OR Today - June 2017

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SPOTLIGHT ON

OR TODAY LIVE

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TAKE GOOD CARE NURSES • SURGICAL TECHS • NURSE MANAGERS

PREVIEW PAGE 40

JUNE 2017

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CONTENTS

features

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OR TODAY | June 2017

AdvanceD 40 Surgical technology OR TODAY LIVE!

OR Today magazine once again comes to life with the third annual OR Today Live Surgical Conference. The conference is scheduled for August 27-29 at the Hyatt Regency Reston in the Washington, D.C. area. Find out more inside.

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ADVANCED SURGICAL TECHNOLOGY Advancing technology has become a fact of life in every aspects of our lives, including in the operating room. A wide range of new technologies are changing the way that surgeries are performed while improving patient safety and outcomes. New technology and advances are also reducing health care costs.

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SPOTLIGHT ON: LORI McLEER MALONEY Lori McLeer Maloney became a nurse because her career as an economist was unfulfilling. Now, the mother of three participates in clinical evaluations, a primary care rotation, and service in a long-term care facility as part of a nurse practitioner program,

OR Today (Vol. 17, Issue #5) June 2017 is published monthly by MD Publishing, 18 Eastbrook Bend, Peachtree City, GA 302691530. 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. Š 2017

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CONTENTS

departments

PUBLISHER

John M. Krieg | john@mdpublishing.com

VICE PRESIDENT

Kristin Leavoy | kristin@mdpublishing.com

56 11

EDITOR

John Wallace | jwallace@mdpublishing.com

ART DEPARTMENT Jonathan Riley Jessica Laurain Kara Pelley

ACCOUNT EXECUTIVES

Warren Kaufman | warren@mdpublishing.com Jayme McKelvey | jayme@mdpublishing.com

26

ACCOUNTING

60

Kim Callahan

WEB SERVICES

INDUSTRY INSIGHTS 11 News & Notes 18 AAAHC Update 20 ASCA Update

Taylor Martin Cindy Galindo Adam Pickney

CIRCULATION Lisa Cover Laura Mullen

IN THE OR

22 Suite Talk 25 Market Analysis 26 Product Showroom 32 CE Article

OUT OF THE OR 54 Fitness 56 Health 58 Nutrition 60 Recipe 64 Pinboard

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66 Index

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INDUSTRY INSIGHTS NEWS & NOTES

STAFF REPORT

Dynarex Introduces Disposable Products Dynarex has announced several new disposable medical products to help provide higher quality and more efficient patient care delivery. New products include surgical sutures, IV administration sets, catheter dressings and syringes.

Dynarex Surgical Sutures are available in various thread thicknesses and needle dimensions to accommodate numerous procedures.

Dynarex IV Administration Sets and IV Extension Sets are available in various lengths and dimensions to accommodate various applications. The IV Administration Sets are available in nine lengths. The IV Extension Sets are available in lengths of six, seven or eight inches.

For use with Dynarex IV Ad-

ministration Sets to help create needle-free sites, the Dynarex Needleless PRN Connector is a needleless male adaptor, which does not contain DEHP and is made from medical grade PVC. It is sterile, non-toxic and non-pyrogenic and is individually packaged.

The Dynarex IV Catheter Dressing offers the ability to write on its foam border to mark the dates of dressing changes, is sterile and made for single use. With a low profile, it is comfortable and waterproof to allow patients to shower.

Dynarex’s line of syringes includes safety insulin syringes, safety syringes, dialysis safety syringes, non-safety syringes, nonsafety insulin syringes, syringes

without needle, hypodermic needles, pen needles and blood collection tube holders. This complete line of syringes includes 95 product specifications. •

Tetra Medical Supply Corp. Introduces Tetra-Flex Clip Free Woven Elastic Bandage Tetra Medical Supply Corp., a provider of general wound care products, orthopedic soft goods, and hot/ cold therapy, has announced the launch of its new Tetra-Flex CF (Clip Free) woven elastic bandage. The Tetra-Flex CF has taken the company’s highest quality, heavy-duty woven bandage to the next level with a new self-closure system.

“For over 100 years Tetra Medical Supply Corp. has been a leader, bringing premium quality, cost-effective bandage solutions to the health care industry,” stated Constance Shier, Chairman of the Board and Chief Financial Officer at Tetra Medical Supply Corp.

The new Tetra-Flex CF is made of a premium weave of spandex and selected long staple cotton. The bandage offers a re-engineered self-closure system, making it quick and easy for clinicians and patients to use. Hospitals, orthopedic surgeons/clinics, head athletic trainers, sports medicine doctors, and vein clinics often consider this bandage’s compression characteristics and durability critical to post-op procedures or treatment. Its design eliminates the need for tape or clips to keep it secure and in place, allowing it to be re-adjusted easily. Furthermore, this new latex- free WWW.ORTODAY.COM

offering is available in sterile and non-sterile options, and in a variety of lengths and widths. The 5.5 yards (stretched length) option is available in four standard widths (2-inch, 3-inch, 4-inch and 6-inch) while the 11 yards (stretched length) version comes in 4-inch and 6-inch widths. • June 2017 | OR TODAY

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INDUSTRY INSIGHTS NEWS & NOTES

Steriliz R-D Rapid Disinfector Outperforms in Study A new independent study demonstrates that the Steriliz R-D Rapid Disinfector is a proven ultraviolet-C (UV-C) disinfection solution for combating pathogens that cause healthcare-associated infections (HAIs).

Published in the March issue of the American Journal of Infection Control, the peer-reviewed study of UV-C disinfection systems detailed the pilot testing and experiences of Vancouver General Hospital and Rochester General Hospital. According to the study, the hospitals selected the R-D Rapid Disinfector because of its shortest average treatment time, dose-based

monitoring, metrics-driven data tracking, pause and reposition capability to illuminate shadowed areas, and easy maneuverability.

Steriliz’s R-D Disinfector is the only UV-C system available that measures, records and reports data for hospitals to gauge effectiveness. The R-D uses patented remote sensors that measure and ensure delivery of published UV-C doses at all points of disinfection. The R-D works in conjunction with manual cleaning to eradicate bacteria, viruses and spores, such as MRSA, VRE and Clostridium difficile. •

AAAHC Announces Award Winners AAAHC recognized the University of Utah Student Health Center and the PAMF Surgery Center Fremont as winners of its annual quality improvement award.

This award recognizes AAAHC-accredited organizations for exemplary quality improvement studies in areas of primary care and surgical/procedural care.

The award – named for Bernard A. Kershner, a leader in ambulatory health care and distinguished past Chair of the AAAHC Institute Board of Trustees – was presented to representatives from the winning organizations at the 2017 Achieving Accreditation conference in Tampa, Florida.

AAAHC-accredited organizations were invited to submit detailed descriptions of completed quality improvement studies, and three finalists in each category were identified from the submissions.

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OR TODAY | June 2017

In the primary care category, the University of Utah Student Health Center implemented a comprehensive improvement study to increase human papillomavirus (HPV) vaccination rates among male college students through the use of electronic medical record (EMR) alerts. The surgical/procedural care winner, PAMF Surgery Center Fremont, conducted an improvement study to increase operating room turnover efficiency and shorten turnover times.

“The Kershner Awards showcase innovative quality improvement studies that have achieved measurable advancement to meet or exceed a defined goal,” said Naomi Kuznets, Ph.D., vice president and senior director for AAAHC Institute. “The AAAHC Institute takes great pride in recognizing this year’s winners for their creativity and collaborative approaches to QI.” •

WWW.ORTODAY.COM

NEWS & NOTES

Mirragen Advanced Wound Matrix Gains FDA Clearance ETS Wound Care LLC has announced that Mirragen Advanced Wound Matrix was cleared by the United States Food and Drug Administration (FDA) for treatment of acute and chronic wounds. Mirragen is a fully resorbable borate glass matrix comprised of fibers and beads proven to be highly effective in wound care management.

Mirragen is packed into wounds to manage and control wound fluids, while the resorbable matrix provides an environment for optimal wound healing.

“Anyone who is treating or experiencing discomfort from acute or chronic wounds will immediately recognize the benefits of Mirragen,” said Peggy Earl, BSN, RN, WOCN, a wound care specialist at Phelps County Regional Medical Center in Rolla, Missouri. “Mirragen has the potential to reduce the required number of episodes and duration of wound care treatment, while allowing the body to effectively heal a variety of wounds, both acute and chronic.”

ETS Wound Care plans to make Mirragen commercially available via a controlled domestic market release in early Q2 2017 and available to the broader domestic market in 2018. •

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13

INDUSTRY INSIGHTS NEWS & NOTES

Stryker Releases SurgiCount Tablet Stryker has announced the release of the SurgiCount Tablet, a new touch-screen interface for its revolutionary SurgiCount Safety-Sponge System, which supports the fight against retained surgical sponges and promotes patient safety.

“We’ve taken our SurgiCount Safety-Sponge System to the next level with the SurgiCount Tablet,” said Nate Miersma, director of surgical safety at Stryker. “The new interface offers expanded capabilities that make it even easier to keep track of each individual sponge or towel used in a surgery and dramatically reduce the risk of a retained sponge.”

The SurgiCount Safety-Sponge System utilizes uniquely identified sponges and towels to provide a precise, real-time count so the surgical team can close a procedure – and a patient – with confidence.

The hospital’s SurgiCount 360 software maintains a record of the SurgiCount-verified correct count so that surgeons, nurses and hospital administrators have a permanent record of the verified count.

The new SurgiCount Tablet features a large, 10-inch display and interactive touch screen with more menu options, including wound-pack reconciliation. Pole or wall-mount options enable hands-free operation, and a slip-in battery slot allows for continuous operation without shutting down.

The SurgiCount Tablet also features new Wi-Fi capability with real-time, fully encrypted data transfer to a secure cloud-based server that offers integration with SurgiCount 360 software and an administrator portal for password-protected VPN access from any onsite or remote computer. •

Study: Surfacide UV-C Light Effective in Pediatric Burn Hospital A recent study at Shriners Hospitals for ChildrenCincinnati, one of only four freestanding hospitals in the country dedicated to the treatment of pediatric burns and specializing in plastic and reconstructive surgery, concluded that the Surfacide Helios UV-C Disinfection System is “… an effective and integral component in reducing bacterial pathogens not killed by the EVS (manual) cleaning process alone.”

The findings were published at the American Burn Association’s 49th Annual Meeting in Boston earlier this year. The authors discussed their findings from 234 cultures obtained from rooms and noted a 37 percent organism reduction from terminal cleaning alone.

When the Surfacide UV-C Disinfection System was used in addition to the EVS terminal cleaning process, the authors reported a “total elimination of pathogens.”

“Surfacide’s Helios system incorporates three UV-C energy emitting towers in the patient environment to eradicate drug-resistant organisms, including superbugs such as C. Diff, MRSA, VRE, CRE and Acinetobacter,” said Gunner Lyslo, founder and CEO of Surfacide LLC. “The system has been shown in studies to significantly reduce the risk of HAIs and lower hospital infection rates.”

The 10- to 20-minute Surfacide disinfection cycle is performed in an unoccupied room, after an environmental services cleaning professional has manual14

OR TODAY | June 2017

ly cleaned the area and wiped down surfaces. Treating the room with UV-C energy is an evidence-based disinfection modality disinfecting areas that were not completely cleaned manually.

Other systems use a single tower. Surfacide’s multiple emitter approach disinfects an entire room in just one cycle, including the bathroom and other hard-toreach areas more quickly and effectively. The Helios emitters are positioned closer to hard surfaces, thereby reducing UV-C disinfection time and improving overall efficacy.

Health care providers are turning to UV-C technology as a complement to traditional cleaning methods to combat healthcare-associated infections (HAIs). UV-C energy (at 254nm) is the peak germ-killing part of the ultraviolet spectrum. • WWW.ORTODAY.COM

NEWS & NOTES

IMP Offers Gel-Infused Memory Foam Pads Innovative Medical Products’ new Gel-Infused Memory Foam Pads are infused with proprietary formulated gel beads that provide 30 percent greater load distribution than standard memory foam pads, as demonstrated by independent pressure mapping tests. This greater load distribution reduces the possibility of pressure ulcers.

IMP’s Gel-Infused Memory Pads also provide for patient protection during surgical procedures, including robotic surgery.

The new, larger pads are specially designed to accommodate most any size patient, meeting dimensional and density specifications for patient safety.

“As patients get bigger and bigger and actually begin to ‘spill over’ the edges of the boot and tradition-

ally sized positioning pads,” noted Earl Cole, IMP vice president.

“There comes a point where a standard memory foam pad will no longer be able to provide sufficient patient protection. Our gel-infused, larger pads are made to prevent just this from happening.”

IMP Gel-Infused Memory Pads come in a variety of shapes and sizes tailored to fit specific IMP patient positioning systems.

These include the Sterile Gel Foam Boot Pads designed for use with IMP’s entire family of De Mayo Knee Positioners, the Sterile Gel-Infused Memory Foam Universal Distractor Pads that cover the entire edge of the boot, and the Gel-Infused Memory Foam Pad for IMP’s MorphBoard Positioning System. •

Xenex Announces 2-Minute Run-Time with LightStrike Operating rooms are supposed to be sterile environments, but studies show that they remain contaminated with microscopic pathogens that can cause Surgical Site Infections (SSI) even after they have been cleaned.

Xenex Disinfection Services’ LightStrike pulsed xenon Full Spectrum ultraviolet (UV) disinfection technology has been proven to quickly destroy the germs and bacteria in operating rooms that cause SSIs. Hundreds of hospitals use LightStrike Germ-Zapping Robots during the terminal cleaning process in the OR after the day’s procedures are complete.

Xenex recommends running the robot for two 8- or 10-minute positions (depending on robot model) during the terminal clean. MulWWW.ORTODAY.COM

tiple positions greatly reduces the impact of shadows on UV disinfection efficacy.

Studies show, however, that bioburden increases in the OR during the day. A leading U.S. medical institution recently studied the effectiveness of the Xenex LightStrike robot in its ORs and found that the LightStrike robot can effectively disinfect high touch surfaces in an OR in 2 minutes.

This short cycle time may make between-case cleaning in the OR a viable option and something hospitals should consider operationalizing within their protocol.

“Running a quick cycle in between cases can be very effective at bringing down the vegetative bacteria bioburden in the OR,” said Dr. Sarah Simmons, Science

Director, Xenex. “The LightStrike robot turns on instantly (no warmup or cool down time) so it can be brought into the OR to quickly disinfect the area around the surgical table in between procedures.”

Hospitals using the Xenex LightStrike system as part of their infection prevention protocol have published studies reporting reductions in hospital infection rates, even Clostridium difficile (C.diff ), which is particularly hard to destroy. Two hospitals experienced significant reductions in their SSI rates after they began using LightStrike to disinfect their ORs and published their results in peer-reviewed journals, crediting the Xenex disinfection robot for the role it played in those reductions. • June 2017 | OR TODAY

15

INDUSTRY INSIGHTS NEWS & NOTES

Digital OR Showcased at AORN Brainlab showcased its fully integrated Digital OR at the Association of Perioperative Registered Nurses (AORN) Global Surgical Conference & Expo in Boston. The digital operating room configuration from Brainlab includes Buzz, the next generation OR centralized information hub.

Buzz is part of the larger Digital OR technology concept from Brainlab that aims to streamline workflows with IP-based video routing as well as robust integration with HIS and PACS VNAs. With an easy to use smartphone-like user interface, Buzz integrates the workflows of all OR staff, including nurses. The system features automatic pre-fetching of patient data, surgical checklists, DICOM Viewer for on-the-fly 3D reconstructions, as well as streaming and conferencing capabilities.

Leading institutions around the world such as Medisch Spectrum Twente in the Netherlands, have opted for advanced, future-proof Brainlab Digital OR solutions that simplify access to clinical information. Adding to the already 400+ digitally integrated operating

rooms globally, University Hospital Klinikum rechts der Isar in Munich is installing Brainlab Digital OR technology in eight new operating rooms this summer.

Buzz 2.0 was scheduled to be released in April.

It was not available for sale at press time and will not be available until all applicable approvals have been attained.

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Building

your patient safety toolkit Patient safety depends on a healthcare team that knows how to assess for risk and the best practices to ensure quality care.

The AAAHC Institute for Quality Improvement supports your team by translating research into highly visual tools-you-can-use.

The AAAHC Patient Safety Toolkit series includes universal topics: ■

Antibiotic Stewardship

■

Allergy Documentation

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Safe Injection Practices

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Credentialing & Privileging

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Peer Review & Benchmarking

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Emergency Drills

And surgery-specific challenges: ■

Obstructive Sleep Apnea in Adults

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VTE (Venous Thromboembolism)

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Preventing Complications from Obesity

Order toolkits at www.aaahc.org/institute.

AAAHC. Improving healthcare quality through accreditation.

INDUSTRY INSIGHTS AAAHC UPDATE

BY NAOMI KUZNETS, PH.D.

OPIOID STEWARDSHIP AND ACCREDITATION

I

n August 2016, the Surgeon General sent a letter to every doctor in the United States asking them to help solve the opioid addiction problem in the U.S.

The Centers for Disease Control and Prevention (CDC) has reported that drug overdose deaths nearly tripled between 1999 and 2014. Sales of opioid analgesics increased by a factor of 4 between 1999 to 2010.

Experts believe that several factors have led to the opioid epidemic: • Prescriber behavior/characteristics • User behavior/characteristics • Environmental and systemic determinants AAAHC Standard 11.K (2017 handbook edition) states: Providers who prescribe, dispense, administer, and provide patient education on medications have easy access to current drug information and other decision support resources.

To support this Standard, the AAAHC Institute has added a new title to its library of patient safety toolkits: Opioid Stewardship. This toolkit is intended to provide an easy-to-use decision support resource albeit one that focuses on the first of these identified factors: opioid prescribing with specific consideration of the volume of prescription, dosage, and length of prescription.

We refer to opioid stewardship to reflect a deliberate effort to improve and measure use so that opioids are 18

OR TODAY | June 2017

only employed when needed and the right drug, dose, and duration are selected. The goals of opioid stewardship include optimizing clinical outcomes while minimizing risk of overuse and addiction.

OPIOIDS IN THE ASC

Opioids are frequently prescribed for four “low risk” surgical procedures that are commonly performed in ambulatory settings: carpal tunnel release, laparoscopic cholecystectomy, inguinal hernia, and knee arthroscopy. In 2012, the doses prescribed for these procedures had mean daily morphine milligram equivalents (MME) of 50, 51, 54, and 59 mg, respectively. The average duration, in days, for the prescriptions were 4.9, 4.8, 4.6, and 5.4, respectively (again, 2012 data).

Further, we know that: • 36.5% of surgical/procedural providers’ prescriptions are for opioids • 42% of orthopedists’ prescriptions are for opioids • Other surgical specialties also may be frequent prescribers The risk of chronic opioid use by patients who were not taking opiates (opiate-naïve) prior to surgeries, such as laparoscopic cholecystec-

tomy, can increase by a factor of 1.33 to 1.62. For cataract surgery, this increase can be a factor of 1.62; 1.33 for transurethral resection of the prostate; and 1.41 for varicose vein stripping.

PATIENT USE OF OPIOIDS POST PROCEDURE

Patients in a study of prescribing in ambulatory surgery (orthopedic, otolaryngology, general, podiatry, maxillofacial, gynecology, and urology) at Boston Medical Center reported taking less than half of the opioids prescribed within 10-days post-procedure.

While 70% reported that they had pills remaining, 14% reported taking pills more frequently than their prescriptions dictated and 10% sought an early refill. More than 50% of patients reported planning to keep unused medications after pain resolved.

A study of patients who underwent ambulatory shoulder surgery showed that the range of opioid pills prescribed (no information on strength) was 40 to 80. The range of unused pills at 90 days was 0 to 50; only 25% of patients had received education/ instructions on opioid disposal. For hand surgery, 13% of opioid-naïve patients continue to refill their opioid prescriptions 90 days after their procedures.

ALTERNATIVES

ASCs committed to Opioid Stewardship have a range of options to consider: WWW.ORTODAY.COM

AAAHC UPDATE

No More

Wheel obstructions • Choose local anesthetic techniques, acetaminophen, and non-steroidal anti-inflammatory analgesic drug (or cyclooxygenase-2 specific inhibitor).

• Provide patient education.

Establish goals and manage expectations with regard to post-operative pain. For example, the primary aim of pain management is not to achieve a certain pain score but to improve postoperative function and allow rehabilitation, while maintaining patient comfort.

• American Pain Society guidelines on post-surgical pain recommend preoperative education, perioperative pain management planning, use of different pharmacological and nonpharmacological modalities, organizational policies, and transition to outpatient care.

The AAAHC Institute for Quality Improvement is committed to expanding the resources for ambulatory facilities. Accredited organizations will receive this new toolkit by mail. Others may order the resource through the AAAHC website.

Naomi Kuznets, Ph.D., is a Vice President and Senior Director at the AAAHC. She has extensive experience developing and reviewing clinical practice guidelines and performance measures, conducting and reporting on quality improvement and benchmarking studies designed for ambulatory health care, and developing educational tools to help organizations improve patient safety and quality of care.

WWW.ORTODAY.COM

June 2017 | OR TODAY

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INDUSTRY INSIGHTS ASCA UPDATE

BY REBECCA CRAIG, RN, MBS, CNOR, CASC

PROTECT PATIENT ACCESS AND REDUCE THE COST OF CARE BIPARTISAN SUPPORT FOR ASC PAYMENT REFORM

L

ate in 2016, as part of the 21st Century Cures Act, the U.S. Congress approved two pieces of legislation that are important to ASCs and ASC physicians. The first exempts ASC patient encounters from counting toward physicians’ meaningful use quotas, and the second requires the federal government to publicly post ASC and hospital outpatient department (HOPD) rates in a way that allows patients to make quick comparisons. While we continue to appreciate the congressional support ASCs and ASC physicians received in both of these areas, the work ASCs need to do on Capitol Hill is far from over.

As recently as 2003, Medicare reimbursed ASCs at an average of 86 percent of the amount it paid to HOPDs for the same procedures. Today, on average, ASC payments are less than 50 percent of the HOPD rates. At the root of the problem are several Medicare policies that reward HOPDs, the higher cost provider, over ASCs, the lower cost provider.

One of those policies, as ASCA has pointed out before, is the formula used to adjust ASC and HOPD payments for inflation each year. ASCs are updated each year based on the Consumer Price Index for All Urban Consumers (CPIU), a number derived using a formula that measures the cost of commodities like milk, eggs and gasoline.

HOPD rates, on the other hand, are updated each year based on the “hospital market basket.” Not surprisingly, that number, which measures the rising 20

OR TODAY | June 2017

cost of medical goods and services, has historically resulted in substantially higher reimbursement rates for HOPDs. Hospitals need to be reimbursed for the many essential services they provide, but the continuing growth in the disparity between Medicare’s HOPD and ASC payments must stop.

To remedy this growing inequity, ASCA is backing new legislation that would require Medicare to update ASC payments based on the more appropriate hospital market basket. To read more about that bill introduced March 30, 2017, by U.S. Representatives Devin Nunes (R-CA) and John Larson (D-CT), go to ASCA’s web site(www. ascassociation.org/ascqaa2017).

While several of the provisions in this legislation are similar to those included in the ASC Quality and Access Act of 2015, that legislation died at the

conclusion of the last session of congress and new legislation was needed.

The new bill ASCA is backing also would create greater transparency in the Medicare quality reporting program for both ASCs and HOPDs by requiring the Centers for Medicare & Medicaid Services (CMS), where applicable, to post online, side-by-side comparison reports from both sites of service.

It also would add an ASC representative to the Advisory Panel on Hospital Outpatient Payment. Since decisions made by that panel impact ASC facility fees and the procedures that Medicare will allow ASCs to perform, it is only fair that ASCs have a voice in the decisions made there.

Finally, this bill would require CMS to disclose exactly which criteria are involved when a decision is made not to add a new procedure to the list of procedures that Medicare will reimburse WWW.ORTODAY.COM

TRIM 4.5”

ASCA UPDATE

TRIM 4.5”

ASCs for providing. Under current policy, CMS can exclude a procedure from this list because of a general concern for up to six criteria but is not required to disclose exactly which of the criteria trigger the exclusion. This process makes it difficult for ASCs to marshal the data needed to respond to any concerns that CMS may have and slows the advance of new procedures to this lower cost site of care.

As Democrats and Republicans continue to face off in the national debate regarding the repeal and replacement of Obamacare and the many other areas of concern that are inherent in our complicated web of national health care policy, these proposals demonstrate that there are still plenty of health care reforms that can and should be implemented with bipartisan support.

Rebecca Craig is president of the Ambulatory Surgery Center Association.

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21

IN THE OR SUITE TALK

STAFF REPORT

SUITE TALK

Conversations from the OR Nation’s Listserv

SCRUB INCIDENT There are always those “special surgeons” who choose to wear scrubs from outside the facility. It can be interesting when one needs to confront these surgeons and discuss the multitude of reasons for changing scrubs. However, sometimes the discussion doesn’t go anywhere, and the surgeon fails to change scrubs. Does this warrant an incident report?

The patient is directly compromised due to the failure of the surgeon to change scrubs.

A: Yes, we do have some who refuse to A: We have surgeons that will wear scrubs adhere to our policies and change scrubs. from one of the other internal hospitals.

This is most noticeable when it is a difThis is against policy. It is difficult to corferent color than ours! I have always rect this practice. They do not wear scrubs said, “you would look so nice in some of from other institutions. our blue scrubs” or “ can I help you with the scrub dispenser?” It doesn’t always A: Yes, I believe it requires an incident rework. We do not have an infection issue. port because it is a potential for injury to I can control the staff who actually are the patient and not current best practice. employed by our organization, but cannot This is the only way the behavior can be control the physicians. tracked and addressed via a peer group.

BLOCK SCHEDULE How do you calculate your block utilization? Our blocks are 8 hours only. Is 7 hours a reasonable time to use for your denominator or lower? What do you use for benchmarks?

A: We use the amount of block allocated to the minutes out of block divided by the allosurgeon or surgical practice. If they are alcated block. located a 10-hour block we use 10 hours and The other thing we do, is to allocate the if they are allocated 8 hours we use 8 hours. reserved block to a practice. The practices alWe also look at and report block utilization in locate block from the practice block for new three ways: surgeons before requesting additional block.

• Adjusted utilization defined as wheels in of first case to wheels out of last case of the day A: We have Meditech and we have had issues divided by the amount of allocated block with this as well with many reports since • Raw utilization defined as wheels in to we went live in 2010. Nothing much imwheels out of every case added together proves with each update but I am told that • Out of Block time defined as amount of time hopefully in this next one, it will be better. used outside of their reserved block. We Turnover time is a horrific manual process review and report this as the number of if you have Meditech.

THESE POSTS ARE FROM OR NATION’S LISTSERV FOR MORE INFORMATION OR TO JOIN THE CONVERSATION, VISIT WWW.THEORNATION.COM.

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OR TODAY | June 2017

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IN THE OR MARKET ANALYSIS

STAFF REPORT

SURGICAL IMAGING MARKET WORTH $1.25 BILLION BY 2019

T

he global surgical imaging market is expected to eclipse the $1 billion mark by the end of the decade.

A report from MarketsandMarkets that studies the global surgical imaging market during the forecast period of 2014 to 2019 predicts continued growth for this imaging segment of the heath care market.

The global surgical imaging market was estimated at $933.6 million in 2014 and is expected to reach $1.25 billion by 2019, according to MarketsandMarkets. The report also indicates that the market will increase at a compound annual growth rate of 6 percent during the forecast period.

Based on products, the surgical imaging market is comprised of mobile C-arms and mini C-arms. The application areas of surgical imaging are categorized into mobile C-arm applications and mini C-arm applications. The applications for mobile C-arms are orthopedic and trauma, neurosurgery, cardiovascular, and gastroenterology surgery, while the applications for mini C-arms are hand and wrist, foot and ankle, and pediatric surgery.

“The major driver of this market is changing trends toward advanced cooling and flat-panel technology, more intuitive platforms with high speeds up workflow,” according to MicroMarket WWW.ORTODAY.COM

Monitor. “Less overheating also drastically improves safety and efficiency. Also, continued growth in minimally invasive surgery, spine surgery and hip surgery, and improved workflow such as improved ergonomics, easier usage, and facilitating efficient feeding of data into the PACS archive and

“ The major driver of this market is changing trends toward advanced cooling and flat-panel technology, more intuitive platforms with high speeds up workflow.”

EMR are the major driving factor of this market.”

“The availability of private and public funding for the purchase of surgical imaging equipment is a major driver for the market in North America,” MicroMarket Monitor adds. “Furthermore, regional governments have taken the initiative to modernize their hospitals in their respective regions.

This has resulted in an increased demand for surgical equipment such as mobile C-arms in North America. In the Asian market, the rise in the number of hospitals is a major driver for the market. Furthermore, the availability of competitively priced mobile C-arms and increase in aging population aid market growth in the region.”

“North America accounted for the largest share of the surgical imaging market followed by Europe and Asia,” according to MarketsandMarkets. “The dominance of the North American market can be attributed (to) the increasing prevalence of sports injuries in this region as well as the availability of private and government funding for the purchase of surgical imaging equipment. However, the Asian market is expected to experience the highest growth in the surgical imaging market. The high growth in the Asian region can be attributed to (an) increase in aging population, rise in the number of hospitals, government funding, and the availability of competitively priced surgical imaging equipment in this region.”

GE Healthcare, Siemens AG, Koninklijke Philips N.V., Ziehm Imaging, Toshiba Corp., Shimadzu Corp., Hologic Inc., OrthoScan and Eurocolumbus are listed as by MarketsandMarkets as some of the prominent players in the global surgical imaging market.

June 2017 | OR TODAY

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IN THE OR PRODUCT FOCUS

BRAINLAB EXACTRAC The Brainlab ExacTrac 6.2 is a new version of its successful room-based patient positioning system providing full interoperability with the PerfectPitch six-degrees of freedom couch from Varian Medical Systems. This full integration enables customers who have a Varian TrueBeam linear accelerator equipped with PerfectPitch and ExacTrac to reap the combined benefits of the two systems. Clinicians are now able to utilize the highly accurate patient positioning and monitoring capabilities of ExacTrac with the precise 6D robotic alignment of Perfect Pitch for all radiosurgery cases in the brain and body. •

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OR TODAY | June 2017

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PRODUCT FOCUS

GE HEALTHCARE OEC ELITE MINIVIEW C-ARM Intended for limb extremity procedures in orthopedics and emergency medicine, the OEC Elite MiniView C-arm focuses on enhancing the user experience by minimizing positioning struggles with fluid, balanced and smooth movements. The mini C-arm offers an exclusive feature called SmartLock, a simple and convenient button that automatically locks the C-arm in place to reduce drift concerns and further enhance surgical procedure efficiency and flow. Its design fosters greater clinical imaging confidence by providing a high displayed resolution and large displayed image size for both primary and reference images to provide physicians with real-time general fluoroscopic visualization of patients’ anatomies of all shapes and sizes. •

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June 2017 | OR TODAY

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IN THE OR PRODUCT FOCUS

GE HEALTHCARE DirectOR The DirectOR* is an integrated surgical suite solution that allows customers to streamline the renovation or completion of their surgical care suites in one stop, including planning, purchasing, managing, installing and servicing equipment and infrastructure needs. With a legacy of quality OR equipment and years of clinical expertise in the surgical environment, GE Healthcare is uniquely positioned to customize a plan and deliver a solution to meet the demanding needs of health care providers. Whether it’s lights, booms, tables, monitors, integration, imaging or anesthesia, this solution now allows GE Healthcare to be a partner in the transformation of a health care provider’s surgical care areas. • *GE Healthcare OEC is an authorized distributor of DirectOR Suite products that are manufactured by third parties and sold in the United States only.

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OR TODAY | June 2017

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PRODUCT FOCUS

CV MEDICAL NuCART NuCART is the world’s first mobile operating room visualization and boom system. Utilizing a wireless tablet to route and switch 15 available video inputs to its displays, the award-winning NuCART turn-key design adapts older ORs to function efficiently for image guided surgery where mobile fluoroscopy, ultrasound, and surgical video are used. It improves viewing ergonomics and provides an equipment organization system that removes trip hazards and clutter, to improve staff and patient safety. NuCART meets the budgetary and technical requirements of hospitals that are adopting modular image guided hybrid ORs and since NuCART is mobile, it eliminates all construction. •

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June 2017 | OR TODAY

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IN THE OR PRODUCT FOCUS

SIEMENS HEALTHINEERS ARTIS PHENO ANGIOGRAPHY SYSTEM The robot-supported ARTIS pheno angiography system, which was developed for use in interventional radiology, minimally invasive surgery, and interventional cardiology, possesses a zen40HDR flat panel detector and GIGALIX X-ray tube for outstanding image quality. The ARTIS pheno boasts new 2k recording technology capable of delivering 2D imaging resolution that is four times higher in all recording processes than prior Siemens Healthineers systems. The system’s StructureScout feature can adapt and optimize imaging parameters to suit the X-rayed area, potentially resulting in less radiation dose than prior Siemens Healthineers systems. The ARTIS pheno also supports the treatment of multimorbid patients and can be fitted with a comprehensive range of optional software applications for complex cases. And to aid with infection control, the ARTIS pheno has large, sealed surfaces with fewer spaces, which are easy to clean and disinfect. •

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OR TODAY | June 2017

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IN THE OR CONTINUING EDUCATION CE414E

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OR TODAY | June 2017

BY ROSALINDA ALFARO-LEFEVRE, MSN, RN, ANEF

WWW.ORTODAY.COM

CONTINUING EDUCATION CE414E

WHO WILL TEACH OUR NURSES? Throughout the world, nurses are called on to work in healthcare settings that are undergoing reform never before imagined.1 Patient needs and care delivery

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 39 to learn how to earn CE credit for this module.

The goal of this continuing education program is to encourage nurses to consider an academic nursing career, to help them learn what steps to take to become nurse educators and to inform them about the consequences of the nursing faculty shortage. After studying the information presented here, you will be able to: •D escribe the impact of nursing faculty shortages on the nursing profession and the nation’s health • I dentify strategies to begin a path to becoming a nurse educator •D escribe the educational and personal qualities needed for an academic career

WWW.ORTODAY.COM

systems are more complex than ever. To give high-quality care, nurses must broaden their practice scope, master technology and information management systems and coordinate care across teams of healthcare professionals.1 Educators must prepare nurses to enter a workforce that’s complex, uncertain and constantly evolving.

According to the National League for Nursing, nurses must recognize that “a critical goal for the future is to endorse academic progression options for all nurses.”1 Not only do the qualifications of the current nursing workforce need to be updated, the Health Resources and Services Administration projects that we’ll need more than 1 million new RNs by 2020. 2 The good news is that nursing program applicants, enrollments and graduates have increased. The bad news is that despite increased enrollments, too many qualified applicants are being turned away from entry-level nursing programs, mostly due to faculty shortages. 3 Some experts believe that even if colleges and universities could produce enough nurse educators to teach students on admission waiting lists, the problem still wouldn’t be solved. The prospect of not having enough nurses to meet the demand is now high on the radar for government and healthcare organizations. It makes many of us wonder: Who will be there to take care of me when I need it?

SAFETY AND SCIENCE ENDANGERED

Ever since an Institute of Medicine (now called the Health and Medicine Division [HMD] of the National Academies) study found that as many as 98,000 people die each year as a result of hospital stays – primarily from medical errors and hospital-acquired infections – patient safety has become a top priority.4 The role nurses play in monitoring patients to reduce adverse outcomes significantly affects preventable complications and deaths.4,5 As University of Pennsylvania researcher Linda Aiken points out, there’s a growing body of evidence to suggest a more highly educated nursing workforce saves lives. According to Aiken, “Our research shows that each 10% increase in the proportion of nurses in a hospital with a bachelor’s degree is associated with a 7% decline in mortality following common surgery.”6 A summary of Aiken’s research is available.7 To create safer hospitals, an adequate number of well-prepared nurses must be available. In 2010, the HMD shook up the nursing field when it called for 80% of all nurses to hold BSN degrees by 2020.8 As a result, there’s been an increase in RN-to-BSN programs requiring additional qualified faculty.9 The nursing shortage – the nursing faculty shortage in particular – not only threatens patient care, but also advances in nursing science. As a profession, nursing June 2017 | OR TODAY

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IN THE OR CONTINUING EDUCATION CE414E is still young. It’s only in the past few decades that nurse scholars and researchers have developed a scientific body of knowledge that promotes evidence-based practice.

For nursing to fulfill its mission, these efforts must continue and expand. Nursing must have enough educators to prepare the next generation of nurses and enough researchers and scholars to continue to advance nursing science.

The nursing field needs skilled educators who are qualified to do the studies needed to answer questions about how students learn and what teaching strategies are most effective. Recruiting more nurses into academic roles is crucial to doing the research to answer these questions.

The following forces drive the nursing faculty shortage:2,3 •M ore faculty are nearing retirement.

•T he number of younger faculty has dropped.

•M ore opportunities exist outside of academia.

•T here is a disparity between faculty and clinical salaries.

•T here are financial barriers, including tuition costs, student loans and lost income while in graduate school.

•T here are older doctoral recipients, leading to shorter careers in teaching.

•F aculty workload demands and role expectations can lead to job dissatisfaction.

WHAT IT TAKES

Being a nurse educator takes a passion for quality patient care, high-practice standards, a commitment to lifelong learning, creativity, flexibility and excellent communication and critical-thinking skills.

It also requires a sincere desire to help students grow and develop. If 34

OR TODAY | June 2017

you have these qualities or are willing to develop them, consider acquiring the educational background that will prepare you as a nurse educator. The nurse practice act in each state determines the qualifications nurse educators need. Some nurse practice acts distinguish between the academic qualifications of instructors who conduct clinical teaching and those who provide both classroom and clinical instruction. Accrediting agencies, such as the National League for Nursing (NLN) and the American Association of Colleges of Nursing (AACN) require full-time faculty to have doctoral degrees.

Nurse educators with master’s degrees (which are generally required) begin their teaching careers as junior faculty, instructors or assistant professors. Many of today’s students continue to work while they study part time, and most graduate programs accommodate the needs of working nurses. Students in master’s programs usually have bachelor’s degrees in nursing. Some graduate programs offer BSN-to-PhD programs and others have a generic master’s program for students with a non-nursing bachelor’s degree.

In these innovative programs, students move through courses at an accelerated pace. Many graduate programs require applicants to have a 3.0 undergraduate grade point average, and some require desirable scores on the graduate record examination (GRE). Most schools require faculty to have doctoral preparation to be eligible for promotion to associate professor or full professor. In addition to teaching students, faculty members are often expected to demonstrate expertise in clinical practice, service, publishing, leadership, and research. Nurse educa-

tors fill positions ranging from adjunct (part-time) clinical faculty to deans of colleges of nursing.

Students come from a variety of backgrounds, ranging from recent high-school graduates, to students with previous non-nursing careers to practicing nurses.

Usually, nursing faculty teach courses that correspond with the focus of their graduate nursing education program (e.g., adult, pediatric, psychiatric, obstetrics, critical care or community health nursing). Some faculty members also teach in areas in which they have evolved as specialists through academic preparation or personal study or experience (e.g., nursing leadership or healthcare management). Whatever the clinical or professional specialty area, nurse educators are first and foremost teachers and must be skilled in teaching strategies, evaluation of learning outcomes and curriculum development. They must know how to guide learners to reach their full potential.

NO IVORY TOWER

Some clinicians think nurse educators work in an ivory tower detached from nursing’s real world. Nothing could be further from the truth. To be effective teachers, nurse educators must devote time to remaining clinically competent and aware of new developments in nursing practice and research. The number of hours faculty devote outside of regular work time to do that can be formidable. One study found that two-thirds of faculty report a workload that exceeds what they expected in an academic role.10 Teaching is challenging but rewarding from professional and personal perspectives, as noted in the NLN’s Top 10 Reasons to Become a Nurse Educator.10 WWW.ORTODAY.COM

CONTINUING EDUCATION CE414E

Top 10 Reasons to Become a Nurse Educator11 10. You work in an intellectually stimulating environment.

9. You have autonomy and flexibility.

8. Your research creates knowledge and advances the field; your publications bring you prestige.

7. Your work has value to society.

6. You can teach anywhere in the world.

5. Using technology, you can teach from the beach or the slopes.

4. You encourage and educate eager minds, and you rejoice when your students surpass you.

3. You shape the future of healthcare.

2. You change lives.

And the No.1 reason to become a nurse educator: 1. You teach what you love.

To find personal stories about the rewards of being a nurse educator, search the Internet for “Great Moments in Teaching Nursing.”

Nursing faculty members shape the knowledge and practice of new nurses on a grand scale.

Many nurses remember the influence that nurse educators had on them by the way they practice nursing every day. As clinicians, we are responsible for our own practice and have control over the care we provide. Nurse educators have the opportunity to directly influence ways in which diverse WWW.ORTODAY.COM

generations of nurses work together to provide care.

Nurse educators in academic settings may work on nine- or 12-month contracts. Faculty salaries vary depending on a person’s title (e.g., assistant professor, associate professor), level of education and the type of institution.

Although the disparity between faculty salaries and those in clinical settings is cited as a barrier to entering academia, many nurse educators who work on nine-month contracts earn additional income by teaching during the summer or working on funded grant projects.

Nurse educators also have predictable and flexible hours that fit well with home and family responsibilities. In contrast to nurses in clinical settings, faculty members aren’t called on to work overtime and have regular time to learn, plan and research. The rewards of a nursing academic career are many, and the future is bright for nurses who choose teaching as a career.

Traditionally, nursing students have been a homogenous group.

Most were young women who entered nursing programs immediately after high school. In contrast, 21st-century nursing students are a diverse group. There are more men in nursing today and more minority students, making knowing how to work with diverse students a crucial educator competency. In general, students are older than recent high school graduates and can be anywhere from their late 20s to their 50s and beyond. They are usually financially independent, bring work and life experiences to the academic setting and strive to balance their studies with job and family responsibilities.

Today’s educators know things have changed. One of the most significant changes in nursing edu-

cation is the increase in online and distance learning programs. Faculty must be tech-savvy and know how to teach and evaluate students they don’t often see in the classroom.

Another significant change is in the skills labs. Nurses have moved from using crude, plastic patient models to using high-fidelity human patient simulators. These lifelike simulators give students a realistic experience that mirrors what happens with real patients in the clinical setting.

Human patient simulators allow students to recognize and respond to real-life situations. Instructors can build in scenarios for important bedside nursing care issues and introduce potential errors in care so students can learn the results of their actions in a controlled environment rather than in the hospital setting.

No learning is more powerful than learning from your own mistakes.

WHAT STUDENTS WANT

Today’s students expect coursework to be practical, relevant and tailored to their needs. Often, classes are at satellite locations and scheduled one day a week or in the evening or on weekends to accommodate student work schedules. To meet students’ needs, nurse educators must be knowledgeable, creative and able to design educationally sound learning. They must know how to coach students, be mentors and apply evidence-based approaches to evaluating competencies. Many faculty members use new learning technology altering traditional classroombased education and make it possible for learning opportunities to occur in various ways (e.g., service learning, interactive video conferencing and standardizing didactic information across several sites). Today’s students are more tech-savvy and have 24/7 access to resources, such as the library and their instructors.

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IN THE OR CONTINUING EDUCATION CE414E Many students juggle family and work obligations with school work, often feeling overwhelmed and needing the support and flexibility of their educators.

CHANGES ON THE HORIZON

While much of nursing still occurs in hospitals, the profession is on the verge of a major transformation. In the past, nursing focused on taking care of dependent, ill people who were told, “We’ll take care of you… we know what’s best for you and you should do as we tell you.” Soon, many illnesses now treated in intensive hospital settings will be detected and prevented in their early stages. Nursing’s focus will be on including patients as partners in care and helping them make decisions about what’s best for them as individuals. Now nurses are learning to tell their patients, “You know yourself best; tell me what’s most important to you” and “I want to teach you how to manage your health so you know what do when I’m not here.” Major nursing responsibilities include counseling, teaching and guiding people to achieve and maintain optimum health.

At the same time the “what” of nursing is changing, the “how” of nursing education is also changing.

Nurse educators are being asked to develop courses on bioterrorism, care for the elderly and vulnerable, genetics, health economics, health politics and policy, mass casualty response, palliative and end-of-life care and patient-care management. These and other topics prepare 21st-century graduates to practice in a dynamic and unpredictable healthcare climate.

Students in nursing programs today enter an increasingly fast-paced, competitive and business-oriented environment. Students need to learn how to provide care in multiple settings with diverse groups of patient populations. They must know how to 36

OR TODAY | June 2017

set priorities, as today’s nurses know all too well that not every patient need can be met.

The NLN and other organizations, such as the Quality and Safety Education in Nursing Institute, stress that significant changes in nursing and nursing education are on the horizon.

Educators need to have specific competencies to transform nursing education to maximize student potential and help each student develop competencies that promote professional practice in a dynamic healthcare arena (see side bar).12,13 Many nurse educators today distinguish themselves by passing the NLN’s certified nurse educator exam, allowing them to put the credentials CNE after their name.14 As the need for leadership and research in nursing education is clear, there’s also a need for more doctorally prepared educators (calling for more qualified educators to teach in doctoral programs as well).15 NEVER BORING

Today’s nurse educator will never be bored. The days of preparing lectures and standing in front of the classroom giving those lectures day in and day out are gone. Instead, nurse educators are working collaboratively with their students. From their first semester of school, students are taught how to be active participants in all learning. Because today’s schools and organizations realize the importance of creating learning cultures where everyone teaches and learns, and learning opportunities are considered an important part of each day in the classroom, clinical and simulated learning is often lively and full of shared experiences.

If you feel intimidated by the preparation educators must do to teach a course, you needn’t be. You’ll get help from fellow educators and also find you have many resources to help ease the time-consuming work

Example RN and Nurse Educator Competencies12,13 RN Competencies Communication Patient-centered care Teamwork and collaboration Evidence-based practice System-based practice Quality improvement Safety Informatics and technology Leadership Educator Competencies Facilitate learning and learner development and socialization Use assessment and evaluation strategies Participate in curriculum design and evaluation of program outcomes Function as a change agent and leader Pursue continuous quality improvement in the nurse educator role Engage in scholarship Function within the educational environment

of making course content come alive.

For example, many publishers give their textbook users free, professionWWW.ORTODAY.COM

CONTINUING EDUCATION CE414E

ally developed PowerPoints and test banks. They also provide online tutorials, case scenarios and videos to facilitate and reinforce learning.

There are many online resources, such as YouTube, Google, and Google Scholar, where faculty post PowerPoint presentations, lectures, activities, illustrations, clinical demonstrations and videos from experienced educators. Teaching and learning today is easier than it used to be and more vibrant and fun.

thanks to the Internet. (See “Educational and Financial Resources” sidebar.) The AACN sponsors Career Link, an online resource that features nurse educator career profiles, a list of programs that prepare nursing faculty, financial aid information, open faculty positions and links to faculty development programs. Federal and private funding are often available to help nurses who are enrolling in graduate nursing education.

SNEAK PREVIEW

The Nurse Reinvestment Act includes a student loan repayment program for nurses who agree to serve as faculty after graduation.16 In addition to developing an awareness of nurse educator careers and its rewards, the American Nurses Association and the AACN have been working to gain increased federal support for the Faculty Loan Repayment Program.

This program, sponsored by the U.S. Department of Health and Human Services, offers up to 85% of loan cancellation for nurses who serve as full-time faculty members.17 Nurses for a Healthier Tomorrow, a coalition of nursing and healthcare organizations, is seeking ways to inspire a new generation of nurse educators.18 Its campaign features stories of nurse educators that highlight the rewards of teaching and a nurse educator career profile, accessible on the Nurses for a Healthier Tomorrow website.

Without nursing faculty, there won’t be enough nurses to meet the country’s needs. Nursing needs to attract an increasing number of men and women who want to work with students as their primary “clients” and who want to pursue teaching as their primary role. Future nursing faculty, standing on the shoulders of past and present nurse educators, must be excited about designing and presenting effective curricula to students and

If you’re up to the challenge of an academic career, start by looking for ways to experience the joys and challenges of what today’s educators do.

Seek out opportunities in your organization to precept or mentor new staff or nursing students and assess the rewards you gain. Volunteer to develop and teach in-service programs, so you can begin to experience the exciting work of reviewing nursing literature, evaluating directions for evidencebased practice and communicating new developments to your colleagues.

Talk to nursing faculty members who bring students to your agency — ask them about what they find most satisfying about their work. Contact experienced educators through social media (e.g., join nurse educator groups on LinkedIn to find an educator). Discussing the challenges related to being a new (or seasoned) educator is lively and informative.

Many students use the virtual nurse educator community to get practical advice and to help find resources. It’s not unusual to read something like, “I’m thinking of becoming a nurse educator … any advice?”

After deciding a teaching career is for you, the next step is to locate a graduate program that fits your needs.

Fortunately, finding information about nursing education careers and graduate programs is easier than ever, WWW.ORTODAY.COM

EASING THE LOAN LOAD

dedicated to developing evidencebased teaching strategies for nursing’s future generations.

NOW IS THE TIME

If you like helping others develop to their full potential and would like a change, there’s no better time than now to start a path toward being an educator. Simply put: We need you.

Students need you to guide them toward reaching their goal of gaining the skills needed to give excellent patient-centered care. They need your help to learn how to collaborate with various healthcare professionals and take their place as leaders (both at the bedside and within healthcare organizations). Educators need you to help alleviate the stress of their workload and allow them to be the teachers they know they can be. Patients need you to guide students and keep them safe; ultimately, they need you to ensure that when they call for a nurse, there’s one there to answer.

If you’re like most nurses who are thinking about going into education, you probably have excellent clinical skills and work experience that will be invaluable to you, your peers and students. Most likely, you can recall bright teachers who had “been there, done that” with diverse patients and situations. You remember how much it helped to have teachers who could mentor and teach from experience.

You don’t have to do it all at once.

Consider your work and personal responsibilities and be realistic about your time. If you’re nervous, start by taking one course that you know is required and transferable, so you can see how it goes. Increasingly, today’s programs are willing to transfer credits. For example, having a course in statistics is often required and transferable. Not only will you get “the feel” of being back in school, you can get this course (one that can be quite rigorous) out of the way, while only taking one subject.

June 2017 | OR TODAY

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IN THE OR CONTINUING EDUCATION CE414E

There’s no doubt that nursing education is challenging, but there are countless rewards. As the saying goes, “I didn’t say it would be easy. I said it would be worth it.” Be a nurse and you touch many lives.

Teach a nurse, and the number of lives you touch grows exponentially. Why not join the ranks of nurses who can say, “I teach. What’s your superpower?”19

Educational and Financial Resources Master’s and doctoral degree programs:

CLINICAL VIGNETTE Rebecca Bream, BSN, RN, has been a nurse for five years and is now considering a career as a nurse educator. What information should Rebecca have as she considers this career choice?

1. Nurse educators must have: B. Excellent communication skills

3. Which experience can help Rebecca make an informed choice about whether a career in academia is a good fit for her?

C. A n interest in helping students grow and develop

A. V olunteering to develop and teach an in-service program

D. All of the above

B. Becoming a member of the nursing practice committee

A. High practice standards

All Nursing Schools

2. What is a possible disadvantage of an academic career?

Best Nursing Degree

A. T he next generation is really difficult to deal with.

D. S pending more time in the medical library

Choosing a Nursing Graduate Doctoral Program

B. It’s not easy to find a common commitment to nursing.

Choosing a Nursing Graduate Master’s Program

C. T he number of hours needed to maintain clinical expertise can be formidable.

4. To be promoted to associate or full professor, Rebecca should know that most institutions require full-time faculty to have:

Scholarships, fellowships, loans and loan repayment programs: AACN

D. N urse educators cannot maintain a predictable and flexible work schedule.

C. Participating in quality improvement activities

A. A master’s degree B. A doctoral degree C. Nursing specialty certification D. Clinical nurse leader certification

Discover Nursing

Rosalinda Alfaro-LeFevre, MSN, RN, ANEF, is an award-winning author of several nursing books and president of Teaching Smart/ Learning Easy in Stuart, Fla.

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OR TODAY | June 2017

1. Correct Answer: D – All of these characteristics are requirements for nurse educators, along with such attributes as a passion for nursing, a commitment to lifelong learning, creativity, flexibility and critical thinking skills.

OnCourse Learning guarantees that this educational activity is free from bias.

2. Correct Answer: C – One study showed that two-thirds of faculty underestimated the time needed outside of work to maintain clinical expertise and keep up with developments in nursing.

the content of this version.

3. Correct Answer: A – Developing and teaching an in-service program will help Rebecca get the feel of what it’s like to be in a teaching role. Although laudable, all the other activities mentioned are unrelated to helping a person determine her or his match with a teaching career.

EDITOR’S NOTE: Maureen Habel, MA, RN, the original author of this educational activity, has not had an opportunity to influence

4. Correct Answer: B – Accrediting agencies, such as the National League for Nursing and the American Association of Colleges of Nursing, require a doctoral degree for full-time faculty positions.

Nurses for a Healthier Tomorrow

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HOW TO EARN CONTINUING CONTINUING EDUCATION EDUCATION CREDIT CE362-60F References 1. Academic progression in nursing education: a living document from the National League for Nursing. National League for Nursing (NLN) Web site. http:// www.nln.org/docs/defaultsource/about/nln-vision-series(position-statements)/nlnvision_1. pdf?sfvrsn=4. Published January 2011. Accessed April 2, 2016.

2. American Association of Colleges of Nursing Task Force on Future Faculty. Faculty shortages in baccalaureate and graduate nursing programs: scope of the problem and strategies for expanding the supply. American Association of Colleges of Nursing Web site. http://www. aacn.nche.edu/publications/ white-papers/faculty-shortages.

Published June 2005. Accessed April 2, 2016.

3. Nursing faculty shortage.

American Association of Colleges of Nursing Web site. http://www. aacn.nche.edu/media-relations/ fact-sheets/nursing-facultyshortage. Updated March 16, 2015.

Accessed April 2, 2016.

4. Committee on Quality of Health Care in America. To err is human: building a safer health system.

Institute of Medicine Web site. http://iom.edu/Reports/1999/ To-Err-is-Human-Building-A-SaferHealth-System.aspx. Published November 1999. Accessed April 2, 2016.

5. Shever LL, Titler MG, Kerr P, Qin R, Kim T, Picone DM. The effect of high nursing surveillance on hospital cost. J Nurs Scholarsh. 2008;40(2):161-169. doi: 10.1111/j.1547-5069.2008.00221.x.

6. Hilton L. Degrees matter. Nurse. com Web site. https://news.nurse. com/2014/04/15/degrees-matter/.

Published April 15, 2014. Accessed April 2, 2016.

7. Aiken LH, Sloane DM, Bruyneel L, et al. Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study.

Lancet. 2014;383(9931):18241830. doi:10.1016/S01406736(13)62631-8 8. The future of nursing focus on education. National Academies of Sciences, Engineering, and Medicine Web site. https:// iom.nationalacademies.org/ Reports/2010/The-Futureof-Nursing-Leading-ChangeAdvancing-Health/ReportBrief-Education.aspx. Published January 26, 2011. Accessed April 2, 2016.

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9. Spencer J. Increasing RNBSN enrollments: facilitating articulation through curriculum reform. J Contin Educ Nurs.

2008;39(7):307-313.

10. NLN-Carnegie study examines nurse faculty workload.

National League for Nursing Web site. http://www.nln.org/ newsroom/news-releases/ news-release/2007/09/20/nlncarnegie-study-examines-nursefaculty-workload-208. Published September 20, 2007. Accessed April 2, 2016.

11. Career as a nurse educator.

National League for Nursing Web site. http://www.nln.org/about/ career-center/career-as-a-nurseeducator. Accessed April 2, 2016.

12. Certification for nurse educators (CNE). National League for Nursing Web site http://www.nln. org/professional-developmentprograms/Certification-for-NurseEducators. Accessed April 2, 2016.

13. Kalb KA. Core competencies of nurse educators: inspiring excellence in nurse educator practice. Nurs Educ Perspect.

2008;29(4):217-219.

14. Competencies. Quality and Safety in Nursing (QSEN) Institute Web site. http://qsen.org/competencies. Accessed April 2, 2016.

15. Academic progression in nursing education: a living document from the National League for Nursing. National League for Nursing Web site. http://www.nln. org/docs/default-source/about/ nln-vision-series-(position-statements)/nlnvision_1.pdf?sfvrsn=4.

Published January 2011. Accessed February 23, 2016.

16. Spigel S. Nurse Reinvestment Act. State of Connecticut General Assembly Web site. http://www. cga.ct.gov/2002/rpt/2002R-0712.htm. Published August 20, 2002. Accessed April 2, 2016.

17. Nurse faculty loan program.

Health Resources and Services Administration Web site. http:// www.hrsa.gov/loanscholarships/ repayment/faculty/. Accessed April 2, 2016.

18. Nurse educator recruitment campaign. Nurses for a Healthier Tomorrow Web site. http://www. nursesource.org/campaign_news. html Accessed April 2, 2016.

19. 10 teacher quotes to inspire your passion. SimpleK12 Web site. http://www. simplek12.com/k12/10-teacherquotes-to-inspire/ Accessed April 2, 2016.

1. Read the Continuing Education article.

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3. If the course you have chosen to take includes a clinical vignette, you will be asked to review the vignette and answer 3 or 4 questions. You must answer all questions correctly to proceed. If you answer a question incorrectly, we will provide a clue to the correct answer.

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ACCREDITED In support of improving patient care, OnCourse Learning is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

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PERIOPERATIVE NURSING DISCOVERING INCREDIBLE POSSIBILITIES!

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ABOUT OR TODAY For over 15 years, OR Today has provided OR

REASONS TO ATTEND • World-class Speakers

nurses, managers and techs with the latest

OR Today brings together the best

up-to-date news and information about the

speakers from across the country.

surgical services profession. OR Today’s print

• CE Super Sessions

and digital content aims to educate readers on

Super sessions cover topics indepth and

new guidelines, techniques and equipment, as

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well as practical information for career building,

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problem solving and overall well-being.

• Vendor Exhibit Hall Vendors showcase the latest technology and resources for your department.

SCHEDULE Sunday, August 27

“ Overall, I feel this is one of the top conferences I have ever attended. The activities allowed for networking, building relationships.”

–Carla Knight, Director of Surgical Services

12 pm Registration 1–4 pm CE Super Sessions 5–7 pm Welcome Reception (in Exhibit Hall)

Monday, August 28 7 am Registration 8–11:30 am Education 11:30 am–2 pm Exhibit Hall (Lunch will be served) 2–4:15 pm Education 5:30 pm Nashville Singer/Songwriter night Featuring Lexie Hayden!

Tuesday, August 29 8 am Registration 9–11:15 am Education 11:30 am – 12:15 pm Keynote Luncheon 12:15–1:45 pm Keynote Address

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June 2017 | OR TODAY

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AUGUST 27-29, 2017 WASHINGTON, D.C. WWW.ORTODAYLIVE.COM

“ Love that the conference is specific for what's going on in the OR today and in the future. Excellent for new managers!” – Kristin Vinson, RN Assistant Nurse Manager

Education Overview TO VIEW CLASS DESCRIPTIONS VISIT WWW.ORTODAYLIVE.COM

Medical Errors Now the Third Leading Cause of Death in the US: Leveraging what we know about SSI prevention David Taylor, Director, CVOR, MSN, RN, CNOR, Methodist Hospital and Melanie Burton, BSN, RN, CNOR, Nurse Educator, TIDI Products You’re Not a Born Leader Chet Wyman, MD Johns Hopkins School of Medicine Lessons Learned From the Death of Joan Rivers Kenneth P. Rothfield, MD, VP, Chief Medical Officer, Chief Quality Officer Saint Vincent’s Healthcare Hot Topics in Infection Prevention and Control for the Perioperative Setting J. Hudson Garrett Jr., PhD, MSN, MPH, MBA, FNP-BC, CSRN, VABC, GDCN, PLNC, IP-BC, CDONA, FACDONA, FAAPM Global Chief Clinical Officer Pentax Medical-Hoya Corporation Building Employee Engagement from the Ground Up Patty Andrews, RN, BSN, MHA, CNOR, Director of Perioperative Services, Marina Del Rey Hospital

42

OR TODAY | June 2017

Eyes Wide Shut: Taboo issues in the OR Jan Kleinhesselink, RN, BSHM, CPHQ, Chief Quality Officer and Carmen Lester, RN, BSN, JD, Chief Clinical Officer, Lincoln Surgical Hospital A Human Factors Approach To Endoscope Reprocessing J. Hudson Garrett Jr. PhD, MSN, MPH, MBA, FNP-BC, CSRN, VABC, GDCN, PLNC, IP-BC, CDONA, FACDONA, FAAPM, Global Chief Clinical Officer, Pentax MedicalHoya Corporation Fear: The Hidden Killer Chet Wyman, MD, John Hopkins School of Medicine Building Strategies for a Successful Surgical Smoke Evacuation Program Donna Watson, RN Medtronic The Educator’s Treasure Chest: Pearls and other jewels for competency assessment Dawn Whiteside, MSN, RN, CNOR, RNFA, Nurse Manager, Credentialing and Education Development, Competency and Credentialing Institute

Connecting with Today’s Patients Christian Pinkston, Founder and President, Pinkston Group Cleaning and Care of Surgical Instruments: A shared responsibility Cynthia Spry, MA, MS, RN, CNOR(E), SPDT, Spry Consulting Thoughts on Leadership James X. Stobinski, PhD, RN, CNOR, Acting CEO, Competency and Credentialing Institute Ken Perez, Vice President of Healthcare Policy, Omnicell Inc. It Takes a Village to Raise a Department: Why facilities fail with CS/SPD support staff Weston “Hank” Balch, CRCST, CIS, CHL, University Health System What would Florence do?

Dawn Whiteside, MSN, RN, CNOR, RNFA, Nurse Manager, Credentialing and Education Development Competency and Credentialing Institute WWW.ORTODAY.COM

PERIOPERATIVE NURSING: DISCOVERING INCREDIBLE POSSIBILITIES!

Multidisciplinary Collaboration in the Sterile Processing Department Elbridge “Eb” Merritt, RN, MSN, CNOR, CHL, Brooke Army Medical Center

The Death Spiral May Begin With You! James X. Stobinski, PhD, RN, CNOR, Acting CEO, Competency and Credentialing Institute

Extinguishing Risk of Surgical Fire Scott Lucas, PhD, PE, Director of Accident and Forensic Investigation, ECRI Institute

Capacity Planning: How to get the right fit Anne Roy, RN, Vice President, Sullivan Healthcare Consulting, LLC

Cracking the Code on Improving Block Utilization Andi Dewes, RN-BC, BSN, CNOR, Vice President of Surgical Excellence, Syus Inc. and Gail Pietrzyk, DNP, RN, CNOR, Corporate Director Surgery, UHS

KEYNOTE ADDRESS: Healthcare Leaders Aren’t Born, They’re Made David Taylor, Director, CVOR, MSN, RN, CNOR Methodist Hospital

REGISTER ONLINE AT WWW.ORTODAYLIVE.COM

SPEAKER SPOTLIGHT The greatest opportunities for me to grow as a nurse and a manager sometimes occur when I don’t perform my best—the situations that I reflect upon and realize I could have handled better. I find sharing these experiences with new nurses does two things: it helps ensure others learn from my mistakes and it brings me comfort to know that while I cannot always fix a problem, I can help ensure it does not happen to another patient.

One situation which I have shared many times occurred when I was a new OR nurse, taking a patient to surgery. Our surgery department was focused on metrics, and I was worried about my turnover times between surgeries. When I went to pre op to get my patient, the patient’s daughter had stepped out of the room. We had to wait for the daughter to return to the bedside and say goodbye to her mom before surgery. Looking back, I was impatient and rushed their goodbyes, as I wanted to get my patient into the OR suite quickly. Unfortunately, the patient did not do well in the surgery, and went to the ICU afterwards. She never went home. If I had known it was the last time they would speak, I would have given the mother and her daughter time to say goodbye. We must always remember the reason we are here—the patient and their family. I’ve shared this incident many times, in the hope that other nurses will remember the importance of taking the time our patients and families need. •

SURGICAL CONFERENCE

Patty Andrews

Patty Andrews, RN,MHA,BSN,CNOR Director of Perioperative Services Marina Del Rey Hospital

Find out more about Patty and her experience in perioperative nursing as she presents, “Building Employee Engagement from the Ground Up” at the 2017 OR Today Live conference being held August 27-29 in Washington, D.C.

Visit ortodaylive.com WWW.ORTODAY.COM

June 2017 | OR TODAY

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Robotic assistance

Adva Surg techn

anceD gical nology

BY DON SADLER

A

dvancing technology has become a fact of life in virtually every area of society. New technologies – from Amazon and eBay to Uber and Netflix – affect the way we shop, travel and entertain ourselves.

The perioperative environment isn’t immune to technological advances.

A wide range of new technologies are changing the way that surgeries are performed – while improving patient safety and outcomes and reducing health care costs in the process.

GOING STAR TREK

“Technology is an integral part of patient care,” says Sharon L. Morris, BSN, RN, CNOR, Surgical Services, North Valley Hospital in Whitefish, Montana.

“And, there are so many

advances in surgical technology today that it can be a challenge to keep up with them.”

“Let’s face it: Surgical technology has gone Star Trek,” Morris adds.

“To practice in the OR today, a nurse almost has to be an electrician and a computer programmer in addition to being a caregiver.”

“New technology in the operating room has helped to avoid the consequences of human error,” adds Gail Horvath, Patient Safety Analyst IV with the ECRI Institute.

She points to the surgi-

cal count to ensure that surgical items (especially sponges) are not unintentionally left in patients as being especially susceptible to human error.”

“Using bar code, RF and RFID technology in conjunction with the manual count significantly decreases the chance of retained surgical items being accidentally left in patients,” says Horvath.

James D. Fonger was a practicing cardiac surgeon for 25 years and now spends most of his time developing new medical device technologies. He places most surgical technology advances into three categories that he calls the “cornerstone surgical technologies” – smaller incisions, catheter-based therapies and robotics.

Advanced Surgical Technology

another primary area where surgical advances are taking place.

“These are becoming increasingly complex with MRI, CT scan and fluoroscopy capabilities allowing for immediate confirmation of tumor removal and more complex minimally invasive procedures,” Horvath says.

“The result is decreased lengths of patient stays.”

ROBOTS IN THE OR?

Dr. Augustine, CEO of Augustine Temperature Management LLC

“For example, half of cardiac valve surgeries are now catheter-based,” Fonger says. “No one would have

Since it first started to gain traction about 15 years ago, robotic surgery has become increasingly common for many different types of surgical procedures. These include prostate, hernia, gall bladder, colon and hysterectomy surgeries.

“Robotic surgery is rapidly expanding in cardiac, ENT, thoracic and neurosurgery, to name a few specialties,”

allowing for faster recovery times. The surgeon performs his or her tasks in a robotic console that’s physically located up to 30 feet away from the patient, viewing a high-resolution 3D image of the surgical site through a camera.

“Robotic surgery has reproduced the hand motions of a surgeon,” Morris explains. “It has resulted in greater precision by reducing hand tremor while also providing enhanced visualization via video images. Some surgeons are now doing robotic total joint replacements.”

INCREASING PATIENT SAFETY

Augustine Temperature Management LLC and Augustine Biomedical + Design LLC CEO attributes many advances in surgical technology to an increased emphasis on patient safety.

“ Robotic surgery is rapidly expanding in cardiac, ENT, thoracic and neurosurgery, to name a few.” – GAIL HORVATH imagined this 15 years ago.”

Morris concurs.

“There is a move from invasive to less invasive and even noninvasive surgical procedures,” she says. “Minimally invasive surgery, robotic surgery and tele-surgery are continuing to replace traditional surgical procedures.”

Advancements in surgical technology are allowing shorter hospital stays and lessening patient pain, Morris adds.

“And fewer procedures require general anesthesia during patient treatment,” she says.

Horvath adds hybrid operating rooms to robotics and telesurgery as 48

OR TODAY | June 2017

says Horvath. “I believe the most common robotic surgeries are still in OB/ GYN, general surgery and urology.”

According to Horvath, some believe that within the next three years, nearly one-third of all surgeries will be performed with robotic assistance.

While the term “robotic surgery” often conjures up images of robots in the OR, this isn’t actually the case.

Robotic surgery is performed by highly skilled surgeons using their hand movements to operate robotic arms to control miniaturized instruments.

These instruments are inserted into the patient through a tiny incision, thus making surgery safer and

“This is evidenced by SCIP and PQRS guidelines and by Medicare refusing reimbursement for many surgical complications,” says Augustine. “As an inventor and medical products developer, I have shifted my attention from creating ‘the better mousetrap’ to creating safer products and therapies to improve patient safety.”

One new technology advancement that Augustine is especially excited about is the market transition from forced-air warming (FAW) to air-free warming.

“Forced-air warming has been on the market for 25 years and is a StanWWW.ORTODAY.COM

Also new is a temperature monitor, that measures temperature through the skin.

Augustine believes that virtually every surgical technology in use today – and especially those that have been in use for many years – should be reexamined in light of the admonition to “first do no harm.”

“In my opinion, many of the bigger opportunities for medical device technology in the OR are in the area of infection prevention,” says Augustine.

BORROWING FROM AVIATION Gail Horvath, Patient Safety Analyst IV with the ECRI Institute.

dard of Care, but studies now show that the waste heat from FAW causes contamination of the sterile surgical field,” says Augustine.

Specifically, Augustine points to two separate studies that have linked contamination from waste heat to 74 percent and 78 percent of joint implant infections.

“Clearly, avoiding forced-air warming during joint replacement surgery – or for that matter, probably all implant surgery – is a wise choice for patient safety,” says Augustine. “The obvious solution is air-free warming, which does not produce waste heat.”

Augustine’s company has also created the air-free, electric HotDog warming electric blanket and mattress.

“These are used simultaneously, warming from above and below,” Augustine explains. “This results in roughly twice the warming effectiveness of forced-air water mattresses or other electric mattresses.

“Also, there is no waste heat to cause sterile field contamination,” Augustine adds. “And HotDog blankets are reusable, resulting in 20 percent to 70 percent cost savings compared to forced-air.”

WWW.ORTODAY.COM

In addition to being a surgeon and medical device developer, Fonger is also a commercial airline pilot.

He believes there are many lessons OR personnel can learn from the aviation industry when it comes to the use of technology – primarily in the areas of surgical checklists, automated monitoring and crew resource management.

“Healthcare is far behind aviation when it comes to the use of checklists and automated monitoring,” says Fonger. “For example, an airliner cockpit display only shows about 10 percent of what it’s actually monitoring. There are hundreds of checks going on in the background, but most of these are only displayed if there’s a problem.”

Peering into the future, Fonger believes that augmented reality (AR) and artificial intelligence (AI) will play greater roles when it comes to OR technology.

“These can provide real-time surgical aids,” he says. “For example, AR can show surgeons electronic visual enhancements like checklists and reference materials ‘in the air.’ And AI can make it easier for surgeons to solve problems they encounter on the fly.”

James D. Fonger, MD, Practicing cardiac surgeon for 25 years

If this sounds like a sci-fi movie, it isn’t. Now is the time to start thinking about and preparing for what the future of surgical technology might look like.

“ many of the bigger opportunities for medical device technology in the OR are in the area of infection prevention.”

–DR. AUGUSTINE June 2017 | OR TODAY

49

50 OR TODAY | June 2017

WWW.ORTODAY.COM

NURSING IS MORE THAN EDUCATION SPOTLIGHT ON: LORI McLEER MALONEY, BSN, RN, MBA, CDE, BC-ADM

By Matt Skoufalos

L

ike many nurses, Lori McLeer Maloney came into the profession as a second career. An economist with an MBA to her name, she’d spent a decade in finance and another on the homefront, raising three daughters, before she decided to go back to school for nursing. Making the shift was a challenge, but Maloney said she was motivated to pursue a change because her business career was unfulfilling.

“I didn’t feel like I was making a difference,” she said. “I felt like anybody with the education could have done the job, but I don’t feel like anyone with the education could do a nursing job. What I love about nursing is you can really change people’s lives; it’s very fulfilling.”

Even in her specialty – endocrinology – Maloney believes she’s a part of a field that offers a unique combination of opportunities and responsibilities. In her role at the Clinical Practices of the University of Pennsylvania (CPUP), a comWWW.ORTODAY.COM

ponent of the University of Pennsylvania Health System (UPHS) in Philadelphia, Pennsylvania, Maloney has a job that’s equal parts patient education and laboratory work. Her patients are battling chronic conditions like diabetes, osteoporosis, neuroendrocrine disorders, hypogonadism, metabolic bone disorders and more.

As part of the nurse practitioner program, Maloney participates in clinical evaluations, a primary care rotation, and service in a long-term care facility. Some of the patients she sees are homeless,

have been incarcerated, or rely on Medicaid to pay for their health care. When communicating with a broad cross-section of people who have such a variety of health care concerns, Maloney said she has to provide clear education on lifestyle modification that’s accessible to a range of listeners – particularly as a number of the conditions she treats can worsen without behavioral changes.

“I’m hugely into health behavior and prevention,” Maloney said.

“In my primary care clinic, I’ll see some patients might have prediabetes, and they don’t understand how important it is to stop it where it is. If you’re not making the lifestyle changes to go along with medication, it’s rough. So then I’ll see you in my endocrine practice.”

“These are the patients who are mentally and physically well enough to seek the care of a specialist,” she said. “The ones in my long-term care, the only time they sought care was when they were June 2017 | OR TODAY

51

NURSING IS MORE THAN EDUCATION SPOTLIGHT ON: LORI MCLEER MALONEY

in inpatient; they’re the ones who wind up with amputations.”

Maloney said neglect of nutrition and exercise regimens is “a nationwide crisis.” She encourages her patients to advocate for themselves both in making long-term lifestyle changes and in choosing practitioners who can tailor treatments to their personalities. The behavioral economics of health care are fascinating to her, and the continuity of care that her practice offers allows Maloney to see patients through various stages of their disease and their requisite challenges.

and customizing that motivational approach can truly make the difference between success and failure.

“I genuinely care that my patients are doing well,” Maloney said. “It’s finding what helps the patients to make the changes, and finding why the changes are in their best interests. Your health is not guaranteed, and it can turn on a dime. It should be the asset that you protect the most.”

Maloney describes how one morbidly obese patient who hadn’t gotten out of bed in three years was finally motivated to do so on a handshake. After six weeks of

‘I think I can do it, and I want to shake on it.’ I went back to see her the next week, and she said she wasn’t going to do it. But then she realized that she’d shook on it. And then she got out.”

Maloney plans to continue her nursing education in the coming weeks and months, applying for a doctoral program in either nursing research or nursing practice.

She graduated from the University of Pennsylvania NP program this spring, thanks in no small part to the support of her husband, Ferdinand, she said. Maloney will pursue a research-focused terminal

“ When someone can say you helped make my life better, it’s really fulfilling.”

“I love that I know what’s going on with you, and for the next few months, we’re going to make some changes,” she said. “People have tremendous success when they want to do something. Patients know that they can reach me offhours.”

Maloney said she’s especially interested in social determinants of health, particularly as they influence individual patient behavior.

Food, exercise, and meditation are as much medicine as any pharmaceutical prescription, she said, but finding what works for one patient 52

OR TODAY | June 2017

building a relationship, she worked the woman up to the idea of getting out of bed.

The plan involved switching up the patient’s medication schedule to synchronize its administration with a social coffee hour in the facility. She began a physical therapy routine, started visiting the hair salon with her peers, and started on a path toward a more active lifestyle.

Afterward, the woman started to believe she could take care of her health.

“I said you need to get moving again,” Maloney said. “She said,

degree, as she explores work that will improve health behaviors, and describes herself as an overall advocate for nursing as a career path particularly because of the diversity of options it offers.

“You will always have a busy, varied career,” she said. “You’re never pigeonholed into anything.

And you’re helping people all along the way. When someone can say you helped make my life better, it’s really fulfilling. It’s hard work – they’re long days and they’re not easy days – but it’s very, very rewarding.”

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OUT OF THE OR FITNESS

BY CHRISTOPHER TRAVERS, M.S. PREMIUM HEALTH NEWS SERVICE

4 EASY TIPS TO HELP YOU WALK 10,000 STEPS EVERY DAY

W

alking is one of the easiest and best activities for losing weight and staying fit. To get the most benefit, some organizations recommend that you aim to take 10,000 steps per day. It’s certainly a great goal to strive for.

This magic number of steps is the equivalent of moving almost five miles. When you walk this distance, you will burn somewhere between 35 and 120 calories per mile. It all depends on how well your body adapts to taking on oxygen and using fuel for energy.

BOOST YOUR HEART HEALTH BY WALKING MORE

Moving around is also important for your cardiovascular health. A sedentary lifestyle could lead to health problems, including high blood pressure, high cholesterol and diabetes.

Cardiovascular exercise, such as walking, can lower your resting 54

OR TODAY | June 2017

heart rate, blood pressure, cholesterol and blood sugars while reducing your risk of developing diabetes or heart disease.

It’s not too difficult to reach the 10,000-step milestone on a daily basis. You don’t have to run a marathon. However, attaining this goal for optimal cardiovascular health is meaningless if you are not doing at least 10 minutes of consecutive walking.

You should walk for at least 10 minutes nonstop to consider it as cardiovascular exercise. Don’t worry about how fast you are moving. You don’t have to make it allout intense – just be sure to make it consecutive movement.

REACHING YOUR DAILY AND WEEKLY GOALS – A LITTLE AT A TIME

Here are four simple ways to help you to put in that distance – almost without feeling it – and also obtain the benefits of 10 minutes of consecutive walking: 1. Park in the space farthest from the door in every parking lot.

Whether you’re at the mall, the rec center, your workplace or the grocery store, always park as far away from your destination as possible. . Take the stairs instead of the 2 elevator.

Walking up the stairs will help toward your goal for cardiovascular exercise too. . Use the bathroom farthest from 3 your desk or station at work.

If you work in a large building, this makes a big difference. You can even find bathrooms on other floors in a multi-floor office building – and don’t forget to take the stairs there and back.

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PROOF S . Walk during your lunch hour.

4 PROOF APPROVED CHANGES NEEDED Take 10 minutes from your allowed lunchtime to go for a CLIENT SIGN–OFF: walk, if you are able.

CONFIRM THAT THE FOLLOWING INDUSTRIES ARE CORRECT By the end of the week,PLEASE you want HEALTHMARK | 800.521.6224 | WWW.HMARK.COM LOGO PHONE NUMBER WEBSITE ADDRESS SPELLING GRAMMAR to achieve, at minimum, a total of 150 minutes of consecutive movement. But you don’t have TRIM 4.5” to follow a structured schedule each day.

One day, you may get a 10-minute walk in during lunch and the next day a 45-minute walk in the morning before work. That’s 55 minutes toward your goal of 150 Lightweight minutes. Some days, you may not non-tethered cooling vests with get in those consecutive steps.

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55

OUT OF THE OR HEALTH

BY MARILYNN PRESTON ENERGY EXPRESS

SO YOU WANT TO QUIT SMOKING?

KNOWLEDGE IS POWER

M

aybe you’re following the debate about legalizing marijuana and want to do a little research of your own. In California, it’s now OK to grow six plants per household for your personal use. And if you just want to try a few puffs, for heaven’s sake, there’s something to be said for inhaling.

Here’s what it is: Cannabis can relax you; soothe your pain; heighten your awareness; make you sleepy; make you hungry; or make you mistakenly think what you’ve just said is positively brilliant. But all the research indicates it won’t give you lung cancer, whereas tobacco smoking is very bad for your health. And that’s all I have to say about weed. Today.

What I do want to talk about is the damage that hot nicotine and tar do to your lungs, which brings me to an article I just read in the online British Medical Journal about a way to make quitting a lot easier.

It doesn’t involve pills, patches or hypnosis. Simply have your doctor or community health center give you a 56

OR TODAY | June 2017

lung function test. Discuss the results afterward; that part is crucial. You’ll learn about your true “lung age” in a clear and understandable way. With that new knowledge may come a greater ability to quit.

In the study, significant numbers of smokers who had lung function tests – using a spirometer to measure how fast and how much air a person is able to breathe – were then motivated to quit smoking. And the numbers were much greater than expected.

Why did taking the test matter?

The researchers speculate that smokers who found out their lung function was “normal” realized that they were lucky, and this made it easier to quit while they were ahead. Others

who learned that their lung function was poor realized that more smoking would only make matters worse, and that motivated them to stop.

In both cases, the real gain comes from taking control of your health. The test is a tool to help you make a cleareyed assessment, and from that place of understanding, it’s easier to do the smart thing, the hard thing, the healthy thing. In other words: Knowledge is power.

So, if the pills, patches, chew toys and disapproving stares of the people hurrying by the glass smoking cages in airports haven’t worked, get a lung function test.

Who knows? All your resistance to change may finally go up in smoke.

KNOWLEDGE IS POWER II: WHEN TO QUESTION AUTHORITY

Some time ago I had a cough that persisted, so I started to investigate. That involved going to doctors, having scans and images and even pulmonary function tests like the one above. And then there was the fun experience of having WWW.ORTODAY.COM

HEALTH

a tube inserted into my nose and down my throat.

I’m happy to say everything checked out. No lung cancer. No COPD. No allergies. Nothing bad.

And no acid reflux. But that didn’t stop this handsome young specialist from telling me to start taking Nexium. “It might help,” he said. “It might help?” I said.

“Nexium is a proton-pump inhibitor,” he said. “It’s one of the most popular drugs we have. I don’t know if it will help your cough, but I suggest you give it a try.”

ROVED CHANGES NEEDED “Are there any side effects?” I asked, shamelessly setting a trap for OFF: the doctor, who had come so highly CONFIRM THAT THE FOLLOWING ARE CORRECT recommended.

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“Nothing to worry about,” he said.

I wouldn’t dare tell you what “No side effects?” drugs to take or refuse, but I will “No. And it might help.” say that Americans take more drugs I didn’t take the drug, and I never per capita than other people in the saw that guy again. I should have world because our doctors prereported him to the principal. While scribe them. I won’t say take mediother people are doing crossword cal advice willy-nilly, but I will say puzzles, I amuse myself with news be vigilant. Do your homework. about medical issues, and I know very Question authority. well that proton-pump inhibitors have serious side effects. They’ve been Marilynn Preston is a healthy lifestyle linked to a higher risk of bone fracexpert, well-being coach and Emmytures, pneumonia and heart problems, winning producer. She is the creator SHEET PROOF S and recently, aPROOF study in JAMA Internal of Energy Express, the longestMedicine reported that the use of these running syndicated fitness column PROOF APPROVED drugs is associated with a CHANGES 20 to 50 NEEDED in the country. She has a website, percentSIGN–OFF: increase in the risk of develop- marilynnpreston.com, and welcomes CLIENT ing chronic kidney disease. Twenty to reader questions, which can be sent PLEASE CONFIRM THAT THE FOLLOWING ARE CORRECT 50 percent! to MyEnergyExpress@aol.com.

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June 2017 | OR TODAY

57

OUT OF THE OR NUTRITION

BY PREMIUM HEALTH NEWS SERVICE

FAT, SALT AND CARBS

CAN BE GOOD FOR YOU?

W

hen it comes to healthy eating, the villains are constantly changing.

It used to be fat that was the bad guy. So people started eating fat-free crackers, low-fat cookies and other carb-heavy foods that left them feeling hungry.

Then carbs came under fire, and people flocked to fat-and-protein heavy diets.

“I’m not sure the pendulum has stopped swinging yet because we’re still talking about all these different things,” said Liz Reid, a clinical dietician at Penn State Children’s Hospital.

“I think often we look at food and pull out one or two nutrients and say that is the whole story,” she said. “What we need to talk about is not only what is in food, but how to nourish ourselves – not just getting the essential nutrients, but getting them in a way that is satisfying so we stop thinking about food so much – when we ate last, when we’re going to eat and how many calories we’re eating.”

So, instead of billing fat, salt and sugar as an evil trifecta, Reid suggests 58

OR TODAY | June 2017

it’s more useful to understand their role in a balanced diet.

Fats are necessary because they are part of all cell membranes in the body, and part of hormones and neurotransmitters, she said. Health professionals have divided fats into good and bad categories, working to wipe out saturated and trans fats, while encouraging consumption of especially omega-3 fatty acids and unsaturated fatty acids that come from foods such as walnuts, fatty fish, avocados, flaxseed, sunflower and olive oil.

“You need fat to absorb fat-soluble vitamins like A, D, E and K,” Reid said.

“That’s why some health professionals would recommend that it’s better to use full-fat items sometimes rather than fat-free ones that are loaded with sugar and chemicals.”

Some shelf-stable baked goods add gums, gels and stabilizers to replace the fat, and they can upset the stomach. Or, they have hydrogenated oils and fats.

“No one thinks those are good for you,” Reid said.

Items such as salad dressings may add artificial sweeteners, colors and sugars to make up for less fat.

“You’re better off making your own,” she said.

When it comes to salt, up to 3,000 mg a day is fine for most Americans.

The trend toward sea salt and Kosher salt may help you be satisfied with less, but because those salts don’t contain the iodine of table salt, you’d need to get it through other sources such as fish or vegetables. Iodine is necessary for production of thyroid hormones, which control metabolism and other bodily functions.

The glucose that comes from sugar and carbs is important for the brain and other organs, but Reid urges people to be smart about where their glucose comes from.

“You want to get carbohydrates from whole grains, vegetables and fruits and eat more whole foods and fewer processed foods,” she said.

Although fruit has natural sugars, it also provides fiber and antioxidants that are important for the body. Reid advocates getting that sugar from whole fruit and getting your fluid requirement met with water rather than juice.

In general, Reid recommends eating a variety of foods, including local produce, when possible.

“You can never go wrong with more fruits and vegetables,” she said.

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SEE US AT APIC BOOTH 637

OUT OF THE OR RECIPE

BY DIANE ROSSEN WORTHINGTON

60 OR TODAY | June 2017

WWW.ORTODAY.COM

RECIPE

DELICIOUS PASTA DISH CREATES OUT-OF-THISWORLD TASTE MEMORY

W

hen I travel, I try and find recommendations for great restaurants. On a recent trip to Venice, I visited a suggested trattoria that serves an amazing lemon pasta dish. It wasn’t on the menu that day, but I asked if the chef could prepare it for me.

When it arrived, the sweet lemon fragrance was overwhelming. Biting into it, I experienced perfectly cooked al dente pasta enrobed with an ethereal citrus cream. It is one of those dishes that has been permanently engraved in my memory.

Those wide ribbons of pasta cloaked with a fragrant and citrus-flavored light cream sauce was a taste memory I wouldn’t forget.

I recently had a hankering to recreate that pasta and wanted a sauce that would easily cling to the pasta strands. Mascarpone seemed to be a good solution. It offers a creamy texture with a faint cheese flavor and mingles beautifully with the lemon

and leeks. And, of course, mascarpone is Italian; although California has a good American version.

You could use fresh pasta, if you prefer, but I tested it with De Cecco pappardelle and it was excellent. You could also add grilled shrimp or scallops to the dish; simply grill or sauté the seafood and top the pasta with a few pieces.

This is a perfect Sunday brunch or light dinner. I like to serve this beginning with an arugula salad featuring spring radishes, avocado and toasted almonds. A chilled Italian pinot grigio, Spanish Albino or a red like a simple Valpolicella would be a lovely accompaniment.

DIRECTIONS 1. In a large sauté pan, heat 2 tablespoons oil over medium heat and sauté the leeks for 5 to 6 minutes, or until soft and golden brown. Add the garlic and sauté another minute. Lower heat and add the lemon zest, juice, mascarpone, nutmeg and salt and pepper, and stir until mascarpone mixture becomes sauce-like. Add the parsley and set aside.

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2. Cook the pasta according to the directions on the package (about 6 minutes) until al dente.

Reserve 1/2 cup of pasta water and drain pasta. Transfer to the sauté pan with the sauce and use tongs to combine the pasta until completely coated. Taste for seasoning.

3. Arrange pasta equally in shallow pasta bowls and garnish with chives. Serve immediately.

iNGREDIENTS Pappardelle with Lemon Mascarpone Cream and Caramelized Leeks Serves: 2 for main course, 4 for appetizer 2 tablespoons olive oil 2 medium leeks, white and light green parts only, cleaned and finely chopped 2 medium garlic cloves minced Zest of 2 lemons 1/4 cup lemon juice 8 ounces mascarpone, softened 1/4 teaspoon freshly ground nutmeg Salt Freshly ground black pepper 2 tablespoons finely chopped Italian parsley 8 ounces dried pappardelle 2 tablespoons finely chopped chives, for garnish

Diane Rossen Worthington is an authority on new American cooking. She is the author of 18 cookbooks, including “Seriously Simple Parties,” and a James Beard Award-winning radio show host. You can contact her at www.seriouslysimple.com.

June 2017 | OR TODAY

61

S A V E T H E D AT E

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OUT OF THE OR PINBOARD

PINBOARD

The News and Photos That Caught Our Eye This Month

OR TODAY

CONTESTS • JUNE • ARE YOU IN THE KNOW?

Have you attended an OR Today webinar? Email a photo of yourself with a workbook from any OR Today webinar to Editor@MDPublishing.com to be entered to win lunch for your department. One lucky person will win a $50 gift card to Subway! Find out more about the OR Today webinar series, including workbooks and a calendar of upcoming webinars, at www.ORToday.com/Webinars.

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OR TODAY | June 2017

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THE ANNUAL OR TODAY LIVE SURGICAL CONFERENCE ( AUGUST 27-29 ) will bring together perioperative leaders and the professionals called on to manage the business decisions and patient care within the OR. In the current health care era, leaders are being called upon to establish quality-focused practices and strategies. OR Today Live offers an exciting opportunity to learn from industry leaders, address challenges, network with influential colleagues, hone management skills, discover new resources and deliver solutions to improve the performance of your facility.

OR Today Live offers quality Continuing Education from an approved and licensed Provider with the State of California Board of Registered Nursing; License No. CEP 16623.

Find out more and register to reserve your spot at ORTodayLive.com.

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PINBOARD

FEAR: THE HIDDEN KILLER Hi, this is Chet Wyman, from Baltimore, Maryland. What you didn’t read about me in my bio is five years ago, on April 1, I was diagnosed with acute promyelocytic leukemia.

Now, as a physician at Johns Hopkins Medicine there was no doubt in my mind that I would be receiving world-class medical care, and yet at the same time I was aware of some very disturbing statistics. For example, one out of five of your patients will have a medication error while in your hospital. Forty-nine times this week we will inadvertently leave something in a patient during surgery and 3.1 million individuals will develop hospital-acquired infections. And sadly, 200,000 people that entrusted us with their lives will lose their lives, probably due to a medical error.

Now, you have to ask yourself, how is this possible? Are we not smart enough? Do we just not care enough? Are we not working hard enough?

Sadly, I don’t think any of those are the answer. I think it’s because we are afraid. People are afraid to hold difficult conversations.

People are afraid to hold others accountable. People are afraid to embrace the messenger, especially when they bring us a message that Chet Wyman we don’t necessarily want to hear.

People are afraid to engage in meaningful constructive conflict.

Please, join me at at OR Today Live!, where we will engage in a very meaningful, engaging, lively and, hopefully, entertaining, discussion on fear: – the hidden killer. I hope to see you there.

Learn more at ortodaylive.com

DECODING FOOD LABELS Food-ingredient labels are getting shorter. Why? Because the people have spoken: We want fewer, better ingredients in our foods. We asked, and the companies that make our food responded by replacing artificial colors and flavors, removing what’s unessential, and using naturally derived ingredients.

But even shorter “clean” labels can still read like a technical manual.

Which isn’t necessarily a bad thing – just because a food ingredient is unfamiliar or has a difficult-to-pronounce name doesn’t mean it’s not good for you.

For instance, you might not have heard of cholecalciferol, and it sounds a little scary. But cholecalciferol is just another name for Vitamin D. You might not have heard of rickets, either; that’s because this once-common childhood disease became nearly

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which labels ar e “clean?”

obsolete when Vitamin D, which prevents rickets, was added to milk (Vitamin D also helps our bodies absorb the calcium in milk).

Another ingredient with a somewhat strange name is carrageenan. This seaweed-based ingredient makes some of our favorite foods more nutritious. It replaces the sodium in lunch meat and can take the place of fats, oils and sugar, which is why that nonfat yogurt you had for lunch tastes just as good as the full-fat option, without the guilt.

Microcrystalline cellulose (MCC)

might look like a mouthful, but MCC – also called cellulose gel – is just cellulose derived from fruits, vegetables and trees. Cellulose, which is the most common organic compound on earth, is one of only seven FDA-approved sources of fiber. So when microcrystalline cellulose or cellulose gel appears on a food label, it means your food contains the same plant fiber found in broccoli and apples.

Understanding what goes into our food is important. But it’s also important that we don’t say “no” to a product just because we don’t recognize every ingredient on its label. When we research the ones we’re not familiar with, we might come to find that those “scary additives” are actually delicious gifts from nature.

To learn more about what’s in your food, visit foodsciencematters.com.

– Brandpoint

June 2017 | OR TODAY

65

INDEX ALPHABETICAL AAAHC……………………………………………………………17 AIV Inc.………………………………………………………… 16 Ansell…………………………………………………………… 10 ASCA…………………………………………………………… 62 Augustine Temperature Management…… 45 Belimed………………………………………………………… 23 C Change Surgical………………………………………… 9 Calzuro.com………………………………………………… 44 Cincinnati Sub-Zero…………………………………… 24

Cygnus Medical……………………………………………… 5 Encompass Group……………………………………… 63 Healthmark Industries Company, Inc.… 4,55 Innovative Medical Products…………………… BC Innovative Research Labs………………………… 19 Jet Medical Electronics Inc…………………………21 MAC Medical, Inc……………………………………… IBC MD Technologies inc.……………………………………21 Medi-Kid Co.………………………………………………… 57

MedWrench………………………………………………… 62 Pacific Medical……………………………………………… 6 Palmero Health Care………………………………… 13 Paragon Services………………………………………… 31 Polar Products…………………………………………… 55 Ruhof Corporation……………………………………… 2,3 Sealed Air…………………………………………………… 59 TBJ Incorporated………………………………………… 53 Tetra……………………………………………………………… 57

Encompass Group……………………………………… 63 Healthmark Industries Company, Inc.… 4,55 Palmero Health Care………………………………… 13 Ruhof Corporation……………………………………… 2,3 Sealed Air…………………………………………………… 59 TBJ Incorporated………………………………………… 53

RESPIRATORY Innovative Research Labs………………………… 19

CATEGORICAL ANESTHESIA Augustine Temperature Management…… 45 Innovative Research Labs………………………… 19 Paragon Services………………………………………… 31 ASSOCIATION AAAHC……………………………………………………………17 ASCA…………………………………………………………… 62 CARDIAC PRODUCTS C Change Surgical………………………………………… 9 Jet Medical Electronics Inc…………………………21 CARTS/CABINETS Cincinnati Sub-Zero…………………………………… 24 Cygnus Medical……………………………………………… 5 Healthmark Industries Company, Inc.… 4,55 MAC Medical, Inc……………………………………… IBC TBJ Incorporated………………………………………… 53 CRANIOFACIAL RECOVERY PRODUCTS Medi-Kid Co.………………………………………………… 57 CRITICAL CARE Innovative Research Labs………………………… 19 DISINFECTANTS Cygnus Medical……………………………………………… 5 Palmero Health Care………………………………… 13 Ruhof Corporation……………………………………… 2,3 Sealed Air…………………………………………………… 59 ENDOSCOPY Cygnus Medical……………………………………………… 5 Healthmark Industries Company, Inc.… 4,55 Ruhof Corporation……………………………………… 2,3

INSTRUMENT STORAGE/TRANSPORT Belimed………………………………………………………… 23 Cygnus Medical……………………………………………… 5 MONITORS Pacific Medical……………………………………………… 6 ONLINE RESOURCE MedWrench………………………………………………… 62 OR TABLES/BOOMS/ACCESSORIES Innovative Medical Products…………………… BC OTHER AIV Inc.………………………………………………………… 16 Ansell…………………………………………………………… 10 PATIENT DATA MANAGEMENT MAC Medical, Inc……………………………………… IBC PATIENT MONITORING AIV Inc.………………………………………………………… 16 Jet Medical Electronics Inc…………………………21 Pacific Medical……………………………………………… 6 PATIENT WARMING Encompass Group……………………………………… 63 PEDIATRICS Medi-Kid Co.………………………………………………… 57

FALL PREVENTION Encompass Group……………………………………… 63 Footwear Calzuro.com………………………………………………… 44

POSITIONING PRODUCTS Cygnus Medical……………………………………………… 5 Innovative Medical Products…………………… BC Medi-Kid Co.………………………………………………… 57

GENERAL AIV Inc.………………………………………………………… 16

REPAIR SERVICES Cygnus Medical……………………………………………… 5 Jet Medical Electronics Inc…………………………21 Pacific Medical……………………………………………… 6

INFECTION CONTROL Belimed………………………………………………………… 23 Cygnus Medical……………………………………………… 5

66

OR TODAY | June 2017

SAFETY GEAR Calzuro.com………………………………………………… 44 Healthmark Industries Company, Inc.… 4,55 SINKS/REPROCESSING STATIONS TBJ Incorporated………………………………………… 53 STERILIZATION Belimed………………………………………………………… 23 Cygnus Medical……………………………………………… 5 Healthmark Industries Company, Inc.… 4,55 TBJ Incorporated………………………………………… 53 SURGICAL INSTRUMENT/ACCESSORIES C Change Surgical………………………………………… 9 Cygnus Medical……………………………………………… 5 Healthmark Industries Company, Inc.… 4,55 TELEMETRY AIV Inc.………………………………………………………… 16 Pacific Medical……………………………………………… 6 TEMPERATURE MANAGEMENT Augustine Temperature Management…… 45 C Change Surgical………………………………………… 9 Cincinnati Sub-Zero…………………………………… 24 Encompass Group……………………………………… 63 MAC Medical, Inc……………………………………… IBC Polar Products…………………………………………… 55 WARMERS Belimed………………………………………………………… 23 Cincinnati Sub-Zero…………………………………… 24 MAC Medical, Inc……………………………………… IBC WASTE MANAGEMENT MD Technologies inc.……………………………………21 Sealed Air…………………………………………………… 59 TBJ Incorporated………………………………………… 53 WOUND MANAGEMENT Tetra……………………………………………………………… 57

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