be an afterthought for most hospitals.

“A systematic approach to preference card management is probably very rare across organizations,” Dr. Kyle said. “Updating preference cards does not directly generate revenue for a hospital so is not often made a priority.”

In turn, the majority of studies analyzing preference cards explore the cost-effectiveness of maintaining them.

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Organizing for Cost Savings

Two 2018 analyses highlighted how streamlining surgeons’ pick lists can increase OR efficiency and lead to savings. In one study, researchers analyzed the costs associated with laparoscopic cholecystectomies six months before and after surgeons began using a standardized pick list (Am J Surg 2018;215[1]:19-22). After standardizing, the authors found that the costs of disposable supplies decreased by almost one-third without affecting patient outcomes or operative time.

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In another study, researchers at the Hospital for Sick Children (SickKids), in Toronto, described how the hospital whittled down the number of instruments for pediatric inguinal hernia repairs from 96 in urology and 51 in surgery to 28 each (J Pediatr Urol 2018;14[1]:20-24).

“Standardizing led to less time counting, cleaning and sterilizing instruments, which likely translates to cost savings,” said the study’s lead author Martin Koyle, MD, FACS, FRCS (Eng.), the head of urology at SickKids and a professor of surgery at the University of Toronto.

Aline Titizian, RN, a clinical support nurse at SickKids who was not involved in the 2018 analysis, believes that standardizing kits for high-volume procedures has improved OR efficiency. “It’s important to know when variety improves patient care and when it doesn’t,” Ms. Titizian said. “Standardizing preference cards helps the OR team use our resources wisely without compromising patient care.”

A Mess in the Cards

A 2005 study—one of the few to explore preference card errors—found many cards at NewYork-Presbyterian Hospital, in New York City, contained incorrect drugs and incomplete or unclear medication-specific instructions, especially when using drug abbreviations (AORN J 2005;82[3]:399, 401-404, 406-407 passim). The analysis also revealed that preference cards were not revised frequently—on average, it took over a year to update them. The authors concluded that using these cards “may provide a false sense of security” and proposed redesigning the hospital’s preference card system.

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A recent analysis from Dr. Dizon and her colleagues in North Carolina also highlighted the importance of routine preference card maintenance (AORN J 2016;103[1]:105.e1-105.e12). When the Duke University Health System was transitioning from several electronic medical record (EMR) systems to one, Dr. Dizon discovered that some preference cards were not accurate or correctly matched to the procedure. The majority of issues, Dr. Dizon explained, came from add-on emergency cases that did not have preference cards in the new system.

The analysis also revealed other issues. Most preference cards were not reviewed before surgery, and veteran OR staff often picked supplies from memory. Picking from memory can be problematic, Dr. Dizon said, because a veteran team may not note the change on the preference card and a new OR team will not be aware of it.

“Ultimately, we had to rewrite the EMR interface, which allowed time for an OR nurse or team leader to check the preference cards for add-on cases prior to scheduling them,” Dr. Dizon said.

Overcoming Challenges

Maintaining preference cards is a complex and time-consuming endeavor.

“There are so many moving parts in the OR, and changes happen on a daily basis,” Dr. Kyle said. “That is why the biggest challenges facing perioperative teams is inaccuracy and why it is so important for institutions to make preference cards a priority.”

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One crucial step is deciding who will be responsible for maintaining them. At Duke, for instance, Dr. Dizon’s team oversees the preference card system, but the health system has also appointed dedicated preference card champions—RNs who review the cards on a daily basis and make specific updates in the system. Dr. Dizon’s team meets with surgeons and preference cards champions to ensure the cards are up-to-date.

“Preference cards are only as good as who controls them,” Dr. Koyle said. “If an institution doesn’t have open communication and a system to constantly update them, they become redundant and an exercise in futility. Hence, the buy-in of leadership is integral, and ongoing engagement of all stakeholders is key to sustainability.”

Even with a strategy in place, lack of resources and time can be a barrier to success. To overcome these challenges, Dr. Kyle suggests using any available moments, including clinical downtime or unexpected free time if, for instance, a case is delayed.

“There is latent time in most organizations that can be used without much impact on productivity,” Dr. Kyle said. “The key is to use this latent time strategically.”

When a new surgeon enters an organization, building the preference cards correctly from the beginning should be a priority. Simply mirroring the surgeon’s former preference card won’t work because it may already contain inaccuracies or supplies not available at the new job.

“These issues can have a snowball effect that starts on the surgeon’s first day,” Dr. Kyle said. “Interdisciplinary communication is the key to success. Start a collaboration early and commit to it on an ongoing basis.”