What Is A Circulator?

A circulator is a nurse who works in the OR. They are responsible for many things, but the main role of a circulator is to be the patient’s advocate. Unlike other departments, the nurse-patient ratio in the OR is 1:1. Yes, you read that right! A circulator gives all their attention to caring for one patient at a time. Also, unlike other departments, the circulator remains in the room with the patient throughout (almost) their entire “stay” in the department. The only time a circulator isn’t in the room when the patient is in the room is if they have to run out for supplies. I am sure you are thinking, isn’t a nurse aways a patient advocate? Yes, but usually patients aren’t under anesthesia.  

A circulator works on a team that consists of a variety of people. These can include a surgical tech, surgical assistant, surgeon, CRNA, anesthesiologist, sometimes NPs or PAs or a combination of these above dependent on what the procedure requires. They will also work with vendor representatives when instrumentation or implants are needed from an outside vendor. This list of people is really only those the circulator will work with during a procedure- like all nurses they will work interdepartmentally with a variety of healthcare professionals.

A “normal” day for a circulator looks a little like this… upon arrival the circulator will receive his or her assignment for the day. Then the circulator will begin preparing for the first patient. To do this, the circulator needs to do a chart review to verify what procedure is to be done, allergies, past medical history, and all other pertinent information to ensure safe patient care is given. Getting the room ready is next, this can be done in a different order based upon the nurse’s assessment, but I’ll share what my normal routine was.

After reviewing the patient’s chart, I would start by looking around the room and see what equipment is needed. For example, most procedures require a suction machine and a cautery machine (AKA bovie). If those are not in the room, I would run and grab them unless the surgical tech was already doing so. Helping the surgical tech open the room is next, I always make a point to help, or offer help, to the surgical tech to help open the sterile field. Verifying sterility of instrument caskets is a two-person job (depending on casket style) once the instrument casket is popped open, the surgical tech will grab the inner tray lift it out of the casket while the nurse verifies all filters are intact and do not have holes present. The surgical tech will verify the internal indicators show sterilization took place (more on that later!), then once all is confirmed sterile, the surgical tech can place the tray on the sterile field and the nurse can place the casket back on the case cart. Once all items are opened and the surgical tech is set, I’ll move back over to preparing the rest of the room.

(In the first picture below is a casket that was improperly closed, which means it was unsterile and unusable. This is always something you need to be mindful of when opening a room. The third picture is a contamination and why the nurse always needs to check the caskets. It’s a piece of tape used to wrap trays, and it’s likely still sterile but we would consider this contaminated. The fourth picture is a type of chemical indicator that is placed inside of each casket to verify sterility parameters were met, the top is an unused one and the bottom is one that went through a sterilizer.)

I’ll take a minute to say that not all circulators help the surgical tech this much, but I know working together and ensuring they are set up or success will result in the best outcome for the patient. Once the surgical tech is scrubbed in, they can’t just walk out of the room to grab something they realize is missing or remembered they needed. A lot of times, these things are caught when we work together to get the room opened. The surgical tech you are working with will greatly appreciate your help and it will be reciprocated.

Okay, back to getting the room ready. Next, I would look to see what positioning devices are needed and grab them if they aren’t in the room already. There are a lot of different positioning devices that are needed, but you can always reference the preference card to determine what the surgeon’s requests are. Always make sure a safety belt is on the bed and ready! Then it is time to grab any medications that are needed. As always, check, double check, and triple check those allergies!

Now I’ll look to see if the patient will need a foley catheter during the procedure, if so, I will retrieve the kit and grab a few pairs of gloves and set them on a prep stand ready to roll up to the patient when it’s time. Then determine how the patient’s skin will be prepped and get that ready. Generally, all hair removal should be done while the patient is in pre-op, but it does not always happen, so I’ll always prepare for that as well.

After all of this I’ll do another check of the room to make sure everything is ready for the patient. Then I check in with the surgical tech and ensure they are ready, or close to it. I’ll also count with them if we have not already done so. Then I’ll verify that the patient is ready to come to surgery. If they are ready, I’ll verify that anesthesia and the surgeon are ready as well and then it’s off to pre-op.

 In pre-op I will interview the patient and ensure we are all on the same page for why they are here. I’ll start by introducing myself and why I’m there, I’ve witnessed and experienced many times where the patient does not understand what is going on because it was not properly explained. So, I always try to use “AIDET”. This is an acronym used to guide introductions by a care team member. Here is an example;

Then I move to the actual interview- I ask the patient to state their first name, last name, and date of birth. During this I’ll ask the patient what their preferred name is. Next, we’ll cover allergies. Then I’ll ask the patient what they are here for. Usually, they’ll state “Dr. Jones is going to fix my right hip today.” Or do their best to explain what the procedure is. After they state the surgeon and procedure, I’ll read directly from the consent what is scheduled and ensure it matches what they believe is happening. Assuming there are no discrepancies, I’ll make sure the surgeon has marked the site (if applicable). I’ll ask if there are any questions or concerns, and I will get ready for the drive back to the OR.

Once, we get to the OR I will introduce the patient to the team and the team will introduce themselves as well. Then it’s time to get the patient moved over to the operating table. Remember when you helped the surgical tech get the sterile field ready? Well, now is the time that they will usually reciprocate and help you getting the patient moved over to the table! As soon as the patient is over to the table always offer warm blankets. Occasionally they will decline, but the OR is considerably colder than other departments, so usually they are very thankful for those blankets. Next, it’s anesthesia’s turn. I’ll remain by the patient’s side through this process to assist if needed and comfort the patient. After the patient is properly anesthetized it’s time to position and perform the skin prep.  

Then it’s finally time for the procedure. I’ll call the surgeon to the room if they are not already present. Once the surgeon is scrubbed in, I’ll perform the timeout. This is an absolute hard stop where every single person in the room must stop what they are doing, listen to the timeout, agree (or disagree if applicable) to the timeout, and ensure everything is exactly right for the patient. Now it’s incision time. Throughout the procedure I will open items to the field as needed by the request of the surgeon or surgical tech.

I will go over the duties during the procedure more thoroughly in a few different posts as it is highly dependent on what type of procedure is being performed. But, then towards the end of the procedure we will perform a final count, I will help gather and place dressings on the patient as needed, then back to the patient’s side while they are waking up with the help of the CRNA. Then it’s time to move the patient back over to the stretcher and transport them to their next phase of care.

Something I didn’t mention previously, is the charting aspect of patient care. Don’t worry, it’s still there and just as important. I’ll cover this in a later post as well! A circulator’s job is an extremely important role in the OR, this was just a quick overview of part of the job. I’ll have more out soon on all aspects of the circulator’s role. If you have any specific questions- feel free to reach out!