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s l a y t ld s l t o o s e a s a c e m p n a e c s e k n e g i a s r e s s e ei cia oye he ld em dsh tr t i th bu loy e alty g s an riti is pr re li s i unl As are yee res ion ev s me n, ou es s a in iti or t tiv co d ch plo s, e g s Th alle te we h H in at OR re um ss cie e r e • m he e g nc th s u • e lo e ct n • A d io w rs a g dd f en ut an ng m ie in c ay ap dd uld es e re pl r t ou th ar en ha in ll p am ci in s k l n d st r e n d n e i pp em fo I w ate ew be e t ng -ca em e s pe ov ces t is od m a wo ogr op ing , w mp th du uld g fin pi • I nu a h rin e a ing inc l o tal be e pp rov rifi a s f t s li ou rie ce • A s a in rog et e r r g • in st e nc ri n g th e s pr ro a t ea nd I sc be rs e ve re ho ein to o g e en ha th it e ica n e ew su p e o s o m lth pe an n e l – l p p ng ge ew itin ng lim tic hav ala sha e o tin or th im r p e th rce e t g a g • al p do ll- age ing ha se l s l-b ed my inin ativ ar ff s te cru pit rg me ar f n s, im s v e t er ee • A ex al tio oye el tia com alle un re b la l w n u i e o h is f e n e c o h n o s t e e l g a e s u r e o t n ie u b s ti n e a r e b cr ain to ibi ey fe aff e t ex ng ud s i ev an rkf f t cki inin an n e l w an xis s to , th nn we en • In tr pe tiv sta eci ll r de l s hei , w nt en ss i nc e d em It um ent life pu mp ob sta eir ch e y s a c tr s nt th /li st ak of iti cl res n al o s o ra tra st a ica m f e nt m rso al all es nd rio era of pr e a ist sfu t rs e um re te ng m g • ul ti k/ po e ir j b th f a Th yee ir e R u f e a s o e m r d b w r t b s c a r n e c nd gi in les ork r o o m ion cru ls i rog ul fe R be is nd su es hys O n o wa the pe ysi ch ye t a Pe iop er ap ar ers ces l t ag uit st rog p lle er vin rri r p o ng ting the e s nd re o e • plo th at te e n w e s t nt re o p ho /li O m n a e oc p As tio ff te R h ng plo en y • er mb m we p uc ica an cr in p om ha ng lea cu ou e w si is o d d a o rc m in re b a a h g r x s k e e io t d r o l a s s t l e – l c c u ra l u O p i e t d r m p o t o h i m e u a r r g l u e e i a p t e m e o n n f r i r C h t r e m ’ l e o e m a h e m m te a l h i a l l i n d • n st a t d i • n n n p t i ir op t nu nis re re sc nt ne wo • T r m ten me m er l a on ete ur s an e b e ui af he r e lik HA ing is c OR nd we an he of e y ar the at t nd al n of s to ve rai ven ork hy rsin rea try t e a c t h es n e fi r n e a t e t ll he c nd r a re a g ta on e n ge e ip ve ev ta ti r O lim e l ar ew q s T lle th s ‘w u os fi lle ch s a e rsin bs rs th de un f r qu ha n en ula are • o e om nta e f n s, e ing e • ma of em gh ien ha As es job bs nd or • T ye g i hr to ne tio rc s h en es e w g l n ery s in ica nd to ma me rn e w nu su pe nd ur yo t o , e ls uld m op s aff s t utc e , w o lie ov rifi s rs se ou er e t • ye ir su a m ce lo sin al t g ge en sou tal be m th sin ica v er ist y t t a p n s b e e r fi i R e e e e c s i t a o i r p r n st i e o m r s n t p p r e a e I t l t h x p c o n l o h e d e e d e n r e n g s d ce l i k e p i e co s s e s g ad a yi o a fin on s se ad • O to all Th sp plie sp l sh the ng nce ve eg cal eir ge me sup im s v to mb g • A s e lan ati mp o t a ain ev kfo ’ em l nu ry r try th e r e r os av be ro dr sur s is le st bu l g i • i r r l c e t c • t o c em o m s g l a p ho e o rs co ati tra rgi th ana uit ts, in ci due me vin m ent ba pu g e o d e m tr es o hy ica ve in han ar th t h y h is a ad of th eir y is ei al e t r s u to s e a e th le d w s t r n s n ue t o se e ve e in h ce ia su t nn l t u s h a th m d u i e o n t v n r a y w a r t t g e m n v l e s a i h h f c e ‘ m r e t a b r n i , t r s t t t p e ed tw It lik ha om try in t or ruc ts, ha rso ica l n wo pe d l s al l a l o e h r o d i n e s i st s e , h a a u s e i e re e re e g ge le u a /l g ng top • ld als utc in g rkf t c en te t pe rit era p t erio an sfu itic OR d rum og p len un re rric r p rk ing exi rc als e b bec s t sin f s is ead old nc o h ate ess ita rk g cia hip fo e t m m ers o u p o n e a t m l u a g s l d n h l s n o s m a r y in ou it l o r ri R s c en to p es es cr s a st p o a yo s cu o wo rs f o it av is o es o t r y co s ic n s w ki p ds n rc he s p t t o M av w sp a de ha e w m tru dic O t i g y of tiv cc is • A es in al r c ch e ee ir to e nu n o es sp h th cr dr lty as ei all o nt nd u ho n ac e s ar f a fo s t he s a f a e c r C i i e h a k e a c , t i i d le • I ho gi ea s th e s in • a he M p n u t n e l – ti e a Th y e t th al io e ho ey l, tw a s p ty d tr th w af r e t A hr f e g at ur ir l aff ss , th – in ns es e th n t s • ou nce g s tha tio loy el tan th of • plo n th rea d er nt th at th ita ble d a pec hip for tist p ff w on co ni ur is e ste st wo giv for H l t sta i s u b s e st o n ll io m c a ve gr i in e la p w s d re e m i h fin n te e th ss sp ka n s ds g h o n t e r d ta t ta ct o m ll on lud ic he R is g g rea he in c b n a o v ni th l h h i e r c e t u r o i e n ai te sfu r t r of ac ini we uc tc la r t y l all pit ien anc op em job su d a mo for y’ ing eal to e g e r ha te nle ho o g the wa an is s My r s du nd m -ca nt inc iot r t e O th itin ou ry r t ar r u re e co n te s ib fo h e r u l t h e fo s h g e c a e s f o e l e p b d o u b a d e u s m s r a l p n g i r e e n r k h r s r g t h a r o i c a u t y w k i n e te f f y • di cc d b ab y o jo re al e ol b e s de pe b g ti he ad in ve o ‘w nu ry yin n s s t d pe ni en c d s ta da es • O e an a o re ol nt e • T tim ec A a v e ff n i u a f g a s s u r r n n t m m tr e e w ng al ve tr ha rn nt in co mu rd tr cl tic e to liv ff es ss in the of ho n a n n al ll r • is ng sta yo on su a u rk m ei se ic /li ly ei m ist ex life si xi o g aff r n wo In th the urg rk cal th sa rs ts k/ nur f e d ve en es th ssi gic s a in r t nce wa ons os m l bu is in bio th ce sy sta , th ce tor e ct sc e i alle rde ion e a lum is alle of e nti n s l a e n r o i k e o h r e h s i r o o i e r t e n e e • r o h f , g c o u t r i l u t h t u i r r t e h a o st l l e n e m p t o T f d ls n d co a l n l t i o om ss re u e a de es o d em fu e w tis m th s ati w ra ion es ls e b ec ro d f s his de ol o c ta uc e a -c ntio hoo an e f kfo ir b tiv he r p ire m asp sin ir r a c ll b dd e a rric as a c be • re ipm s r r s f d e o u sm ur ye t h ss th ta e or C p e ne t rc ta v b c ad o t a ly w m an in n e c n g o e ra t e l d o l u e d a a w u , a l b lo es te t ce d is s s th g f HA ur th ge ten ou spi ha is le a nd lty , as ir le cal p t ur e re ss or e o ret g s le i len w th pe ate nev ca s t cia n th te e c he ke r c hip ted nu orc ct o eq t h • i m u ee t n h t li ei s n r kf e s, l a p rc a O s e t th f n o l R in io n c n e n h o d e e s o y th b a a p e ti o u e r g r i t d s r r l s o i s ca m u in su fi ay iv iti g to fin th c si r ha O o re h he l, a g ci hi th is t f • e c ec e te s h rd se lle r p ie th es n- w e eso lim ng to od s g cru hou at to n are he at s t ita ork kin pe ds or tat My taf , th pro dir ak ct nur eir a c he em pe elim ou su han st to ab pre in cia em in t wa re a wo l as pl te om tr h s p g h a g t i e s r f s p a h f a h o r i e t e p m ne he o e nc yin ce th l re Alt hre ing th rns e e t nle os n w rac he wa d is s • e s em ver cal o m sp ee t t ed • T s t p o to el s s ec m like arn ys rin pre t s ng st ys a s the cia su dic utc s in t s t rie tr or e al • l t ry er ce av at u h de s t t te an y ive tiv th e gi s t l a s ou nt en ive u es n • A m he ld le wa ha ap • I rsi tic a o s ru ts, in l o er aff i a w t s n r c ve gie pe in rkf l tim are um rea in t old on o h di pe nity ur n i ude ic s aff od y l era ate ld su sm cia e to ab ese rd s g gro eg son ng nd n, t ou uld al ff s m ng nu io al e ro st c en ns ica ad st a fi o w o as a a vi l tib s du ac o m io g le f rk l s o a i c s t i n co u l b i o c l t s t t u s p i n u a o o a e u y s ly t e a n i r u i k r n p r b u h i l l at e r e i o te ex r t r t l o l o r a e o w i c ra ts ad R tion w rric ve der cal tw ant ons dos mm ca en s in tib he rce ir b erio lim sh As ha st ld lea ys all e t m str R p ll-b d t pin • I s sh a h f s e t lea gic an a h ge le e m stru uc su eir er w t e s - t l i n t o n o th e ur in n n ab th in ed ul th b n en i i l • ec o u d a c r ie le O d lik cu a ea ist p w ct en co n re o an r kf he p o e e o l w e tim e nd O we ge o ng se re r e le k f m e r at eir he ad s ir s is ir l at to aff du n a e o of ho in fo or n t of s t nn ing d m e m I w ou al th al am s a s • al len my ini ur a be of s a of s ole ar al or n, ll – se ss for nu urd itm rio e e i h a o a n s e s r l h e p e c e s i n m e w w u r r e e n r i e in th t sc e c v d b t h T e m h e i e st y st e n c ie so e n h • r n • th see n t s th r th is • M ur e r ess or ke ec g rol eng R em rou eg er ll-b fi n, t g s s ha g i itio he tiv om ys cha • I d t ive ati nu be oye lty eir ativ a en pin w th uc an lle all ecr f p n a , a i f t r s p n l p e to i o i n s e n a i n d t e n c p h l t g es an ra e ler m pl ci th er o rd o job m g s ff m -c r o a de te It g , a fo ay es O e oc ct a s si ir al e O th l g rat r d r n r ur cia • in ip d od liv f • , th pr ire m l a ur he ch h es al st OR l w ed pin rai nu are ha a fo inc ou d in ye nt e iop al me m pe ut op re bu my ir he in sta s on nd up gic ng re ing urs sh an e t sy taf m er l d s to cia e n t t a • T iv sm d • ica ng o d t ve e f s he ng te al l an be lo e iop er sm er y’ e e s bo eri mo all In he e t nc e o a e s a gro ur vi pp av l n ard aff rc bu e s the ev ica m cru se ou ed en is g e an es hys alle my an ati ativ taf te t uiti spi gic ta are mp ipm Per e p a ng wh th n a p n -c • o t at rie r th e t e th ee all f s pro on y b t d h m s m e e n s d in e o t o r n n g is s e u r r u s o r le a h o u ‘ e r t f w o v t p k r a e h a s t o e n e gic ste e rk hei ati ate ld sur an os e t rn sen bur e t sa tiv tco d c • I en pe pe of eci rec t d l su me we ew eq ty • • T e yo ng lud lea Th ev e o yee to lim exp e f e d a pl sm lty n im er fo u p d m m e ia i • s h o s e i r , h o t u e h e n u n g s r n , io io r r l s u r g g ik a e l s u t i c r t w i n p e m i h o s a e c e m d l l e p r a l t i m t h ce l o l a e i n e e i p m e r e r b e p p a l r s i s f e i e r s f n i e s a f e i fi e e d h e s s i n c u l d fi e m e e t p l ce o n t s e n e n to e m e c s s R n v io fo OR m rio eli el s A m th ul ld ys e c al for in ica nta b oy qu • P p um a re pe ces th ag t o pl g s er ng • T dr ls ho eri co ak em ur s t tie all all s ing sa sp re • O ff a s e tib ge he he pe to nn g • nd on, wo ou wa th tion g ite rg me are pl , e ty The r n am e a Cs uc l to an en sup in s v lle rce ad hoo s s s v be m w eso gie pa ch ch ism ist the he rog es sta e A n fi v e t s h l n n m e e s e x t r a a r r t a e l e T s o f e s s o i n o n i I s a i n d i i t i s p s u i r e e m i e f e • l e te w A c a m t m s , o c i h a f o d c s i e i s to n lp m e o • al n • ive p gi er -be d t opi g • es as ng ad ru de ful he , w w pl sa fie al he ike H ing riti R rui nt pr en a c rk an g s nur nc , th ms of the tra ou ted of ch of fo de tia tco th ec on p e l h c u e p ll g lu n O c e m t r b i a s o o g n t s e p g i m t l c t n s h i e e de s g ro at R e ge y ini ur a ar he re is ss o er n su in er s f s ug n s c s re m i e of w in si e et ta nis nt ve d t t en or m on tin c ta ou fo is lat ur thi ll g str O l w en m ra e n en sh e t all ers cce l t ag of s, ov s v o a s o em ho rie t i • A d tru s in mp re he ck ur tiv mp spi ha me ha an ea res m nd nti rui s in bs al e th pu am • I g n a l t r a e r n t e n c a r • , l a f t a t t l s n t r t s t I e e r i o s l c a u t v o n e c o o fi l u o c a f r n i i n p p e d s a p n h i o p e c a o i n a a e s e n h t e c e s s e t a d g e s s i e i m sm an e ys ch s • an rat ive sta ec ar Cs g rit m me me im enc due mb It • A ex e t tio es – i gr ir n m os is se op ir c ty h m cru ts t tiv al t ys ev to re ll re ho e ur alle pit g p the yee am s e t a s d e a c d s h s in r n o ri e i d e n n e r e A in c R it u n t e t f e • e s m h g o ts c la e ll ro e e m ive tco d p ein oye en iop era r o pp e w H nc t is O ru str s i pe ge m ng lum en lan pu loy we l p th ev ac tio e t Pe th un fin d r wa ce y r alw e ge ar re g s ma ful a c ho rs of pl the o i n e r s o m e n n s a i n e ss d t y n u e r s e m r I w nt ou n b pl m er p be a lik gh rie a As ec in res m len er vi cu ti ba po p b ia nd s le n lik • nd m o an ff e h t a e v s t ce al al a re em uip • P erio um am s ou pe e t • d r ll – og r co hal ng lea rri r p ife g em r jo an d a m kab ret ld ety d a om d es ta ite a v ha ec all cer we ur ha cce te uni ral b w fo • te s p u e u u a n n e r i c c e e t e o r l in g i u f e a b h n e n s u en q e m e g ng a ic t p n te m h x c t f s s s / o y c c o r rg en we ew s, e fet he er he see Al ts e lan ati s a b w al p the f a y ar ir c o rk urs stin the ub ain be wo t o wo sa ain n a eng loy u de is i ren his g co lik ee ital g s res mm en me f n itin ini str s m s, f n ie a T all t It • n ba ul ee jo ti d o he es he to wo l n xi o s tr is n c • I ng tr r i all p • O st th a l, t ein o s s p in p co g er t o ru ra d es f r l s t e e e o i ei ger t o pp g e • sm s o • lum atie fe op loy eir tan an re • T oye in t eat e ra f e o d ade en , th rd sp g ov en cto ch em aff rsi as tive ita b tw eem e t hos nc ys a th ng en rec d an urs tc a en su vin ifi a er ng u p /li p p h bs ed o e pl g hr th ne o s t m be al bu l a nin pr be re g g st pe , ra sp re op s lik t rie wa in n u tm ll an es n u an tm s, ro er to b avi ric ur rk ing em o t su in n m orc m in l t nd ge ion ce e ve pit ll ia rai im e di ein stin e s hip pe ho e a y t • It ld ha pe al or tha yo rui e a nt tiv ive al o rio v t r c a t s v v s l o r f a i e e C x o s e s t e r ea fi e nt ur av a os -c ru ui nt p s e em le u e n at i c e w r g d e tr v k ’ in a a b x ti A d io y , w M g u e e a c r h ec a cr me im cie du m re ir c t to e nu stin to ad n s e or hy l nu ry r to th ete so ls h y h h on t c nd ss y h gic are f e era H ar per nit rs s • vin wo cat ts a h ire lde • T d r e ipm inc per rg e p is a w e n n r a h l i s d o e n u h t e y e I i r w u e o h w n g w p ‘ e g e g ru i en e e s he ea t ra x e m e e e e qu e io s T a ca e n a r r ta h it e os t re he u e ve ea • d ie n l st ess et eng ng ee n t thr nd ne f e urc ave e b om th ing rgi a v ryi r th are the spi ss t un th m en og s t a s , w tion erio ou st Th mm na y li e l g in at are ica ally orc s a lik , e pit er ful • th re u y i t e r p ll r in s p fi e o o o a s v c s s u s g c f e s s s P s e e o h ic • o m e e m r s s s h e s l n e i p e i fi r t s t e a o r k k n p og om ha y plo ing ea to e g ion res ls ha s b ros res f s is s in old rn ave t h unl om a , th uip al nle • A ge te of Al io fie a c R m bu es ain tio ur tiv su ist or oy em plie de y • ce eri anc m lly r a o ra a at w pl e p ist et c v al n a m n q ti u c c e o t h r y ce h a • tib ri in O ir e tr c a re p c s e c r a h m rs y ng th nt e it ey hi ac d u h e g e f ei of • T y’ e nu er ryi an te th sp th l, t le ad alty as ad all on to e t op n a s to inio s, e tan ope in an are ou um an ve or s the loy nd edu t to pe As s st he em It , su ers sa g s ies e b ev isti o A e m s v t h re ve o ss ta b d ci , • t s p g i n n c l i f s at s t i st g p t a r ea rio • e s ic c s t c i gr ul in ies ct • in e e h al a h t i a n e ip le t o t a s r m p li b sc b or orc ‘w gic is s in er are ha at nle sp rk a pe sh eir tis tw an dic do to nis y o pp su do ell- OR ern all rric le nc ire on m ’ em en ese thr pe ing day ros tin ing en Cs vin nc ete rk/ m st sm e a kf ng ur is er ld s to th u ho wo ing e s rd th sta p ff w in en irec ha m su de en l w As nc sm cu r ro ete al d ati he hy pm th al he be to ac xis av um HA ro rie p wo eco y is ani th e p e m l t , e T k h a r s to e le r i s n c In , a i o or si s th d o rn s e e y a a h te oy c e l r a p t n p s f t b d c es o s lea lly ce nt a o it e ac e t ew fo y i y st on a l d e • nt m an ic n • c me ei he m gi pu es ‘w qu m y r • el rc ble of re s gh im xp co he s a l dr lty p, a ir ica on wa dic osc un urd s tr ud st nd da • M ur cti ess ica d m es e ve ss hys tio wo sa th t t co sur po giv ing , e the er ifie l w fo ka n s a – in ou in s e eir d t thi to me eci mp c t e n ou r v r a rk or io e l r e ra s es e h s s n t h n , ce d n d m b i cl ic a o a hi he t c f O u c g n ye um a ce p a g

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e ts in rgi /l is tio es ing im nd th ist ate res ou og e t o of an im u rk ay di ye rs n ci d w r e n w el l s o d d lo nu s i an l t sta re ad • I l p op s i o f f o f u w to a p s ca is pp nd g ntia sc nt ta t ss he e he m ee re es iti a o l n te s ies ce t rc t ’ e s og c cr day m g a ini sta nd ica s a n ra b e s re ur g c nd fo te y to r ro s e O te s u fi r k i a w h e l p r p t i to te k i t u n y • A ar f • tra ng to wo rec g ‘ lik tia ve ha rce he rac nd e s s a ph n ns t n s a f s c i g R p p i n l d a n n e e fo f t t t a a d e s n d t i o e r e r st n d e n y i n O a e ss o u st l d n c r k o i s e n m o c l a l a n c f nc ive s a eri tr he m dr I w ub ou la wo ers tion m ve pr ta opu co p o st b n ip ha er en p o u si co at ve p in T ea d • e s h ba o er nti ex rs n • e t d a ng ad l s fe OR em te qu ls ev m g tw gro er p tw p e ts de e th n ni m ne /li e m re , e ta n ir sin p ll p rio inc en ea rd of g a rai e on rk Th r of es pi ld he ur to a Cs al i l t to p e e bu rs kin d t av ers wo n • nge ct pli hos ou o t l n My sm HA re r h h t a y f it pa eir ll e e p M o sp ur th ca be rac an ls R p he rde ou sp su at l s al er s • m gh ery fo a t u • p y a , h e ic n e sa u v e t u n e s de o r e m t nt it es ro t o fo th me is e sp • O nd l b he ial nt e n rit g liv e ho a ng ff l i v l l g r s i s a t t n d i n e r i o n i p m h o e s o fi c a l • T u c e c a t r s o i s c h e sy r t h A l t s i s a l l e s t a e r t u o • hi h f g sy a e re f a g g nt u t m t e e cr um di pe t f n b r n t p n a c a o un ing q c r b u s m s t h a f r i u te e h co n g t h r s t s t i n R h a i r g m s r e C al st ha yo re s, e t ut ryi in kfo o in ns O e t r th he tin lu , a d a be yo ack u p e m i A • c f e t o t ei t r e s o e – i m e r e th sa H y r th ff h t o pl ica al in ing o he ll cti es an lde in cru rric hi nt um Th s t I in he ugh er for sta • T ec sup ind gic rs ar e w , t we du m bal y o m re cu rds ese r n • n i g • l o v r e h h n e ll f e p a r e e io n a t e ll em r ho a e o rc as ts, ns su ad f s s t io job r tc ife a th a eir w p all rc nt ini ti th fo lt is ng er o l n o l le af s in r se ou /l tic s re h te ys m fo e a an s s g A is lle b rkf cia e cti sfu ir st ro op ei he al rk is ive a n t c s a s rk ret tr st ces d b o ve tin • th a m o u um u s e f ac y th , t ic o at g e i ti lw a o f gi ui um s ch nu w cr tr ed ce th r o le m do m rg e w s st is e w ing bio s a to e w t o t an su pr l to e e u h i th ik rs ti i s c r u l , a a e r h e st n s r u c o r e b I n b i s e h a ha due th ec en ad ver ica stio f t s y s e sl u n th re ic ip d ll t o – p m k • t t l e a l l u r r s h n te m a o s s e m e l l t h e i n g a n d n u o r e s e s a te s f u n d d a t i m m a l n i n a e n a e o s s a s p m m n e c r i t a t i i w e rc n es fi to l ee c r ng cr al ui ve ld s st ec c f c rd e s r h w , im e r l t ar eir wa res o a ac , t b em ien af lle en loy ou mi cc to ce na t s rgi ole e a lle a ci eq ha ou t i is pr na e th te p t le ion jo th er st a rd p es eli su ng or tio • I su ir r tiv ha ble ru s, ls sh ha ay ap m s ys ue ab in eir te xp he s bu em e r o g yi rkf di g f e ra c a t c lie ita l e t d m tio w in c di like g oti lwa e d ork op th na s e r t o a all ew th s t cin n tr o ad vin ty o t th pe f a ork os pp sp nne nc to ea is i t fo t c n e i e n i w e a l u i o o w m u o o l a ce t n in i a g w y o ad s e m rs tib s en n m d lim ien e e n- f av eg rie rs R th le cia o er re n e , s t h rs a or he tio ru th ee nu an ha all de In to e at ng du o t o h rat e de e O te re pe ab p o de , th ts ha pe e b kf f t en nst e m p n l o a p s rn he n ur n e t R lif or o et i o te t s a i n a h u r • s t l l e e h e n to s t x e a h i a ia • I gic le ren a c l b es rce ies our ha eng e t tm ts d s e ir l • T rec ees he lea • T ve ll b inio um ate O rk/ w ers f r ll – s t s a l e u • t o e ie i n n t k i r o a f r R e c l y e c l ec g o g a n p b a p y n t e a a a i r u d t pr in f su ir ive e o -c lo eso ate t to a ha m cr w s tie th de ap plo de ul rifi es -c o ins nd es w e O m ec b w eg his ap eav o the rat or on mp e r str ea ted a c to re aff tive pa for ur m em clu ho ve om on my – s i om the Th me sp jo rat s t e • s b a t a fi A l y r n f s d t n s ll n c r a ir m e e h c e r t d am re alt ut pe n th th se o m n r s en u nd all te hy’ ls i es ies be th • In we tio out nd n • ge ial he d s ip, eri • fi e n c t n h v g y te a ci o io e e ew ve an al e re is s a u nc o a c e c e o rs c e es e ab per ev ak f n ha es re pr o an ee • O e i to aff he th ‘w ho nu ten his ak ees job du cal to rd ou ru do s a rds es ein all t m y i b ic f g c s u y c s m h y o e i v y th e sp n it t t t e e f i a r m g , a c e r s o o n y b e r c g y i s l t t r e o f o t t v of lo the lea Th m to en s t en ve wa en e pl ta esp re e in rs ssi g tiv mp ita to plo he se ur yin all he os s t ti ew en ell tis rs mp e d • co s m nt c a al ev d m m s d l th th ing be re sin ra co p s m t e l s tr c • T m e en st et l w ta s c h e r n e e l o c of u be ’ e lud ou ifie b ism ruit wa e i s is as es fin g tiv sist rea fo ar em dd ur ope eir ho ism w e d , t ssf in the ce he ur in tic mp ca is s he nt h i a n s t o s t h n em hy nc sh ver thi han rec aff spi thi a com to sti era er ry ge f s m d ee eri th ity han ne s to em ce er in for n, es ite ibio r co ys ay • T me h c d t r p i p e n f r n n h i m w i s f k r g ‘ ols se es al, ec d r s de as re be ed ex iop s v lle ta ge a o s • P nd un ec o rce e t su ea ing or inio e es nt he p tod ce uit the a s r r t ge sin ho ur nci pit m an Ou ist ip, e a is ng of er AC s a ha f un ing e t ty d a m m nt ou at g ir l ar w p th t d in n d e f o c o r to un es sc e n te os nd es • rs sh tiv , th lle n f p H is i a c r o yo ck lik afe ine com find me res min cin he f sh the y o ave sis le and l a orc rk re g f ike l n t f it ta kf o nd n m h er ro li yo dr g iv e h fi ye ff pe rd ra al ha tio o gh h be e ra d s a e ad sin rat mp ity to lo sta s wa pe pit g c en up ou s t ted m Th is t ul ng tr in a to cru the o e erie for sta oss In to p ir ned en or e w s a uiti uld m, o i en r t ro h , a n u • s e i m w h e r o e C e io s n r • s d e r e o n d p t p f Th • and nu iop ir c mu ge em tive HA st er ho ei e re l g Alt ip ese r n ce ion I w rov be to ge d r ave ies ex and r o ac es nt AC t th tra eir R s t ye rec I w th ibi s b e n t a ce g ee er he m len ng ra h tic p ty e ar al • sh pr all for en g • mp ve rec lle an o h eg ts ff be ble ye w h H ou en th e O ro plo all • ate ant i a o n i f t t a g in s a t l k or in s P t co al ti e ug io he ni ar s m m rd s n b e o h c t a g m f kf ck to • nd a ch xis riop ho tib • T mu e ern e s ulu wa ay sm or f re ini in y h al d ch ee ts tra atie e s nu ork mp ta ou n a e b l t • T le a em are nin im e in s h r v ca y n s l i n w c e lt n or ra e ty a n c g c e w a w h r w e ra s r t a a ti en ab ing e ra e rol a l w t l i k f e d r i n g f p e A a fi e m s , n a m r i s t a l to e t o t e s h e g i i n l o a d r p t l e u e is d sa ne to ei o f • in ri co er co s ur ic s e th ec d gr s t ur be mp ff w an ou for al en ew O • A d le y h cri rd ork ist e w d t to ir ess l e is bu w ex lik an ies he c m rd n • e a s th n ul g ai c b ion o m le ve a g o he r c ot ha u ss p an ro s s e e a e e o p o i t f d e s r u s h e t f i a l ss ti wo vin t ir ar nt u ulu ro es in an tw r e ib na e ro l a nt l p n s ar ng s iv t t g a bu o af lum o t t ll n of s t g t t ro ro ten • I ro een al d e ete gro ric eir nci tor m op fo th ant re ng ac ia me tia e u • A e isti ur ent ea llen to all ent st cu sh ess tha ca de n em en ate ou r p a le le uc p n p g in O c hr a e c r h e c R t p b ic w r ll e ri es nl e ur io e m tr b ve ac re ,w x e f ng im e g s, re a cu t t et ire O y tin g in ve al b r ui ta co ng rs e • in t ch du n- itm tiv ur rs u nce th l b nt It s uip d s n a ne o ru ra c u e a in al te • q n r b l t o i n i i n av u r e r a s m i r o u p d s M r u i s i n l e t i c h k a t c e q b s o s e i e o f a f f t e a l a ka c ra s h a s ag ns e he b om al A s • c r r ro era f a or os s, su nd ll-b nag on st spi y re ed nge the ec pe eir e n cop bal g -c re g , e s a lea uld u • e n r o h iv s r o i p e w m ie e e e a i e n t in n e in s e or pe t es y s r er m t a c ic w as nd gr the A ma nc sa in arn eir urg tion liv all al the rio re o en he pl ad n w m ent tiv de ve en alle ke nd eri in t rat do life ar e o ar av plie tiv uld l sh a h s p • R o e ng le h s a y e ic t s e a l a t o s r g t en ial t a ro ss g l c h i pe o rd , t u m s ca R et er is a re ch m s a f p g pe en k/ s th rn l p en h ne rd uc en al p le in s O o r t rs ld nd s a pu bu e a ur ou e m bu ion s, s ve es si s O e r p ers s is p a to ee o sin rio n or aff ke ce are , su inc s s on bu cr m ti un be A tw fo nu ou a • A po eir w f s ab Th ven all in nt ha roc hy A ar rio p hi ays of s oy up ur e s a e w st a on s ts e rse rs sh ed g ng th ike y o rn e • e -c op me als r p d p n • rns pe Cs s t lw re ism pl gro al n • P ces th of o m c yee en pit nu pe s n t a n n i l t e an io e of A , a a o n m ll ic ty o d er t wo lo um es e R ai ei s in s al le rifi e o y ru i t c m a e s H r tr l-b nur m m eci ld ve om he n m nst osp nev al ula on up h hip has n ch g ma rg afe r p fin mb sm p t mp str t d tiv • O u t e e n i g s a I s s o c u h s e n p t el l he e p ou s ec t d ro u ds a v e ti n i to e i n s i r s w era s t It s e s sh cie b ke s • ll – at ul me po wo l g ho ar en s e d m xis me of ing nev g r n ha y hy’ l – er pe me n e c M n ve • th s en is a ee e th ho ir g t al lt w ar e n e sa ty v w el p rio o yi ll ge gi g e rse et l, th o m loy b w te l s he sin op sm • A ste ve om o fi of e ial pro uld tr ma me s • g ‘ w Cs Pe utc is vin lud u p ta s t p jo ica ne t ur t e m ic ti ec t n th ec m ho in s d ve in ob A • o th lea nc e n om spi sm em eir nd on l to l n My am lu iot era s b ed ntio for sp in i l s rs o a fin y li ess ir j h H ty cal i s c o u e e t to s r e g f e g i i i e s tiv ir ni w th s er ca ra • s ic tib op h ng te g e s n d u d h u a ar ol ra he y h ha ne do on p riti ene ves the urr an eri l, t lle re tin th res on lea due ed r b ad o t ho s sur a i i g e s i R l c t p c ho pe t it ec of g g r n ei d d lt in l ita h re u d g r ir e sc rio nd un m nt s to duc • O t is he sy fo eir le i he sp g c s a ecr clu pro pe he ng len th an to • A ov sfu s a m d e e e s a t bu g h o T o in n r in l R r t le al in g s Pe r l pr e n t r h • ned om fin itm urc e r me th an eir iti in ir e • ty be ce al ls ntia • O fo hal ch m kin rce lum im cc h s c e e u o n t re oo ta s d c g he ac ou cu n su ai r u s o e co c t h r g h i fi n i e tr in a ed ec re , th ut lan er in t rec sin t t ver u ar co e a ch bs me an f a ein s t tr es rri ss i ng m e o w s u o ff o b e is r cu e ci d r e r g ll ur ou s m lo a l s v to len nd th he ca e b ly o em e a l n ab cie om s, w tw ke ing e utc sta re are gi ion the ir gr ien al s a ve t rgi /lif al th ar ica n en a c er op li rs ad l o he mo e is nt e the pro er ch ee ha ate su rk stic ves e rg ear et in ag y t ms nu m ica r t n , w th te hav in ial xp w u l p r an M e e ve g o ve rs e re e o ti oy to in ul f o g t s e gi o pl ts lim sf e w ta is like f uld om ct m s • t s se ha ur e s e ge tim of s t sin tan nts s o s s c I to l s l n g e n a a l c t n t u r b s i e an e e th s th s y ho r ire R ve • w to ucc nd y i e em ialt s s hei l d s O y li g ike ita sfu lle om ma ion pe wa l n su pat it as ff ca e r es s fi da tim se c e t ca A s in l sp es ha ec gi ing to to al It spe urs nd rgi n • bu eav uld ho cc a c s b OR dd ial ta rgi ad ou n a u i o i r e l o a t s u d h i s e a c r s s u m to c g ce o n • e s e u en yin or iti ng th ive ed a lat th ar I w th ng te l, t • A th cr u f ve t tr rkf dd avi e at ain s u in es • te ci en ita n te st • O y o ha rea in o a le lud per tr • A pop m ye ing ica ien res sp tio cia o aff ialt als th w e e c l m r p o la e n e o n h u r e st e c i t a R th r in io e ng g h l ai d e s O e s a ls er be ei in t p tr in xp y y p p th e p sp re e iat ee o • P ve l-b urs ves ’ em d ns s e lwa nit po ap n, tiv e s ho ry i y an io t a l n u g m io ra h t ve a Th c y ho • pre plo sc fety y h we ral is g wh nt uct ien as m sin ea in pe e t tha a m r t p l t e n a p m n g s a h e a n e t h g ‘ e e d a h o u e o r i o l u d te i s rd m ’ e rsi g s t sic ge e in ipm e r r p na a c al n th y pe nc ca his bu ea hy nu vin es hy e tim ess qu es ou are in er of n m of s i di s t w

As a teenager Edward McKay pushed through a childhood that included the realities of the illegal drug trade, gang violence, and family hardships just to make it through high school. At 18, he practically willed himself into his foot-in-thedoor job at Hopkins, a position in the hospital environmental services department. Then he met a man who changed his life.

SPOTLIGHT ON: EDWARD MCKAY

We look at the top industry concerns as expressed by OR Today readers in a recent survey. Among the top perioperative concerns for 2016 we examine are work/life balance; staff recruiting, retention and training; infection prevention; and the sterilization and cleaning of endoscopes/utensils.

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January/February 2016 | OR TODAY

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CORPORATE PROFILE: D.A. SURGICAL

Dan Allen, president and founder of D.A. surgical, is a respected pioneer and product designer of patient positioning devices that continue to be used every day in operating rooms around the globe.

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TOP PERIOPERATIVE CONCERNS FOR 2016

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OR TODAY | January/February 2016

features

OR Today (Vol. 16, Issue #1) January/February 2016 is published monthly by MD Publishing, 18 Eastbrook Bend, Peachtree City, GA 30269-1530. POSTMASTER: Send address changes to OR Today at 18 Eastbrook Bend, Peachtree City, GA 30269-1530.

For subscription information visit www.ortoday.com. The information and opinions expressed in the articles and advertisements herein are those of the writer and/or advertiser, and not necessarily those of the publisher. Reproduction in whole or in part without written permission is prohibited. © 2016

CONTENTS

departments

PUBLISHER

John M. Krieg | john@mdpublishing.com

42

VICE PRESIDENT

Kristin Leavoy | kristin@mdpublishing.com

EDITOR

John Wallace | jwallace@mdpublishing.com

24

ART DEPARTMENT Jonathan Riley Jessica Laurain Kara Pelley

ACCOUNT EXECUTIVES

Mike Venezia | mike@mdpublishing.com Jayme McKelvey | jayme@mdpublishing.com Andrew Parker | andrew@mdpublishing.com

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ACCOUNTING Kim Callahan

WEB SERVICES

INDUSTRY INSIGHTS 11 14 18 20 23 28

Clorox Advice AAAHC Update Company Showcase: Sealed Air ASCA Update News & Notes Company Showcase: MD Technologies

Betsy Popinga Taylor Martin

CIRCULATION Lisa Cover Laura Mullen

IN THE OR 30 33 34 42

Suite Talk Market Analysis Product Showroom CE Article

OUT OF THE OR 68 70 72 74 76

Health Fitness Nutrition Recipe Pinboard

MD PUBLISHING | OR TODAY MAGAZINE 18 Eastbrook Bend, Peachtree City, GA 30269 800.906.3373 | Fax: 770.632.9090 Email: info@mdpublishing.com www.mdpublishing.com

PROUD SUPPORTERS OF

78 Index

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OR TODAY | January/February 2016

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WE’VE GOT YOUR FLOOR COVERED! Optimized Ergonomics & Fluid Management

CONTACT US TO TRY OUR PRODUCTS! 888-633-5843 www.flagshipsurgical.com @flagshipsurg #ORergonomics

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When choosing a UV system, you’ll want assurance of optimum performance.

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• Enhanced data capture • Remote status and operation • Usage analysis

Proven Efficacy To protect your patients (and your investment), you’ll want a highly effective, tested and trusted UV device.

• Kills over 30 pathogens in 5 minutes at 8 feet • 4-log reduction of C. difficile spores • Greater than 5-log reduction of over 20 pathogens, including MRSA, VRE and CRE

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Use products as directed.

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INDUSTRY INSIGHTS CLOROX ADVICE

BY KATHERINE VELEZ PHD, SCIENTIST CLOROX HEALTHCARE

MAXIMIZING THE BENEFIT OF ULTRAVIOLET-C TECHNOLOGY

I

mplementing emerging technologies such as ultraviolet-C (UV-C) light emitting devices can help facilities in the fight against hospital-acquired infections (HAIs).1 Despite upfront capital costs, UV-C devices may be cost effective when compared to the direct and indirect costs of these lifethreatening HAIs.2 With so much at stake, it is important to implement UV-C technology in the most efficient and effective way possible.

WHY PROTOCOL MATTERS Some UV-C device manufacturers recommend a single device placement per room, while others recommend multiple device placements per room. Multiple device placements are essential because UV-C is a line of sight technology and it will only reach the surfaces it can “see”.

Since the materials in many hospital rooms absorb UV-C energy instead of reflecting it, it is important to expose key surfaces to UV-C by changing the position of the device. This is especially important in the operating room, where multiple surfaces must be treated in order to protect patients and staff from potentially

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to UV-C energy, and can be placed on surfaces throughout the room to ensure that sufficient UV-C dose for inactivation of MRSA and C. difficile has been delivered to key surfaces.

KATHERINE VELEZ, PHD, SCIENTIST, CLOROX HEALTHCARE

dangerous pathogens.

UV-C device manufacturer directions for use vary, but for the Clorox Healthcare™ Optimum-UV Enlight™ System, the recommended protocol for most standard operating rooms is three 5-minute cycles. The device is placed in three different positions to ensure maximum exposure of key equipment that may harbor microorganisms. Since the exact layout in every hospital is unique, Clorox Healthcare also offers dose verification cards to help facilities identify ideal device placement for their particular room configuration. The cards change color upon exposure

MAXIMIZING THE IMPACT OF UV-C When evaluating UV-C technology for use in the operating room, facilities should consider both what the device offers as well as what the device manufacturer can provide to help maximize that investment.

Some UV-C devices offer functionality to help facilities improve infection control processes and minimize workflow challenges. For example, the Clorox Healthcare™ Optimum-UV Enlight™ System offers smart data capabilities including a mobile app that allows for cycle status monitoring, remote start/stop, and automatic syncing with a data reporting website. Device data can be analyzed on the reporting website to help identify and solve workflow challenges, conduct device diagnostics, and generate usage reports to communicate the value of UV treatment to facility leadership. Clorox Healthcare also offers workflow support, technical support, and public relations services to help facilities get the most out of their UV-C investment.

Using UV-C effectively is also the January/February 2016 | OR TODAY

11

TRIM 4.5”

CLOROX ADVICE

TRIM 4.5”

key to maximizing impact on HAI rates. Epidemiologists from Penn Medicine recently found that after implementing an enhanced disinfection protocol using the Clorox Healthcare™ Optimum-UV™ System in combination with manual surface disinfection using bleach, C. difficile infection rates decreased by 25%, and the hospital saved an estimated $134,568 to $191,604 in direct medical costs by preventing PUBLICATION 1 21 cases of C. difficileMEDICAL infection.

DEALER TECHNATION ORTODAY Due to optimized workflow and BUYERSobserved GUIDE OTHER staffing, the study authors no negative impactMONTH on room turnaround times when using the UV-C SURGICAL CONFERENCE devices.

J can F be M a great A M J J A S O N D UV-C technology supplement to manual surface DESIGNER: JL disinfection practices.

Taking advantage of both device features and manufacturer services can help maximize the impact of UV-C. Importantly, effective and efficient use of UV-C can help facilities realize a measurable impact on HAI rates.

AD SIZE 1/3 Page Square 4.5”x4.5” NOTES

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REFERENCES (1) Pegues, D.; Gilmar, C.; Denno, M.; Gaynes, S. In IDWeek (poster presentation); 2015.

(2) Zimlichman, E.; Henderson, D.; Tamir, O.; Franz, C.; Song, P.; Yamin, C. K.; Keohane, C.; Denham, C. R.; Bates, D. W. JAMA Intern. Med. 2013, 173, 2039–2046.

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OR TODAY | January/February 2016

the Surgical Services Community

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INDUSTRY INSIGHTS AAAHC UPDATE

BY MARY SIBULSKY, RN

WRITING A DISASTER PLAN FOR YOUR ASC

A

good disaster plan can help any ASC meet the standards of accreditation or certification for CMS. But more importantly, a well-written and rehearsed plan could potentially save lives. So what does it take to create a plan that meets your facility’s needs and helps you to achieve accreditation standards? A good plan includes an overview of your facility and the various factors that will impact it in the event of a disaster. Defining what makes a disaster is the first step.

WHAT MAKES A DISASTER? Why does this matter? Not everyone understands that disasters are not limited to just weather occurrences like hurricanes and flooding; they can also include events as simple as a minor plumbing leak – a “disaster” that might prevent the safe use of the operating rooms. So start your plan with a definition of what types of disasters could affect your organization. A good way to further break down this definition is by identifying internal and external disasters. Ask your staff members this question: “What occurrences would make working a severe hardship and potentially impact the care we provide?” You might be surprised to hear some of them refer to the loss of phone service or medical records access as a disaster!

HAZARDS OR RISK ASSESSMENT This is the next step. According to 14

OR TODAY | January/February 2016

FEMA, “A risk assessment is a process to identify potential hazards and analyze what could happen if a hazard occurs. A Business Impact Analysis (BIA) is the process for determining the potential impacts resulting from the interruption of time sensitive or critical business processes.” Make a list of the potential hazards or risks your facility could face. Then assess the probability and severity of those risks.

Once the risk assessment and description are completed, an authority and communications chart should be created. This will include a list of who will be in charge and which employees will be asked to respond. When completing the roster, consider: • Assessing who is activated and their ability to respond • Contact information – include cellphone and landline numbers • Creating an authority chart • Alternates (staff members desig-

nated to substitute for the primary contact in the event that person is unable to respond) • Creating a call list

The call list is kept near the main phone area for your facility and tested periodically to verify contact information. A copy of the list should also be maintained offsite. Along with the internal contacts, a list of local/county and national resources should be created. This can include numbers or access information for: • Police, Fire, Paramedics • Building Management • Building Security • Telephone Company • Power and Gas • IT Resources • Insurance Company • County Office of Emergency Management • City Street Department • City Water Department • City Sewer • FBI Local Office • Poison Control Center • Medical Gases Suppliers • State Police • Road Conditions Reports • National Weather Service PROTECTING THE ORGANIZATION A comprehensive disaster plan includes an overview of what steps would be taken to protect the lives WWW.ORTODAY.COM

AAAHC UPDATE

and assets of the organization. This can include a description of the disaster drill schedules; fire drill plans and policies; quality assurance meetings that review the facilities functions; education relevant to disaster awareness such as OSHA training; security precautions; CPR classes; emergency back-up equipment in the building and how it is tested; availability of shelter-in-place plans; and the equipment needed to secure the building. If staff members are allowed time to participate in outside preparedness training programs such as those available through FEMA, the Medical Reserve Corps, or online training, this should also be included.

For a contingency such as mass illness in either employees or staff you will need to put in place an emergency pandemic plan. Assistance creating a good pandemic plan is available from the CDC at http:// emergency.cdc.gov/planning/ ADDITIONAL PLAN COMPONENTS The disaster plan and drills need to have an evacuation plan in place that includes more than one location for assembly to cover all potential events. An annual disaster drill should allow practice for staff members to assemble at the evacuation point; and there should be a prior discussion about what equipment will be required during an evacuation. Hands-on practice with evacuation equipment such as emergency patient slides or transport materials should occur regularly.

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Communicating your disaster plan with local, county and state authorities allows them to provide input regarding the details of your plan. Knowing what your emergency response plans are may be vital to the strength of your community’s emergency responders in times of disaster.

No plan is complete without giving serious thought to what will occur AFTER the disaster occurs. Putting a business back together and dealing with the psychological impact of severe disasters requires planning and compassion for the effect that a disaster may have on staff and the business clients served. Training in critical incident debriefing can be very helpful in getting the organization back on track.

Assessing the plan to accreditation standards and Medicare guidelines is critical and should be undertaken at least annually. CMS guidelines have been provided recently that include a checklist for health care facilities.

“The Centers for Medicare & Medicaid Services (CMS) Survey and Certification Group (SCG) has developed this site to provide useful information to CMS Central and Regional Offices, State Survey Agencies (SAs), their State, Tribal, Regional, and local emergency management partners, and health care providers, for developing effective and robust emergency plans and responses. This website provides information and tools, utilizing an “all hazards” approach for disruptive events “ Another great resource comes in the form of the AAAHC “Patient

Safety Toolkit: Emergency Drills” available from the Accreditation Association for Ambulatory Healthcare (AAAHC).

Lastly, all staff members need to be educated about the plan’s use, location and implementation. A plan is only paper if the information in it isn’t disseminated to those impacted by the plan. Just as we regularly rehearse for cardiac emergencies to feel competent and be prepared, disasters require the staff to feel well trained and ready to respond.

HELPFUL WEB RESOURCES • www.ready.gov/business • https://www.cms.gov/medicare/ provider-enrollment-and-certification/surveycertemergprep/ downloads/sandc_epchecklist_ provider.pdf • https://www.cms.gov/Regulationsand-Guidance/Guidance/Manuals/downloads/som107ap_l_ambulatory.pdf • www.redcross.org/prepare • https://www.medicalreservecorps. gov/HomePage MARY SIBULSKY is Nurse Manager of an Ophthalmic ASC in North Idaho and has been a nurse since 1975. She is actively involved with the Medical Reserve Corps and was selected as part of the Federal Cadre team specially trained to respond to national emergencies including responding to Hurricanes Katrina and Rita. She has worked as an ASC Surveyor for AAAHC since 2007 and in the course of her work has been in facilities during major earthquakes, shortly after a tornado impacted the area, water main rupture, dust storms and power failures.

January/February 2016 | OR TODAY

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{

THE AAAHC SURVEYOR

}

Helping you raise the bar on patient care.

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OR TODAY | January/February 2016

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COMPANY SHOWCASE SEALED AIR

SEALED AIR Diversey Care

O

R Today keeps readers updated on the newest medical devices and products.

Sealed Air Diversey Care’s Carolyn Cooke, Vice President Healthcare, North America, recently took some time to share more about health care needs and solutions.

Q

WHAT ROLE DOES SEALED AIR DIVERSEY CARE PLAY IN HEALTH CARE?

Cooke: Diversey Care’s Solutions Designed for Healthcare™ offers an integrated approach targeted to reduce the risk of HAIs, improve outcomes and satisfaction, and safely and sustainably enhance a facility’s image. Our solutions can be categorized as those that help prevent infection, those that help improve image, and those that help improve productivity. To learn more, visit www.sealedair.com.

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OR TODAY | January/February 2016

Q

WHAT ARE SOLUTIONS DIVERSEY CARE PROVIDES?

Cooke: The Sealed Air Diversey Care division offers a broad range of products from disinfectants and cleaning validation systems to cleaning equipment, work stations and tools that enable us to provide an integrated solution that addresses infection prevention, facility/ brand image and staff productivity.

As experts in the arena of cleaning and disinfection, we understand the challenges faced by health care facilities. Our sales and service team is comprised of dedicated health care experts who work with customers to assess their current programs, identify opportunities and implement solutions that help them achieve their goals.

Whether it is improvements in compliance, patient safety, productivity, speed of turnover, or patient and staff satisfaction, Diversey Care can help design an integrated solution to address a facility’s needs.

Q

WHAT DO YOU SEE AS THE BIGGEST CHALLENGES IN CLEANING AND DISINFECTION IN OPERATING ROOMS?

Cooke: The biggest challenge is ensuring that the quality standards required to protect patients and staff are not compromised with the need to increase the speed of OR turnover.

Q

HOW CAN DIVERSEY CARE HELP FACILITIES BE MOST EFFECTIVE IN IMPROVING RESULTS?

Cooke: At Sealed Air Diversey Care, it is our goal to ensure that our products, tools and training can help deliver on both the quality and speed requirements in the OR. Our systematic approach to cleaning includes fast, broad spectrum disinfectants that enable staff to address the key pathogens of concern in just one minute along with labor-saving tools and equipment that can improve results while allowing staff to WWW.ORTODAY.COM

SPECIAL ADVERTISING SECTION

work safely and effectively. We couple this with best-in-class procedures and training tools that can enable staff to execute effectively. Our procedures have the AORN Seal of Recognition, and have demonstrated success in helping our customers standardize processes and improve results.

Finally, we encourage facilities to measure cleaning and disinfection results and provide feedback to staff to drive continuous improvement in process and results.

second is our range of TASKI® machines and tools. TASKI machines, work stations, and tools are designed to increase the speed and efficiency of any job, decreasing turnover times. Even better, the ergonomic design puts less strain on workers, and enables them to get more done on each shift, while reducing fatigue. Our recent addition of the TASKISUM™ disposable mopping system is another tool to aid in fast OR turnover.

Q

Q

WHAT ARE YOUR COMPANY’S CORE COMPETENCIES AND UNIQUE SELLING POINTS?

Cooke: Diversey Care’s focus on the health care sector is incorporated in all aspects of the business, from research and development, marketing, and application expertise to sales and service professionals. This enables Diversey Care to invest its resources in product and process innovation which is designed to deliver the lowest total cost for customers.

Diversey Care representatives have all been trained to look at the total program of a facility including its processes, products, training and validation programs. They understand what can go wrong in cleaning and disinfection, and how to address the risk. By looking at all dimensions of the programs, Diversey Care representatives can help ensure that AORN-recommended practices are introduced, that the most efficient and effective products are being used, and that implementation and monitoring programs are supported with customized training materials and a validation system.

Finally, sustainability is incorporated in our DNA. From more sustainable packaging, to super concentrates used with dilution WWW.ORTODAY.COM

WHAT IS ON THE HORIZON FOR YOUR COMPANY? HOW WILL IT EVOLVE IN THE COMING YEARS?

CAROLYN COOKE Vice President, Sealed Air Corp. Healthcare, North America

control equipment, to systems designed to use less energy, chemicals and water, we have a legacy of ensuring our products and practices reduce environmental impact both internally, and within our customers’ environments.

Q

WHAT PRODUCT OR SERVICE THAT YOUR COMPANY OFFERS ARE YOU MOST EXCITED ABOUT RIGHT NOW?

Cooke: We have two very interesting products that can really improve the performance of operating room staff. The first is our Oxivir® Tb Wipes, which is powered by Accelerated Hydrogen Peroxide (AHP®) technology.

Oxivir Tb wipes are effective against a broad spectrum of pathogens, in just one minute. The

Cooke: At Sealed Air Diversey Care, we continue to work on innovative solutions that will create a safer environment for patients and staff. Most of these innovation discoveries look at the overall cost of a process, and seek to reduce labor, inefficiencies and risk. It is all about optimizing outcomes!

Q

IS THERE ANYTHING ELSE YOU WANT OR TODAY READERS TO KNOW ABOUT YOUR COMPANY?

Cooke: Sealed Air Diversey Care is very focused on helping customers address the risks in creating safe and satisfying environments of care. We understand that every facility has unique challenges and needs, and by working together closely, our goal is to jointly understand these risks, and find solutions that help address them and achieve positive change toward quality improvement or cost control.

FOR INFORMATION, about Sealed Air go to www.sealedair.com January/February 2016 | OR TODAY

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INDUSTRY INSIGHTS ASCA UPDATE

I

BY BILL PRENTICE

JOIN ASCA IN DALLAS THIS MAY

f you work in or with an ASC – or want to learn more about what working in an ASC is like – I encourage you to come to ASCA’s annual meeting this year in Dallas, Texas, May 19-22. ASCA’s annual meetings have long been the largest ASC meetings of the year, and we are expecting the number of participants in this year’s meeting – ASCA 2016 – to meet or exceed numbers we have seen in the past. That means that you will be able to spend three or four days with thousands of other ASC professionals who will be talking about best practices in ASCs.

Whether you have years of experience in an ASC or are connecting with the ASC community for the first time, it is a valuable opportunity and one you are not likely to find anywhere else this year.

At ASCA’s last annual meeting, we asked some who attended to tell us why they came to that meeting. We also asked why they return to ASCA’s annual meetings year after year. You can hear what they told us in the video on our website at www.ascassociation. org/asca2016. Most agree: ASCA’s annual meetings are can’t-miss events for anyone with an interest or investment in the ASC community. Key reasons why ASCA’s meetings are that popular include the networking, the programming, the expert faculty and the many opportunities that the program provides to hear about the latest tools, technology and services available to ASCs. NETWORKING To help you make the most of the networking opportunity that ASCA 2016 represents, we have developed a 20

OR TODAY | January/February 2016

program that gives you multiple chances to connect with your colleagues both one-on-one and in small- and large-group settings. In the educational sessions, we build in time for you to ask questions and start discussions that tap into the expertise of the presenters and the other ASC professionals in the room. During meals and coffee breaks, you can spend time with those you already know and those you are meeting for the first time. Our popular evening social event gives you a chance to shed the formalities of the day and spend a few hours getting to know your colleagues away from the intensive educational schedule that will fill most of your daytime hours.

Whether you are involved with a single- or multi-specialty ASC, a large or small facility or a rural or urban center, someone at ASCA 2016 will understand the many challenges you face and have experience and expertise to share. You will find top experts in business and finance as well as human resources, clinical care, accreditation and much more. I

am confident in saying, “If it has to do with ASCs, you can find it at ASCA 2016.”

PROGRAMMING Whether the topic is quality reporting, medication management, collections, sterilization, patient selection, how to prevent or respond to a violent event in your ASC or any of the hundreds of other operational issues involved in running an ASC, odds are something has changed this year and you will need to do something differently next year to ensure that you are meeting standards and delivering state-of-theart care. ASCA 2016 will include updates on all of the most critical changes occurring in 2016 and projections for 2017. It will also give you many opportunities to ask questions, discuss your concerns, explore new ideas and get the information you need to follow up later with colleagues who have special insights into the areas that interest you most.

This year’s pre-meeting workshops also offer exceptional value. Alongside the certified administrator surgery center (CASC) review course and accreditation updates we traditionally offer, these workshops will focus on: • the dos and don’ts of social media; • the role of infection prevention and control in a Quality Assessment and Performance Improvement (QAPI) program; and • current Centers for Medicare and Medicaid Services’ (CMS) physical environment and Life Safety Code requirements.

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ASCA UPDATE

The presenters of these workshops are top notch and have many years of experience in the areas they will address. You can learn more about them using the dropdown menus available at http://www.ascassociation. org/asca2016/schedule.

help you address the biggest challenges in your ASC today and the new developments you can expect tomorrow. At ASCA 2016, you can have the conversations that your busy work schedule prevents you from having with these providers during the rest of the year and take advantage of the broad experience that these vendors offer you.

EXHIBIT HALL If you are looking for new technology, services and ideas that can help you provide better care to your patients, INSPIRATION AND run yourAPPROVED ASC more efficientlyCHANGES and REJUVENATION PROOF NEEDED build for the future, plan now to There’s no better way to recharge spendSIGN–OFF: as much time as possible in our yourself and reinvigorate your team CLIENT Exhibit Hall. This year, hundreds of than to spend a few days with other product and service providers that THE FOLLOWING ASC professionals whoCORRECT share your PLEASE CONFIRM THAT ARE cater to the special interests and concerns, challenges and commitment LOGO NUMBER ADDRESS needs of ASCs will bePHONE in the hall to to yourWEBSITE patients, physicians and staff. share information and ideas that can This year’s program also features a

Wellness Track with several opportunities for you to invest in yourself by building some light exercise into your meeting schedule.

THE VENUE ASCA 2016 will take place at the Gaylord Texan Resort & Conference Center in Dallas – a facility filled with eclectic shops, world-class restaurants and a kind of Texas-sized hospitality that you will find only in the Lone Star State.

While you are there, you can also enjoy the 4½ acres of indoor gardens and winding waterways the facility offers.

For more information about ASCA 2016, visit ASCA’s website at www. ascassociation.or/asca2016. If you have SPELLING questions, please callGRAMMAR 703-665-4145.

I hope to see you in Dallas.

PROOF SHEET

WIDTH 7”

HEIGHT 4.5”

ACTION is a registered trademark of Action Products, Inc. © 2016 Action Products, Inc.

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January/February 2016 | OR TODAY

21

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H QUALITY O.R. PRODUCTS TO NEW HEIGHTS.

OVE SEA LEVELINSIGHTS TO BE EXACT. INDUSTRY NEWS & NOTES

STAFF REPORTS

THE KEY SURGICAL PROUDLY OFFERS: I T Y TJC LAUNCHES CAMPAIGN TO REDUCE READMISSIONS

er

N

811 0

O.R. Products

Identification Tape

The Joint Commission has develed by The Joint Commission’s oped two new resources to help sentinel event data compiled from Instruments health care providers in their efforts January 2014 to October 2015. The and Pin Management to reduce patientWire readmissions and data show a total of 197 sentinel improve the discharge process. The events – from suicide to falls to resources are a new Speak Up wrong site surgery – and the root CoFlex campaign for providers and organicauses included failures in patient Instrument Tracking zations to educate patients, includcommunication (127 incidents), ing an infographic, animated video patient education (26 incidents) and and podcast; and a QuickInstrument Safety Cleaning patient rights (44 incidents). The majority of the patient education newsletter for health care profesInstrument Protection failures were related to not assessing sionals that includes suggested the effectiveness of patient educaactions for improving transitions.

Personal Protection tion or not providing education. The The importance of transitions in patient rights failures included improving patientTags safety is illustrat-

EW CTS KEY SURGICAL PROGRAM

absent or incomplete informed consent, and lack of the patient’s participation in their care.

The new public service campaign “Speak Up: Avoid a return trip to the hospital” uses easy-to-understand language to help patients understand the steps they should take after they are discharged to avoid returning to the hospital. The materials are free and available on The Joint Commission’s website.

TO LEARN MORE, visit www.jointcommission.org/speakup.

Sterile Processing Products

PROMOTES PATIENT SAFETY

perating room and instrument care supplies to our valued

DIVERSEY CARE HELPS FIGHT CROSS CONTAMINATION

remained consistent: offer a wide variety high-quality Key Surgical Inc.ofoff ers an online

ll with unbeatable customer service.program These seemingly small for education designed

and personnel ck. If you are alreadytechnicians a customer, we sincerely appreciate yourwho

in thethis field of sterile r continued support.work If not, consider an invitation to call

processing. The program, available at www.keysurgical. com, is comprised of virtual learning labs that focus on topics such as surgical instrument care o r and vis i t k e yloaner surg i c a l .c o m managecleaning, instrumentation ment, and endoscopic reprocessing.

The program is free and serves up a learning experience that is simple, fun and interactive.

Each lab is followed by an interactive quiz that allows the participant to answer questions based on the information learned.

The Key Surgical education program is designed to allow the user to choose the material most timely and relevant to them. The material is accredited by the International Association of Central Service Healthcare Materiel Management (IAHCSMM) and the Certification Board for Sterile Processing and Distribution Inc. (CBSPD) for one continuing education credit (CEU). With these accreditations, the Key Surgical educational program can be used by certified sterile processing professionals to fulfill the CEU requirements to maintain their certification. •

ld be the start of a great relationship for many years to come!

. 79 9 5

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Sealed Air’s Diversey Care division has introduced the new TASKISUM Disposable Mopping System, an alternative to microfiber mops that require an effective laundering process. The mops are ideal for health care environments where speed and efficiency are critical, and cleaning and disinfecting effectiveness cannot be compromised.

Improving operating room turnover speed can help increase revenue, while improving patient room turnover can help increase patient satisfaction and staff efficiency.

TASKISUM mops allow staff to clean in a single location and then dispose of the mop, reducing the risk of cross contamination and laundering concerns. They also provide the benefits of microfiber with the convenience of disposables, and are available in two size options (40 and 60 centimeters).

When used with Diversey brand cleaners, disinfectants and TASKI tools, TASKISUM mops provide staff with an ergonomically designed system that enables them to work effectively and efficiently. TASKISUM mops have a dense core into which the microfibers are stitched allowing them to hold and more evenly distribute chemical; improving productivity and results. The mops can be used dry or damp. • FOR INFORMATION about the TASKISUM mop systems and other products from Diversey Care, visit sealedair.com.

January/February 2016 | OR TODAY

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INDUSTRY INSIGHTS NEWS & NOTES

GETINGE ENTERS INTO LOWTEMPERATURE MARKET Getinge Group’s business area Infection Control has acquired Stericool, a Turkish company specializing in low-temperature sterilization, and also signed an exclusive global distribution agreement with Canadian company TSO3 Inc., an innovator in sterilization technology for medical devices.

“Today’s announcement marks a major milestone in Getinge’s latest offerings to our customers. As a global leader in infection control, Getinge has a unique opportunity not only to enter into the fast growing low-temperature sterilization market, but also to leverage our legacy of excellence as a complete solutions provider,” says Joacim Lindoff, Executive Vice President of Infection Control.

The minimally invasive surgery market is a leading indicator of growth for the low-temperature sterilization market. The instruments used in such surgeries are extremely sensitive to the high temperatures and pressure of a steam sterilization process. As the minimally invasive surgery market continues to grow at an expected compound annual growth rate of 10 percent, demands for alternatives to steam sterilizers will also increase thereby providing great potential for accelerated business growth within infection control. • 24

OR TODAY | January/February 2016

CPAC EQUIPMENT INTRODUCES HVHA DEVICE

CPAC Equipment is introducing the COX Rapid Heat Model 6000 as a cost-effective alternative to “Immediate-Use” steam sterilization. Leading the industry in High-Velocity Hot Air (HVHA) sterilization with FDA cleared 6- and 12-minute cycles, the COX RapidHeat table-top sterilizer incorporates patent-pending instrument organizers and pouches to secure instruments during the fast turn-around sterilization process.

The COX RapidHeat HVHA sterilization system does not require the use of water, steam or toxic chemicals. Drying cycles are eliminated in HVHA systems and with the absence of water, steam and chemicals there is no corrosion, pitting or dulling of instruments.

The COX RapidHeat Sterilizer has been recently proven by an independent third-party to average 84 percent less energy per sterilization cycle than competitive steam sterilizers, and can sterilize up to 150 instruments per hour in pouched cassettes. The fast turnaround eliminates the temptation of medical staff to bypass or shorten cycles that can jeopardize instrument sterility. • FOR INFORMATION, call 800-828-6011, extension 1372.

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NEWS & NOTES

SILICON MESH COVERS ADVANCED COOLING THERAPY PROTECT DELICATE EXPANDS TEAM INSTRUMENTS Medical device firm Advanced Cooling Therapy (ACT) has expanded its team and achieved several strategic milestones in the commercial launch of its first product, the Esophageal Cooling Device (ECD).

Within less than 90 days of obtaining its de novo clearance from the FDA and manufacturing labeled product, the company has already had its first U.S. sales of the ECD, along with first human use in the country. A total of four clinical papers have now been published globally on the efficacy of the device.

To support the strong demand for the ECD, the company promoted Robin Drassler to Vice President of North American Sales, hired Maria Gray MA, RN, as Director for Clinical Services and added key sales managers to accommodate growth in the U.S. and globally.

The ECD is a temperature modulation device that is approved to use the esophageal environment for whole-body temperature modulation, including both cooling and warming. It’s designed to modulate and control patient temperature when clinically indicated through a single use, fully enclosed triple lumen system that is inserted into the esophagus. It received FDA de novo clearance in June of 2015, its CE Mark in Europe in 2014, and is licensed for sale in Canada and Australia. •

Healthmark Industries has announced the addition of silicone mesh covers to its ProTech instrument tray line.

The material is made from silicone; two mesh covers that have a flexible frame, and two possessing a stainless steel frame for added weight. These latex-free blue mesh covers are manufactured to protect delicate instruments during washing by covering baskets in order to restrict movement of medical devices during mechanical cleaning. Available in different sizes, the silicone mesh covers are heat resistant up to 275°. • FOR INFORMATION, call 800-521-6224 or visit www.hmark.com.

CV MEDICAL’S NuCART WINS PRIZE CompView Medical (CVM) has announced that NuCART won the “Best In Show” prize in the annual Excellence in Surgical Products contest from Surgical Products magazine.

NuCART is the mobile version of the popular NuBOOM system, extending advantages of turn-key video integration that can be wheeled to the point of care.

NuCART provides HD images to surgeons during minimally invasive surgery where mobile fluoroscopy, ultrasound and surgical video are used. NuCART also provides an equipment organization system that removes trip hazards and clutter, to

WWW.ORTODAY.COM

improve staff and patient safety.

The NuCART meets the budgetary and technical requirements of hospitals that are adopting modular image guided hybrid ORs for procedures such as urology, GI, interventional (vascular and radiology) and general surgery.

NuCART is designed to exceed the ergonomic adjustability required by surgeons when utilizing mobile C-Arms, video cameras, and ultrasound during MIS. Workflow compatibility with mobile C-Arms is especially important because the days of ORs being regularly populated with fixed X-ray equipment are rapidly waning.

NuCART is mobile, not built-in.

The cost-saving approach of a mobile boom system accommodates more flexible surgery scheduling because each OR can be easily reconfigured. •

January/February 2016 | OR TODAY

25

INDUSTRY INSIGHTS NEWS & NOTES

MEGADYNE WINS SURGICAL PRODUCTS AWARD Megadyne Medical Products has announced that its newest product release, the ZIP Pen, is the first place winner in the “Surgical Instrument” category of the 2015 Excellence in Surgical Products (ESP) Awards. The Zip Pen’s patented design functions like a standard electrosurgical pencil, while effortlessly removing surgical smoke in a highly ergonomic manner unlike any other surgical smoke removal pencil.

Expert users of cutting-edge products and innovative technology identified which companies and products were deserving of the 2015 ESP Awards by selecting those that contributed most to surgical performance,

efficiency and safety. This panel of experts awarded the ZIP Pen with the first place award, recognizing it as a premier product in the surgical instrument category.

Surgical smoke is an operating room hazard that has gone virtually unchecked for decades, due in large part to surgeon resistance to cumbersome smoke evacuation hand pieces.

Unlike other smoke evacuation pencils, ZIP Pen provides ergonomic grip options that eliminate the drag historically created by the tubing on the back of smoke evacuation pencils. The result is a smoke evacuation device with ergonomic options for surgeon comfort and procedural flexibility. •

STRYKER INSTRUMENTS AWARDS $250,000 TO AORN FOUNDATION In honor of Perioperative Nurse Week 2015, Stryker Instruments committed $250,000 to support AORN Foundation, the philanthropic arm of the Association of periOperative Registered Nurses (AORN).

Stryker’s LEARN Scholarship award will enable nurses from around the world to attend the AORN Surgical Conference & Expo in Anaheim, California, April 2-6, 2016.

26

OR TODAY | January/February 2016

The AORN Surgical Conference & Expo is the largest education symposium for perioperative nurses in the world and the largest surgical products trade show in the U.S. Presented over four days, the conference gives nurses the opportunity to network with their peers and gain more than 100 contact hours as they learn the latest clinical practice techniques and processes

for surgical patient and health care worker safety.

“We are grateful that for the third year Stryker has made a significant investment in perioperative nurses,” said Twilla Barlow, director of AORN Foundation. “The grant from Stryker enables perioperative nurses to have better access to expanded knowledge and skills for 2016.” •

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NEWS & NOTES

VERSUS ANNOUNCES WI-FI REAL-TIME LOCATING PLATFORM AND ASSET TAG Versus Technology Inc. has released its new Wi-Fi locating platform and asset tag which, combined with its existing precision locating systems, create an effective and scalable RTLS available to health systems.

“With the addition of our V-Net real-time locating system platform and Asset Net Tag, health care facilities no longer have to choose between Wi-Fi RTLS and the precision locating Versus is known for,” says HT Snowday, Versus President. “The combination of precision infrared with the ubiquity of Wi-Fi are now available in one tag, leveraging the benefits of both options – benefits that are vital to deliver operational efficiency.”

With lower reimbursements and higher operational costs, health systems need solutions to optimize operations.

Administrators require systems that can leverage existing infrastructure, yet still solve urgent issues such as increasing capacity through improved workflow, or enhancing patient and staff safety.

As a Cisco Solution Partner, Versus now offers hospitals the ability to leverage their existing Cisco infrastructure to track assets across entire buildings and the entire health system for enterprise-wide fleet visibility. When the hospital is ready to grow into advanced clinical applications that require precise locating, they simply add small, discrete wired or wireless infrared (IR) sensors where necessary.

This highly scalable, building block approach offers a wide range of proven RTLS solutions, including enterpriselevel fleet visibility, par-level asset management, nurse workflow, and patient flow process improvement in the ED, OR, and hospital-wide.

A dual Wi-Fi and IR option for staff and patients, the Clearview Net badge, will be released in early 2016, extending the benefits of Wi-Fi RTLS to staff locating and patient flow.

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January/February 2016 | OR TODAY

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COMPANY SHOWCASE MD TECHNOLOGIES INC.

MD TECHNOLOGIES INC.

M

D Technologies Inc. has saved the medical community millions of dollars by providing safe, environmentally-friendly, cost-saving fluid management products to hospitals, surgery centers and physicians’ offices.

Since 1990, MD Technologies has isolated health care workers from exposure to suctioned fluids with systems offering tremendous cost savings, usually paying for themselves within one year. These compact, wall-mounted Environmate® DM6000 Series SuctionDrain™ Systems silently collect fluids directly from the suction field and dispose directly to sanitary sewer. Three unit models are available: DM6000 for SPD/ utility rooms with optional footswitch; DM6000-2, for Endoscopy, with two independent suction inputs for dual-field EGD, ERCP or bronchoscopies, or providing redundancy in single-field colonoscopies; and DM6000-2A, with unlimited fluid capacity for urology/cystoscopy and arthroscopy procedures. An optional totalizer records fluid volume aspirated on DM6000-2A. Always aware of emphasis on cost savings, MD Technologies provides a unique tool to assist customers with its savings calculator. This simple tool permits quick estimation of cost savings when using an MD Technologies system, and is available online at ww.

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OR TODAY | January/February 2016

DM6000 Silently collects fluids directly from the suction field and disposes directly to sanitary sewer.

3 models are available.

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MD Technologies uses its expert insight and decades of experience to focus on key points and best practices, ensuring clients receive just what they need. In 2002, the company introduced the PT20® Trap, a single-specimen collection jar with cap and screen. Today, many single polyp traps are available. With its screw top and finemesh screen, the PT20® remains the favorite of many facilities.

Waste management experts at MD Technologies are quick to share best practices and help clients put a plan in place. Dispos-

ing fluid directly to drain is by far the most efficient, cost-effective solution. This minimizes staff or patient contamination due to inadvertent contact with fluid.

Closed systems have advantages over systems requiring fluid to be transported to a central disposal site, since transporting introduces steps where exposure can occur.

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collects spilled fluid.

Finally, MD Technologies suggests clients carefully select equipment that meets fluid management needs for anticipated procedures. Lower-cost systems may meet needs for all but those few procedures where requirements are only met by higher-cost features such as fluid volume totalizing. The company

will help you select the best equipment with the required capabilities for your needs.

MD Technologies can be on hand to evaluate space requirements in the procedure/operating room, and assist with selection of systems compatible with space constraints and traffic patterns in the surgical suite. The company also provides consulting services and technical support with medical gas and emergency power systems for new center construction.

For additional information, contact MD Technologies Inc. at 800-201-3060, or visit the company’s website at www.mdtechnologiesinc.com.

January/February 2016 | OR TODAY

29

IN THE OR SUITE TALK

SUITE TALK

Conversations from the OR Nation’s Listserv

Q

REUSING IMPLANTED SCREWS Often times surgeons want to re-use screws that have been implanted. Is it acceptable to remove a screw from a patient from a prior surgery and use it in a new space which is in close proximity to the placement of the original screw?

A: I was always told by the sales reps that once a screw has been used, it weakens the threads for reimplantation and should not be used.

Q

STERILE PROCESSING Is it acceptable to eat and drink in an alcove off the main area of the clean side of sterile processing? Should any food or drink be allowed in the clean side of sterile processing?

A: No.

Q

A: No food or drinks anywhere in the area.

A: No.

OR RN & ACLS REQUIREMENTS Do you require your OR RNs to be ACLS certified? Some argue that BLS is all you need in OR as CRNAs are documenting their medications during codes. What are your thoughts?

A: We require all of our RNs to be ACLS certified. We are also a small standalone surgery center with 2 ORs. A: All of our RNs (and all staff actually) have BLS, the Nurse Manager has to have ACLS and PALS. A: Yes we do. At our surgery center, both the OR and pre-/post-op staff are ACLS certified.

30

A: Agreed … cannot reuse.

OR TODAY | January/February 2016

The pre-/post-op staff is also PALS certified.

A: ASCs (per accreditation) require the OR team to have BLS and the PACU RNs to have ACLS. A: Right now most of my RNs are not ACLS certified, except the nurses in the CVORs. I do require my RNFAs to be ACLS.

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SUITE TALK

Q

SUCTION BOVIES Some facilities have started using suction bovies on certain procedures. Some surgeons don’t like them. There has been documentation that bovie smoke is hazardous to staff. Is it going to be mandatory to start using the suction bovie? Should it be up to the surgeon or the staff? The staff is exposed to smoke all day. Surgeons don’t work in surgery everyday like staff.

A: We have a smoke evacuation device that is mandatory for use when a bovie is involved.

A: We are just moving to mandatory smoke evacuation as a staff safety measure. I’m surprised OSHA hasn’t made this mandatory yet.

Q

CHANGING CLOTHES Is it acceptable to work in the endoscopy department, then go to the OR and do a regular case such as a Lap Chole without changing scrubs?

A: No.

A: Not acceptable.

A: Not acceptable.

A: I agree that it is not acceptable. Unless they have soiled the scrubs, there is no recommendation although it sounds like a good idea. If you are assisting at the BS with the GI procedure, you are wearing PPE – gowns, face protection, etc. Good food for thought, but many ORs do endo procedures during cases.

A: It seems to me that if the Endo-Suite is part of and staffed by OR personnel that the scrubs they wear would not have to be changed unless they become soiled or they leave the building when discharging a patient.

I do think though that if staff work in another department such as radiology or OB and they come to the OR for a procedure that they should change their scrubs.

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A: Me too! We have Stryker Neptune units that have a smoke evacuation chamber with disposable hook-ups, separate from the fluid evacuation chamber.

January/February 2016 | OR TODAY

31

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OR TODAY | January/February 2016

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IN THE OR MARKET ANALYSIS

STAFF REPORT

MARKET ANALYSIS Surface Disinfectant Market Expands

T

he global surface disinfectant market is expected to eclipse $600 million by 2022, according to Grand View Research.

The market is growing at an estimated CAGR exceeding 11 percent over the forecast period, according to a 2015 report prepared by the market research and consulting firm.

Increasing health care expenses, the growing number of hospitalacquired infections, and a spike in surgical operations are expected to drive market growth over the next seven years, according to the report.

“Strict guidelines along with legislative guidelines such as Affordable Care Act have forced hospital authorities to ensure cleanliness in their facilities. Rising concern regarding healthcare-acquired infections, as it affects the base line of existence of these facilities, is expected to drive the surface disinfectant demand over the forecast period,” according to Grand View Research. “Recent Ebola outbreak has highlighted a need for health care facility cleanliness and disinfection.”

Surface disinfectants are used to disinfect and sanitize surfaces such as floors, furniture, washrooms, tiles, walls, instruments and clothes.

“According to the World Bank estimates, global health care WWW.ORTODAY.COM

expenditure has witnessed remarkable growth from $3,786 billion in 2003 to $7,427 billion in 2013, growing at a CAGR of 7 percent over the forecast period. In the same period, public health care spending increased at a CAGR of 7.28 percent, from $2,198 billion in 2003 to $4,440 billion in 2013. This high growth rate, along with the huge size of health care spending, is expected to drive surface disinfectant market growth,” according to Grand View Research.

“Rising awareness regarding

ide, and alcohols.

“Hypochlorite held the largest market share in 2014 and is expected to lead the market over the forecast period,” according to Grand View Research. “Hypochlorite is primarily used for bleaching, disinfection, and water treatment.

Quaternary ammonium compounds are expected to witness fastest growth on account of their more effective and biodegradable nature.”

On the basis of formulation, products are classified as liquids, sprays and wipes.

“North America holds maximum share in the global surface disinfectant demand and is expected to retain its position over the forecast period.” home cleanliness and the need for disinfection is also expected to fuel the product demand. Rising disposable income coupled with increasing focus on child health has positively affected the home disinfectants demand,” according to the report. “Recent infectious disease outbreaks such as Ebola, influenza, and chikungunya are expected to fuel the surface disinfectant demand over the forecast period.”

On the basis of product, the market is segmented as quaternary ammonium compounds, peracetic acid, hypochlorite, chlorhexidine gluconate, phenolic compounds, aldehydes, iodine compounds, chlorine dioxide, hydrogen perox-

“Liquid disinfectants account for largest share in the global market and are expected to be the fastest growing segment over the forecast period,” according to Grand View Research.

“North America holds maximum share in the global surface disinfectant demand and is expected to retain its position over the forecast period,” according to Grand View Research. “High standards of living have driven home cleanliness and other hygienic habits in consumers.

Government initiatives and enforcements regarding public health and hygiene have also driven market growth. Asia Pacific is expected to be the fastest growing region over the forecast period.”

January/February 2016 | OR TODAY

33

IN THE OR PRODUCT SHOWROOM

CLOROX HEALTHCARE® BLEACH GERMICIDAL WIPES Clorox Healthcare® Bleach Germicidal Wipes provide powerful surface and equipment disinfection for hospitals. The wipes meet CDC, SHEA and APIC guideline recommendations for killing C. difficile spores and are EPA-registered to kill 51 microorganisms in three minutes or less*, including norovirus, TB and C. difficile spores. The combination of a gentle, odor-masking formula and an anticorrosion agent ensure both patient comfort and compatibility with hospital-grade surfaces. Clorox Healthcare® Bleach Germicidal Wipes come in three convenient sizes to ensure the right wipe is used to meet the disinfection needs of today’s surgical suites. For more information, visit www.CloroxHealthcare.com. • *Use as directed on precleaned hard, nonporous surfaces.

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OR TODAY | January/February 2016

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PRODUCT PRODUCT SHOWROOM FOCUS

CONTEC PERIDOX® CONCENTRATE SPORICIDAL DISINFECTANT AND CLEANER Combat C.diff, MRSA, and over 42 other dangerous pathogens with Peridox Concentrate – a broad spectrum, EPA-registered, one-step disinfectant and hard surface cleaner with a 3-minute Sporicide claim at 99.9999% efficacy. Ideal for rapid OR turnover, Peridox Concentrate contains no alcohol or bleach, requires no rinsing, and leaves minimal residue on surfaces. Peridox Concentrate will not damage stainless steel, sensitive OR equipment, or clothing. Proven effective against both non-enveloped and enveloped viruses, Peridox Concentrate is the cost-effective approach for using a high-level sporicidal disinfectant to keep HAI rates in check. For more information, visit http://www.contechealthcare.com/products/critical-care/peridox-concentrate-sporicidal-disinfectant-and-cleaner/. • WWW.ORTODAY.COM

January/February 2016 | OR TODAY

35

IN THE OR PRODUCT SHOWROOM

PALMERO HEALTH CARE DISCIDE ULTRA DisCide ULTRA is a one-step, quaternary ammonium, high-level, alcohol-based disinfectant that’s laboratoryproven to kill deadly pathogens in one minute. DisCide ULTRA is noncorrosive and nonstaining, and leaves behind a pleasant herbal scent with no unsightly residue. It’s registered with the U.S. Food and Drug Administration and Environmental Protection Agency, and it meets the disinfection requirements of the federal Occupational Safety and Health Administration’s (OSHA) Bloodborne Pathogens Standard. It is available as a spray, or towelette, and in gallon refills. Palmero’s DisCide disinfectants offer ready-to-use, fast-acting, hospital-quality products that are designed to expedite operatory turnover. Each of these products is ideal for use in the central sterilization room and office areas. • 36

OR TODAY | January/February 2016

WWW.ORTODAY.COM

PRODUCT PRODUCT SHOWROOM FOCUS

PDI HEALTHCARE SANI-CLOTH® AF3 GERMICIDAL DISPOSABLE WIPES Looking for faster turnover in cleaning the OR? Sani-Cloth® AF3 Germicidal Disposable Wipes are effective against 45 clinically relevant microorganisms in just 3 minutes, including: Multi-Drug Resistant Organisms (MDROs), Bloodborne Pathogens, TB and viruses. Sani-Cloth® Pail and Refill format for Sani-Cloth® AF3 Germicidal Disposable Wipes are ideal for use in the OR as each contains 160 pre-moistened, ready-to-use extra-large wipes. Sani-Cloth® AF3 is both alcohol and fragrance free. The alcohol free formula makes it ideal for use on equipment sensitive to alcohol and fragrance free makes it ideal for use around patients and staff with respiratory sensitivities. For more information, visit pdihc.com. • WWW.ORTODAY.COM

January/February 2016 | OR TODAY

37

IN THE OR PRODUCT SHOWROOM

RUHOF BIOCIDE® DETERGENT DISINFECTANT PUMP SPRAY Ruhof Biocide® Detergent Disinfectant Pump Spray is a ready-to-use quaternary germicide cleaner and disinfectant for use in patient rooms, operating rooms, ICU areas, public restrooms, or any other area that needs to be disinfected. It is formulated to be highly effective against a broad-spectrum of pathogenic microorganisms, including bacteria, antibiotic resistant bacteria, viruses, fungi, mold and mildew. Ruhof Biocide® Detergent Disinfectant Pump Spray is for use on all hard, non-porous inanimate environmental surfaces: floors, walls, metal surfaces, stainless steel surfaces, bathrooms, shower stalls, bathtubs, cabinets, etc. In addition, this product deodorizes smelly areas such as garbage storage areas, empty garbage bins and cans, basements, restrooms and other places which are prone to odors caused by microorganisms. •

38

OR TODAY | January/February 2016

WWW.ORTODAY.COM

PRODUCT PRODUCT SHOWROOM FOCUS

DIVERSEY CARE OXIVIR® Tb WIPES Oxivir® Tb Wipes, powered by Accelerated Hydrogen Peroxide (AHP) technology, reduce OR turnover time while keeping costs in line. Speed up time from wheels out to wheels in with disinfectant wipes that are effective against a broad spectrum of pathogens, in just one minute. Oxivir Tb Wipes improve compliance by staying wet for the required label contact time, ensuring disinfection while streamlining the process. With one pass, Oxivir Tb Wipes are tough enough to clean and disinfect surfaces and equipment, while being gentle on staff, equipment and surfaces. Oxivir Tb Wipes are non-irritating to eyes and skin, and require no safety warnings or personal protective equipment. The 11x12 size is available for large surfaces, as well as smaller 6x7 and 7x8 sizes. For more information and a free sample, visit http://solutionsdesignedforhealthcare.com/sample •

WWW.ORTODAY.COM

January/February 2016 | OR TODAY

39

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January/February 2016 | OR TODAY

41

IN THE OR CONTINUING EDUCATION 472C

42

OR TODAY | January/February 2016

BY NANCYMARIE PHILLIPS, PHD, RNFA, CNOR(E)

WWW.ORTODAY.COM

CONTINUING EDUCATION 472C

AVOIDING LOWER EXTREMITY POSITIONING INJURIES IN THE OR

I

magine you are sleeping soundly in your warm bed when a tingling in your arm awakens you.

In a haze of sleep, you reposition your arm, roll over and fall back asleep. The tingling, the result of compression of a nerve or blood vessel, caused you to change positions to decrease pressure, maintain blood flow, stop pain and avoid injury. Patients undergoing surgical procedures who have had general, regional or sedation anesthesia cannot perform this function due to the loss of protective reflexes, making them susceptible to peripheral nerve and vessel injuries. Imagine the reaction of a patient awakening from surgery only to find an injury that might have been prevented. The circulating nurse collaborates with the anesthesia provider and the surgeon to position the surgical patient in a manner that prevents injury.1

OnCourse Learning guarantees this educational activity is free from bias. The planners and authors have declared no relevant conflicts of interest that relate to this educational activity. See Page 48 to learn how to earn CE credit for this module.

The goal of this continuing education program is to provide nurses with information about positioning anesthetized and sedated surgical patients to avoid nerve and vessel damage in the lower extremities. After studying the information presented here, you will be able to: • Identify nerves of the lower body susceptible to injury in the sedated or anesthetized patient • Describe the arterial supply and the venous drainage of the lower extremities • Discuss the collaborative efforts of the OR team, including nurses, to prevent lower extremity nerve and vessel injuries

WWW.ORTODAY.COM

Lower extremity nerves that are most susceptible to injury include the lumbosacral plexus, femoral nerve, common peroneal nerve, tibial nerve and the sciatic nerve. The associated vessels include the bilateral common iliacs, femoral, tibial and doralis pedis arteries. Understanding where these nerves and vessels are located is the first step in preventing their injury.

The primary means of avoiding injury to these lower extremity nerves is to prevent stretch and pressure on these structures.2 ANATOMIC CONSIDERATIONS FOR THE LOWER EXTREMITIES: LIGAMENTS AND NERVES The lumbosacral plexus is made of nerves from the ventral rami of T12 to L4 and branches to the femoral, obturator, ilioinguinal, iliohypogastric, genitofemoral and lateral femoral cutaneous nerves. The sacral plexus is made up of nerves from the ventral rami of the S1 to S3 spinal nerves and forms the sciatic, pudendal, posterior femoral cutaneous and muscular branches to the pelvis.2,3 The other most common injuries of this plexus

are a result of flattening the natural spinal curves in the supine position, suture placement, compression when positioned laterally and ischemia from occlusive pressure over vessels.2 The sacroilliac ligaments bind the sacrum and pelvic bones to the hipbones. The ligaments measure about 1.5 to 2 inches of layered fibers that stabilize the lower spine. The sacrotuberous and the sacrospinous ligaments attach the sacrum to the lower angle of the pelvic bones and attach the ischial tuberosities. The ischium bears the weight of the upper torso when seated.2,3 The natural lower spinal curve terminates at the sacroiliac joint at the base of the lumbar vertebrae.

Flattening or causing torsion of the natural lower spinal curve can cause severe postoperative pain that mimics sciatic pain. Extremes of flexure can result in tearing, or avulsion of the superior aspect of the hamstring muscle.

Patients with existing coccygeal injury are susceptible to strain at the sacroiliac region.2,3,4 The femoral nerve is formed within the psoas major muscle by posterior divisions of the second, third and

January/February 2016 | OR TODAY

43

IN THE OR CONTINUING EDUCATION 712 Improper surgical positioning can injure the sciatic nerve. This injury occurs when the nerve is put under tension in the lithotomy position when the hip is flexed and the knee straightened or when the flexed hip and flexed knee are excessively rotated.3 Patients with peripheral vascular disease are at risk from gluteal ischemic pressure when positioned supine.5 Of the sciatic nerve branches, injury occurs most often in the common peroneal nerve, usually as a result of positioning during surgery.1-3 The common peroneal nerve is vulnerable to direct pressure at the fibular neck when surgery is performed in the lateral decubitus position or in lithotomy position with inadequate padding between the fibular neck and a stirrup or leg strap.2,4,5

Artwork courtesy of Steve Bhimji, MD. PhD

fourth lumbar nerves. It emerges from the lateral border of the psoas muscle to descend in the groove between the psoas and iliacus major muscles and enters the thigh by passing beneath the inguinal ligament lateral to the femoral artery and divides into multiple branches that include segments of the ilioinguinal nerve. This nerve serves the anterior muscles and skin of the thigh from the inguinal ligament to the knee.2,3 The femoral and ilioinguinal nerves can be injured by compression with self-retaining retractors during abdominal hysterectomy; pressure and stretch in lithotomy position with excessive hip abduction and external rotation; inadvertent 44

OR TODAY | January/February 2016

suture placement; femoral artery cross-clamp-induced ischemia and high tourniquet pressure compressing the nerve.2 The sciatic nerve is made of two divisions that travel in the same sheath. These divisions are the tibial and peroneal nerves. The tibial nerve is made up of the anterior branches of L4 to S3, and the peroneal nerve is made up of the posterior branches of L4 to S3. This sheath leaves the pelvis through the greater sciatic foramen and descends posteriorly between the ischial tuberosity and the greater trochanter down the posterior thigh, where it divides into the tibial and common peroneal nerves at the level of the knee.3

ARTERIAL SUPPLY AND VENOUS DRAINAGE OF THE LOWER EXTREMITY Lower extremity positioning requires knowledge of the vasculature of the lower pelvis and leg. The oxygen-saturated arterial blood supply bifurcates from the lower aorta into the internal and external iliac arteries. The superficial femoral arteries branch off laterally through the thigh into the popliteal artery at the knee. The deep femoral profunda arteries create three branches that run deep into the musculature of the upper thigh. The tibial arteries bifurcate below the knee and course distally through the anterior and posterior calf to the foot. The peroneal artery is the largest branch of the posterior tibial artery that supplies the ankle and terminates in the heel at the calcaneal artery. The foot is supplied by the plantar arteries that unite with the dorsalis pedis on the dorsum of the foot. The dorsalis pedis is also a continuation of the anterior tibial arterial supply. Compression and/or occlusion of the arterial supply not only causes tissue ischemia, but deprives the nerves of their blood supply.2,3,4 WWW.ORTODAY.COM

CONTINUING EDUCATION 472C

The venous drainage is equally important. Anatomically, the veins are critical for the return of blood that bears metabolic waste from living tissue. Occlusion of veins prevents the return of desaturated blood to the lungs for re-oxygenation and promotes accumulation of blood cells that lead to deep vein thrombosis within the vessel.1,2,5 A thrombus (clot) can become embolic and travel through the venous system via the vena cava directly into the right atrium of the heart. The force of the heartbeat causes the right ventricle to send the clot directly to the lungs. A clot in the lungs (pulmonary embolus) prevents the exchange of gases in the alveoli creating an obstacle to oxygenation and movement of the blood through the heart.2,5 The venous return from the lower extremity begins at the foot with the dorsal venous arch and moves up the anterior tibial vein. The movement of venous blood is very low pressure and requires some muscular contraction to move it along. The blood flows proximally through the tibial and popliteal veins to the saphenous and femoral veins where they join the iliac veins.

The iliac veins converge with the vena cava and the blood flows into the right atrium and ventricle back to the lungs for oxygenation.2 HEMODYNAMIC CONSIDERATIONS FOR POSITIONING THE LOWER EXTREMITIES Patients undergoing lower extremity surgical procedures can have a variety of anesthetic approaches.2,3 Regional anesthesia, such as spinals or epidurals, have risk factors specific to the manner of administration, which are discussed later in this module.3,4 Patients under general anesthesia have a higher risk of neuro- or vascular compromise because of complete immobility, loss of natural protective reflexes, surgical positioning and the WWW.ORTODAY.COM

use of many types of surgical instruments.1-3 As a rule, the arterial system is monitored and controlled by several anesthetic agents. Blood volume and pressure can be modified with drugs. Usually, a paralytic agent is used so the patient’s breathing can be controlled.3 During induced surgical paralysis, body areas under pressure from body weight and positioning devices cannot shift or reposition to relieve tissue sensory deficits.2 Vascular stasis and compression of nerves can go uncorrected for prolonged periods of time, leading to permanent injury.

Care must be taken to use positioning aids, such as gel pads, to provide an alternating pressure surface to relieve as much pressure as possible on the patient’s tissues.1,2 Another consideration involves the actual positioning process of moving the patient’s lower limbs. If the patient is positioned in a lateral position, care is taken to prevent the weight of the upper leg pressing on the lower leg.2 A pillow should be placed between the patient’s knees. The patient’s bony pelvis is under pressure from the weight of the torso. Use of a gel pad mattress offers some relief.2 Patients in a prone position have the potential for injury to the knees and dorsum of the foot. Gel kneepads or sheets can be used. The feet should have enough elevating padding at the dorsum to prevent the toes from resting on the mattress or extending over the foot of the OR bed. Other injuries could occur to the feet and toes if they are hanging off the OR bed when draped and a table or piece of equipment is pressed against them.1,2 Positioning a patient into the lithotomy position requires two people moving the legs simultaneously. The process is performed slowly after the anesthesia provider has given the “OK” to proceed.1,2 Both positioning personnel should grasp the patient’s ankle with one hand and the fleshy

portion of the calf with the other. The legs should be held together and flexed slowly at the knees as the limb is lifted.

As the legs are separated to place them into the stirrups, care is taken not to force any flexion movements or let the hip joint externally rotate.1,2,4-6 The legs are gently placed into the stirrups and secured.

The blood in the leg veins can rapidly autotransfuse the patient’s cardiovascular system, causing changes in the vital signs if the limbs are raised too quickly. Moving one leg at a time can cause lower back strain over the sacroiliac joint.2,5 When the procedure is completed, the legs are slowly lifted from the stirrups, knees slightly flexed, legs brought together, then lowered.

The process of moving the legs out of the stirrups too quickly can create a hemodynamic shift causing hypotension.2,5 MECHANISMS OF INJURY DURING POSITIONING The five most common mechanisms for nerve and vessel injuries include: stretch, compression, ischemia, metabolic issues and surgical section.2,3 Stretch and compression can be avoided by proper positioning. Stretch can be prevented by positioning the patient while he or she is awake, before being returned to a position that facilitates induction of anesthesia. If a position is uncomfortable while the patient is awake, it can cause injury when maintained for a long period of time under anesthesia.3 If the patient experiences discomfort while awake, injury can occur if the nerve(s) or vessel(s) is compressed for extended time periods. Proper padding of bony areas, minimizing the time that a tourniquet is inflated and preventing OR personnel from leaning on the patient will help avoid pressure injuries.1,2 Lithotomy position is associated with changes in intracompartmental pressure in the lower extremiJanuary/February 2016 | OR TODAY

45

IN THE OR CONTINUING EDUCATION 712

ties, depending on the method used to support the legs.6 Leg support with stirrups attached to the OR bed employs three different types of table attachments.2 The first type is the knee-crutch stirrup. This type is commonly found in urology suites.2 The legs are positioned with the knees supported with the feet dependent.

The full weight of the leg is balanced on the knee compartment. If pressure is placed on the knee or calf to support the lower extremity (using stirrups and a knee support device), it can result in pressure on the vessels and nerves within the compartment and can cause vascular or nerve injury.2,6 The second type of leg holder used is the sling, or “candy cane” stirrup.

The upright posts of the stirrups are mounted on the sides of the OR bed at the level of the patient’s hips.2 When placed in the sling stirrups, the knees are bent in toward the patient’s abdomen and the feet are placed in slingstraps that hold the bottom of the foot and the posterior ankle to raise the legs.2,3 Extreme flexion at the hip can result in ilioinguinal nerve damage by crush injury.2 The pressure is distributed at the level of the foot and ankle.

Elevating the lower extremity using a sling support at the ankle decreases pressure at the knee, but places the weight of the leg on the sole of the foot and ankle. The feet must be well padded to prevent nerve damage that can result in permanent foot drop.1,2,3 Care is taken to avoid allowing the lateral aspect of the legs to rest against the upright post of the stirrup frame. This can result in serious peroneal nerve injury from pressure.2 The third type of leg holder is a boot-style, known by several names, such as “Yellow Fin,” “Lloyd-Davies” or “Allen” stirrups.2 The boot-type stirrup supports the leg from the inferior aspect of the knee along the calf and under the length of the 46

OR TODAY | January/February 2016

foot. The weight of the leg is evenly distributed. These stirrups are commonly used for longer surgical procedures where the abdomen and the perineum must be accessed.2,6 The levels of the legs in lithotomy during the surgical procedure can vary from low (even with the OR bed) to high with the legs and feet elevated into the air.2 Constant external compression applied by antithromboembolism stockings does not decrease intracompartmental pressure in the lower extremities. The use of intermittent external compression (e.g., sequential compression devices), however, reduces this pressure increase and decreases the likelihood of nerve or vessel injury from increased intracompartmental pressure.2,3 COMPARTMENT SYNDROME ASSOCIATED WITH LOWER EXTREMITY POSITIONING Each muscle group of the lower extremity is enclosed in fascia, which is a tough, fibrous connective tissue.

Fascia is minimally flexible and does not expand in response to abnormal swelling of encased muscle tissue. In addition to nerve, vessel or superficial tissue damage, swelling in the fascial compartments of the lower extremity can lead to permanent muscle destruction known as compartment syndrome.2,6 Compartment syndrome can be caused by crushing, bleeding into tissue, vessel obstruction by a clot or prolonged pressure during periods of immobility under anesthesia. Patients with blood dyscrasia and anticoagulant therapy are at risk. Patients who have been in lithotomy greater than three hours should be evaluated for compartment syndrome postoperatively.2,6 The mechanism of compartment syndrome is a repetitive cycle. Muscle tissue becomes ischemic under

pressure, causing plasma to seep out of the capillaries. This increases fluid loss from the arterial circulation into the surrounding muscle tissue, causing even further swelling. Despite the changes in circulation, arterial pulses may appear unchanged.2,6 If the pressure is not relieved, muscles, vessels and nerves will infarct and decay. Postoperative patients with a positioning injury caused in the OR may take several hours to manifest the syndrome. If the patient had regional anesthesia, the process can delay the diagnosis when no verbalization of discomfort is made.2,3 ,6 Signs and symptoms of compartment syndrome include complaints of burning and extreme deep ache in the muscle group in the patient with intact sensory perception.6 Flexion and extension of the limb will cause increased pain. The extremity may have a localized enlargement and tenseness with a firmness that does not depress when pressure is applied. Compartment syndrome that goes untreated can lead to muscle breakdown (rhabdomyolysis) and the release of myoglobin into the cardiovascular system.2,6 The myoglobin is passed into the major organ systems, causing multi-system organ failure and death. Urinalysis reveals dark, brownish urine with free myoglobin.2,6 Compartment syndrome is treated surgically with long linear incisions along the length of the fascial covering of the muscle group (fasciotomy) to manually release the pressure.2,6 The incisions are left open for prolonged periods of time, sometimes weeks or months, thus requiring antibiotic therapy. Many of these incisions require skin grafts for complete tissue coverage. Muscle tissue does regenerate to a large degree, but vessels and nerves can suffer irreparable destruction.2,6 WWW.ORTODAY.COM

CONTINUING EDUCATION 472C

PATIENTS WHO ARE AT RISK FOR LOWER EXTREMITY INJURY Metabolic diseases such as diabetes can also cause neuropathies. It is important to assess a patient’s medical, surgical and social history and document pre-existing neuropathies or peripheral vascular disease when planning perioperative care.3 Additional risk factors for neurological or vascular compromise include the use of anticoagulants, nicotine, oral contraceptives or hormone replacement therapy (estrogens), pregnancy, sepsis or history of previous DVT.2,3,6 Extremes of body weight and length of surgery also increase risk of lower extremity nerve and vessel injury, especially when the patient undergoes surgery in the lithotomy position.3 ,4 Regional anesthesia, such as a spinal or epidural, has been a potential cause of nerve damage. Documentation serves as a record of what steps were taken in a patient’s care and when the need to examine that care arises.1-3 Documentation and checklists serve another important purpose: to remind the provider of steps that need to be taken in a patient’s care.3 Documentation not only provides a record of the steps taken, but it also focuses attention on specific aspects of patient positioning that prevent injury to the lower extremities.4 SIX PRACTICES AORN (The Association of periOperative Registered Nurses) recommends six practices with regard to positioning the patient in a perioperative setting.1 Outcomes of these guidelines include optimal exposure of the surgical site, proper access for airway management, proper ventilation, proper monitoring access for anesthesia personnel, physiological safety of the patient and maintenance of patient dignity by controlling unnecessary exposure. The six practices are:1 WWW.ORTODAY.COM

1. Preoperative assessment for positioning needs should be made before transferring the patient to the procedure bed.

The preoperative interview should include questions to determine patient tolerance to the planned position. The OR nurse should assess both patient and intraoperative factors.

Patient factors include age, body build, skin condition, nutritional status, preexisting conditions and mobility limits. Intraoperative factors include anesthetic concerns, length of the planned procedure and position required for the planned procedure.

2. Positioning devices should be readily available, clean and in proper working order before placing the patient on the procedure bed. Properly functioning equipment and devices contribute to patient safety and help provide adequate exposure of the surgical site. Selection criteria for positioning equipment includes its availability in a variety of sizes and shapes; durability; ability to maintain normal capillary interference pressure (32 mmHg or less); resistance to moisture and microorganisms; radiolucency; fire resistance; non-allergenic properties; ease of use; cleaning; storage and retrieval; and costeffectiveness.

3. The perioperative nurse should actively participate in monitoring patient body alignment and tissue integrity based on sound physiological principles. Use of the proper number of personnel for patient positioning decreases the risk of positioning injury.

Catheters, tubes and cannulas can be accidentally pulled

out if too few personnel are used. Maintaining proper body alignment and supporting the extremities also decreases the chance of injury during and after positioning.

4. After positioning, the perioperative nurse should evaluate the patient’s body alignment and tissue integrity. This evaluation should include, but not be limited to, the respiratory, circulatory, neurological, musculoskeletal and integumentary systems.

Unusual findings in any of these areas can lead to lower extremity nerve injury if not corrected.

5. Documentation of surgical positioning should be consistent with AORN’s “Recommended practices for documentation of perioperative nursing care.”

This documentation includes the nursing assessments, interventions and treatments, and evaluations of the quality of the care delivered. Documentation of care activities provides a picture of the care delivered and its outcomes.

6. Policies and procedures related to positioning should be developed and reviewed annually, revised as necessary and be available in the practice setting. These policies and procedures should include, but not be limited to: assessment and evaluation criteria and documentation; anatomic and physiological considerations; safety interventions; documentation of patient position or repositioning, positioning devices and personnel positioning the patient, and positioning device care and maintenance.

January/February 2016 | OR TODAY

47

IN THE OR HOW TO EARN CONTINUING EDUCATION CREDIT

Careful positioning, along with knowledge of anatomy and careful documentation, can greatly reduce the incidence of lower extremity nerve and vascular injury in the OR. EDITOR’S NOTE: Don Beissel, RN, MSNA, RN, CRNA, was the original author of this educational activity, but has not had the opportunity to influence the content of this current version.

OnCourse Learning guarantees the content of this educational activity is free from bias.

NANCYMARIE PHILLIPS, PHD, RNFA, CNOR(E), is professor of perioperative education for nurses and technologists at Lakeland Community College, Kirtland, Ohio.

REFERENCES 1. AORN. Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc.; 2014;183-208, 481499.

2. Phillips NM. Berry and Kohn’s Operating Room Technique. 12th ed. St. Louis, MO: Elsevier; 2013;489-495, 501, 596, 783.

3. American Society of Anesthesiologists Task Force on Prevention of Perioperative Peripheral Neuropathies.

Practice advisory for the prevention of perioperative peripheral neuropathies: an updated report by the American Society of Anesthesiologists Task Force on prevention of perioperative peripheral neuropathies. Anesthesiology. 2011;114(4):741-754. doi: 10.1097/ ALN.0b013e3181fcbff3.

4. Bouyer-Ferullo S. Preventing perioperative peripheral nerve injuries. AORN J. 2013; 97(1):110-124.

5. Operating room risk management: patient positioning. ECRI Institute Web site. https://www.ecri.org/ Documents/RM/ORRM_TOC/ORRM_Surgery_PatientPositioning.pdf. Published August 2011. Accessed November 10, 2014.

6. Bauer E, Koch N, Janni W, Bender G, Fleisch M. Compartment syndrome after gynecologic operations: evidence from case reports and reviews. Eur J Obst Gynecol. 2014;173(2):7-12.

48

OR TODAY | January/February 2016

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CONTINUING EDUCATION 472C

CLINICAL VIGNETTE A 41-year-old man presents to surgery for a hemorrhoidectomy for his Grade 3 hemorrhoid with prolapse. The patient’s history is negative for low back pain, obesity, muscle cramping, radiating pain, diabetes mellitus, weight loss, compression neuropathies, trauma or family history of polyneuropathy. An epidural anesthetic is used with 2% lidocaine, 7% sodium bicarbonate and epinephrine 1:200,000. No pain, paresthesia, blood or cerebral spinal fluid is noted during the block placement, which uses loss of resistance to find the epidural space. The epidural and operative procedures are performed in Sims’ position, in which the patient is in a right lateral recumbent position with the left knee flexed and left hip abducted. The patient remains in this position for 90 minutes.

The day after the operation, the patient has left foot drop with numbness in the left posterior thigh, lateral leg and foot. Neurological examination shows severe weakness in dorsiflexion, plantar flexion, inversion and extension of the left ankle and a decreased touch sensation on the anteromedial aspect of the left leg and foot. Tendon reflexes are negative in the left ankle.

At one month, the patient has improved sensory function, but numbness remains in the sole of the left foot. Motor deficits improve in the peroneus longus muscle. Electromyogram studies performed at one month show left sciatic neuropathy with active denervation. The patient experiences gradual improvement over the next three months.

1

2

What action could have helped prevent this injury?

A. Using general anesthesia instead of a regional technique B. Testing the patient’s comfort in this position C. Using lithotomy position instead D. Using a different solution for the epidural

2. Which component of this patient’s position increased the risk of injury?

A. Being recumbent B. Hip flexion C. Head turned to the right D. Hip flexion combined with abduction

3

Upon discovery of the injury, which action should the nurse take first?

A. Vigorously massage the affected extremity.

B. Notify the operating physician and request a neurology consult.

C. Page the anesthesia provider stat, D. Apply ice and elevate the extremity.

4

If a myelogram performed immediately after surgery showed active denervation, it could mean: A. The injury existed before the surgery.

B. The injury is extremely severe.

C. The patient has an increased chance of recovery.

D. Immediate surgery is necessary.

4. Correct Answer: A — It usually takes three weeks for degeneration potentials to be evident on myelogram. An immediate positive myelogram indicates that the injury is at least three weeks old.

3. Correct Answer: B — Notifying the operating physician and requesting a consult are the nurse’s first actions because immediate evaluation by a neurologist can establish causation and provide continuity of care with regard to the nerve injury.

2. Correct Answer: D — Hip flexion combined with abduction increases stretch on the sciatic nerve.

1. Correct Answer: B — Assessing the patient’s comfort in the position before anesthesia and adjusting position according to patient feedback reduces nerve injury risk.

WWW.ORTODAY.COM

January/February 2016 | OR TODAY

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51

>>

CORPORATE PROFILE <<

D

an Allen, president and founder of D.A. surgical, is a respected pioneer and product designer of patient positioning devices that continue to be used every day in operating rooms around the globe. We sat down with Bobby Allen, D. A. Surgical’s Director of Marketing Communications, to find out more about the company and what customers can expect in 2016 and beyond.

Q Why does D. A. Surgical exist?

Our founder is R. Dan Allen, the inventor of the Allen Stirrup. His observations during robotic surgery led him to develop a robotic surgery patient positioning system.

The system is made up of four parts. TrenGuard™ Trendelenburg Patient Restraint is the 52

only No-Slide™ Trendelenburg positioner in the market. ArmGuard™ Arm Protector provides immediate access to lines and ports and does not clash with robot arms.

PatientGuard™ Stirrups improve exposure and aid in docking. FaceGuard™ Head Protector protects the patient’s face from injury and acts as an instrument tray.

The versatility of these devices allow them to also be used during conventional surgery.

OR TODAY | January/February 2016

Q

How is positioning for robotic surgery different?

Robotic surgery technology has introduced certain device incompatibility and new patient positioning safety risks.

In terms of device incompatibility, typical finned stirrups can clash with robotic arms and interfere with docking.

Further, toboggan arm supports often clash with the fourth arm.

Literature describing patient injury associated with robotic surgery makes clear that sliding on the table during robotic surgery should be considered a never event. A recent paper states that patient slippage during the use of fixed robotic trocars creates a serious potential for patient risk.

This is because the surgical robot is not programmed to detect,

and then compensate for, a change in patient position caused when the patient slides on the table.

This results in the patient hanging on the trocars, creating incisional tears, post-operative hernia formation, and increased postoperative pain due to overstretching of the anterior abdominal wall.

Q

What are the dangers of using miscellaneous materials to position patients in Trendelenburg?

When creating “homemade” restraint devices, like the use of tape and foam or tape and a gel pad, clinicians attempt to stabilize patients to the table without brachial plexus pressure, but in doing so they are in fact using products in an “off label” manner. The off-label use of materials supersedes the most basic WWW.ORTODAY.COM

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Shown: 505 lb model in 40 o Trendelenburg with PatientGuard TM 800 Stirrups, ArmGuard TM Arm Protector and TrenGuard TM 600 Trendelenburg Patient Restraint

FDA guidelines as there is no testing, no analysis, no methodology and certainly no quality control. If, in an attempt to keep a patient from sliding on an OR table, clinicians utilize materials in an unintended manner, each member of the surgical team and the institution are fully liable for any post-operative positioning related patient discomfort or injury. One robotic coordinator recently summed it up best, “We spent over a million dollars on a robot and now tape our patients to the table. It’s ridiculous to do this when we could have a device specifically designed for our needs in robotic surgery.”

WWW.ORTODAY.COM

Q

Why do clinicians prefer your devices for robotic surgery?

Most notably our TrenGuard™ Trendelenburg Patient Restraint has developed a stellar reputation for product efficacy, patient safety and stability, improved efficiencies and ease of use. Clinicians are often introduced to our devices by our network of representatives, at clinical congresses and by way of personal references from respected colleagues. Each new customer contacts us out of a need to solve robotic positioning issues.

They find our product range to be the right

“We spent over a million dollars on a robot and now tape our patients to the table.

It’s ridiculous to do this when we could have a device specifically designed for our needs in robotic surgery.”

answer. To that end, our products are being recognized on a global basis as meeting the otherwise unfilled clinical requirements for positioning patients for robotic and conventional MIS surgery.

Most recently our positioning system earned the first place award for Excellence in Surgical Products presented to us by Surgical Products magazine in the category of Surgical Tables, Positioning and Accessories.

Q

Besides Trendelenburg positioning, what’s another challenge your customers face?

It seems that as early as 2009 the AORN felt that there were enough upper extremity injuries caused by tucking patient arms that they published patient positioning guidelines that recommended that “patient

January/February 2016 | OR TODAY

53

“As a small company we are able to respond quickly to the continuously changing surgical environment.

As a result, we are the only company that offers a comprehensive robotic surgery patient positioning system.

arms should not be tucked in the supine position unless absolutely necessary due to increased risk of injury to the patient.” Few nurses are aware of this guideline and even fewer follow it. There had not been a viable alternative offered by the industry until we developed 54

and introduced our ArmGuard™ arm positioning system. We are told that clinicians appreciate that ArmGuard™ provides safer arm restraint, allows immediate unobstructed access to ports and lines in an emergency, and has a low profile that eliminates clashing with the robot arms.

for use in the broader surgical arena without any adjustments in the products or their uses.

Q What advantages do

Clinicians have expressed frustration at the lack of guidelines in this area.

There is little information beyond what not to do and some descriptions from robotics early-adopters of how off-label use of miscellaneous materials helped them restrain patients. To that end we will be giving a one-hour CE webinar on safe Trendelenburg positioning on January 28 at 2 p.m.

More information on the webinar will soon be available on our website.

you offer in comparison with your competition?

As a small company we are able to respond quickly to the continuously changing surgical environment. As a result, we are the only company that offers a comprehensive robotic surgery patient positioning system. Further our products also translate well

OR TODAY | January/February 2016

Q What guidelines can

people use for robotic patient positioning?

Q

What is new?

The most recent addition to our positioning accessory offering is a robotic surgery stirrup. Designed to work seamlessly with the surgical robot, our stirrup is familiar to use and provides benefits for clinicians and patients that are not available with the yellow stirrup.

D.A. SURGICAL is entering the global marketplace in 2016 with the addition of distributors throughout the EU and the Pacific Rim. Visit our website at www.da-surgical.com and watch us grow!

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“TrenGuardTM is the ONLY safe restraint for extreme Trendelenburg without a single report of a patient sliding.

There has never been a report of postoperative discomfort or patient injury.”

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Exceeds AORN 2015 Guidelines “..patient’s arms should not be tucked at his or her sides when in the supine position.”*

CALL US

800.261.9953 WWW.ORTODAY.COM *Guideline for f positioning the ppatient. atient. In: Guidelines for f Perioperative P rio Pe riop iopera r tive ra v Pr ve PPractice. ractic ra tice tic ce. Denver,r,r CO: AORN, Inc; 2015:563-582. Emphasis added.

EMAIL US

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da-surgical.com

2016 | 2015 OR 55 AORN does not endorse any company’s products or services. AORN is a trademarkJanuary/February of AORN, Inc. Multiple Patents Pending Copyright D. A.TODAY Surgical AD20150226

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lth per hat n • and st ss om ore th rac n rat om osp ch itm o h s a re pre n m fin en cru ls ub ica ng l, t op tea s p a e a en e e m n s ic ha • d t e s A x t o s s iti in re r c m ss t ee pe c h e ru t ve th s ve o et re oo s rg lle ita p e e e s ta ci ar s i n a m c ue b t tim e s s a om hy g c ees t a er tiv f s re e AC ing cr R m itm um n i ten d em • I • ts e ce lat ee ll – rog hei en cro n is o s rio eir ity d m ec nts nti eal ay s e d t e r all ch ade l su ha sp ing f th oye s m ive tc p in y en op ra r o pp w H nc is O ru str s i pe ge m g um n lan pu loy e p t ev a io t e th un n d r a ce r lw e ge ar e g s m fu c ho rs o pl he sa nt ou nd be plo m eri pe e a ike gh ie at As ec in es m en er vin ul tie ba o p b w ial nd s le nt like • P nd m o fi an f w in ery s a om en ns ar in e ss d a y nu rs m r t I b r t p l f c l e r e h t a e v s e t b r l o r a a e e i a l i m g e c – l m o y u v t a t e r e a • a n r j a g t s p fo • e c e ce l l a re m ip P rio m am s e c d h t a e n t al b e n l i g m a in ica nta a e qu y • pe nu te m tho exp ce on and el ro eir ch ou re l cur ur /lif sin g eir sta ed co ork f re oul fe ed co ged ee r st sp s a na b ch nc e w nu ls h uc en u er em ew ng ng ra n i s es m en w l p h a y a ir o rk r tin th b ain e w o w sa in a n loy u e s i re his g co lik ee ta rg e we ew , e et e r e ee Al s an ti s m f i t i i n st t l su r m rs, f n lies saf Th alle f th It s • ent ba ula ee job tia d of he es he to wo l nu xis o su tr is b en ect • I ing tra r in alle p • O st d thi a l, t ein o s o s spi ing pr com e g er t o ru tra d e • m o • m ti e op oy ir an an re T ye t at e ra e d de en th d p g v n to h em ff si s ive ta b tw em t o nc ys a h g en ec d an rs ei e t o p g t • r f i th ag n up in ifie s rs g ulu pa lif p pl he st d o e lo in re th ne o to a e l, u as in ro ee ec c g ta er , a at p re p se ike t h rie a in n un m ll r n s nu u g a e b a n / s e o a h r b l b p t e w s m r n p p l b g v s s e an m , o er o b vi ric ur rk ng em o t su in n m orc m sin l t nd ge ion ce e ve pit all cia rai im e di ein stin e s hip pe ho e a y t • It ld tha pe al tor tha yo rui e a nt tiv ive al o v a s v l a fi r e n t c e a e f e r i iv C s o e c t r x s t d m it ts pr v t m ea r o o si w u e r r b g c u e c u a a r y M e a k e a l x n ’ s i t u n d a h e e v n u e a i g e t A w i r o e , cr e im ie du m re ir c t to e nu stin to ad n s e or hy l nu ry r to th ete so ls h y h h on t c nd ss y h gic are f e era H ar per nit rs s • vin wo cat ts a h ire lde • T d r e ipm inc per rg e p a e e r w u r a e a th l i s m ee e w ‘w a e d o e ty I i u e e a o p h w n n g an r re a re um in nc e s n su h t tr ss te g ge es th re d era ex rce e b m he g ic v yin th re e it th ni he o nt gr th su we n io ug ste he m ag liv le • nd tie re al lly rce a ike eq ite rio l • T ha ns re pe llen un ye in l th fin en of ou hav ve eco s t sin urg is a tr er s a th osp ess mu e t e m me ro ss s a s, ntio per ho ic • T om an sy re ing s i pa e a gic ca fo es s l s, sp Pe sfu e e t o r i k e t t s fi a o r k n p og om ha y lo ng ea to g on es ls ha b os es f s is in ld rn ve h nl m a th ip l nle A e te f Al io e a c m bu s ain io ur tiv su st or y m lie de y • e ri nc m pr r c a c he mp rsi y r ng the nti e r ita ey his acr dr o th ers y o ce ha hat e u co m n, qu tia u g • ag re p o • tib rifi in OR ir ee tr ct o ra a ati w plo see pp ist fet ucc ve ala en ca n o n y e i T ei f ’ e nu er ryi an te th sp th l, t le ad alt as ad all con to e t op n a s to inio s, e ta op ein a are ou um an ve or As the loy nd edu t t pe As s st the em It , su ers sa g s ies e b ev ist v t h re e o s ta b d i , le ic m s gr ul n es ct c lif s t • ts p g n i p a r a rio • t h o e • hy a l p ie s c b ts t c i v s c e n h t a g a in r t re ha t le pi rka an pe hip ir tis wo an ic os tor ism o pl sub os ll- R rn ll ric le i ci ire n • i em nt se hre pe g ay oss in ng en s in ci ten k/ me sta ms or rc ‘w ic is m kfo ng urg is ers lde s a to tha 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mu he al of tion of ing o sin r ir n e in o s n n g d r c e e h e d b re e e m T h t w e d c tr e d c e d r p n ir e h h ra s r s sh ln t or liv tiv , t ev al o m as nu the lle Th m eri ate el el ing e he at el s o t ne bu all of ses en al th ad tra ins rat ar eir r m ur e o co sin s to hei su th be ad co n • g c ers te ec rui to nu g sy era em d n gic s t ial see t ha • he f p in nn l w be itm o t dic nn al t ge eir re ty ur be sic an he is l – st ew th ei ll b th o res ce t de al ve r le a de ein b re sp rec es ee ou bu op th ul sur ism ruc to bou a c en s t o elim rso ica re cru d in so tic he th e a ial e n ve hy r th e t on el nd st nd th ca ke tw dd ur g in ma y re ha hei r in ur b em are al a all urc o s lth se e ys e a re to ns er ri t in w ec iv ha p e iat ti w a tic a l to e ma op a so in e er ey t to ll b are r m s ci e so t A he r i te h o a a d rd ve up o n c e pe ina l s s ha st lik rn nte bu gi ro s t R p ph w d es tio p is c an m ike sp rat ey and old ec ten job ves io 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“Perioperative nurses

should learn about their

role in antibiotic stewardship,

as this is a very real threat to our

patients experiencing successful surgical outcomes.”

“Our staff wants to have the

resources to do their job

well – instruments, supplies,

equipment and training.”

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ce ar T m e o e u nt iv ch le ec • y nc ha y oy i th n e n s ls be c ar gi s w m h ro e r ur c in ic r an -c f t o m a e t t p c e w t d c e o e fi m on s o y t w e g ‘ pe plie ing du le sur nci he ec er ac on ad so eir ss urg ys in ner a l as s t in ew e • om s, w o c th ir c n a ra f a ab sp ing afe ete a c Th pl th eal to en ete e r ita ve be s g r h p a is ro t b ld le c d re th re s a r e am ia ce te st ifi c r w or e i pe o rk l a n s p f • e er M e in of p rs re ld l e i s e i l h em in r th b s • f n ess up , su nu se ou sfu pet nd his y o ab wo an he in rog fu alw cto e g te uc our sp tic er n a ag p t g f n t ole rio re wo cia tra ng om e o ce y’ ng ery ing the are e t ho y h l, th ac g fi h k t g t g p ss s re th e cr s e io s v r i n to in i r r e o n ru d vi c or or h si v ry n s av t em ve t o dr o ts al e s es m o , t ll r i h t he ta le in a d m y li en ad l gr en gic , th es cc co g t ital tica wo top kin ave rsin tial cce ha l d an f t st e re st tib cie cto m y ruit 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ec lim iop xp ine ad m tod n- usy te aff of ma pe pe • A tica er pi nts gh the ei a s lat ir b we f s le ies s b the ini es, pro tra be ac and ty ds r th ist to r s tio do om ll b re ing the hal e o p e r e a le m l r t y u c x o c a f s t c Th g o a u p li l th b u e e o ld c i s re t y n s e n b s g o s a o t e a c e a r s i n r e i l e r n h o i i u e t o k e g f o fo r jo he s t P nts n t eir a c rc th eir of ur ial av ts er ein tat ou my f w tho ou nd A op th s li lty ou te l, t ak y pp tia ee th ab in ec ew d st • M • O ed n e in a on- ct nu ou a • s b d en e r a e e e i t i e y • i e e t h n k fo e t h c t O e c h e n p - b s y I n t a f A l a b a g • p i n m c i a s h p e t a m m s u a n e b l , r k c k s p st a n i s s f f r e a e th ude eg fet pat be for or i or ak in pe ff • sp tals ati The ell y is he • r s • rn ed in ing em ee pe es om spi to In ts, bst av pita wo tra e tic ff ay live sta ese ess cto th asp se rn ent rd giv r t h u • s a d n e T cl a a r ve d ct w m m as ta e pi p • l w a • es u m ea ai b rs th t s s r c o s s en su h s n is t io t o y e th c re e al to ea s b is g in str g s ou ha an ire OR to he ial e s th os our fie ca tod ce ye • O ulu d l tr ell- l nu es • I the nu eir y h ism ee m e ey ho de on de tib e s e t us tiv m, pro di ak ci ike d l pre all th all d r lo ff ric ul en w ra iv g e ve th nit an oy tru ad th ity ur ti lu an th rc ir b ra e r al m ru l ul s c e sm n ri si e d i n to y f f d e m s s t c i v d e t h o an rov at the sta cal Th nis ive cru rat clu ha t t ve phy orc rkfo mp sta ur ho be al ne s g vin lud ati nd u ch pl ins m ess un ll b ten inc in for kfo he pe th eve gic s to st c uld sho ay the tim e s a e m e m i • a g t e in t a es c s e e l m a e ls e e e r t i o te n u r f o ic e i a c er a lw n al m ve m p e s o o r g – h v r e e e r s s e s n k o c im th les th ur en ch is o iop ls ate thr nci and or w ew tiv eir ses av hy e g e t e l s in iop ed com d m w e ell ha u m n- of oo rol ng w in pe ina uld a s ism m I w se s a g i ion sa nti co l s r w the f n ra th ur y h p th im ar ol er in a fin ne w ls pe co o ct ch ir lle R em of im o s an the • ur ha rin it the ce ut ta al un or a rd me e th e m pe oo dic al ete al l h d e a e h g n O a d s e re e e f s bu d th f sch in re p nt OR ss t o op in e n he an an al t es ho • P tr in to of ob it sco n a th pe g th ha e th p e l s • A ec n, in e na ha ad or in l o en b o j e p i c h s f s n t s n op g • A ll fin tim n, t o e s i e o n ri ng iv t l th n ye sc y ou to e g m io in iv re s e i te c a m e r ry m or sc llen g ca to al io up ing ion ve co ir m Th acr me pe rsi rat less nta er itio lo g fet bee ct ged en ei ho nd tor ak al a urs ou d a • T ive gr ies nn ein d pin tra rat e a aff th ing sp rgi eir ar ew o t b e n g ll n e v e c m i e t e u a in he d on in ro rs ct a eir he • le uit of nu pe n e ld d mp sin sa e ire n tm th at n ire o uc e n a nt e is a eg ers ll-b fi y o nd op ti f s ate ui d l s th w f n r u m o d e r t n v d le i o h l ch e t e iti op g u u s l-b in ng dd y all e n red is i th to de kab ec up ica erio pe ir lly e a y’ nu ing ha al hal cru d e t s a l d s t cr se arn se urd th sm rat p we to m t a eri era r o eci ecr sist sfu l to rs, t o pp r o e el c c re to at es ca m st o le re l b e e st R l ed In en P p be r l r r s a ge en u e a m m se e th nd l ur or p l e e ic a a d r rg P co h ca th h ee v y i o t w ng ll s o s s p a O m e t p i g o i w l c a • i s i m i g • a n i g b s g e ‘ r c s • d d s c r ar ch th • I e to he as d iti ll n w an all f su ty do to tist ate g to p th su ein and rce di pro urg an m ike ul ys ca al t sa an s • sic len es ipm ty per um ap re a s p ucc crit an itm ts, im n m a C s e hy l e u f e i m ss a b s h he l ho a e n e s sh g e s am ke , t p, ne cr ca e es u in r o fe n a l a c i i n m ru n n hi ai s e rd e sm y a e ic st e ss ke n le s e es o s e a ec t ld s lw th io th e m p ha y eq a he er a e HA ng t is R ec me s i ies i n at e e s l i i i m r i s i s , l e r o v n s y t v l a u r e s e l t o t u e c l h n i s be rec loy th uld the rd n t at n t l b plo me ial ng an cri y is pp dr ld ss u • A e a loy re tio ne As d m ion wo se as in di for nt tc nd g p es, ng • T a e t e w gh nci ha s O d r tru res nc u t s c a d u re pe g e g r u a in em li vi e sm th ik u e a ee th i al p p or o e w p h u c l d • n i n I u h n a d g ce o l a i e A a n n s g te d l m sa e vi s is a o w i p e ap em g f I w nat te e b ce ing n-c e he sp ro oce at tod am d I w rog co ein rs, em e t ed ou ing o fi op g • e n na ar he itin in al nta b w up pro erifi a of s tho er nc • es – i pro pe ge e s v g t e p r h • i p la n e ll l m n ng v r h e t y n v re h t u te ic e re e s n r o p s b e v to s m l w n te n a e a e i n x s i n o a • r o g a i t e i s r A l a m c i , p h l b e ne uit ing elim oti ha bal sh he ist for e t n im er ce orc he ng ng tia nd ell nag tin o h es el ll- ged n m ain rat e a aff iate ec sp urg r m e a of ts in i ies ue be se • s e ba lati loy we nti co hal ou ar r e s i f t t i i t i n r s f d e n e y s p t I r e v e c w h t t i a t f i i v b n w n u I n c a m c m l cr in o bi ey e e k f t e n l t f k s t n n ex g d s d t l l re tra s t nti th /lif sta ake of itin clu ess ne ala or s o rac rai sta an ca m f ex nts m, so al w alle s • nd riop ra of pre a st sfu th rs, en um res ten ge me • ulu tie k/li op em r jo bs the f a he ee ir T p g ei su d o d ie a ss rk of m n ru in gr ld b w er t t ub ss si R o a e er ic h ee a e pe r p re rsi s to ge itm tr g pe len r ing ic pa r • oy he an eg in le o r to io ec ls ro ou life R b is nd s ce hy s O n f w th p ys g c oy nt • P rio be a e a e ce al na ru ns ro m al ge av urr r wo ing tin th e an re e pl t e t i l o t e O n n p o e h p a f w R n h p e i h e o e r m o / c e A e n m m w p uc ic a c p t t y s l ou he rs xis do ad ed mo orc em g in thr l b r a o s o i c – a l d p s u c t t e e k e ra ol u e i O s t r d en ll p t i m in n kf y’ in al st ir r pe th um ism ret a sch tia nel or Th m nt en ma r p an n • ten r s ina • nd be em ipm fe e nu te like AC g cr R m d r ell tia eir f a yo are ei to d t nu f e to r re th at n al o s ve ra ve or h rs re try H in is O n w an th o e s e o d n n e an n w • er te m e ve l io re u im es a re w qu sa Th le he s th osc fin ller cha ar e a ing st rso the en ng f re uip av ne nta lat re • O el m tal e a ne , e ng • al f t m gh enc at s s a ob bst d re Th ee in re o fi ner ion rce ha n t s e w ‘w nu ry in ca d to a e ns w urs sub pe d rd ou o eq s h ld e pu s a ff to tco en w of ies vi ifie sm s o see ou eri th • A ee ir j su an mo e • loy ng l th t ge nt u als ee e the ing al ve rs sti e ti s l ro r a b o m s ss i c a m m r e n r t n u y ct , al u r m o n ta s u m s, t en h p e n oy e e d n rc p si a ng te s o i t d b e e p e e s l e r o p t r I fi i R c i t o g e r h e e s e a e x i e n e l s p n g s d ce l i k e o p i c e d e a yi a n n s e ad O to all Th sp plie sp l sh the ng nce ve eg cal eir ge me sup im s v to mb g • A s e lan ati mp o t a ain ev kfo ’ em l nu ry r try th e r e r os av be ro dr sur s is le st bu i • t a l e d m tr s or y a e n an ar th h h s ac d f hi ir is ir l t i c i h a t , t r to fi co m s m • a ie e e o a i a i t y t e o e to o ee to e es ing e e • al up h ne to rs co rat tra rg o t an ui ts in c du m vin m en b pu g o e e h h y ic v s he w n h e u n h e a i e v s r i s h t s t n du ed tw It s like hav om try n t orc uc s, ha so cal l n wo pe d s l su al t m ec en es ete ge er lea ulu at life po stin s t ha ee om he ‘w urg s a er er rn av th th l, t abl and lty , as r t da in t sm s e h e s ta k i e i o i kf cr nt t er ti ra t io n u c R r m gr p n ng e ic p k/ g i ce ls b c t ng s a i i e t s i x r s ad ld c n g p • d l s tc i n r g c i i p fo t r r r a f m rs le to ng ul ita ou rs ring or st me ate p cr ne top pe s ss rit s O and stru ro om alle ou ar ur ou or rsin f e ou ita ave s b oss ssi of thi r le y o on to ica nle sp wo kin pe sh nd rce em sa pe t c ts d u o o y i o u ic R is ge y f ive ce c A s in l p c h y es c o l w u o s sp h hi r re ty s ei ll c s rd a fo th e s at r s c r O M v w sp a de a w n h c e o l • lea • I ho gic ea sh the e m st ind • at he M p o nt uc t i n • ee l – tia eir a The ye hei t t the al n ion e r ho ey l, t e a dd ia p, a th tica tw an s in pe ty de tra the wa aff rk es r th AC hre af a w n o i r s a c i r s e t o i v o H t st h a l lo t r t h t t t e g t ur r l ff s th in s es th t s • u ce s ha io oy el an th of • e i s e t i d n f u p n e o h i t e b ar in tha l s hei sta ros n, ll – ion m ce an ive gro in ing e t lat pl w bst nd re ce mp in thr fin en te e tha ss sp ka nd sp ds d f tat to taf tio osc u l b on ud ic s he R w is g g f gh eal e n a e ar n s y s uc d m l i n l t t O h in u r th ri o e ct co an th l ll ite nc nc pu em b u a o r ’ e ng l o g re av e le o or t t o ai e fu t of c i o a t m a t c g tr cat ess for er le a pin b w du ou bal er usy ma sp rie ala po g ir j e s ed n m rkf hy rsi re g t he are o h cat un ty h w in e th ew ff a y is • M ur red en co n-c ten s in ibio for he e rui ltho ery for sha ge t d n O n t d i e n i e n c k d st t a a s t l v e ff n di cc d b b o jo re al e ol b s de pe b g ti he ad in e o ‘w nu ry in n s • e a a o re o n e T tim ec A p in su an um rka my eir se ic /lif ly eir me ist ex life sin xis o t m tra ev e w ng al ve try ha rn nts in co mu rd tra clu tic e s tod live ff es ss in he of ho n a ng n • al ll r • is a ng sta you o t g ff n o n th the urg rk cal th sa rs ts k/ nur f e d ve en es th ssi gic s a in r t nce wa ons os m l bu is in bio th ce sy sta , th ce tor e ct sc e i alle rde ion e a lum is alle of e nti l k e o h e r r h s e i d o l n ls i o o a e m s e r i in ta er w • I o s o i n e e n r t r h f , g l c o u t r i l u t t u i r t e h t a o n s e m p l o r a f d o c u l s n o o o p a o c c e r n ch ber • T ret pm e a e es d m fu e w tis m th s ti w ra on s ls e b c ro d s is de ol ta uc e a -c ti o an f kf r b tiv he r p ir m s si r a l b dd e ric s th sm urd ye s to the ss th sta he for AC pa he ne nti rce ita av be ac ad of s th lea lly two r s ed an in on ten sch in ge or ei ra e t ve l d to al a ur hei d cal a w ur p, a d a m ce of ui ho q r t e e u p h s n w h e e e c e e t n u r e a e u r d y a b o a H

TOP

PERIOPERATIVE CONCERNS FOR

2016 • BY DON SADLER •

BY DON SADLER

In the most recent OR Today Reader Survey,

readers were asked to identify the most perti-

nent issues that will affect OR nurses and surgi-

cal techs this year. Here, are the things that are

top of mind for OR professionals as we enter the

new year with insights from industry experts.

n t p te w re ss in h f s y u e i n a O e • l t o g t h c h h e s t h u p to n n g • fi n d m e q g r e e co n d m e e r l i m r i e r t f f s t h e f e es es ica ng re af se c tor e t in t n , ro b a fi it h e e fo a T e o s so n m rit rsi are st he pro ec ak ec rs ou d a • iv gr gie er ei to • I ies l p ve in to ru e t to xp d st oss • In e an of r s o co c u s u r , t r i r m s p n u a b te n g l l te p l - b d s p l i a a o r d e c v s s a e h e a t e s c n e d i to al a ee rn en rd thi sm tra OR el ng ye up an ey ct ge d r h gie nts aff er a ee s t t al ern • O em ev al w s st h ire en an to te ie t b le oy nt s ea es u e ha er c ff th n ic ms ci b e d s • al lle plo s, t s b l r l t ll n s l a t p l on a e ld rg is ru to c im m n ub s l d a s ts ra a e um a p a s ge o c st nat ou su an t c ike uld ys ca l t sa s a me ysi ch em en s les ca ch ee an st r p th r n ork em ff w AC e i h a h s l o a e a e e o h g w m de n gi g oy w d u r e w a H n l h c o o n o c l t w n v l h r u h u p w d f e f n t tw iv m s a at l i e l A s e m u l s s a l t t i o t t i u d e i n t r e s u e i m p t a f s a to e m a e n n e r s u g h u t b e s e t ng s rd f u o er o e nn • d m he wo se as in di for cen l o an e b of ins e m op a v bo e o op s t so ng fin , t I ur h ing ad g in ica al ar nt l – av sc As are ng ur nti rea lle a bu t • O lth a av h n • n o ie er ei • e t i O e t h a to l l e n f f A r n h na ar e tin e rg nt e e l e o o t s h d h i e i g c s i eg R p ll-b d t in in tiv are sh e t ru sp su me s, w uitm w ital en ng , w exi ff • in eal a c ue -ca itm sta • lea hey s i s b m e d n r a t i u e r r d r n p e O e e p in ra e ff t ec e ul r e f • l w ng y o tra pe tiv sta cia ll r t d ssf hei ge rec ir jo os s a l-b ge o st pit ry ted ge e o ecr tiv ulu oul ss at th all a e e h in l a n e s e s a e r a c t h n ic all m nd rio era of pr e a rsi ce o an d he t es e n io tiv de v en le th d er rri sh nl e t g -c ys ch • In t a Pe op er ap ar pe suc al t m an o t tha roc al w ma ent ra st is a res hal ke an op cu es e u nc rin on p c ma s ri ir rs p la ha he n • ri b m e s g ic R es d e p ic R et pe rsi is e e t r s e ng es e u o e m ty p um ea e w AC in rit s O ye to a e ys O e r rio e th y f a o ye p he n sc ba f s t oy ip fe e n t ik H nc c A lo es ic ev h As r e s p s wa o s t lo of in t ive do ife taf ake are are pl qu sa Th ller the s l h rie t is • mp rc ind n d p • s a f p C , a al re m p p t n /l s m s s , g d g a A , e ing • a f em u pe ha ion e ou ns ul an on ern p o H hip as mo nis em ou in er n e rk of o rn ee ts es ov rifie sm rs o se tho ex e t lat ing res tio ho tal lati nc ou gh ds a h en ha ng l gr urs op s a wo er s t ce loy en l i r s i l n t pr ve a e It A ts nc pu is e uc l en u co gr ou a en ev ec st a l n er es he b sm o p um m es e to mb g • • ien ala po ex th ed nne m op o all lth tew ar s m exi sm ica • P oc d t um ani o c em str t n e d p w e r r ’ n is p e f r i m t e s h i i n b f e g w o u n v t A r nc d r m avi ulu pa ife ing n o ha ese ers the ing p sm • tic tiv om fin o am sur ety er p fi lle ec p t hy l – ers rio e e le ic ur /l rs io o h p s to me m io ra ec to ion s f af v to a m to ‘w el p e P e b g w s t e o s e g m d to u r y ng g rr o k u t t t lu b un are cu to or l n ten ts m, OR al l n M sa cu nti iop is ed en th ty g d n in a s fin My sin b C y • l yo es ir at e w era re an the • itic era s • the rri a er , th eng ret or ial vin ul try to to • es r jo HA fet ica ive l s f c o o e t n p al ll e s r i w ye h re th en re f e e cr n ve r cu i g e r h in e d e d e gh sa rg ra ta t e r a t lo in l th d g s a taf nat om is ge y li fo eir ole Th pi ch s a tin sp imp el s rs du ge liv ad th ou g l su pe en er n e s e e n y d o h in u io m b n s g a fi h r n s i tc a t h e s n g h r r • o g n u i e n d e t in re to n t ce ur lim ou th n t bu uiti in t hei fie y h ein cer ecr e th s i son lea ng all bu an o d Al rov ssf er eir um g s t • p ce p t h n t ri it b n r d es r r lle ch ir ry g ha on O e al e a ir r g ve yin r t c ff • s to gic anc r th the rec sin ut ve un re co all clu gr pe hei ha g he kin ce m im uc The to ler tr de wo sta ie ur al de in all ur bo ies m e a wo re in pro R r t a c ein n t rac ur ulu in s • al al R in ol p t e teg l s e b ol m re l n n a nc om , w p t e a ols al • O fo of e b m i is t eso rric ess ing ifie itic sm O e i f lly to tiv tra sfu /li lly the a ica ar te a c rs to w ho nt es nd re ar he n e r cu gr nc er cr a As he ar ca My era s es rk ica es we rg d le pe in ge y like sc sta om f a o e s t tio th ir pro rie s v is to • T ns • iop and ucc wo tist iv ike f su ul om tor ana • M s ng ub tc taf n m s, w ive ten ve the al xpe cie hat ue ion e • cer d at rc n o c c u s e r g e a g l o s s ti e n t s m i s s h v o n r e r m e h er s e l e r i n e e i he ta is s e s s e e s e l e g t y e s g f r t fo o i f p t i v c i n d i s t h e m a l t e s t h e d i O R l i v t s n u a d i c a r t h e s n a t h t o to i n g s t a e n t p e n c e n g o p u r k o c e se ci rs d al s sy • I ee m rg o m a e c ts s b ti m la ll p o en n fin ay r u a o a a f w tw e e m n u e u c m s nc eri to od l ti • It sp n an rgi • A r b ing to ave l su ge eco R tim sp wa l nu e s r p r c e b ch ing he op e d d u ei lif a rs t t p g t a n i u n b O l a f a u h e v v a g l e ex yin rce ion in th ati ine a s tio th lea like als ssf alle is As ion cia taf gic ma o o th k/ of nu ss My s r e t d or e l ro • tr fo it av e er ra s la n e d it e h th • it u n rk dd le lud op n t • A pu m i ar ul sp ucc a c al, n dd cr ur f su av at an w or era ac es h re d e m n le iv o o s t O o o o a e c i e it io s s h w e a r i n e r e g p h e e w h g e d p at e a o s • l e th n e b l R th es ls • P e b ein ing s t oye • I at cin nt hos ul th m aff alty ita al t ain d ve e g ka sy n e h r u p e e t i p e r e l g th n v b s e te e o ia loy cho fety ha ell- ur giv mp in te rie res ity po iat , th e s ec os y r n t o fi es n t wo ir b p s sa ey w l n is ’ e ain ca e p un ng ec n tiv sp t h er ee g t om ha en he p s l a r o r i v b n c t t d i em ng g th a r th y t d x y m si p ni ra he ha r r si in s sic ne e wh d in s e wa m ur ap pi pe e t e t is a ave try be de bu in o i o d at i s h n i s o l l l ur ov les hy ge tim g ‘ an ns nt al co l n m m r pr un p he al sin nt tio tie as n a era ea my e clu ic th ey s i , th lly ca the im pe nd n t ion res me uc pa a h r i en e t In of p in ind as th der tal ica on- es ls s , s a pi t o l a a i t d i p d r n to g h • iv sc ta th dd ad qu re ou re ec he f t es up oo ion hip les le os tis the g e se to e a ir t s o ye ro ch ct ds un eir h sta e his en er a d , m o l d t h e a n i e s t h e at t i v a l d h a n e r l o l l g g s d u a r p e t h i t y i s a k e t l , re ra ic t b p a r n e w l y te n g p r m m m in r e co o u ay m im e al ia ki up hem l th op urg de e e s urs se st os d f m od to l t ec ac , s t a ri s ol m w me n he tic d an om t ms na e r e pr s tr nts ate y r pe s a lly ge f n sa see , t bio en ff a c rce nis itio i e in er e A a n o e i n a c u o e m t a st n fo a d on um im v Th • ti o nt th t th an s e r i rk ch ad tr el s a • ing tis e y e or ike e in es th to o e e ns to is i ifie be sta Th uitm g f d l nat le roc or rec R w d m th l i r i e f o e s t h e l l i s • c r t i n u m r r p e d O fi n at gi as s v we ay rce re rui wo eli eir ve ng cal he to eci e l T I i p , c i a o d f o n d e c • to t h n e l l e g • d p r hi en sic e t ork s a ll r g es ut ld ha sur en ge ap t y c n o u c e a in i d pe ph or w ye re in eg ab ho a s a ur lle am d rkf the lo a tra rat rn l s ed A l b ha te an wo ss mp we nd st lea ne ent g • cal g c he n R ro e ke a nd d o es in e in f t O ac ing s li ent s a oul ers pr -be th be s o le ist m m ve sh p ys ell in re er ab ex see uip nti es OR wa l w ing e a mb l o f I t e q n ce u r s s • s a i c a h a r s , w m e • , r n e a s

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STAFF RECRUITING, RETENTION AND TRAINING “My top two concerns are retention of existing employees and recruitment of new employees,” says Ren ScottFeagle, MSN/Ed, RN, CNOR, Clinical Educator for Surgical Services at the University Medical Center of Southern Nevada in Las Vegas.

“In my opinion, the most crucial aspect of retention is tracking and addressing ‘why’ employees are leaving,” Scott-Feagle adds. “Failure to measure and analyze separation statistics and address the ‘why’ question results in a revolving door that negatively affects patient care and staff engagement.”

Susan Phillips, Vice President of Surgical Services at UNC Hospitals in Chapel Hill, North Carolina, says that staff recruiting and retention are what keep her up at night.

“It seems like we are all recruiting for the same small group of perioperative staff,” she says.

Director of Surgical Services for Pen Bay Medical Center

Virginia Chard,

“The perioperative

arena has always

presented a

challenge for the

staff and for their

leaders in trying

to find the work/

life balance that

is critical to their

mental and physical

well-being.”

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to help OR staff achieve a more healthy work/life balance. Employees who work the day following a night of call are only scheduled to work a four-hour shift that day, but they’re paid for an entire eight-hour shift.

“The younger members of the team appreciate the additional time this gives them in their busy lives,” says Chard.

“And Sleep Time has provided a safety net for all staff for those busy nights of call.”

WORK/LIFE BALANCE “The perioperative arena has always presented a challenge for the staff and for their leaders in trying to find the work/life balance that is critical to their mental and physical well-being,” says Virginia Chard, Director of Surgical Services for Pen Bay Medical Center in Rockport, Maine.

“As a surgical director in a community hospital, this becomes even more of a challenge due to a smaller number of staff sharing in the call burden,” Chard adds.

Along with the challenges associated with call – the uncertainty, sleeplessness and stress – another factor that Chard believes is impacting work/life balance in the OR is the generational differences in today’s workforce.

“The OR workforce today is statistically older than the general nursing population,” she says. “Senior team members have a different expectation and understanding of the perioperative role, including the responsibility of call, while younger staff are seeking more of a balance.”

Younger OR staff have a different expectation of their role and the on-call responsibilities that go with it, Chard adds.

“As OR managers, we are being challenged to find mechanisms to make the on-call burden workable across the workforce,” she explains.

Pen Bay Medical Center has created a system referred to as “Sleep Time” that is designed

n n be rs a m e ip e r a er ch g b p t c xp lle ng t m age e te uit e w equ tiv lea ss ad a ein eir ’ em en du s e ha lle ke n r ik , e e f b h c a a m re t an f th rec s l ies nce uld roc ir l e o re in t hy uip se en a ch m i ho p e or a ‘ w q e a t i e d f a to o d m pl h rs an ee p ite s er t m we em ng , e th p nt o s s t s su sp ses ev for n s, th si ies m, ur se re ism yee • I ts, de ur n d eve er es res pl he o re mo an plo g v d p t o p n t n ld n h ng e is e u a s a gi d u e t t s n c m pvi um ers tiv ho aff me an is d a s, s at ea ay eve me g e rio tr p ra l s st co m th n nt in hr lw s d in e n s C s p e n e h e b e O R e g a m e e l i m a l t s a m e fi n x i st f p A l o • e h a o to e A io n t s s im in u p c f H r s o r h i A l t k t r to r in Pe er fo t • na rac ins es ery ena be ed n o rou lum le e • p e l, n t – gi v ar is g io g u ro ifi r y R ng ita io tio s c l h n O e p t d i i l l te a e t l e n t a l r i i r e • all os ula ad ion we tra s is tiv al, hal te sm cur the s v ie u r t ch h op e nt b s hi ra it c re a ity p th te jo nd t pe sp g re me ei u nc m re d un g te re eir a as io ho ein a sa th bo te om e a n , s m si ia of h es ip er ty b n e in a pe c w ns m ur rec ct o t tiv sh e p ni are cer th ng arn om n a rs, er n i e c u r i e d n d n h l e c al app sp to ce ar T m we co fo urs ld ir tor ag con r • m n e g fo a l l a s i ew e o s, o in l n ou h ec an o am cia rce ite st rifi a c er tw uit ica sh d t dir m tw ing gic n l R p it r u u sp ic e n ag p r g s cr eso de iot s v r i an to rec sur rse d a ica s O to ru f su ses r b e o u e g A y ec o ur r st t i c i t m y l l f n r he rsi an en irec R • M e a y o e n rai su • • M ll lty n ed a ia ve in s r t v t a on s O t i a e i pe in e d s es a al ti s le mp cal A liv we eci era een As lat live ar pec rat tr • A • y e s e en g ro o gi e p p b • u y ir ir c sur ion bus lik e s rio ve ing pop us e w he iop be ein ula t b k t r s h e a e e b i p a e r e th s a ul ei em e t • P y h l-b ing eir s l de P av ell- po r ng aliut d l e l s h st a l v i i A p th e d lu • h ia e op m y c v i g b o te i • po in t s clu fet th we ur in t ee nc ty ey l w ing n t n e i s at o n l e a p e r n e r a l t h e in a n n i I e a l s s g g s s a p ch s s t a l d a t st i t i e rs rn se n m • in sa les ica ral m It ls saf th sic ur s y n o bs u th is d ar he le he a os n i nu ea re si e g ls g e s • d n e u r t h v i n o o i n u hy n t h g h o i n g l e s p h a l su sho ce ay a es e t uld • T of acr tio ee ld l s p ll me e d n l n s u ay ca ti e es a h ov e p ge s in sc v n er he ye d o iv le sc pr cop nd he ive av g ro e u and en a d n e l a to t l o l u s h r i fi e o r b l e e te to h o l w e a l e g g le in p p l g m n b a e te p n c s m a r e s a th n s o m ar in im os l a t s a e so fe rc ia m ls i se ve n rk f lik es as n tio s rs in nd ta an thi are ur in i sc nt the av er li fo ec ’ e o ur s ve wo ct o ld rs h g i di h n h p n u ss e e n t e s s do e n u a n d k/ rk r y o n ie e p e re an m er im ee see res en ir m ha ls R or wo ap ‘wh sch ve enc es en spe ou e n ren ari e a t y t i d ita • O w R o g s s e i r o l a l l o to o g a n t h e e r g g at et m rd a I w iv a sh th r sp s he O am in in er p co bu ial • at ve ff te pr e th y n p e d s r s s e i o c o a l l t i o e m l i k l p s to o l ho e t e t s r p m e ll c g e t ta ia t om nd Th e re nu rio co s b ca ru nin iop era f s ec p r l t i c d i ’ d t i a ce a l l y i c h y t l i a l d o r c fi e r • ca is ad h u an r tic a f t ad see P hei , th on st tra er iop r o pp th ut o P r e a • t l e o iti tat e ‘w wo st er p cri stic e o t en o b v s i s th g I at al ng rd rs nd to ty d ita th m nd • pe mb m y a e i c a u n e c e p i s e s i n • s u n e t i t at di gi ry b b g ke af a s ke h t et e u a a s at s g e in ur n t all em kin d li s ed ho a n, t en saf Th r n e te ci re in ad ld th is e re dd rain m ou ce ay ns ul s rs i e c r m ac ul ing ain ity o m nio ipm g e • all th a t e sh n d tio f e h e tr o v tr n t i u in rifi sm of s o a t u v s p w v r d n d n d h a n e l b a l e to uc ces ea in ng is • I p en m sm y o , eq ro ve a rs a s n p s o e c ed c r l g ou ion g im be om ni m s t b e e r m n t i t a l r s o l i fe fo r i i a i c l su ei in y t in in se g th har he ten in s ave a ch • In pp in enc due em p e k/ rk m u he in r s T re tra es h in e s os p or o ss t R w , t enc fo aff e • of d gr ey or d m ee s, s re pe ge er O w n g t o d g y • the OR em ri n st rc t an pr th ec fin lo nt ro om lle n t h p e f a o f fo e c t l ss i r o p e p c a o u d he e ex af r rk sp en tia le d t m um al ir ch e y fin • T a t s st e o a m n n a l e d e t r t i h e a in nt e mb e w ial ip sta e u ic ng ew ins an t of Th en • im ie th u h c qu b p rg le n – st nd el pat or r n s t cru , e su co su al of ll ub d a ore rce to ur e f alle ros st lies de dos s a ch nt we e s ne m fo es o g m ac mo pp ma en • A ing me job ad rai ven ork gi o len s e e it u m nt e w te t t al a bl he s ve an ng b ru ir e s ra a h to ka , t s, ha ss ei are ec the av bee me the r b st re c e r n nt t h a u o i o e l s ce l l - e d o s h e o s s nd al ted e d n w pin um ita ro we , w an o d tal av bec ro h t i re n g e o tr sp p l rs s ac s n o e er a e e s sp ey is rd y y es lle u m – in t h ev sic ag oye rce ho th l, th ble a n hy a n l a pr a l b n p o u a t ss i t a r k s ch al I ll th d a -c s • we te ul d p m em res th nle sp wo o f o n e e b c a h o a n O R g e te u h o n e e oy jo di l s al s tin th ica pe y th pl eir in ne nt • A xis ve nd co nit urd i s n e h a s u b em o t ion rso m on f e h ns do m all o to o n m c ir ti d t e i c e e n a t to u p h u l i o t s c n co n s red OR o t op nt an du s a a e o t p e w e n h

w

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January/February 2016 | OR TODAY

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“Practice excellent

hand hygiene and

provide a clean

environment for the patient.”

Wood notes that since the White House issued the National Action Plan for Combating AntibioticResistant bacteria early last year, there has been an increased focus on antimicrobial stewardship in infection prevention.

“Perioperative nurses should learn about their role in antibiotic stewardship, as this is a very real threat to our patients experiencing successful surgical outcomes,” Wood says.

STERILIZATION AND CLEANING OF ENDOSCOPES AND UTENSILS Education and experience are of the utmost importance when it comes to sterilizing and cleaning

INFECTION PREVENTION Fortunately, there is some good news on the infection prevention front. According to the most recently released statistics from the Agency for Healthcare Research and Quality (AHRQ), hospital acquired conditions (HACs), which include health care associated infections (HAIs), fell by 17 percent in 2014.

Due to this decrease in HACs, 87,000 fewer hospital patients died and $19.8 billion in health care costs were saved between 2011 and 2014, the AHRQ estimates.

“Although HACs persist despite incentives and strategies to eliminate them, these reductions indicate that hospitals have made substantial progress in improving safety,” the AHRQ noted when releasing the statistics.

Amber Wood, MSN, RN, CNOR, CIC, Senior Perioperative Practice Specialist with the Association of periOperative Registered Nurses (AORN), says that the best way to reduce HAIs is to follow the manufacturer’s instructions for application of the skin antiseptic.

“Also, practice excellent hand hygiene and provide a clean environment for the patient,” says Wood.

MSN, RN, CNOR, CIC, Senior Perioperative Practice Specialist with the Association of periOperative Registered Nurses (AORN)

Amber Wood,

equipment in the surgical arena that is so foreign to nurses just getting out of school.”

“Even more than in the past, we are searching for candidates who are knowledgeable, adaptable, flexible and professional,” Phillips adds. “I still think compensation may move a candidate, but fit will keep the candidate on your team.”

According to Phillips, UNC Hospitals does Workforce Engagement Surveys every year to determine what staff members want from their jobs.

“Our staff wants to have the resources to do their job well – instruments, supplies, equipment and training,” she says.

“And they want engagement and involvement in their daily work environment,” Phillips adds. “They want to see that fairness is used and for everyone to do their job well, completely and consistently.”

Sharon Morris, Surgical Services Staff Nurse at North Valley Hospital in Kalispell, Montana, says that they are getting a large number of new “green” nurses in the operating room.

“They are not really receiving much training in the area of surgery at their schools of nursing,” she says.

“I would like to see nursing schools include the specialty of surgical nursing in their curriculum,” Morris adds. “There is such a wealth of information in regard to sterile technique, instrumentation, positioning and the ability to operate medical

r s d n n n h a t e tw r re a in o te sc in ng o he er e v p Ou se ess tor he f re ng ole lle R w n t op nat ne i i i ld a i r c t • r e c o ff th ro ire ake ct urs eir ch e O em pe lim ou , p d a h e h n f e h h l T t r t s em ve ica o m asp ee ut ted • es p o to el t s n u s o ne rg s al o en e iv o ie nn d su ism uci e t ab res urd is g l gr teg rso l r k n a s an c li ar p l b th a ra pe A h st ld le ys al e sm st R a c d O ec o u d im e m m wo oul alw the l t m an • l e I a a s s a th • sh has in ion e s ive me sic hal g s y t t i n e a n g d i t h n co h c in urs ren ari ad for ce ut d p ing w e h n in o a e n n s e l g ve ive aff th tin ite ica al a re b of ni at st te ui sp rg nt a t er of cia cr de su e e en ll – ve r re l re ist ul ir m s, w itm we ha b e p p a l r s ss f h e e r c r u b a l s a e e e t g jo it ar p c o a re r p n si a m e C s s u c a l t a n n d h e i o s s s a hy p g w A m a t th e ic g ke h H cin rit OR es do ha roc and sin e o t p l ur c g n s y t s o u r i e t i • A p l o s a te e r n t a l n m e a ce ic ev e ra e e xp th ion em ur nd n m ne th ar ce l a t n g s o s i u l d e i r g e e s e s an pu sti re ion ho th e iv ye i g h e o t po ex th c l s to t is pl • il n e u • le d h e tof ve ed nn ica tha e t em ing in ng on ro e a r t si rce ti ss av ’ r ld en lik uip n- e on h se rso cri er tim hy rain ons a- ive i- ti- - is ur o en re h ei u s to e pe is ld l ‘w t ti r p at rg is rk oy ms eq ce tiv al he at al- l n rkf et d to e se th ho pre l ts , th R at y o na g nd uc ou er su tat wo pl ee s, e in ra gic • T th ch era wo re r ad nts th the ut l s ys ica f m O th all itio sin t a red to iop a s s he em t s lie it pe ur e ce a n e a nd a de , bo ne a ys r o he s • ce tic dd res en e at er As y i s t ng • I upp esp rio l s rifi lan of ge th rns g a ff w clu em n a son alw ph be R e n is a d m es e p • a s ti g s d e fu e a re e ss e in ta in th r er s d m O v t r P h d a om ala sta the ad uip , th th he ing to cro xis vin ts, ist • ess es fe b mo n t cro onc ck r s ls te le p ha an nu As T l b a u o a d R a al r • a e a n s y c i i d q a l e a c r e r t a l c fe y is iate an s, e hem re e • l-b orc ble of e le me pe fe suc en rk/ ven th le o is t • O cho min ou • O ren nt alle on a r b w t a e m ti t y fi l f a n r u s li e h g a o e s i c s f s t e e r e i a r n a g k e r s f od pre kin pl ate ve ve l w or ork ntio es nst AC ng cin p e w es old rk op tio ta ing to es me ive ir m a s ula m t e i o t s c p i a ap tra , su min is a ies sic R w n w ete oye l – h H rov ien co th com lly w y ten ve urs ies urs tco era th to pop i n g n u p o e n l r d is ts eli is nc hy O de e r pl e ug p e eir n be ica e • M re at o o t u ng e e e d f p fi t r i r e e r m l n t w h o l d h r on e to s t et d p Th bu s a em b lth in i ex t to his tis bu ves t o pe se tra tiv ica per ica e rsi a a g u t o c o i s r t l g i l um s a p n • ll n y’ jo A s ts nd g t it tr gie ip, om al a en -ca cer wh eir • es en a in tal, is s cal sy spe er ke nd pe sur he cr llen al n T is a r ‘ h m gr ti ed ry i - u a f p li a io l te s h r c t d n n ra rd ei en ur e o co ing o t ulu ro pa ain in t osp day on ir b ial o ld es Per sfu e • at ch ene a t h m l l b h o ss d i c l p u r t r s h to h e e u c u p o u t i v • e s r i fi t h f a g t ew nd eir ca e tw re to urr tia o en der ity e e t th cr ro I w en ty cc ve ce o he a th e ak op dd es c an to e a un rc ak in st ll g • nc fe su s n re t e a o n r o e i b h ed l to n t o m y t d a urc hei bst eat e ir l m rkf m em mo ma ing te sa ng nci bal m ha a i t M an so t u hr av e om o to th e s in pi ng ci te e n rt tic ing ms s • g re in e s al t y h r th a c R w s es , th me tra es ovi ien pe /lif eve de ar nis ve kin he ing ad re he fo n O ism iv n sa d t d pr er m rk s ol sh ha y li rac e t rs m ry s t nd or i he an is g inio e an sis im xp co wo me lly e r h t r u e h s a ec us s t hav l n av ve nle ff a ect • T ec th op r t en pe s in ts hei he eco tic e t o a h a n m b i r s ir on to ic ls is e u sta di en m im my g f pm Cs res tie d t d s b ti he nti ts urg ita is op he al urd find al t In tin ui HA og pa an fin thi sta i eq r r d o l, is e n s p th c t ic b n • et wa of os as os or urg all to tio es cru s, ugh l p ou ne g t ita y h , f d f s c ed di ye re lie o tia o ai in sp da a f l t y at i p n e a h n t r y l s t c i a t h s h n e n g s t h e e n g a d p l o a l u p p A l t t a a t n t t r h o e to e e rd a lle A in ll he m re s • bs re ee in ity rc u h b s n o s p a t a ss a • ha t e a s, ic ew ce ch ing ing c te w e nt lum e s al t e er u rkf nd st ro d a be ar ing cia f ne e w me cu ad re hav ead mm o w p l i h k tic r te ll- s be re o li ru rr m ry y ir co io ve en we aff re pp nt ms nst cu ve ve the he a OR a e i r ha a s t in e e i n e e s a l st a r d pr sic of we am uitm se ll – the ls s is les fo or Th s y r , te r I t e ta i n d ct • n w i ay h e rs e ec • pi th u n e en w d p mb ge th d r ing job ing os as pe ff a dir rd l a f o an nu n o an av ir rs t h ip, sc sta ica l bu a e u r a s e le m r es l th n h sh do e g al al R be ye are o cal te t ard en th sur e c r d i O m s e l o s o g c a w n fo a t h A r m mp yee s t sur di ste s a e As in in ic es ng • g e e l o ce o f n ng ng mp ur y ns ot oc lle ng ri

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DNP, RN, CNS-CP, CNOR, ACNS, ACNP, FAAN, Director, EvidenceBased Perioperative Practice for AORN

Lisa Spruce,

“Any fabric worn

in the OR should

be tightly woven, low linting,

stain resistant

and durable, no

matter the type

of fabric.”

AORN MAKES CHANGES TO SCRUBS DRESS CODE According to Lisa Spruce, DNP, RN, CNS-CP, CNOR, ACNS, ACNP, FAAN, Director, EvidenceBased Perioperative Practice for AORN, the changes made to the AORN surgical attire recommendations are minimal.

“For example, ‘no fleece’ was removed from the guideline,” she says.

“Any fabric worn in the OR should be tightly woven, low linting, stain resistant and durable, no matter the type of fabric,” Spruce adds. “There are some fleece fabrics that meet this requirement and may be worn as long as they are laundered by a health-accredited laundry facility.”

The other major change, says Spruce, is that when nonscrubbed personnel are in the restricted areas, they should completely cover their arms with a long-sleeved scrub top or jacket.

“So arms should be covered while in the restricted area, while prepping the patient’s skin, and while preparing and packaging items in the clean assembly section of the sterile processing area,” says Spruce. “Previously, the guidelines said that arms had to also be covered in the semirestricted area.”

Also, AORN reinforced the recommendation to not home launder scrubs, Spruce adds.

OVERCOMING OR CHALLENGES Keep these tips and ideas in mind as you and your staff strive to overcome the greatest OR challenges of 2016.

scopes and utensils, says Nancy Chobin, President and CEO of Chobin & Associates Consulting in Lebanon, New Jersey.

“OR personnel should never process an endoscope unless they have been trained and their competencies verified,” says Chobin. “And competencies should be performed annually.”

Chobin has observed that scope processing often gets put aside until “there is time” since the patient must come first.

“However, delays in processing a scope can lead to cleaning issues which can ultimately impact successful high-level disinfection,” she says.

“I usually recommend that the facility limit the number of nurses assigned to scope processing so they do not have lapses in the processing,” Chobin adds. “The nurses should be assigned the responsibility for processing the scopes as their major responsibility that day.”

While regular instruments and utensils are usually processed by sterile processing staff or trained endo technicians, Chobin says most facilities today are using endoscope technicians to reprocess scopes.

“These devices are highly sophisticated and should only be cleaned by staff who continually perform these functions and who have demonstrated competencies for processing each type of endoscope used at the facility,” says Chobin.

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61

Edward McKay, Jr. Surgical Technician, Johns Hopkins Hospital Pediatric OR Photo courtesy Johns Hopkins Medicine

GETTING IN THE DOOR SPOTLIGHT ON EDWARD MCKAY, JR.

By Matthew Skoufalos

You have a better chance of being me than you do of being Ben Carson,” said Edward McKay. “To be a neurosurgeon, you have a better chance of being me than him.”

But when you’re McKay, a surgical technician in the pediatric OR at Johns Hopkins University Hospital, you still get to work alongside Ben Carson for the better part of a decade. McKay considers Carson a mentor, maintains personal connections with him, even from the Presidential campaign trail, and has benefited from his guidance.

SPOTLIGHT ON EDWARD MCKAY, JR.

F

or a teenager who pushed through a childhood that included the realities of the illegal drug trade, gang violence, and family hardships just to make it through high school, McKay considers statistically unlikely to have reached the position he’s achieved in medicine himself. Growing up in the Latrobe projects of East Baltimore, where his family still resides, many of McKay’s friends didn’t finish the ninth grade, let alone earn a professional degree.

“I was the only one from my group that finished school,” he said. “Standing outside on the corner every day, that wasn’t for me. If I didn’t get a job here, I was almost in the streets. This job helped me out a lot.”

At 18, McKay practically willed himself into his foot-in-the-door job at Hopkins, a position in the hospital environmental services department. By 19, he had moved into his own apartment, and was able to support himself comfortably. Then McKay became a father, and the budget became a bit tighter. He wanted to move up at Hopkins, either through his union position or additional schooling. But every time he approached the human resources department, there were opportunities neither for scholarships nor advancement. Then one day, as he was emptying the emergency-room garbage, McKay met a man who changed his life.

“Here at Hopkins, you see a lot of people walking around in suits, and the only time they approach you is when you do something wrong,” he said. “He asked me [whether I’d thought] about school, and I said, ‘I’ve been inquiring about it, but

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OR TODAY | January/February 2016

everybody kept slamming the door in my face.’ ” That man was Kenneth Grant, Vice-President of General Services and Supply Chain Management at Johns Hopkins. Grant recommended McKay for a surgical technician

“I was looking for a way out, and I couldn’t find one, and I kept hearing about how Hopkins would send you to school,” McKay said. “I don’t think I ever really asked [Grant] ‘Why me?’ but it was a blessing.”

The door had been opened for

I never ever thought about going to college because the only people I knew who went to college were people on TV with football and basketball scholarships.”

certificate program the hospital offers in partnership with Baltimore City Community College. Through it, McKay could work part-time at his current position — while simultaneously being a full-time student — and still collect full-time wages. The arrangement kept him from having to choose his education or his career.

McKay, but walking through it was only the beginning. In addition to work and school, he juggled time with his two-year-old daughter.

Without a car, McKay had two long bus trips to school daily for a year-and-a-half. He recollects the certificate program as “one of the hardest things I ever did.”

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“I had to learn the instruments for the OR, sterile technique, book reports, presentations, my daughter, and I had to come to work,” McKay said. “It was pretty stressful. [But] there was no Plan B. There was no going back to housekeeping. I could not pass up this opportunity.”

Compounding the intensity of his experience, McKay’s challenges were alien to both his friends, many of whom had not finished high school, and his coworkers, all of whom had post-secondary education under their belts.

“I never ever thought about going to college because the only people I knew who went to college were people on TV with football and basketball scholarships,” McKay said.

“If you’re lucky to go to high school, you get a job.

I work in an OR where everybody went to a college or a university.”

But through it all, McKay kept his daughter – and the size of his opportunity – at the center of his focus.

“I did not want her to go through anything that I went through at all,” he said. “My mother worked, up to a point, and then drugs distracted her; same thing with my father. I had a great childhood as far as gifts, my mother provided me with everything, but that doesn’t WWW.ORTODAY.COM

mean that the other stuff didn’t happen.”

Nyree McKay is 13 now, embarking on her own high school career, and Carson is on the Presidential campaign trail.

Edward McKay is still working at Hopkins in the operating room, and he’s leveraging the opportunity of his success for all that he can. His remarkable rise was chronicled in an in-house documentary series on employee diversity at Hopkins, and McKay has taken that well-deserved notoriety and channeled it into outreach to other children from East Baltimore as well as in advocating for surgical technicians in general.

“All you hear about are nurses and doctors, but the surgical tech plays a prominent role in the operating room,” McKay said. “A lot of us feel underappreciated at times because we feel like we don’t get our just due for what we do. I work side by side with the surgeon. If blood gets on him, it gets on me. I’m right there at the field.”

McKay’s biographical video has been viewed more than 12,000 times on YouTube (https://youtu. be/J-Bi3F9Nj20), and has become part of the Hopkins orientation process. He’s gotten correspondence from people in Ghana, Colombia, Australia, Germany,

I’m happy, but I’m not satisfied. I want to take it further. They let me in the door with that video, now I’ve got to kick down the door and take it one step further.”

England, who tell him how inspirational they’ve found his story. All the while, McKay has gone on to assist surgeons like Alfredo Quinones-Hinojosa and George Jallo – and still he views it as only an entry point to the next,

bigger thing.

“I’m happy but I’m not satisfied,” McKay said. “I want to take it further.”

“They let me in the door with that video,” he said.

“Now, I’ve got to kick down the door and take it one step further.”

January/February 2016 | OR TODAY

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OUT OF THE OR HEALTH

BY MATTHEW KADEY, M.S., R.D. ENVIRONMENTAL NUTRITION NEWSLETTER

TOP FOODS TO BOOST SATIETY

O

ne of the biggest challenges to maintaining a healthy weight is fending off the hunger pangs that can spiral into cookie jar raids. Luckily, staying trim might be as simple as stuffing your grocery cart with more of the foods that can keep you feeling full.

Such satiety-boosting foods are rich in fiber, protein and healthy fats, according to Alissa Rumsey, R.D., spokesperson for the Academy of Nutrition and Dietetics. She says, “These components are digested slower in our bodies, so we feel full for longer.”

Such foods also prevent a blood sugar spike and subsequent crash, which can cause feelings of hunger shortly after eating. On the flipside, heavily processed foods, such as sugary boxed cereals and doughy white bread, deliver little in the way of satiety power, which can lead to the hunger pangs that precede overeating.

So, here are our top food picks to keep your hand out of the cookie jar.

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OR TODAY | January/February 2016

1

Oatmeal If you have visions of doughnuts dancing in your head come high noon, perhaps you should wake up to a bowl of oatmeal. According to 2015 research in the Annals of Nutrition & Metabolism, subjects who kick-started their day with oatmeal reported feeling less hunger and ate 31 percent fewer calories at lunch than those who ate the same number of calories in the form of a processed cereal. The satiety power of oatmeal is likely due to its high levels of soluble fiber, which essentially forms a gel in your stomach to slow down digestion and keep you feeling full for a longer period.

2

Eggs More proof that we shouldn’t be chicken to eat eggs: A 2015 American Journal of Clinical Nutrition investigation found that people who ate two eggs for breakfast during a three-month study period reported less hunger and increased satiety post-breakfast

than those who consumed an egg-free meal. Importantly, the high egg diet had no detrimental impact on blood cholesterol numbers. Eggs provide lots of protein for relatively few calories, and a high-protein breakfast can reduce levels of circulating ghrelin, an appetitestoking hormone. Still, if you are at risk for heart disease eggs are best consumed in moderation. And to save on calories, opt for hard-boiled or poached eggs instead of fried.

3

Almonds A 2013 European Journal of Clinical Nutrition study discovered that people who snacked on 1 1/2 ounces of almonds experienced less hunger and desire to eat throughout the day. They also did not gain weight, despite the calories almonds provide, which suggests that by increasing satiety the nuts worked to reduce people’s calorie intake during their other snacks and meals. Other nuts like pecans, hazelnuts and walnuts may bring about the same benefit.

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HEALTH

4

Beans It should go without saying that a diet geared towards quashing hunger and overeating should include a daily dose of legumes – among them, beans, lentils and peas. A 2014 review of studies by researchers at the University of Toronto confirms that beans and their like can bolster satiety by up to 31 percent. So try a veggie-laced bean salad to take advantage of the legumes’ fiber and protein hungerfighting effect. In fact, research shows that plant-based protein can be just as effective at bolstering satiety and promoting weight loss as animalbased protein.

5

Rye bread When it comes to sandwiches, take a cue from the Scandinavians and make your hand-held meal with rye bread.

That’s because studies show that hearty rye bread does a better job at encouraging satiety and reducing post-meal insulin levels compared to standard supermarket loaves.

Structural differences and extra fiber (a slice of pure rye bread can have up to 5 grams) make rye a more satisfying option.

6

Greek Yogurt A 2014 study published in Nutrition Journal found that volunteers who consumed a high protein yogurt snack in the afternoon experienced greater reductions in afternoon hunger and consumed fewer calories at dinner than those who snacked on chocolate or crackers. The lofty amounts of casein protein in WWW.ORTODAY.COM

Greek yogurt can help slow digestion, which leads to prolonged feelings of fullness. Kefir and the up-and-coming Icelandic yogurt called skyr are other protein-rich fermented dairy options, but opt for plain versions to side-step added sugars.

7

Avocado Including this creamy delight in your meals (think slices on salads, tacos, and soups) may keep you out of the tub of Chunky Monkey later on. Scientists at Loma Linda University, California, found that including about one-half of an avocado with a meal can reduce the desire to eat by up to 40 percent – avocado’s high amount of hearthealthy monounsaturated fat works to temper hunger pangs.

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8

Salmon Go fish for your protein fix.

Research suggests that including at least 25 grams of protein with meals can have a positive impact on appetite and weight loss. A 4-ounce portion of salmon will help you nail this quota and give you a healthy dose of heart-healthy omega-3 fats, to boot.

Sablefish, mussels, Pacific halibut, catfish and mackerel are other swimmers that provide high amounts of protein.

Reprinted with permission from Environmental Nutrition, a monthly publication of Belvoir Media Group, LLC. 800-8295384. www.EnvironmentalNutrition.com.

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For more information, visit www.environmentalnutrition.com January/February 2016 | OR TODAY

69

OUT OF THE OR FITNESS

BY MARILYNN PRESTON

AGING IS AN ADVENTURE

A

ging isn’t just for old people. It’s something we all do, whether we like it or not. And many of us, witnessing our muddled brain, sagging skin, the dreaded chin whiskers, just don’t like it.

That’s because most people don’t see it the way Frank Lloyd Wright did.

“The longer I live,” this worldfamous architect informed us, “the more beautiful life becomes.”

More mysterious, too.

“The secret to staying young,” Lucille Ball once revealed, “is to live honestly, eat slowly and lie about your age.”

MY NINE RULES There must be 10 gazillion books on the subject of healthy aging. It’s a multibillion dollar industry that’ll never die, even though every one of us will. That’s why it’s a compelling subject for all ages, Instead of an overview, I’m going out on a limb to offer a point-of-view, 70

OR TODAY | January/February 2016

my current Nine Rules – ideas? theories? self-delusions? – for Healthy Aging based on a lifetime of reading, writing, learning, exploring and, oh, yeah, growing older.

Each rule could be a day’s discussion or an 8-week online course. Forget that. The clock is ticking, space is limited, and I want to keep it simple. In fact, keeping it simple is the 10th rule.

The order is random, much like life. No. 1 is not more important than number nine, unless it is to you:

1

EXPECT SUCCESS Aging is not a disease. It’s part of the natural flow of life. So embrace the positives about aging – wisdom and freedom are two biggies – and let go of the negative. People with positive perceptions of aging live seven years longer than people with negative perceptions. (Fact!)

Not just longer, but happier, more meaningful lives!

2

EXERCISE MIND & BODY This is the key. Stick it in your door. To age gracefully, stay

active. It’s a must. Move it or it disappears. Walk, bike, swim, whatever you like. Strength train, too. If you decide to run with only one of my so-called rules, make it this one.

3

NOURISH YOUR BODY. To age well, you have to eat well. That means real food, clean food, yummy food in amounts that don’t make you sick or obese.

The drama of dieting is over the day you give up processed foods, fake foods, high-in-sugar foods and let the healthiest part of you prepare and eat food that nourishes your body in a way that hot dogs and Pop-Tarts never will.

4

ACCEPT WHAT IS. Strive to accept your life as it unfolds, without being angry or bitter, or feeling victimized. At the same time, fight hard to live the best, most balanced life possible.

Don’t dwell in the past or obsess about the future. Live in the moment, and love the kind, compassionate person you are.

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FITNESS

5

RELY ON YOURSELF Self-care is the best care. Seek the finest medical care, but beware of over treatment.

Be smart about early detection and prevention, but avoid too much scrutiny. “What is a well person?” a doctor once asked his students. “A well person is a patient who hasn’t been completely worked up.”

6

VENT IN HEALTHY WAYS Difficult things happen as you age. Sickness, pain, loss. You can’t avoid the stress but you can, you must, learn to deal with it in healthy ways. Yoga, qi gong, meditation, exist for that purpose.

7

TAKE RISKS If you want to feel vital, fully alive as you age, keep taking risks. Keep challenging yourself. Keep testing your limits. “Go out on a limb,” Jimmy Carter said. “That’s where the fruit is.” When was the last time you went out on a limb?

8

DO UNTO OTHERS The older and crankier you get, the more kindness and forgiveness have to come into play. Helping others adds more meaning and purpose to life. Love and be loved, and you will live longer and die more gracefully.

9

UNDERSTAND DEATH AND DYING We all die. It’s not if, it’s when. So delve into it with humor, curiosity and spirit. And find a community that supports your choices and beliefs.

Now take the first letter for each rule — E-E-N-AR-V-T-D-U — and spell out a word we both embrace. Life’s a great game, and ultimately, like aging, you have to unscramble it for yourself.

MARILYNN PRESTON is the creator of Energy Express, the longest-running syndicated fitness column in the country. She has a website, marilynnpreston.com, and welcomes reader questions, which can be sent to MyEnergyExpress@aol.com.

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January/February 2016 | OR TODAY

71

OUT OF THE OR NUTRITION

BY LINDSAY WESTLEY EATINGWELL.COM

WHAT DOES A DAY OF HEALTHY, GLUTEN-FREE EATING LOOK LIKE?

E

ven if you don’t avoid gluten, a protein found in wheat, rye and barley, chances are you know someone who does. One in 141 people is affected by celiac disease, an autoimmune reaction to gluten.

For people with celiac disease, eating foods containing it can cause their immune systems to damage the lining of the small intestine, which can lead to nutritional deficiencies. If you’re following a gluten-free diet – or cooking for someone who is – use this guide as inspiration for a healthy gluten-free day.

BREAKFAST On the go: Blend up a smoothie. The whole fruits contribute fiber and vitamin C; the nonfat yogurt delivers a satisfying combo of carbs and protein.

Puree 1 cup nonfat vanilla yogurt with 1/4 cup fruit juice until smooth.

Push 1 1/2 cups frozen fruit, such as blueberries, raspberries, pineapple or peaches through the hole in the lid of the blender and puree until smooth.

355 calories; 14 g protein; 6 g fiber.

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OR TODAY | January/February 2016

At home: Cook up some gluten-free grains. Go for certified gluten-free oats (some brands of oatmeal can be cross-contaminated with trace amounts of gluten-containing whole grains), or make a batch of apple-cinnamon breakfast quinoa instead.

Quinoa provides about twice the fiber, which may help you feel fuller longer.

LUNCH To Go: Pack up grains to go. Hearty (gluten-free) grains-based salads can be prepped and dressed in the morning without wilting by lunchtime.

Make a large batch of quinoa or brown rice on Sunday and customize it all week long by adding a variety of fresh, in-season veggies and tossing with a gluten-free dressing. Aim to try some new-to-you-grains also, such as millet, teff, buckwheat or amaranth.

At home: Eat in season. Top a green salad with fresh, seasonal ingredients.

Add a source of lean protein, such as chicken, beans or seafood, and toss with a gluten-free dressing.

Afternoon snack: Fruit is a great to-go snack, as it often has its own convenient (and natural) packaging.

Or try making your own granola bars with gluten-free oats or packing a handful of nuts and dried fruit.

DINNER Eating out: Dinner can be one of the easiest meals to eat out, since most menus offer veggie or lean protein-based options that go beyond pasta dishes. But hidden sources of gluten can lurk in surprising places, so don’t forget to ask questions about food prep. Will the chef use flour or soy sauce in the dressing or sauces? Does the restaurant have a dedicated prep area for gluten-free foods? It’s always a good idea to call ahead to ask.

At home: Start with the vegetables.

Try this trick: Fill your cart like you should fill your plate, with lots of fruits and veggies, sources of lean protein (e.g., poultry, lean beef, tofu), low-fat dairy and whole, gluten-free grains and starches. Plan your meal using the same hierarchy: vegetables first, supplemented by lean proteins, dairy products and starches.

EatingWell is a magazine and website devoted to healthy eating as a way of life. Online at www.eatingwell.com.

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73

OUT OF THE OR RECIPE

74

OR TODAY | January/February 2016

BY EATINGWELL

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RECIPE

‘SPAGHETTI’ WITHOUT THE CARBS In this low-carb spaghetti squash lasagna recipe, garlicky broccolini, spaghetti squash and cheese are combined for a healthy take on a favorite casserole. This bakes right in the squash shells for a fun presentation. Serve with a big Caesar salad and some warm and crusty whole-grain bread.

SPAGHETTI SQUASH LASAGNA WITH BROCCOLINI Serves 4 Active Time: 30 minutes Total Time: 40 minutes

INGREDIENTS: • 1 2 1/2- to 3-pound spaghetti squash, halved lengthwise and seeded • 1 tablespoon extra-virgin olive oil • 1 bunch broccolini, chopped • 4 cloves garlic, minced • 1/4 teaspoon crushed red pepper (optional) • 2 tablespoons water • 1 cup shredded part-skim mozzarella cheese, divided • 1/4 cup shredded Parmesan cheese, divided • 3/4 teaspoon Italian seasoning • 1/2 teaspoon salt • 1/4 teaspoon ground pepper

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METHOD:

1

Position racks in upper and lower thirds of oven; preheat to 450 F.

4

Use a fork to scrape the squash from the shells into the bowl.

Place the shells in a broiler-safe baking pan or on a baking sheet.

Stir 3/4 cup mozzarella, 2 tablespoons Parmesan, Italian seasoning, salt and pepper into the squash mixture. Divide it between the shells; top with the remaining 1/4 cup mozzarella and 2 tablespoons Parmesan.

2

Place squash cut-side down in a microwave-safe dish; add 2 tablespoons water. Microwave, uncovered, on High until the flesh is tender, about 10 minutes.

(Alternatively, place squash halves cut-side down on a rimmed baking sheet. Bake in a 400 F oven until the squash is tender, 40 to 50 minutes.)

3

Meanwhile, heat oil in a large skillet over medium heat. Add broccolini, garlic and red pepper (if using); cook, stirring frequently, for 2 minutes. Add water and cook, stirring, until the broccolini is tender, 3 to 5 minutes more. Transfer to a large bowl.

5

Bake on the lower rack for 10 minutes. Move to the upper rack, turn the broiler to high and broil, watching carefully, until the cheese starts to brown, about 2 minutes.

RECIPE NUTRITION: Per serving: 194 calories; 11 g fat (5 g sat, 5 g mono); 20 mg cholesterol; 13 g carbohydrate; 0 g added sugars; 4 g total sugars; 12 g protein; 2 g fiber; 587 mg sodium; 334 mg potassium.

EatingWell is a magazine and website devoted to healthy eating as a way of life. Online at www.eatingwell.com.

January/February 2016 | OR TODAY

75

OUT OF THE OR PINBOARD

PINBOARD

The News and Photos That Caught Our Eye This Month

OR TODAY

CONTESTS • JANUARY/FEBRUARY •

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WHAT ARE YOU READING? Send us a photo of yourself or a colleague reading a copy of OR Today magazine to be entered in a contest to win a $50 pizza gift card!

Snap a photo with your phone and email it to Editor@MDPublishing.com to enter. It’s that easy! Good luck! •

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• OCTOBER, NOVEMBER & DECEMBER •

October Winner!

November Winner!

December Winner!

We love our contests and are excited to announce winners from the past three issues of the magazine. Julie Gottlieb is the winner of the December contest thanks to her resolution for 2016 to take more time off for vacations. Becky Gentry said she is thankful for her “crazy, hardworking and friendly coworkers” to win the November contest. Wanda AlexanderKehoe shared a spooky full moon story to win the October contest.

“If we could change ourselves, the tendencies in the world would also change. As a man changes his own nature, so does the attitude of the world change towards him. ... We need not wait to see what others do.” – Mahatma Gandhi WWW.ORTODAY.COM

January/February 2016 | OR TODAY

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INDEX ALPHABETICAL AAAHC ……………………………………………………16 Action Products, Inc. …………………………… 21 AIV Inc. ……………………………………………………41 ASCA …………………………………………………… 50 Bulb Direct …………………………………………… 40 C Change Surgical ………………………………IBC Cincinnati Sub-Zero ………………………………16 Clorox Professional Products ………………10 D.A. Surgical …………………………………… 52-54 Dabir Surfaces……………………………………… 40 David Scott Company …………………………41 Doctors Depot ………………………………………61

Encompass Group, LLC ……………………… 50 Enthermics Medical Systems, Inc. …… 22 Flagship Surgical …………………………………… 9 GelPro …………………………………………………… 27 Gopher Medical ……………………………………… 71 Healthmark Industries………………………… 32 Innovative Medical Products, Inc ……………BC Interpower Corporation ……………………… 5 Jet Medical Electronics ………………………… 12 KAPP Surgical Instrument …………………… 51 MAC Medical ………………………………………… 73 MD Technologies …………………………… 28-29

MedWrench ………………………………………… 73 Pacific Medical LLC ……………………………… 6 Palmero Health Care …………………………… 51 Paragon Service …………………………………… 13 Ruhof Corporation ……………………………… 2-3 Sealed Air ……………………………………………… 17 SMD Waynne Corp. …………………………… 50 Surgical Power …………………………………… 40 TBJ, Inc. …………………………………………………… 4 VBM ……………………………………………………… 67

INDEX CATEGORICAL ACCREDITATION AAAHC ……………………………………………………… 16 ANESTHESIA David Scott Company …………………………… 41 Doctors Depot ………………………………………… 61 Gopher Medical ……………………………………………71 Paragon Service ……………………………………… 13 APPAREL Healthmark Industries……………………………… 32 ASSOCIATIONS AAAHC ……………………………………………………… 16 ASCA ………………………………………………………… 50 BEDS Innovative Medical Products, Inc ………… BC CARDIOLOGY C Change Surgical ………………………………… IBC Gopher Medical ……………………………………………71 CARTS/CABINETS David Scott Company …………………………… 41 Encompass Group, LLC …………………………… 50 CLEANING SUPPLIES Ruhof Corporation ……………………………………2-3 CLAMPS Innovative Medical Products, Inc ………… BC DISINFECTANTS Clorox Professional Products ………………… 10 Palmero Health Care ……………………………… 51 Sealed Air ……………………………………………………17 DISPOSABLES Pacific Medical LLC …………………………………… 6 ENDOSCOPY Bulb Direct ………………………………………………… 40 Clorox Professional Products ………………… 10 MD Technologies ………………………………… 28-29 Ruhof Corporation ……………………………………2-3 TBJ, Inc. ………………………………………………………… 4 FALL PREVENTION Encompass Group, LLC …………………………… 50 GEL PADS GelPro ………………………………………………………… 27 Innovative Medical Products, Inc ………… BC GENERAL AIV Inc. ……………………………………………………… 41 78

OR TODAY | January/February 2016

GelPro ………………………………………………………… 27 MedWrench ……………………………………………… 73 Surgical Power ………………………………………… 40 HAND/ARM POSITIONERS Innovative Medical Products, Inc ………… BC HIP SYSTEMS Innovative Medical Products, Inc ………… BC INFECTION CONTROL/PREVENTION Clorox Professional Products ………………… 10 Encompass Group, LLC …………………………… 50 Palmero Health Care ……………………………… 51 Ruhof Corporation ……………………………………2-3 Sealed Air ……………………………………………………17 INTERNET RESOURCES MedWrench ……………………………………………… 73

POSITIONERS/IMMOBILIZERS Action Products, Inc. …………………………………21 D.A. Surgical ………………………………………… 52-54 David Scott Company …………………………… 41 Innovative Medical KAPP Surgical Instrument ……………………… 51 Products, Inc ……………………………………………… BC POWER COMPONETS Interpower Corporation …………………………… 5 REPAIR SERVICES Bulb Direct ………………………………………………… 40 Pacific Medical LLC …………………………………… 6 SHOULDER RECONSTRUCTION Innovative Medical Products, Inc ………… BC

INSTRUMENT TRACKING

SIDE RAIL SOCKETS Innovative Medical Products, Inc ………… BC

INSTRUMENT TRANSPORT MAC Medical ……………………………………………… 73

SOCIAL MEDIA MedWrench ……………………………………………… 73

KNEE SYSTEMS Innovative Medical Products, Inc ………… BC

STERILIZATION TBJ, Inc. ………………………………………………………… 4

LABORATORY TBJ, Inc. ………………………………………………………… 4

SURGICAL AAAHC ……………………………………………………… 16 Bulb Direct ………………………………………………… 40 KAPP Surgical Instrument ……………………… 51 MD Technologies ………………………………… 28-29 Surgical Power ………………………………………… 40 VBM …………………………………………………………… 67

LEG POSITIONERS Innovative Medical Products, Inc ………… BC MONITORS Doctors Depot ………………………………………… 61 Jet Medical Electronics ………………………………12 OR TABLES/ ACCESSORIES Action Products, Inc. …………………………………21 D.A. Surgical ………………………………………… 52-54 Dabir Surfaces…………………………………………… 40 Innovative Medical Products, Inc ………… BC ORTHOPEDIC Surgical Power ………………………………………… 40

SURGICAL SUPPLIES Cincinnati Sub-Zero ………………………………… 16 David Scott Company …………………………… 41 KAPP Surgical Instrument ……………………… 51 Ruhof Corporation ……………………………………2-3 VBM …………………………………………………………… 67 SUPPORTS Innovative Medical Products, Inc ………… BC TEMPERATURE MANAGEMENT C Change Surgical ………………………………… IBC Cincinnati Sub-Zero ………………………………… 16

OTHER Action Products, Inc. …………………………………21 AIV Inc. ……………………………………………………… 41 Encompass Group, LLC …………………………… 50 SMD Waynne Corp. ………………………………… 50 TBJ, Inc. ………………………………………………………… 4

WARMERS Encompass Group, LLC …………………………… 50 Enthermics Medical Systems, Inc. ………… 22

PATIENT MONITORING Gopher Medical ……………………………………………71 Pacific Medical LLC …………………………………… 6

WASTE MANAGEMENT Flagship Surgical ………………………………………… 9 Sealed Air ……………………………………………………17 WWW.ORTODAY.COM

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