Document Type

DNP Project

Publication Date


Degree Name

Doctor of Nursing Practice

Faculty Advisor

Kerry A. Milner DNSc, APRN, FNP-BC, EBP-C



Delayed first case on time starts (FCOTS) in the operating room (OR) have a trickle-down effect throughout the day leading to wasted resources, patient dissatisfaction, and healthcare staff stress and burnout. In the local practice setting the mean FCOTS was 65%, well below the national target of 83%. Surgeons being late and missing electronic health record documentation were the most common reasons for delays. A push notification system had been implemented to improve FCOTS however few surgeons and nurses were using this technology.

Project Goals

  1. Develop a process and training for a push notification system for surgeons and nurses.
  2. Increase FCOTS by 7.5% from baseline, within 20 weeks.
  3. Increase surgeon and nurse push notification system use by at least 50% from baseline, within 20 weeks.


The Model for Improvement was used to guide this evidence-based quality improvement project. The clinical setting was three adult perioperative pavilions in a large New England health system. Push notification process mapped for nurses and surgeons and disseminated in training sessions. Tracked first case push notification usage for nurses and surgeons, and reasons for first case delays weekly for 12 weeks then biweekly for 8 weeks.


A total of 4 PDSA cycles were completed from September 2023 to January 2024. PDSA #1 resulted in 87% (n=60) of nurses trained and 100% (n=89) of surgeons received email with training and 31% (n=23) responded to email. PDSAs #2-4 focused on optimizing the push notification usage to increase FCOTS. Nurse push notification usage increased from 22% at baseline to 39% at 20 weeks. Surgeon usage was 7% at baseline and 9% at 20 weeks. The mean baseline FCOTS was 64.67% and 65.67% after 20 weeks. Only one pavilion had an improvement in FCOTS baseline mean 48% and 58% at 20 weeks.

Implications for Practice

While there were some improvements in nurse push notification usage and one pavilion saw an increase in FCOTS, there's still room for improvement, especially in surgeon engagement and overall FCOTS rates. Perioperative policy requirements should include the use of the push notification system.


A DNP project submitted in partial fulfillment of the requirements for the degree of Doctor of Nursing Practice, Sacred Heart University Davis & Henley College of Nursing.

Creative Commons License

Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License
This work is licensed under a Creative Commons Attribution-NonCommercial-Share Alike 4.0 International License.

Available for download on Monday, January 20, 2025

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