OR Today - March 2018

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Baby Boomers

Beth Ann Swan

Lower Extremities

FITNESS

SPOTLIGHT ON

CE ARTICLE

MARCH 2018

IMPROVING TEAM

COMMUNICATION

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OR TODAY | March 2018

contents features

44 IMPROVING TEAM COMMUNICATION

IMPROVING TEAM

New AORN guideline champions communication skills and error avoidance in the operating room. OR Today takes a closer look at the new guideline and shares insight from lead author and AORN Perioperative Practice Specialist Mary C. Fearon, MSN, RN, CNOR.

COMMUNICATION SURGICAL CONFERENCE

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Everyone who works in a perioperative setting (surgical services leaders, nurse managers, charge nurses, specialty coordinators, PACU nurses, CRNAs, and CS/SPD professionals) can benefit from attending the annual OR Today Live!

Surgical Conference.

The global surgical instruments/equipment market is anticipated to reach a value of $20.3 billion by 2025. An increasing number of minimally invasive surgeries across the globe is anticipated to fuel the growth.

Patients undergoing surgical procedures under general, regional, or sedation anesthesia are at risk for nerve and vessel injuries due to the loss of protective reflexes. This educational activity will address the location of these structures and address positioning during anesthesia to prevent injuries.

OR TODAY LIVE!

SURGICAL INSTRUMENTS

CE ARTICLE

OR Today (Vol. 18, Issue #03) March 2018 is published monthly by MD Publishing, 18 Eastbrook Bend, Peachtree City, GA 30269-1530. POSTMASTER: Send address changes to OR Today at 18 Eastbrook Bend, Peachtree City, GA 30269-1530.

For subscription information visit www.ortoday.com. The information and opinions expressed in the articles and advertisements herein are those of the writer and/or advertiser, and not necessarily those of the publisher. Reproduction in whole or in part without written permission is prohibited. Š 2018

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MARCH 2018 | OR TODAY |

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contents features

PUBLISHER John M. Krieg

john@mdpublishing.com

60

VICE PRESIDENT Kristin Leavoy

PINBOARD

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Each month we post the news and photos that caught our eye. Be sure to enter the photo contest this month!

EDITOR John Wallace

jwallace@mdpublishing.com

ART DEPARTMENT Jonathan Riley Karlee Gower Kathryn Keur

ACCOUNT EXECUTIVES Lisa Gosser

lgosser@mdpublishing.com Jayme McKelvey

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ACCOUNTING Kim Callahan

DIGITAL SERVICES

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Learn about Beth Ann Swan’s career path as a nurse!

Cauliflower, Mushroom and Pea Risotto

SPOTLIGHT ON

RECIPE OF THE MONTH

Travis Saylor Cindy Galindo Jena Mattison

CIRCULATION Lisa Cover Melissa Brand

INDUSTRY INSIGHTS 10 News & Notes 19 OR Today Live!

IN THE OR

VISIT OR TODAY AT AORN BOOTH #329!

WEBINARS Linda Hasluem

MARCH 24–28, 2018 NEW ORLEANS, LA

22 Suite Talk 25 Market Analysis 26 Product Focus 34 CE Article MD PUBLISHING | OR TODAY MAGAZINE

OUT OF THE OR 50 Fitness 52 Health 54 Nutrition 56 Recipe 60 Pinboard 66 Index

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INDUSTRY INSIGHTS

news & notes

New Device for Feeding and Medication Administration Medical device firm Attune Medical has received 510(k) clearance from the U.S. Food and Drug Administration (FDA) for a new EnsoETM model capable of administering tube feeds and/or medication while simultaneously cooling or warming patients using the esophageal space.

The newly-cleared model of EnsoETM, which manages patient temperature through the esophagus, allows for enteral fluid administration with the ENFit connector while managing the important task of temperature management through the patient’s core. With this new extension of the EnsoETM product line, the need for a separate feeding tube is eliminated, and clinicians can leverage the EnsoETM for comprehensive temperature management as well as gain compliance with an increasingly accepted standard of care using the ENFit connector.

“Attune Medical is focused on developing innovative targeted temperature management products with increasingly useful clinical features such as this new capability to administer tube feeds and medication through our device, all while delivering a safe, cost-effective and now more comprehensive alternative to other targeted temperature management options,” commented Attune Medical’s Chief Executive Officer Keith Warner. •

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New 7-Day Indicator Hangtime Label Healthmark is pleased to announce the addition of a new 7-Day Time Indicator Hangtime Label to its endoscopy product line.

Designed as a visual reminder for health care workers, the 7-Day Indicator Hangtime Label features a 7-day elapsed time indicator adhered to a green 8.5 x 2.5 inch self-looping label. To activate the indicator simply press the blister on the strip, and upon activation a safe dye migrates along a seven-day display run-out window, which shows elapsed time. No preconditioning is required, there are no moving parts, and no power source is required. • For information, visit www.hmark.com.

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INDUSTRY INSIGHTS

news & notes

Biodex Highlights Surgical C-Arm Tables Last November at McCormick Place in Chicago, Biodex Medical Systems Inc. joined more than 650 leading manufacturers, suppliers and developers of medical information and technology at the world’s largest medical equipment exhibition, RSNA Annual Meeting.

The medical manufacturing company highlighted the latest enhancements to its line of surgical C-arm tables, including unique motion capabilities intended to enhance quality in medical imaging.

Available for hands-on demonstrations was the Biodex Surgical C-Arm Table 840 – a stable, accessible and vibration-free fluoroscopic table designed to keep a patient at exactly the right position and angle for a cardiovascular procedure. Features such as a stainless steel base, larger

radiolucent area, exclusive SmoothGlide movement and more finite controls have been added to the table design to help ensure a clear image.

A standout capability of this table is the isocentric lateral roll motion, a movement that maintains image center during tabletop motion, minimizing image distortion. RSNA attendees were invited to the Biodex booth to view the table in action.

“We were very excited to bring this line of tables to market,” said Rich Schubert, senior product sales manager for medical imaging at Biodex. “Our goal is always to improve the imaging process for our customers and their patients. That’s what these new enhancements are all about.” • For more information, visit http://www.biodex.com/c-arm.

Baxter to Broaden Portfolio of Surgical Products Baxter International Inc. has announced an agreement to acquire two hemostat and sealant products from Mallinckrodt plc: RECOTHROM Thrombin topical (Recombinant), the first and only stand-alone recombinant thrombin, and PREVELEAK Surgical Sealant, which is used in vascular reconstruction.

“Uncontrolled intraoperative bleeding can lead to a wide variety of clinical and economic complications for patients and hospitals. As a provider of advanced hemostats and sealants, Baxter is focused on continually identifying solutions to help meet surgeons’ varying needs,” said Wil Boren, president of Baxter’s Advanced

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Surgery business. “We are excited about the addition of RECOTHROM to help surgeons address less severe intraoperative bleeding and PREVELEAK to complement Baxter’s existing portfolio of sealants for cardiovascular and other surgical specialties.”

The transaction is expected to close in the first half of 2018, subject to the expiration of the waiting period under the Hart-Scott-Rodino Antitrust Improvements Act and other customary closing conditions. •

MARCH 2018 | OR TODAY |

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INDUSTRY INSIGHTS

news & notes

Hologic Receives CE Mark for MyoSure MANUAL Device in Europe Hologic Inc. has announced that the MyoSure MANUAL device, which was designed to simplify tissue removal procedures regardless of setting, has received CE mark in Europe. The MyoSure MANUAL device joins the MyoSure suite of gynecologic surgical products that offer simple and effective solutions to resect and remove tissue.

Hologic offers the complete MyoSure system, which is a minimally invasive hysteroscopic treatment for women with problematic tissue that requires no cauterization, ultimately preserving uterine form and function. The system enables quick and convenient removal of tissue, including a range of fibroids and polyps that may be the root cause of abnormal uterine bleeding (AUB), which affects up to 30 percent of pre-menopausal women.

“There is an increased demand to simplify tissue removal procedures regardless of where they are being performed, inoffice or in the theater. We continuously look to meet this need by developing innovative solutions that provide flexibility and convenience for both physicians and patients in any setting,”

said Edward Evantash, M.D., medical director and vice president of medical affairs, Hologic. “The MyoSure MANUAL device is designed to simplify tissue removal procedures in theatre, ambulatory or outpatient settings, requiring minimal set up and no fluid management capital equipment, while offering direct visualization when used with the MyoSure hysteroscope.”

The MyoSure MANUAL device has a fully integrated vacuum with no external suction required. It involves the support of a one-liter saline bag – there is no need for a controller or additional fluid management capital equipment. The clear tissue trap allows visual confirmation of tissue removed during the procedure and holds up to 4g of tissue; it also detaches to send to pathology. In addition, the MyoSure MANUAL device gives physicians multi-function control of the 360-degree blade. Other devices in the MyoSure suite of products include the MyoSure, MyoSure REACH, MyoSure XL and MyoSure LITE devices. •

Miami VA Healthcare System Adds LiveData PeriOp Planner LiveData Inc. announced that the Miami Department of Veterans Affairs health care facility has added LiveData PeriOp Planner to the medical center’s LiveData PeriOp Manager workflow solution.

PeriOp Planner is a web-based solution that front-ends and synchronizes surgical scheduling enhancing the patient’s journey from surgical consultation through preoperative steps to the scheduled day-of-surgery. LiveData partner Document Storage Systems Inc. (DSS) integrated PeriOp Planner with existing solutions and installed it in clinic offices and OR suites.

PeriOp Manager integrates patient information and perioperative case workflow to allow visual management both by the patient’s clinical team, as well as by other caregivers throughout

12 | OR TODAY | MARCH 2018

the VA Healthcare System. With PeriOp Planner, clinic staff can track and remind patients to complete labs or consults prior to surgery, or determine if anticipated surgical dates need to be changed. Hospitals and operating room schedulers can easily view and search patients’ preoperative work plans to improve case forecasting, fill surgical blocks, and identify potential cancellations.

“We implemented LiveData PeriOp Manager to streamline clinical workflows and improve access to surgical care for our veterans in the Miami area,” said Dr. Seth A. Spector, chief of surgery, Miami VA Healthcare System. “With the addition of PeriOp Planner, patients arrive at medical centers prepared for surgery, and last-minute delays and cancellations are avoided.” •

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RTI Surgical Acquires Zyga Technology Inc. RTI Surgical Inc. has signed an agreement to acquire Zyga Technology Inc., with closing subject to filing with the state of Delaware. Zyga Technology is a spinefocused medical device company that develops and produces minimally invasive devices to treat underserved conditions of the lumbar spine. Zyga Technology’s primary product is the SImmetry Sacroiliac Joint Fusion System.

“Acquiring Zyga Technology further advances our strategic transformation focused on reducing complexity, driving operational excellence and accelerating growth,” CEO Camille Farhat said. “We are increasing our focus on both internal development and external investment, and acquiring Zyga Technology’s innovative minimally invasive treatment both accentuates our robust spine portfolio and opens significant opportunities to accelerate growth.”

Zyga Technology is a private company with approximately 30 employees and approximately $4 million in annual revenue. Upon closing, RTI Surgical will fund the acquisition through a combination of cash and borrowing under its existing credit facility.

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INDUSTRY INSIGHTS

news & notes

Masimo Announces CE Marking of Oxygen Reserve Index rainbow Lite Sensors Masimo recently announced the CE marking and release of RD rainbow Lite SET sensors, which enable the monitoring of Masimo Oxygen Reserve Index (ORi) and RPVi, an improved PVi that allows clinicians to assess fluid responsiveness noninvasively and continuously at a fraction of the cost of invasive methods, and at a fraction of the cost of rainbow sensors. rainbow Lite sensors utilize twice as many wavelengths of light as SET sensors, allowing rainbow Lite sensors to provide ORi and RPVi along with Masimo SET Measure-through Motion and Low Perfusion pulse oximetry.

ORi is the first noninvasive and continuous parameter to provide insight into a patient’s oxygen reserve in the moderate hyperoxic range. In conjunction with SET pulse oximetry, ORi may provide advanced warning of impending desaturation, which may allow clinicians to intervene sooner.

For example, in a study of 25 pediatric patients undergoing general anesthesia with orotracheal intubation, researchers found that ORi helped clinicians identify impending desaturation a median of 31.5 seconds before noticeable changes in oxygen saturation (SpO2) occurred. In another recent study of 106 adult patients scheduled for surgery with arterial catheterization and intraoperative blood gases analyses, researchers found a significant relationship between change in PaO2 and change in ORi. In addition, ORi may provide insight into oxygen reserve when titrating patients who are receiving supplemental oxygen. “rainbow Lite sensors allow clinicians, who depend on powerful SET pulse oximetry technology, to augment their patient monitoring with ORi and newly introduced RPVi. Given the positive reception of ORi in available markets, and feedback from clinicians who see great value in the benefits of ORi monitoring, we are excited to make ORi and RPVi accessible via the cost-effective solution represented by RD rainbow Lite SET. Hospitals that standard-

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ize on RD rainbow Lite SET will pay only nominally more per sensor than for SET,” Masimo CEO Joe Kiani said.

Masimo RPVi is a multi-wavelength version of Pleth Variability Index (PVi). RPVi is designed to provide enhanced assessment of changes in fluid volume compared to PVi5, which has been shown in over 90 independent clinical studies to be as effective as invasive monitoring methods.6 With the addition of RD rainbow Lite SET, the RD family of sensors is now available in three levels of capability: RD SET, utilizing two wavelengths (2 LED) and featuring SET pulse oximetry; RD rainbow Lite SET, which utilizes four wavelengths (4 LED) and adds the ability to measure ORi and RPVi; and RD rainbow SET, which utilizes over seven wavelengths (7+ LED) and enables the measurement of additional advanced noninvasive parameters such as SpHb (total hemoglobin), SpCO (carboxyhemoglobin), SpMet (methemoglobin) and SpOC (oxygen content).

Devices with ORi and RPVi measurements and RD rainbow Lite SET sensors have not received FDA 510(k) clearance and are not available for sale in the United States. •

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INDUSTRY INSIGHTS

news & notes

U.S. DoD Expands Standardization of ZOLL’s Propaq Technology ZOLL Medical Corporation has announced the receipt of a sole source contract from the Defense Logistics Agency to supply Propaq M deployable vital signs monitors to the U.S. Air Force and the U.S. Army.

The Propaq M, selected as the joint “Product of Choice,” is an advanced vital signs transport monitor, with capabilities far beyond the Propaq Encore 206, which has been the tried and trusted vital signs monitor serving the U.S. military over the last 25 years.

The Propaq M was designed specifically for the rigors of military operations in the most austere environments. The Propaq M can be equipped with an integrated defibrillator and pacer for critical lifesaving mission readiness. This con-

figuration, known as the Propaq MD, eliminates the need to carry a separate monitor and defibrillator to improve operational efficiencies. During the competitive evaluation period, military subject matter experts stressed the importance of printing the 12 Lead ECG report and related patient data directly from the vital signs monitor. The Propaq M is the only airworthy vital signs monitor that is available with an integrated printer, thereby allowing the services to reduce size, weight and cube by eliminating the need to carry a separate standalone printer. •

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INDUSTRY INSIGHTS

news & notes

VITOM 3D System Receives Innovative Technology Designation KARL STORZ Endoscopy-America Inc. has announced that its VITOM 3D system for visualization in microsurgery and open surgical procedures has received a 2017 Innovative Technology designation from Vizient Inc. The designation was based on direct feedback from hospital experts who interacted with the new VITOM 3D system at the Vizient Innovative Technology Exchange in Denver on September 14, 2017.

The VITOM 3D system represents a revolutionary solution for the visualization of microsurgical and open procedures in a range of medical specialties.

The compact technology optically magnifies the surgical field, enabling the entire surgical team to directly observe procedures on a 3D monitor. The VITOM 3D system offers a high level of

user friendliness owing largely to improved ergonomics. A modular system design helps support efforts to increase efficiency while reducing procedure cost.

With its U.S. release of the VITOM 3D system, KARL STORZ now provides three-dimensional visualization capabilities for performing delicate surgical tasks

required for precision surgery. Using the new system, surgeons gain the advantages of enhanced depth perception to better distinguish distances between anatomical structures. Several current Vizient Inc. member hospital organizations were among the first U.S. early adopters of VITOM 3D technology. •

Surgery Center Demonstrates Excellence in Orthopaedic Care Surgery Center of Long Beach (SCLB), an AMSURG-affiliated ambulatory surgery center (ASC) in Long Beach, California, has received the first ever Center of Excellence Award in Orthopaedic Certification by the Accreditation Association for Ambulatory Health Care (AAAHC) for its high-quality orthopaedic services.

“The Orthopaedic Certification validates Surgery Center of Long Beach’s expertise in advanced orthopaedic procedures and commitment to providing quality care,” said Troy Sparks, BSN, RN, CNOR, regional vice president and total joint program coordinator for AMSURG. “As an industry leader in outpatient ser-

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vices, AMSURG holds all of our partnering centers to extremely high standards, and SCLB consistently demonstrates our patient-centered approach and adherence to strict quality measures. We are proud to support the center and congratulate the team on this major accomplishment.”

AAAHC develops standards that advance patient safety and quality care and accredits a wide range of outpatient settings. The certification program expands upon the AAAHC ASC Accreditation and was designed in response to a growing number of total joint replacements being performed in ASCs. To achieve certification and become a Center of Ex-

cellence, ASCs must be accredited and meet a number of criteria, including the credentialing of providers, rigorous patient screenings and the practice of evidence-based medicine.

The new program has two levels of certification – specialty and advanced specialty. Surgery Center of Long Beach achieved the advanced specialty certification, which establishes the center’s ability to perform complex procedures safely and effectively as well as care for patients that are more complex.

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INDUSTRY INSIGHTS

or today

SURGICAL CONFERENCE

10 Reasons Every Perioperative Nurse Should Attend OR Today Live!

By David Taylor, MSN, RN, CNOR aking care of today’s patients requires more knowledge than nurses can obtain from their basic education or through their daily experience at the bedside. Licensed professionals have an obligation to seek out learning opportunities that will ensure they have the necessary competence to provide effective nursing care. One way to keep up with evidence based practice standards is to attend a conference.

T

Because our profession and the perioperative nursing specialty is continuously evolving, it requires nurses to seek upto-date information. They must educate themselves with what’s relevant and what they can use in their daily practice while providing the very best to their patients. That is why I am so passionate about the OR Today Live! Surgical Conference and why I feel every perioperative nurse should attend. It is important to me that my colleagues have the tools they need to do their job. It is about working smarter not harder, especially in an industry that seems to be changing right before our eyes. OR Today has been around for nearly 20 years and has provided readers with relevant information that educates and provides practical information for career building, problem solving and overall well-being.

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As a nurse and surgical services leader, I feel fortunate and honored to chair the OR Today Live! educational advisory board. The board is made up of perioperative professionals just like you – our readers. The board represents nurses and thought leaders working in the ambulatory market, education, CS/ SPD, the military, certification/credentialing and leadership segments of health care. Each brings an expertise to the table that speaks on behalf of nurses working in those areas. The focus is finding the best speakers in the industry and bringing them to OR Today Live! so they can present relevant information that attendees can use once they return to their organizations.

If you work in the perioperative setting or are a nursing student considering a perioperative career, you don’t want to miss OR Today Live!

If you have been to one of the OR Today Live! conferences, you know how impactful it can be. If you have never been, or have not been in several years, you’re going to want to be a part of the Nashville show in August.

budget, far too many nurses will not have the opportunity to attend a regional or national nursing conference. More nurses now have to foot the bill if they want to explore new educational opportunities. I personally feel the OR Today Live! Surgical Conference brings incredible value for attendees in time and education, as well as in dollars spent for what you have available.

Estimated Cost to Attend AORN Global Surgical Conference and Expo

• • • • • • • • •

Total ~$2,694-3,414

Reason #10 Value: The OR Today Live! Surgical Conference is a tremendous value. It is a fraction of the cost of other conferences. Attending the OR Today Live! Surgical Conference is so affordable that you can afford to bring a friend, or several, and provide a tremendous experience for your entire team. In today’s health care climate and limited budgets, one of the first things cut is education. And with no education

Registration: $615-$950 AORN Foundation Night Out in NOLA Party: $35 AORN Foundation Night Out in NOLA T-Shirt: $20 AORN Foundation Steps to Health Challenge: $20 AORN Foundation Yoga Fitness Class: $20 AORN Foundation Zumba Fitness Class: $20 5 Nights in NOLA (including taxes & fees): $1189-$1574 Airfare to NOLA: ~$400 Incidentals: ~$375

Estimated Cost to Attend OR Today Live! Surgical Conference

• • • •

Registration: $300 Flight to Nashville on Southwest: ~$350 Renaissance Nashville Hotel (2 nights): $400 Incidentals: ~$100

Total: ~$1,150 MARCH 2018 | OR TODAY |

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INDUSTRY INSIGHTS or today Reason #9 Time: Far too often health care conferences are too short or too long.

In most cases it’s the latter. Many of my colleagues tell me they cannot afford to take time off work and attend conferences because they have too much responsibility. Our hectic work lives impede us from attending conferences because of their length and the time away from work. When we take too many days off, the workload becomes overwhelming and we simply feel it’s easier to not go. In addition to time away from work, we have family responsibilities which can make it equally as difficult. With the OR Today Live! Surgical Conference starting on a Sunday and lasting only three days you can have your cake and eat it too.

Reason #8 The Education:

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The learning opportunities are endless at the OR Today Live! Surgical Conference. Presentations cover clinical, leadership, CS/SPD and ambulatory topics. As an attendee, you will have access to all of the learning opportunities for one low price. This allows you to learn new skills in all areas of perioperative care without paying more for additional conferences.

With several CEUs available you are sure to get tips on improving CS/SPD departments, patient outcomes, expanding case volumes, growing as a leader, protecting employees and much more. In an intimate setting that is innovative and interactive, the OR Today Live! team will make sure you have a seat at the table so you never miss an opportunity to learn. OR Today Live! is approved for up to 28 continuing education credits hours. OR Today has been approved and is licensed to be a Continuing Education Provider with the State of California Board of Registered Nursing; License No. CEP 16623.

Reason #7 Industry partnership with CCI: For those interested in the CCI certification a representative from that organization will be conducting a CSSM Prep Course.

Attendees can register for CCI’s course as an add on to the conference. A separate registration fee will apply. All CEUs are subject to CCI’s rules and are separate from the OR Today Live! education.

Reason #6 Networking: Developing one’s career takes effort and networking is part of it.

Networking with peers and colleagues can have a significant impact on your professional growth. At the OR Today Live! Surgical Conference you will have numerous opportunities to network with your peer group, vendors and speakers, too.

Reason #5 Speakers: The speakers are sure to please at OR Today Live! Speakers are selected to bring the latest information so you can implement what you learn immediately upon returning to work. Speakers and attendees have several opportunities to

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make a connection and network after the presentations and throughout the show.

Reason #4 The Exhibit Floor: With dozens of exhibitors you are sure to find products and services that make your job easier. Health care is changing rapidly and so are surgical innovations. Exhibitors will share their latest advancements with you. The difference at the OR Today Live! Surgical Conference is that attendees actually have time to develop a working relationship with the vendors and not feel rushed to cover endless miles of exhibit hall floor. Magic happens when industry partners with nursing professionals, and whether you are a decision maker or an influencer, you will find exhibitors who are more than willing to share information that will impact your practice and help you better meet the needs of patients. You won’t want to miss the opening of the exhibit hall with the latest products, technologies and services, along with hors d’oeuvres and drinks in a festive atmosphere. Plus, you will have a chance to win great prizes.

AUGUST 26-28, 2018 RENAISSANCE NASHVILLE HOTEL

Reason #3 Location, Location, Location: Although you will be coming for the education, nothing beats a mini vacation in a great city. This year the OR Today Live! Surgical Conference will be held in Nashville, Tennessee a.k.a. Music City USA. Home of legendary country music venues like the Grand Ole Opry House, home of the famous Grand Ole Opry stage and radio show, the Country Music Hall of Fame and Museum, historic Ryman Auditorium and more. For information about Nashville, visit http://www.visitmusiccity.com

Reason #2 Webinars: No matter how hard you try, you can’t make every presentation. It can’t be done. For the ones you miss, recordings of each session will be made available on the OR Today Live! website. Also, OR Today magazine offers a webinar series for additional educational opportunities.

Reason #1 Renew, Refresh and Excite Your Inner Nurse: Nurses struggle with physical, mental and emotional exhaustion from the work they perform. A recent survey in American Mobile reports a high rate of nurse fatigue.

The survey found that 98 percent of hospital nurses reported their work is physically and mentally demanding and 63 percent reported their work has caused burnout.

Each of you is vital to our profession, what you do is important to the health of our nation and that is why it is so important to take care of yourself first. Attending the OR Today Live! Surgical Conference will help you re-energize and re-focus on you.

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www.ortodaylive.com

MARCH 2018 | OR TODAY |

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IN THE OR suite talk

Suite Talk

Conversations from OR Nation’s Listserv THESE POSTS ARE FROM OR NATION’S LISTSERV JOIN THE CONVERSATION, VISIT WWW.THEORNATION.COM

Q

MOTIVATION

Why is it when some staff members are done with their cases they just sit in the lounge and visit, while others go around and offer help? How does one change the work ethic of others? The staff members who sit in the lounge and visit are the first ones to complain about others not helping them. Back in the day nurses were trained to check in with the charge nurse when their assignments were finished, today it seems like they disappear. There is always work to be done in the operating room. Does anyone have any suggestions on how to motivate others?

A: I noticed that charge nurse rounding really

helps with this. We used to have a jobs list that had to be done during any down time as well as proactively assigned staff to assist when their rooms were down. Also, we implemented hourly rounds through the lounges and other favorite hiding spots and if folks were lounging we would offer work or go home early option. That usually got everybody moving or off the clock at least. It also promoted changes in behavior so that people got the message very quickly that they would be rounded on routinely and lounging wasn’t going to be an option.

A: What you allow is what will continue. Why

are staff members allowed to sit in the break room? We have this issue as well but assign rooms/carts/areas for staff to maintain, clean

22 | OR TODAY | MARCH 2018

and check out dates. Occasional downtime is OK! It allows the staff to decompress, socialize, etc. but shouldn’t be the normal routine.

Let your staff know you are aware of who is abusing downtime, recognize the “worker bees” without calling out the “lounge lizards.” A little bit of peer pressure can go a long way!

A: I once put a sign over our break room that said

“herpetarium.” That was too far, just in case you’re wondering where some of the boundaries are. Some good did come out it in the end as it created an environment for discussion on this topic that “administration” had been unwilling or unable to deal with. There are other ways to deal with it that are less passive/aggressive but leaders need the tools, guidance, education and support to enact and follow through. Once it gets rolling it is a joy to be a member of.

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Q

IN THE OR suite talk

BLOOD CONSENT

Should a blood consent be separate or included in the surgical consent? Some surgeons want it all in one consent and others want it separate. The majority of facilities have separate anesthesia consents. One facility had a separate consent for if they wanted their anesthesiologist to pray with them. If the blood consent is included in the surgical consent, is it true that it is the surgeon’s responsibility to inform the patient of the risks and benefits to receiving blood?

A: Our informed surgical consent includes a

blood transfusion as per the Paul Gann’s Act. If for some reason the physician wasn’t able to provide the patient the information, the nursing staff has access to the informational pamphlets. They would hand them out to the patient to review and the patient would speak with the surgeon regarding their decision prior to entering the OR.

consent to receive blood products. The patient circles “Yes” or “No” and initials it. This could be a facility policy or even a state mandate in your area. I suggest following up with your quality department to find out what is expected.

A: Our facility has the blood and anesthesia

consent in the surgical consent. It is a threepage informed consent form. In California it is the physician’s responsibility to give the patient information regarding risks and benefits of

A: Blood is part of our surgical consent. We do have a separate anesthesia consent.

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TOGETHER WE CAN STOP PRESSURE ULCERS FROM STARTING IN THE O.R. 1

1 2 3 4 5

Pressure ulcers are a painful and unnecessary side effect of surgery, and the incidence of OR-related pressure ulcers may be as high as 66%.2 Lessen the risk to your patients and facility by incorporating Mepilex® Border dressings in the perioperative environment. Only Molnlycke’s Mepilex Border dressings have Deep DefenseTM technology to provide proven protection against all 4 extrinsic factors that cause pressure ulcers – pressure, shear, friction and microclimate. Don’t just protect patients from pressure, provide them with Deep DefenseTM against all the factors that contribute to OR pressure ulcers. Learn more at www.molnlycke.us/see-the-proof 1. Poster presented at AORN 2017 Conference: A Formal Process for Reducing the Risk of Perioperative Pressure Injury.

Diane Kimsey RN, MSN, MHA, CNOR • Christine Flannigan RN, BSN, CNOR • Jan Quill RN, CRNFA, CNOR 2. Positioning the Patient in the Perioperative Setting; Perioperative Standards and Recommended Practices. 2013.

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Distributed by Mölnlycke Health Care US, LLC, Norcross, Georgia 30092. © 2018 Mölnlycke Health Care AB. All rights reserved. 1-800-882-4582. MHC-2018-36492

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AORN BOOTH #431

IN THE OR

market analysis

Surgical Instruments Market Growing Staff report

he global surgical instruments/equipment market is anticipated to reach a value of $20.3 billion by 2025, according to a new report by Grand View Research Inc. The increasing number of minimally invasive surgeries across the globe is anticipated to accelerate the market growth.

T

Also, the treatment of chronic diseases often require surgeries. A rising prevalence of chronic diseases, such as cardiovascular and neurological disorders, is adversely impacting the world’s population. Surgery is considered as the primary mode of treatment for patients suffering from such diseases, which in turn is giving a rise to the number of surgical procedures being conducted. Minimally invasive surgeries are also highly adopted by surgeons for treating several heart disorders and will fuel the market’s growth.

Road and other accidents are also anticipated to increase the demand for surgical instruments in the coming years. Accidents are one of the leading causes of severe injuries. Based WWW.ORTODAY.COM

on statistics from Association for Safe International Road Travel, around 2.35 million people are injured every year due to such accidents. As a result, there is a high demand for wound closure surgical procedures, which in turn is expected to raise the demand for surgical tools.

The study also found that the global surgical equipment market was valued $10.5 billion in 2016 and is expected to grow at a compound annual growth rate (CAGR) of 7.8 percent from 2017 to 2025. A closer look showed that surgical sutures and staplers held the largest market share in 2016 owing to its high cost and huge application in wound closure surgeries.

Electrosurgical equipment is anticipated to witness growth over the forecast period due to a growing trend toward minimally invasive surgeries, according to the report.

Obstetrics and gynecology dominated the market in 2016 due to large number of caesarean surgeries being performed worldwide. Plastic and reconstructive surgeries are expected to show lucrative CAGR in the com-

Electrosurgical equipment is anticipated to witness growth over the forecast period due to growing trend towards minimally invasive surgeries.

ing years due to increasing concern for esthetics among women.

In 2016, North America dominated the market due to the availability of skilled surgeons and technologically advanced surgical tools in the U.S. Asia Pacific is expected to show the fastest growth over the forecast period because of a rising number of road accident cases in India.

Major companies operating in the market include Becton, Dickinson and Company; Stryker Corporation; B. Braun Melsungen AG; Zimmer Biomet Holdings, Inc.; Aspen Surgical Products Inc.; Smith & Nephew plc; Medtronic; Alcon Laboratories Inc.; and Ethicon Inc.

MARCH 2018 | OR TODAY |

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IN THE OR

product focus

Anzen

Safety Scalpel Anzen Safety Scalpel has a reusable stainless steel handle similar in weight and balance to traditional metal handle scalpels, providing surgeons and techs with necessary safety features without losing the familiarity, control and ease-of-use of their current scalpels. Features of the scalpel include an intuitive design to provide effortless blade exposure, slim cartridge design that does not interfere with view of incision site and a single-use protected blade cartridge that makes sharps injury prevention easy and convenient. Also, the scalpel’s protected blade stays retracted when attaching and detaching cartridges. By minimizing unnecessary exposure to the scalpel blade, health care professionals can ensure fewer preventable workplace injuries in the operating room. •

26 | OR TODAY | MARCH 2018

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IN THE OR

product focus

Exactech

Truliant Knee System The Truliant Knee System is a surgeon-inspired, comprehensive platform that embodies the power to achieve reproducible results in primary and revision total knee arthoplasty. With advanced design philosophies and surgical technologies, Truliant effortlessly aligns with surgical protocols and allows for easy intraoperative adjustments along the continuum of care. Seamlessly integrating with the ExactechGPS system, Truliant supports a simple transition to computer-assisted surgery for real-time data and guidance. •

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MARCH 2018 | OR TODAY |

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IN THE OR

product focus

Kapp Surgical Instrument Inc.

Cosgrove Mitral Valve Retractor System The Cosgrove Retractor is a unique heart retractor designed and proven specifically for heart valve surgery. It provides surgeons with the greatest visualization of the operative field, plus exceptional and consistent exposure of the right and left atrium, tricuspid valve and mitral valve, for surgical repair or replacement, while reducing the need for surgical assistance. The readily detachable, selfretaining atrial retractor requires placement only during the intracardiac portion of the procedure.

The universally adjustable atrial retractor blades are made of durable, malleable surgical stainless steel. Several styles and sizes of retractor blades are available. Kapp provides the Cosgrove Retractor System mounted on a Cooley sternum retractor or custom mounted on any other sternum retractor, on request. •

28 | OR TODAY | MARCH 2018

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IN THE OR

product focus

KARL STORZ

Reusable Instrument Sets KARL STORZ provides leading endoscopy and video imaging equipment, as well as our latest minimally invasive surgery technologies. These include reusable instrument sets developed and optimized for minilaparoscopy procedures, which have become a popular surgical technique offering a flat learning curve and enhanced cosmetic results. Our minilaparoscopy set provides a comprehensive line of miniature hand instruments. Among these are 20 different graspers, scissors and punches for use with monopolar energy, as well as 3.5 mm bipolar graspers, hook cautery, palpation probe, suction-irrigation systems and needle holders. KARL STORZ also offers reusable lightweight trocars, friction-less access ports and smaller diameter telescopes. •

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IN THE OR

product focus

Stryker

System 8 Power Tools Stryker’s System 8 family was developed by working closely with orthopaedic surgeons and hospital staff to deliver solutions to address the complex challenges of today’s health care environment.

Improved ergonomics give surgeons a better neutral wrist position, and textured areas help provide a firmer grip. A quick and efficient keyless drill chuck prevents loosening through a secondary locking mechanism, and advanced material and coating on pin collets prevent sticking and slipping. The handpieces are built to be actively washed; able to be temporarily submerged when you need to do so during cleaning, prior to sterilization. •

30 | OR TODAY | MARCH 2018

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IN THE OR

product focus

Zimmer Biomet The IntelliCart System

The IntelliCart System from Zimmer Biomet delivers advancements in day-to-day OR fluid and smoke waste management technology. With market leading 34-liter fluid capacity, extra quiet vacuum pump at only 47.5dB (3.87 sones), clog-free suction manifolds with integrated high-flow filters and portable smoke evacuation, the IntelliCart System makes managing surgical fluid and smoke waste hazards simple and convenient. •

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MARCH 2018 | OR TODAY |

31

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MARCH 2018 | OR TODAY |

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IN THE OR

continuing education

34 | OR TODAY | MARCH 2018

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IN THE OR

continuing education

CE472

Avoiding Lower Extremity Positioning Injuries in the OR

by Nancymarie Phillips, PhD, RNFA, CNOR(E)

magine you are sleeping soundly in your warm bed when a tingling in your arm awakens you. In a haze of sleep, you reposition your arm, roll over, and fall back asleep.

The tingling, the result of compression of a nerve or blood vessel, caused you to change positions to decrease pressure, maintain blood flow, stop pain, and avoid injury. Patients undergoing surgical procedures who have had general, regional, or sedation anesthesia cannot perform this function due to the loss of protective reflexes, making them susceptible to peripheral nerve and vessel injuries. Imagine the reaction of a patient awakening from surgery only to find an injury that might have been prevented. The circulating nurse and the surgeon collaborate, with guidance from the anesthesia provider, when planning the position of the surgical patient.1

I

Lower extremity nerves that are most susceptible to injury include the lumbosacral plexus, femoral nerve, common peroneal nerve, tibial nerve, and the sciatic nerve. The associated vessels include the bilateral common iliac, femoral, tibial, and doralis pedis arteries. Understanding where these WWW.ORTODAY.COM

nerves and vessels are located is the first step in preventing their injury.

The primary means of avoiding injury to these lower extremity nerves is to prevent stretch and pressure on these structures.2

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

Ligaments and Nerves The lumbosacral plexus is made of nerves from the ventral rami of T12 to L4 and branches to the femoral, obturator, ilioinguinal, iliohypogastric, genitofemoral, and lateral femoral cutaneous nerves. The sacral plexus is made up of nerves from the ventral rami of the S1 to S3 spinal nerves and forms the sciatic, pudendal, posterior femoral cutaneous, and muscular branches to the pelvis. The other most common injuries of this plexus are a result of flattening the natural spinal curves in the supine position, suture placement, compression when positioned laterally, and ischemia from occlusive pressure over vessels.1 The sacroilliac ligaments bind the sacrum and pelvic bones to the hipbones. The ligaments measure about 1.5 to 2 inches of layered fibers that stabilize the lower spine. The sacrotuberous and the sacrospinous ligaments attach the sacrum to the lower angle of the pelvic bones and attach the ischial tuberosities. The ischium bears the weight of the upper torso when a person is seated.3 The natural lower spinal curve terminates at the sacro-

Goal and objectives The goal of this continuing education program is to provide nurses with information about positioning anesthetized and sedated surgical patients to avoid nerve and vessel damage in the lower extremities.

After studying the information presented here, you will be able to: • Identify nerves of the lower body susceptible to injury in the sedated or anesthetized patient • Describe the arterial supply and the venous drainage of the lower extremities • Discuss the collaborative efforts of the OR team, including nurses, to prevent lower extremity nerve and vessel injuries

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IN THE OR

continuing education

iliac joint at the base of the lumbar vertebrae. Flattening or causing torsion of the natural lower spinal curve can cause severe postoperative pain that mimics sciatic pain. Extremes of flexure can result in tearing, or avulsion, of the superior aspect of the hamstring muscle. Patients with existing coccygeal injury are susceptible to strain at the sacroiliac region.4 The femoral nerve is formed within the psoas major muscle by posterior divisions of the second, third, and fourth lumbar nerves. It emerges from the lateral border of the psoas muscle to descend in the groove between the psoas and iliacus major muscles and enters the thigh by passing beneath the inguinal ligament lateral to the femoral artery and divides into multiple branches that include segments of the ilioinguinal nerve.2 This nerve serves the anterior muscles and skin of the thigh from the inguinal ligament to the knee.

The femoral and ilioinguinal nerves can be injured by compression with self-retaining retractors during abdominal hysterectomy, pressure and stretch in lithotomy position with excessive hip abduction and external rotation, inadvertent suture placement, femoral artery crossclamp-induced ischemia, and high tourniquet pressure compressing the nerve.1,2,4 The sciatic nerve is made of two divisions that travel in the same sheath. These divisions are the tibial and peroneal nerves. The tibial nerve is made up of the anterior branches of L4 to S3, and the peroneal nerve is made up of the posterior branches of L4 to S3.5 This sheath leaves the pelvis through the greater sciatic foramen and descends posteriorly between the ischial tuberosity and the greater trochanter down the posterior thigh, where it divides into the tibial and common peroneal nerves at the level of the knee.2,5

36 | OR TODAY | MARCH 2018

Improper surgical positioning can injure the sciatic nerve.1,2 Ninety percent of the intraoperative lower extremity nerve injuries involve the sciatic nerve.2 This injury occurs when the nerve is put under tension in the lithotomy position when the hip is flexed and the knee straightened or when the flexed hip and flexed knee are excessively rotated.1,2,4 Patients with peripheral vascular disease are at risk from gluteal ischemic pressure when positioned supine.5 Of the sciatic nerve branches, injury occurs most often in the common peroneal nerve, usually as a result of positioning during surgery.1,2,4,5 The common peroneal nerve is vulnerable to direct pressure at the fibular neck when surgery is performed in the lateral decubitus position or in lithotomy position with inadequate padding between the fibular neck and a stirrup or leg strap.1,4,5 Placement of the retractors for total hip procedures can easily injure nerve branches as the hip is flexed and rotated, causing the slippage of the tip of the instrumentation.2

Arterial Supply and Venous Drainage of the Hip and Lower Extremity Lower extremity positioning requires knowledge of the vasculature of the lower pelvis, hip, and leg. The oxygen-saturated arterial blood supply bifurcates from the lower aorta into the internal and external iliac arteries.

The superficial femoral arteries branch off laterally through the thigh into the popliteal artery at the knee. The deep femoral profunda arteries create three branches that run deep into the musculature of the upper thigh. The tibial arteries bifurcate below the knee and course distally through the anterior and posterior calf to the foot. The peroneal artery is the largest branch of the posterior tibial artery that supplies the ankle and terminates in the heel at the calcaneal artery. The foot is sup-

plied by the plantar arteries that unite with the dorsalis pedis on the dorsum of the foot. The dorsalis pedis is also a continuation of the anterior tibial arterial supply. Compression or occlusion of the arterial supply not only causes tissue ischemia, but also deprives the nerves of their blood supply.1,4 Venous drainage is equally important. Anatomically, the veins are critical for the return of blood that bears metabolic waste from living tissue.

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

The iliac veins converge with the vena cava, and the blood flows into the right atrium and ventricle back to the lungs for oxygenation.1

Hemodynamic Considerations Patients undergoing lower extremity surgical procedures can have a variety of anesthetic approaches. Regional anesthesia, such as spinals or epidurals, has risk factors specific to the manner of administration, which are discussed later in this module.

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IN THE OR

continuing education

Patients under general anesthesia have a higher risk of neuro- or vascular compromise because of complete immobility, loss of natural protective reflexes, surgical positioning, and the use of many types of surgical instruments.1,2,5 As a rule, the arterial system is monitored and controlled by several anesthetic agents. Blood volume and pressure can be modified with drugs.

Usually, a paralytic agent is used so the patient’s breathing can be controlled.

During induced surgical paralysis, body areas under pressure from body weight and positioning devices cannot shift or reposition to relieve tissue sensory deficits. Vascular stasis and compression of nerves can go uncorrected for prolonged periods of time, leading to permanent injury. Care must be taken to use positioning aids, such as adequate layers of gel pads, to provide an alternating pressure surface to relieve as much pressure as possible on the patient’s tissues.1,4 Another consideration involves the actual positioning process of moving the patient’s lower limbs. If the patient is positioned in a lateral position, care is taken to prevent the weight of the upper leg pressing on the lower leg.

A pillow should be placed between the patient’s knees.1 The patient’s bony pelvis is under pressure from the weight of the torso. A gel pad mattress offers some relief.

Patients in a prone position have the potential for injury to the knees and dorsum of the foot. Gel kneepads or sheets can be used. The feet should have enough elevating padding at the dorsum to prevent the toes from resting on the mattress or extending over the foot of the OR bed. Other injuries could occur to the feet and toes if they are hanging off the OR bed when draped and a table or piece of equipment is pressed against them.1,4 Positioning a patient into the lithotomy position requires two people moving the legs simultaneously. The WWW.ORTODAY.COM

process is performed slowly after the anesthesia provider has given the OK to proceed. Both positioning personnel should grasp the patient’s ankle with one hand and the fleshy portion of the calf with the other. The legs should be held together and flexed slowly at the knees as the limb is lifted. As the legs are separated to place them into the stirrups, care is taken not to force any flexion movements or let the hip joint externally rotate. The legs are gently placed into the stirrups and secured.

The blood in the leg veins can rapidly autotransfuse the patient’s cardiovascular system, causing changes in the vital signs if the limbs are raised too quickly. Moving one leg at a time can cause lower back strain over the sacroiliac joint.2,5 When the procedure is completed, the legs are slowly lifted from the stirrups, knees slightly flexed, and legs brought together and then lowered. Moving the legs out of the stirrups too quickly can create a hemodynamic shift, causing hypotension.1,4

Mechanisms of Injury During Positioning The five most common mechanisms for nerve and vessel injuries are stretch, compression, ischemia, metabolic issues, and surgical section. Stretch and compression can be avoided by proper positioning. Stretch can be prevented by positioning the patient while he or she is awake, before being returned to a position that facilitates induction of anesthesia.1 If a position is uncomfortable while the patient is awake, it can cause injury when maintained for a long period under anesthesia. If the patient experiences discomfort while awake, injury can occur if the nerve or vessel is compressed for an extended time. Proper padding of bony areas, minimizing the time that a tourniquet is inflated, and preventing OR personnel from leaning on the patient will help avoid

pressure injuries. Care is taken when using a bed-mounted retractor frame.

The upright pole could create pressure on nerve bundles and should not be in contact with the patient’s body.1,4 Lithotomy position is associated with changes in intracompartmental pressure in the lower extremities and the body of the gluteal muscles, depending on the method used to support the legs.1,3,4 Leg support with stirrups attached to the OR bed employs three different types of table attachments. The first type is the kneecrutch stirrup. This type is generally found in urology suites. The legs are positioned with the knees supported with the feet dependent. The full weight of the leg is balanced on the knee compartment. Pressure placed on the knee or calf to support the lower extremity (using stirrups and a knee support device) can result in pressure on the vessels and nerves within the compartment and can cause vascular or nerve injury.5,6 The second type of leg holder used is the sling, or “candy cane,” stirrup.

The upright posts of the stirrups are mounted on the sides of the OR bed at the level of the patient’s hips.

When placed in the sling stirrups, the knees are bent in toward the patient’s abdomen, and the feet are placed in sling-straps that hold the bottom of the foot and the posterior ankle to raise the legs. Extreme flexion greater than 90 degrees at the hip can result in ilioinguinal nerve damage by crush injury.1,5 The pressure is distributed at the level of the foot and ankle. Elevating the lower extremity using a sling support at the ankle reduces pressure at the knee, but places the weight of the leg on the sole of the foot and ankle. The feet must be well padded to prevent nerve damage that can result in permanent foot drop.1,4 Care is taken to avoid allowing the lateral aspect of the legs to rest against the upright post of the stirrup frame. This MARCH 2018 | OR TODAY |

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continuing education

can result in serious peroneal nerve injury from pressure.1,4,5 The third type of leg holder is a boot-style, known by several names, such as “Yellow Fin,” “Lloyd-Davies,” or “Allen” stirrups. The boot-type stirrup supports the leg from the inferior aspect of the knee along the calf and under the length of the foot. The weight of the leg is evenly distributed and decreases the risk of nerve pressure.1 These stirrups are generally used for longer surgical procedures in which the abdomen and the perineum must be accessed. The levels of the legs in lithotomy during the surgical procedure can vary from low (even with the OR bed) to high, with the legs and feet elevated into the air.1 Constant external compression applied by antithromboembolism stockings does not reduce intracompartmental pressure in the lower extremities.5,6 Intermittent external compression (e.g., sequential compression devices/stockings), however, reduces this pressure increase and decreases the likelihood of nerve or vessel injury from increased intracompartmental pressure.1

Compartment Syndrome Each muscle group of the lower extremity is enclosed in fascia, which is a tough, fibrous connective tissue.

Fascia is minimally flexible and does not expand in response to abnormal swelling of encased muscle tissue. In addition to nerve, vessel, or superficial tissue damage, swelling in the fascial compartments of the lower extremity can lead to permanent muscle destruction known as compartment syndrome. Compartment syndrome can be caused by crushing, bleeding into tissue, vessel obstruction by a clot, or prolonged pressure during periods of immobility under anesthesia.5,6 Patients with blood dyscrasia and anticoagulant therapy are at risk. Patients who have been

38 | OR TODAY | MARCH 2018

in lithotomy more than three hours should be evaluated for compartment syndrome postoperatively.5,6 The mechanism of compartment syndrome is a repetitive cycle.5 Muscle tissue becomes ischemic under pressure, causing plasma to seep out of the capillaries. This increases fluid loss from the arterial circulation into the surrounding muscle tissue, causing additional swelling. Despite the changes in circulation, arterial pulses may appear unchanged. If the pressure is not relieved, muscles, vessels, and nerves will infarct and necrose.1,5,6 Postoperative patients with a positioning injury caused in the OR may take several hours to manifest the syndrome. Some patients with a positioning-related nerve injury arouse from general anesthesia screaming about leg pain, although the procedure did not involve surgery on the leg.1,5,6 If the patient had regional anesthesia, such as a spinal or epidural, the anesthetic can delay the diagnosis of injury when no verbalization of discomfort is made.1,5,6 Signs and symptoms of compartment syndrome include complaints of burning and extreme deep ache in the muscle group in the patient with intact sensory perception.5,6 Flexion and extension of the limb will cause increased pain. The extremity may have a localized enlargement and tenseness with a firmness that does not depress when pressure is applied.

Compartment syndrome that goes untreated can lead to muscle breakdown (rhabdomyolysis) and the release of myoglobin into the cardiovascular system.1,6 The myoglobin is passed into the major organ systems, causing multisystem organ failure and death.

Urinalysis reveals dark, brownish urine with free myoglobin.1,6 Compartment syndrome is treated surgically with long linear incisions along the length of the fascial covering of the muscle group (fasciotomy) to manually release the pressure.1,3 The incisions

are left open for prolonged periods of time, sometimes weeks or months, thus requiring debridement and antibiotic therapy.1 Many of these incisions require skin grafts for complete tissue coverage.

Muscle tissue does regenerate to a large degree, but vessels and nerves can suffer irreparable destruction.1,5,6

Patients at Risk Metabolic diseases, such as diabetes, can cause neuropathies. It is important to assess a patient’s medical, surgical, and social history, and document pre-existing neuropathies or peripheral vascular disease when planning perioperative care.1 Additional risk factors for neurological or vascular compromise include obesity, the use of anticoagulants (blood thinners), nicotine (a vasoconstrictor), oral contraceptives or hormone replacement therapy (estrogens), pregnancy, sepsis, or a history of DVT.1,3,4 Extremes of body weight and length of surgery also increase the risk of lower extremity nerve and vessel injury, especially when the patient undergoes surgery in the lithotomy position.3 Regional anesthesia, such as a spinal or epidural, has been a potential cause of nerve damage.

Documentation serves as a record of the steps that were taken in a patient’s care and when the need to examine that care arises. Documentation and checklists serve another important purpose: to remind the provider of steps that need to be taken in a patient’s care. Documentation not only provides a record of the steps taken, but it also focuses attention on aspects of patient positioning that prevent injury to the lower extremities. Documentation should include the names and job titles of all people positioning the patient to validate that the positioners have the knowledge and skill to use the appropriate devices to safely position the patient.

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IN THE OR

continuing education

Six Practices The Association of periOperative Registered Nurses (AORN) recommends six practices with regard to positioning the patient in a perioperative setting.4 Outcomes of these guidelines include optimal exposure of the surgical site, proper access for airway management, proper ventilation, proper monitoring access for anesthesia personnel, physiological safety of the patient, and maintenance of patient dignity by controlling unnecessary exposure. The six practices are: • Preoperative assessment for positioning needs should be made before transferring the patient to the procedure bed. The preoperative interview should include questions to determine patient tolerance to the planned position. The OR nurse should assess both patient and intraoperative factors. Patient factors include age, body build, skin condition, nutritional status, preexisting conditions, and mobility limits. Intraoperative factors include anesthetic concerns, length of the planned procedure, and position required for the procedure.

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

• The perioperative nurse should actively participate in monitoring patient body alignment and tissue WWW.ORTODAY.COM

integrity based on sound physiological principles. Having the proper number of personnel for patient positioning reduces the risk of positioning injury. Catheters, tubes, and cannulas can be accidentally pulled out if too few personnel are used.

Maintaining proper body alignment and supporting the extremities also decrease the chance of injury during and after positioning.

• After positioning, the perioperative nurse should evaluate the patient’s body alignment and tissue integrity.

This evaluation should include the respiratory, circulatory, neurological, musculoskeletal, and integumentary systems. Unusual findings in any of these areas can lead to lower extremity nerve injury if not corrected.

• Documentation of surgical positioning should be consistent with AORN’s recommended practices for documentation of perioperative nursing care. This documentation includes the nursing assessments, interventions and treatments, and evaluations of the quality of the care delivered. Documentation of care activities provides a picture of the care delivered and its outcomes.

• Policies and procedures related to positioning should be developed and reviewed annually, revised as necessary, and be available in the practice setting. These policies and procedures should include assessment and evaluation criteria and documentation, anatomic and physiological considerations, safety interventions, documentation of patient position or repositioning, positioning devices and personnel positioning the patient, and positioning device care and maintenance.

Careful positioning, along with knowledge of anatomy and careful documentation, can greatly reduce lower extremity nerve and vascular injuries in the OR.

EDITOR’S NOTE: Don Beissel, MSNA, RN, CRNA, the original author of this educational activity, has not had the opportunity to influence the content of this version.

OnCourse Learning guarantees this educational activity is free from bias.

Nancymarie Phillips, PhD, RNFA, CNOR(E), is a retired professor of perioperative education for nurses and technologists at Lakeland Community College, Kirtland, Ohio.

References 1. Phillips NM. Positioning, prepping, and draping. In: Berry and Kohn’s Operating Room Technique. 13th ed. St. Louis, MO: Elsevier; 2016;479-513.

2. Wang T, Chen HY, Tsai CH, Hsu HC, Lin TL. Distances between bony landmarks and adjacent nerves: anatomical factors that may influence retractor placement in total hip replacement surgery. J Orthop Surg Res. 2016;11(1):1-9. doi: 10.1186/s13018-016-0365-2.

3. Pereira B, Heath D. Gluteal compartment syndrome following bariatric surgery: a rare but important complication. Ann Med Surg. 2015;4(1):64-66. doi: 10.1016/j. amsu.2015.01.002.

4. AORN. Guideline for positioning the patient.

Burlingame B, Denholm B, Link T, Ogg MJ, Spruce L, Spry C, Van Wicklin SA, Wood A. In: Guidelines for Perioperative Practice. Denver, CO: AORN Inc.; 2016:649-668.

5. Stornelli N, Wydra FB, Mitchell JJ, Stahel PF, Fabbri S. The dangers of lithotomy positioning in the operating room: case report of bilateral lower extremity compartment syndrome after a 90-minutes surgical procedure. Patient Saf Surg. 2016;10:18. doi: 10.1186/s13037-016-0106-9.

6. Chavez LO, Leon M, Einav S, Varon J. Beyond muscle destruction: a systematic review of rhabdomyolysis for clinical practice. Crit Care.

2016;20(1):135. doi: 10.1186/s13054-016-1314-5.

MARCH 2018 | OR TODAY |

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IN THE OR

continuing education

Clinical Vignette for CE472 A 40-year-old man presents to surgery for a hemorrhoidectomy for his grade 3 hemorrhoid with prolapse. The patient’s history is negative for low back pain, obesity, muscle cramping, radiating pain, diabetes mellitus, weight loss, compression neuropathies, trauma, or family history of polyneuropathy. An epidural anesthetic is used with 2% lidocaine, 7% sodium bicarbonate, and epinephrine 1:200,000. No pain, paresthesia, blood, or cerebral spinal fluid is noted during the block placement, which uses loss of resistance to find the epidural space. The epidural and operative procedures are performed in Sims’ position, in which the patient is in a right lateral recumbent position with the left knee flexed and left hip abducted. No pillow was used to support the left leg in this superior position. The patient remained in this position for 90 minutes.

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

At four weeks later, the patient has improved sensory and motor function, but numbness remains in the sole of the left foot. Motor deficits improve in the peroneus longus muscle. Electromyogram (EMG) studies, electrical recordings of muscle activity that aid in the diagnosis of neuromuscular disease, performed at four weeks show left sciatic neuropathy with active denervation. (It usually takes three weeks for degeneration potentials to be evident on EMG. A positive EMG immediately after surgery would indicate that the injury is at least three weeks old.)

The patient experiences gradual improvement over the next three months, but shows no sign of complete resolution. pon discovery of the injury, which action 3 U hat action could have helped prevent should the nurse take first?

1 W this injury? a. Vigorously massage the affected extremity a. U sing general anesthesia instead of a regional techb. Notify the operating physician and request a neurolnique ogy consult b. Testing the patient’s comfort in this position c. Page the anesthesia provider stat c. Using lithotomy position instead d. Apply ice and elevate the extremity d. Using a different solution for the epidural hich component of this patient’s position 2 W

increased the risk of injury? a. Being recumbent b. Hip flexion c. Head turned to the right d. Hip flexion combined with abduction

4 I f an electromyogram performed immedi-

ately after surgery showed active denervation, it could mean: a. The injury existed for several weeks before the surgery. b. The injury is extremely severe. c. The patient has an increased chance of recovery. d. Immediate surgery is necessary.

1. Answer: B, Assessing the patient’s comfort in the position before anesthesia and adjusting position according to patient feedback reduces nerve injury risk. 2. Answer: D, Hip flexion combined with abduction increases stretch on the sciatic nerve. The stretch is increased when the left leg is unsupported in the superior position. 3. Answer: B, Notifying the operating physician and requesting a consult are the nurse’s first actions because immediate evaluation by a neurologist can establish causation and provide continuity of care regarding the nerve injury. 4. Answer: A, It usually takes three weeks for degeneration potentials to be evident on EMG. An immediate positive EMG would indicate that the injury is at least three weeks old.

40 | OR TODAY | MARCH 2018

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IMPROVING TEAM

COMMUNICATION

By Don Sadler It has been nearly 20 years since the publication of “To Err is Human: Building a Safer Health System,� a report prepared by the Institute of Medicine. The report revealed that as many as 98,000 hospital patients die in the U.S. each year as a result of medical errors.

Since the report was published in 1999, subsequent studies have estimated that patient hospital deaths could actually be four times higher than this.

IMPROVING TEAM

COMMUNICATION Emphasis on Improving Communication Eye-opening statistics like these have prompted the health care industry to place greater emphasis on improving team communication in order to limit medical errors that lead to patient deaths.

With this in mind, the Association of periOperative Registered Nurses (AORN) recently published the “Guideline for Team Communication.”

According to AORN Perioperative Practice Specialist Mary C. Fearon, MSN, RN, CNOR, the lead author of the guideline, this is the first evidencebased guideline to address the importance of communication in the perioperative environment.

In addition to new content, Fearon says the guideline includes information from the AORN position statement on the prevention of wrong site, wrong

standardized communication processes in place, the occurrence of human error is decreased,” she says.

“When a perioperative team is working together with a shared mental model, they are more resilient and can more effectively minimize the risk of human errors,” she adds.

Creating a Safety Culture Most perioperative team members would probably say that their team communicates well. But Fearon believes that all perioperative teams can improve their communication.

“Many institutions are utilizing tools such as TeamSTEPPS and Crew Resource Management to help incorporate a safety culture within the perioperative environment,” she says.

The AORN “Guideline for Team Communication” provides instructions

70 percent of adverse events in the surgical environment are caused by breakdowns in

members are under increasing pressure from numerous demands and complex functions that lend themselves to error,” says Fearon.

Despite these pressures, though, patient safety must remain a top priority for perioperative nurses and cannot be sacrificed for efficiency.

“Communication tools and team training programs provide a foundation to improve the chances that communication is conveyed effectively and received accurately,” says Fearon.

Specifically, she notes that the surgical safety checklist is an effective tool for improving communication in the perioperative environment.

“The guideline provides tools such as checklists and briefing and debriefing processes to assist facilities in designing tools that work in their specific setting and address their individual needs to overcome obstacles to effective communication,” says Fearon.

Importance of Simulation Training

Fearon believes that simulation training on the use of tools like checklists will communication among health care providers. enhance communication practices in any facility.

“Allowing the perioperative team to patient and wrong procedure surgerfor improving perioperative team com- develop the checklists based on their ies. It also includes the “Guideline on munication through a culture of safety environment and type of practice or Transfer of Patient Care Information.” that incorporates the following: surgical specialty strengthens the value “We received more than 500 com Team training of any communication tool,” she says. ments on the guideline during the Simulation training “Otherwise, the briefings and debriefpublic comment period, including Standardized transfer of patient ings are run by rote and the risk for comments from other professional information (e.g., hand overs or mistakes increases.” organizations,” says Fearon. hand offs) In fact, AORN recommends a stronFor example, the American College Briefings and debriefings ger focus on briefings and debriefings. of Surgeons noted: Timeouts “Performing a highly engaged brief“Overall, the guideline is well writ Surgical safety checklists ing with the entire team prior to the ten and thorough. It matches the curAccording to Fearon, the collective patient entering the operating room alrent safety culture we and many others evidence demonstrates that commulows the team to gain valuable knowlare implementing, recognizing that nication breakdowns in the perioperaedge from each professional,” says communication breaks are a key and tive setting are a factor in events that Fearon. “It also leads to a shared mental common issue when safety and quality adversely affect patients. model or shared focus on the plan of issues arise.”

For example, 70 percent of adverse care for each patient.”

Fearon says that most adverse events in the surgical environment are Briefings and debriefings can also events in the health care setting are caused by breakdowns in communica- prevent potential distractions and caused by human error. tion among health care providers. delays during the procedure.

“The research demonstrates that “The perioperative environment “A quality debriefing provides safety when health care organizations put is stressful and perioperative team checks for prevention of retained surgi-

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cal items by announcing the status of the count,” says Fearon. “It also improves specimen identification and disposition by confirming what was stated during the procedure.”

“An effective debriefing gives the perioperative team an additional review to improve care and outcomes for future patients,” Fearon adds.

Health care organizations should also promote respect among team members by encouraging honesty and collaborative practice and making sure team members are comfortable speaking up.

Other ways to promote team member respect include fostering learning, holding team members accountable for their behavior, providing opportunities for shared decision making at all levels, and recognizing the value of each team member’s contributions.

Takeaways from the Guideline AORN has identified a number of key takeaways from the “Guideline for Team Communication.” These include the following: Health care organizations should establish administrative processes to create a patient safety culture and encourage team members to actively engage in the culture.

“Perioperative team leaders can promote safety by discouraging disruptive behavior by team members and encouraging behaviors that promote reporting of safety concerns,” says Fearon.

Health care organizations should establish an interdisciplinary team with authority and responsibility to provide oversight for the patient safety culture.

This team should include nurses, support personnel, surgeons, anesthesia professionals, perioperative services executives, quality management personnel and risk management personnel.

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Performing a highly engaged briefing with the entire team prior to the patient entering the operating room allows the team to gain valuable knowledge from each professional.

Health care organizations should establish and implement a standardized briefing process before the surgical procedure.

The interdisciplinary team should create the briefing process with input from perioperative team members representing individual service lines.

Standardized safe surgery checklists should be used during a timeout and adapted to the patient population served.

Fearon notes that standardized safe surgery checklists have been associated with fewer complications, improved communication, improvement in facility safety culture and increased detection of potential safety issues.

A health care organization’s quality management program should evaluate and monitor team communication and the culture of safety.

In addition, dashboards of patient safety indicators should be developed to provide personnel with visual information on progress in improving safety and sustaining safety measures.

Perioperative team training should include simulation training with all perioperative team members.

“Providing team training in a simulation environment allows the team to improve communication and fosters team building in a non-stressful environment,” says Fearon.

Obtaining the Guideline The AORN “Guideline for Team Communication” became effective on January 15, 2018. For information or to purchase the guideline, visit https:// www.aorn.org/guidelines.

MARCH 2018 | OR TODAY |

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SPOTLIGHT ON Beth Ann Swan

S P OTLIG H T O N

By Matt Skoufalos

hen Beth Ann Swan PhD, CRNP, FAAN, was headed into college, she’d planned to leverage a strong background in math and science into a career in chemical engineering.

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Unfortunately, she was discouraged from those pursuits by the prevailing wisdom of the mid-1970s: women, if they studied for an advanced degree, were meant to be either teachers or nurses. She chose the latter. In doing so, what she discovered was a job with “an infinite number of opportunities.”

“I got into being a nurse by not wanting to be a nurse,” said Swan. “I always say it’s the best decision I never made.”

From such reluctant beginnings began a career that has hit some of the professional summits of its field. Starting out as a staff nurse in an urban academic health center, Swan parlayed advanced degrees into work in hospital and ambulatory care settings before she was tapped to lead a collaborative practice among nurse practitioners and anesthesiologists. She worked her way up from there to become the director of operations for 10 nurse-managed practices for underserved patients. Eventually, Swan took on international assignments before settling into her current academic role with the Jefferson College of Nursing at Thomas Jefferson University in Philadelphia, Pennsylvania.

In addition to her commitment to academics and professionalism, Swan credits mentors and supervisors in her youth with encouraging her to become involved in nursing leadership organizations. She is a past president of the American Academy of Ambulatory Care Nursing (AAACN), a role she said helped shape her thinking about

48 | OR TODAY | MARCH 2018

the need to close the loop between hospital and offsite acute care.

“If you look in the broader context, the U.S. health care system really hasn’t kept pace with the changes in care delivery,” Swan said. “While the payment was focused on hospitals and physician providers, the care was and is delivered outside the hospital in a variety of settings.”

In the mid-1980s, care began transitioning into a variety of non-hospital settings – primary, specialty outpatient, transition, community-based – which placed much of the onus for recovery onto individuals and their families “with little consideration for if that individual and family or support person has the capacity to manage all that care outside the hospital,” Swan said.

“I believe the antidote is registered nurses who are very well versed in coordinating care and managing those transitions,” she said. “RNs must be able to lead between the hospital and post-hospital care, not just from hospital to home.”

Swan’s answer to that growing need was to co-author a core curriculum for registered nurses that would focus on care coordination and managed transitions. Evidencebased expert panels identified nine core competencies that formed the basis of what would become the Care Coordination and Transition Management (CCTM) certification program: support for self-management, education and engagement for individuals and families, cross-setting communication and transitions, coaching and counseling of patients and families, the nursing process, teamwork and collaboration, patient-centered planning, population health management and advocacy.

Since the CCTM certification has been offered, 674 WWW.ORTODAY.COM

SPOTLIGHT ON Beth Ann Swan

nurses have earned it nationwide in a variety of settings.

Organizations that have implemented CCTM acute care and ambulatory care settings have realized improvement in care outcomes, including in Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores.

“We see this as important for every nurse, no matter what setting they’re practicing in,” Swan said. “It’s looking at that care experience and how the communication was across providers, and how when those things are in place, that patients are perceiving being well cared for, and are perceiving quality and safe care.”

As more patients transition into managed care programs in home settings and other non-hospital environments,

“There is always a need for nurses in the operating room,” Swan said. “Another area is going to be technology mediated, whether it’s telehealth or virtual health. You need to be able to relate to a person very quickly when you’re on the telephone or in front of a computer.”

“Places where people go for social reasons may not be traditional places where nurses are, but they’re important places for nurses to be,” she said. “We’re supporting those experiences for our students.”

More than any other skill, however, Swan believes the foremost talent of a successful nurse is a personal commitment to caring for those in need.

“Nursing is not about having a job and a paycheck,” she

" Nursing is not about having a job and a paycheck.

Nursing is a personal commitment, and you really have to have a passion and compassion in order to really contribute to caring for people."

Beth Ann Swan, PhD, CRNP, FAAN, Professor, Jefferson College of Nursing Thomas Jefferson University

Swan foresees an increasing need for CCTM and similar education to manage the variety of complicated conditions they see. Having experienced so many different nursing assignments over the years has convinced her even more that training nurses to be as flexible as the circumstances in which they deliver care is the best guarantee of successful outcomes.

That said, there are career trajectories in this shifting landscape in which Swan believes “recruiting really great nurses” will always present a challenge in settings that don’t embrace continuing education. That’s why her college of nursing encourages students to participate in a spectrum of traditional and nontraditional professional experiences.

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said. “Nursing is a personal commitment, and you really have to have a passion and compassion in order to really contribute to caring for people.”

“If you choose to become a nurse, it’s important both to have the compassion to care as well as the knowledge, the art, and the science,” Swan said. “It’s hard work; it’s rewarding work, and your commitment is really to the individuals and families that you’re caring for. Sometimes those situations can be very joyful, and sometimes those situations can be very sad, and it’s how you’re able to handle that spectrum of physical care and emotional care with compassion and understanding.”

MARCH 2018 | OR TODAY |

49

OUT OF THE OR fitness

Fitness Tips for Baby Boomers aby boomers whose exercise routines have gone bust may be thinking about putting the boom – and a little sweat – back into their lives.

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But thinking and doing are two different things.

“In our society, everyone wants a great body,” says Jaime Brenkus, a nationally recognized fitness expert and brand ambassador for Evergreen Wellness. “The problem is no one wants to work for it.”

In some cases, baby boomers – those born from 1946 to 1964 – may consider themselves “too far gone” to embark on a serious fitness regimen at this stage in life.

But you don’t need to train for a triathlon, Brenkus says. Even out-of-shape people in their 50s, 60s and 70s can take manageable strides toward improving their physical wellness.

“Success in life is not about a matter of inches and pounds,” Brenkus says. “It’s when you start taking your first steps toward a realistic and reachable goal.”

For out-of-shape boomers who want to lose weight, feel better, look better, get fit and put that boom back in their lives, Brenkus offers a few simple exercises to get started:

Sit and get fit Four easy moves you can do on a chair will give you a slimmer, trimmer and

50 | OR TODAY | MARCH 2018

tighter waistline. Do at least 20 repetitions of each exercise. For the first, place your hands behind your head, crunch forward and then lean back as far as you can while keeping your feet on the ground. For the second, you can do side bends. Place your hands behind your head again, but this time alternate bending from one side to the other. For the third, rotate your body side to side with more twists. Finally, scoot to the edge of the chair. Bring both knees into your chest and then lower your legs to the starting position.

Round-the-world lunges You will do a forward, a side and a reverse lunge. Perform each in one movement.

Forward lunge. Stand with your feet together and back straight. Place your left hand on a chair for balance and support. Slowly take a big step forward with the right foot. Lower your body until your right thigh is parallel to the floor and your right shin is vertical. Then move back to the starting position.

Side lunge. Slowly step to the side with your right foot about 3 feet and squat so your thighs are parallel to the ground. Move back to the starting position.

Reverse lunge. Slowly step back with your right foot about 3 feet.

1

2

3

“Success in life is not about a matter of inches and pounds.”

Bend both knees and lower yourself until your left thigh is parallel with the ground. Return to starting position.

Morning rituals Brenkus says he starts each morning with fitness moves that work the entire body. The first is push-ups.

Start with an amount you’re comfortable with. For example, if you do 10 every day, that adds up to 300 for the month. If you’re a beginner, it’s okay to start your push ups by doing them on a wall. Next are squats. Your feet should be shoulder width apart. With your abs held tight and your back straight, slowly lower yourself into a seating position until your bottom touches a seat. Make sure your knees don’t go past your toes and are aligned straight. If just starting out, try quarter to half squats where you’re not bending down as far.

“When it comes to exercise, people think more is better,” Brenkus says.

“That’s not true. Better is better.”

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OUT OF THE OR health

Small Moves and Big Government:

BY MARILYNN PRESTON Well-Being Matters in 2018 have been clearing off my desk. It was piled high with articles, notebooks and coffeestained press releases leftover from 2017. It’s an activity, like skinny-dipping, that I highly recommend.

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One thing I am keeping is an intriguing new book called “The Psychobiotic Revolution,” by Scott C. Anderson, John F. Cryan and Ted Dinan.

It explains the cutting-edge science that proves your gut and your brain are interconnected, and why many foods we innocently eat mess up our physical and mental health, causing depression, anxiety – Alzheimer’s, too.

(Maintain your microbiome! The research is in. Does your doctor even know how to spell microbiome?)

I’m letting go of “Green Smoothies for Life.” It’s a highly recommended new release, but I’ve decided life is too short to gulp down your breakfast, even if it is a healthy and balanced mix of 10 fruits, 10 vegetables and enough protein powder to get you through dinner without actually chewing. (Did you know you can put banana peels in a smoothie?)

Time-saving smoothies also conflict with one of my primo resolutions for 2018: to slow down – a daunting campaign now in its 18th year.

This process of sorting through and tossing out has me thinking about two aha! insights of 2017.

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INSIGHT NO. 1: TINY MOVES BRING BIG RESULTS

INSIGHT NO. 2: TIME TO DO WHAT EVERY OTHER CIVILIZED NATION DOES

When most people think about doing more exercise, they mean big-motion activities: more walking, running, swimming, basketball, biking – whatever sparks joy.

All are stellar choices. Have fun; play sports! But here’s my wish for you: don’t ignore your inner body.

Sensing how to communicate with it is a giant step forward when it comes to taking care of your personal wellbeing.

This isn’t woo-woo, it’s science: You can learn to make tiny, subtle moves within your own body. These small inner shifts of muscle, tissue and breath – done slowly, with awareness – help energize your spine, balance your sacrum, and lubricate your joints so when you do play sports or pick up heavy suitcases or groceries, you’re less likely to screw up your back, or wrench your shoulder. And if you do – accidents happen – you’ll have some self-care tools to speed your recovery.

Collectively it’s known as somatics training: teachers and practices that help you develop inner body awareness. Somatics-based yoga, Feldenkrais, the Alexander Technique, qigong, tai chi are all proven ways to direct your attention inward, to connect and balance your mind, body and breath. Do all that on a regular basis – with patience and kindness – and you can audition for Jedi knight.

I live several months a year on a small island in the Aegean and have the good fortune of having friends who are citizens of Greece, France, Sweden, Holland, Italy, Germany, Belgium, England and other countries.

Why am I telling you this? Because none of them worry about health care costs. In the U.S., everyone worries. It’s a leading cause of anxiety, stress, even bankruptcy! My European friends don’t understand. When they get sick, they see a doctor. So do their kids and their aging parents. That drama is gone. Also the paperwork. The health care in their countries – in virtually every developed country in the world – is not the for-profit business it is in the U.S. It’s basically free for everyone to use, just as they use roads, schools and the police and fire departments.

Is their health care as good? It depends.

It’s often better.

The year 2017 taught me that everyone, pretty much, strives to be healthier and happier. In the future, the first political party to offer (basically) free medical care for all – just like virtually every developed country in the world – will win the hearts and minds of the majority of voters.

– Marilynn Preston is the author of Energy Express, America’s longest-running healthy lifestyle column. For more on personal wellbeing, visit www.MarilynnPreston.com.

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53

OUT OF THE OR nutrition

Is Pasta Healthy?

By Densie Webb, Ph.D., R.D.

hink of Italy and you probably think of pasta.

But it’s not just Italians who are passionate about this comfort food. Pasta has been crowned the world’s most popular dish, even more so than pizza. That would explain the almost 20 pounds of pasta we put on our plates each year.

T

Pasta nutrition Pasta has a history that goes back possibly thousands of years. This dish is also a mainstay of today’s healthy Mediterranean diet, which includes beans, lentils, nuts, fruits and vegetables. Most dry pasta is enriched with iron, riboflavin, thiamin and folic acid. Thus, a one-half cup serving is an excellent source of B vitamins and a good source of iron.

Choose whole-wheat pasta for a good source of fiber.

Cook pasta al dente, which translates “to the tooth” – a slightly firm texture, not soft and mushy. The time to reach al dente varies among pastas, from as little as 2 minutes to as much as 8 minutes. Al dente pasta has a low glycemic index (GI).

Overcooking raises the GI, making it more likely to raise blood sugar levels.

54 | OR TODAY | MARCH 2018

Pasta and health Studies show pasta consumption is linked with a reduced risk of cardiovascular disease, obesity, diabetes and metabolic syndrome. This may be due to many factors. When pasta is cooked and cooled, it becomes a resistant starch, which is not broken down by digestive enzymes. Resistant starch increases fat burning and reduces the fat storage of fat cells, suggesting it may help with weight loss. Whole-grain pasta may have the added benefit of promoting fullness and reducing hunger. In addition, pasta is often paired with healthful foods, such as tomatoes, vegetables and herbs.

Worldwide, most pasta is made from high-protein, hard durum wheat – the same wheat used to make couscous. A different type of wheat is used to make bread and Asian-style noodles. Additional ingredients are added for specialty pastas, such as eggs for egg noodles or tomatoes or spinach for vegetable pastas. As a plant-based food, pasta is environmentally friendly, leaving a much smaller carbon footprint

than beef, cheese, fish, pork, eggs or poultry.

– Environmental Nutrition is the awardwinning independent newsletter written by nutrition experts dedicated to providing readers up-to-date, accurate information about health and nutrition in clear, concise English.

For more information, visit www.environmentalnutrition.com.

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OUT OF THE OR

Recipe

recipe

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.

the

56 | OR TODAY | MARCH 2018

INGREDIENTS: • 4 tablespoons olive oil • 3/4 pound sliced cremini mushrooms • 2 leeks, light green part and white part only, finely chopped • 2 garlic cloves, minced • 1 (16 ounce) package riced cauliflower • 1 cup peeled and diced butternut squash • 1 cup vegetable or chicken stock • 1 cup frozen petit pois • Zest of 1 lemon • 1/3 cup freshly grated Parmesan cheese, plus extra for serving • 1/4 cup finely chopped parsley or mixed fresh herbs • Salt and freshly ground black pepper

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OUT OF THE OR recipe

Cauliflower Risotto is a dieter’s best friend I love risotto and have made more versions than I can remember. I’ve used stock, wine and sometimes cream, along with different vegetable combinations that always seem to turn out delicious.

Recently, I wanted to come up with some lighter dishes that didn’t sacrifice an ounce of flavor. That’s where riced cauliflower comes in. It’s easy to work with and provides rich results in each dish I have tested.

I had heard about making cauliflower into a risotto, and soon thereafter I enjoyed it at a restaurant where the riced vegetable included cream and lots of cheese. Yes, it was definitely tasty; but I tried to figure out how I could cut down on the extra calories and still make it a dish I would want to eat.

It’s quicker to make than ever because now you can find it already riced for you. If you want to rice it yourself, trim a whole cauliflower and then grate

it with a large hole box grater to yield 4 cups. The mushrooms should be well cooked so that they offer an earthy flavor. You can find butternut squash peeled and diced at most markets now, so add that for its orange color and velvety texture. Sweet frozen peas add additional vibrant color and a garden pea flavor. They should be added frozen to the dish so they don’t become overcooked. Note that this dish will not be creamy like its rice cousin but it will be satisfying in its own unique way.

Feel free to add different vegies or different cheeses to the dish. The fresh lemon zest and a generous grinding of black pepper bring all the flavors together. If you like a richer flavor you can add a drizzle of olive oil to the top just before serving. I have served this as both a first course and as a colorful side dish to simple entrées like grilled or roasted chicken, turkey, beef or pork.

Cauliflower, Mushroom and Pea Risotto Serves 4 to 6 1.

Heat 2 tablespoons oil in large sauté pan that will fit the ingredients on medium-high heat. Sauté the mushrooms, turning to evenly cook, for about 4 minutes or until cooked through and lightly brown. Remove to a small side bowl.

2. Add remaining oil to pan, and sauté leeks for about 5 to 7 minutes or until soft and light brown. Add the garlic, and cook another minute. Add the cauliflower and butternut squash; sauté, mixing with a large spoon, until crisp-tender, about 4 more minutes.

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3. Add the stock, cover, and cook another 5 minutes or until the cauliflower and squash are tender. Remove top and reduce the liquid until just a little bit remains. Add the peas and cook about 2 minutes or just until they are cooked through. Add the reserved mushrooms, lemon zest, Parmesan and parsley and mix to combine. Season to taste with salt and pepper.

4. To serve: Place in shallow soup or pasta bowls and serve immediately with extra Parmesan cheese on the side. You can also serve this as a side dish with most entrees.

MARCH 2018 | OR TODAY |

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The News and Photos that Caught Our Eye This Month Tips for speed cleaning your home

hat is one of the biggest Alicae. apellen sourcesXimost of stress? ditiam ut voluptatur, tem It’s cleaning on a deadline, apiti ditium eum eosae inum, especially when guests are on their way.

W

declutter rooms. Set a timer if needed to help you stay on track evelestibus. andFero avoid spending too much time voluptur, officipsum in one room.

Put things where quianduntem laborepeles ilia they belong, or if they don’t have a home, put them in a room or under beds where no one will see. Save decluttering those hidden storage areas for later. Prioritize rooms you use so iffaccaec you runtemporem out of time, Itatemost, conem guests won’t notice an untidy area. as eum cusaepre dolluptatios debis est, corrum esedio occus 2.maio Onlytemolupti clean whatodis guests see prewill quaeJoin the more than one-third rum quaeperumet audita exped of Americans whoeos don’t bother molores reiumet num qui cleaning rooms people won’t see. core ped quibus, estestis di teniYou have enough to stress about tatiate voluptur si conseribus es as the host. Don’t waste your predes nulparc imolorro offic tem cious time cleaning parts of the es molorro bernatio.

Unti home no oneiumqui will ever see. Simply consectotae.

Quibus explaborshut doors to rooms that you want est, offici sus eum faceria ea to keep private, signaling toea guests not to enter.

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Decoding Food Labels

But with the right plan in place, even last-minute cleaning can be efficient and stress-free, says ut Alicae.

Ximost apellen ditiam Debra Johnson, Merry Maids home voluptatur, tem apiti ditium eum cleaning expert. eosae inum, evelestibus.

In an online survey conducted Fero voluptur, officipsum

by Toluna, more than half of quianduntem laborepeles ilia respondents admitted that most venimpo rehent. ofdolum their cleaning takes place just Ut guests inctorum eosWith sedisciendae before arrive. a bit cumfocus, reptatiantia si offic tendani more this preparation can be quick and effective, musapernat laboriwithout nos et stress. fuga.

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They’re about itatis sit pa volor aspisquibus spending time with friends and id maximincia dolupiendis family. et quissum et, saped et quid Johnson shares the following quidunt, omnim fuga. Ovit, con tips to clean smarter, not harder, in nem. Im vel et volut vernatisthe limited time you have before cius volo mosae ventisquia nos guests arrive. es dolorita cumque re ipsam ut fugitatem eius pe rem.

1.vid Ready, set ... declutter The important first step is to

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3. Skip the sweep

OUT OF THE OR pinboard

Fear: The a dry mop when you can vacuum Hidden Killer instead. Vacuuming is far more

efficient and faster at removing dolum venimpo rehent. dust, dirt and other debris from the Ut inctorum eos sediscienfloors. Keep a portable hand-held dae cum reptatiantia si offic vacuum nearby in case of a big tendani musapernat laboriduring nos a mess, like a glass breaking et fuga.

Et velibus accum fuga. will party.

Within seconds, the mess Et itatis sitcan pa go volor beincipic gone and you back to aspisquibus maximincia doenjoying the id festivities. lupiendis et quissum et, saped et quid quidunt, fuga.

4. Speed-clean theomnim bathrooms All you need to Im clean bathOvit, con nem. velyour et volut room quickly is a damp microfiber vernatiscius volo mosae ventisclothnos to give every surface a quick quia es dolorita cumque re wipe-down and a toilet brush to ipsam vid ut fugitatem eius pe clean the inside walls of the toilet. rem. Itate conem faccaec temTo freshen it up even more, pour porem as eum cusaepre dollupa half-cup of baking soda into the tatios debisand est,add corrum toilet bowl whiteesedio vinegar along with a few drops of your favorite essential oils. Allow the mixture to bubble for a bit and scrub with a toilet brush. Then, voila: yourduciand bathroom is clean, shiny maximus aecepereped and smelling great. quam et laborem core velestorro officiendunt et doluptianis 5. Tackle the microwave mess molora quae dolorio nempoYou know people will want secrero fugitii sitatium ondscorestrum well after the leftovers are put rerfero oduse et this por tip aped quist miaway, so to tackle officta sperovid mossitiam, tem crowave build-up: Combine lemon faceptatur aut aut sinimus juice and water in aqui microwavesafe bowl andaut runutit ersperibus, for about two molorioratur minutes.

The lemon water will nonsed qui dolupti berit, omnihil loosen any gunk or food in the ipsunt. microwave for an easy wipe Aligend uciistrum fugias down with eictat.a microfiber cloth. Now guests can reheat their leftovers in a clean Test, conseribus. Upiende microwave. llandem olorem nos et as aut veritat etusapis doluptatibus – Brandpoint esto quate volupta vellaud igendis doluptatem resectate re pra

Don’t spend time sweeping with

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INDEX

advertisers

Alphabetical Arthroplastics, Inc.……………………………………… 33 AIV Inc.………………………………………………………… 20 Avante Health Solutions……………………………… 6 C Change Surgical……………………………………… 13 Capital Medical Resources………………………… 53 Cincinnati Sub-Zero…………………………………… 18 Coast 2 Coast……………………………………………… 42 Cygnus Medical……………………………………………… 9 D. A. Surgical……………………………………………… 67 Diversey …………………………………………………………17

Doctors Depot…………………………………………… 51 Encompass Group……………………………………… 58 Fobi……………………………………………………………… 53 GelPro…………………………………………………………… 15 Healthmark Industries Company, Inc.……… 4 Innovative Medical Products…………………… 68 Innovative Research Labs………………………… 63 Jet Medical Electronics, Inc……………………… 62 Kapp Surgical Instrument, Inc………………… 62 MD Technologies inc.………………………………… 43

Medi-Kid Co.………………………………………………… 33 MedWrench………………………………………………… 32 Microsystems……………………………………………… 55 Mobile Instrument Service & Repair……… 24 Mölnlycke……………………………………………………… 23 Pacific Medical…………………………………………… 65 Paragon Services………………………………………… 59 Ruhof Corporation……………………………………… 2,3 Soma Technology, Inc………………………………… 58 TBJ Incorporated…………………………………………… 5

Encompass Group……………………………………… 58 Healthmark Industries Company, Inc.……… 4 Ruhof Corporation……………………………………… 2,3 TBJ Incorporated…………………………………………… 5

Doctors Depot……………………………………………

Jet Medical Electronics Inc………………………

Mobile Instrument Service & Repair………

Pacific Medical……………………………………………

Soma Technology, Inc…………………………………

categorical ANESTHESIA

Coast 2 Coast………………………………………………

Doctors Depot……………………………………………

Innovative Research Labs…………………………

Paragon Services…………………………………………

Soma Technology, Inc…………………………………

42 51 63 59 58

INSTRUMENT STORAGE/TRANSPORT

Cygnus Medical……………………………………………… 9

51 62 24 65 58

REPROCESSING STATIONS

INSTRUMENT TRACKING

TBJ Incorporated…………………………………………… 5

MEDICAL GAS

Fobi……………………………………………………………… 53

Innovative Research Labs………………………… 63 Soma Technology, Inc………………………………… 58

CARDIAC PRODUCTS

MONITORS

SAFETY

Doctors Depot…………………………………………… 51 Pacific Medical…………………………………………… 65 Soma Technology, Inc………………………………… 58

GelPro…………………………………………………………… 15 Healthmark Industries Company, Inc.……… 4

CARTS/CABINETS

ONCOLOGY SERVICES

TBJ Incorporated…………………………………………… 5

ONLINE RESOURCE

MedWrench………………………………………………… 32

Cygnus Medical……………………………………………… 9 Healthmark Industries Company, Inc.……… 4 TBJ Incorporated…………………………………………… 5

OR TABLES/BOOMS/ACCESSORIES

STERILIZERS

ASSET MANAGEMENT

Microsystems……………………………………………… 55

C-ARM Soma Technology, Inc………………………………… 58 C Change Surgical……………………………………… 13 Jet Medical Electronics Inc……………………… 62 Kapp Surgical Instrument, Inc………………… 62 Cincinnati Sub-Zero…………………………………… 18 Cygnus Medical……………………………………………… 9 Healthmark Industries Company, Inc.……… 4 Innovative Research Labs………………………… 63 TBJ Incorporated…………………………………………… 5

CRANIOFACIAL RECOVERY PRODUCTS

Medi-Kid Co.………………………………………………… 33

CRITICAL CARE

Innovative Research Labs………………………… 63

CS/SPD

Microsystems……………………………………………… 55

DISINFECTANTS

Cygnus Medical……………………………………………… 9 Diversey …………………………………………………………17 Ruhof Corporation……………………………………… 2,3

ENDOSCOPY

Capital Medical Resources………………………… 53 Coast 2 Coast……………………………………………… 42 Cygnus Medical……………………………………………… 9 Healthmark Industries Company, Inc.……… 4 Mobile Instrument Service & Repair……… 24 Ruhof Corporation……………………………………… 2,3

Microsystems……………………………………………… 55

Avante Health Solutions……………………………… 6

Arthroplastics, Inc.………………………………………

Coast 2 Coast………………………………………………

D. A. Surgical………………………………………………

Innovative Medical Products……………………

Soma Technology, Inc…………………………………

33 42 67 68 58

OTHER

AIV Inc.………………………………………………………… 20

PATIENT MONITORING

AIV Inc.………………………………………………………… 20 Avante Health Solutions……………………………… 6 Jet Medical Electronics Inc……………………… 62 Pacific Medical…………………………………………… 65

PATIENT SAFETY PRODUCTS Mölnlycke……………………………………………………… 23

PATIENT WARMING

Encompass Group……………………………………… 58

RESPIRATORY

SINKS

STERILIZATION

Coast 2 Coast……………………………………………… 42

SURGICAL

Avante Health Solutions……………………………… 6 Fobi……………………………………………………………… 53 Soma Technology, Inc………………………………… 58

SURGICAL INSTRUMENTS/ACCESSORIES

Arthroplastics, Inc.……………………………………… 33 C Change Surgical……………………………………… 13 Cygnus Medical……………………………………………… 9 Healthmark Industries Company, Inc.……… 4 Kapp Surgical Instrument, Inc………………… 62

SURGICAL LAMPS

Fobi……………………………………………………………… 53

SURGICAL TABLE

Fobi……………………………………………………………… 53

TELEMETRY

ERGONOMIC SOLUTIONS

PEDIATRICS

Medi-Kid Co.………………………………………………… 33

AIV Inc.………………………………………………………… 20 Pacific Medical…………………………………………… 65

FALL PREVENTION

POSITIONING PRODUCTS

TEMPERATURE MANAGEMENT

Diversey …………………………………………………………17 Encompass Group……………………………………… 58

FLOOR MATS

GelPro…………………………………………………………… 15

GENERAL

Cygnus Medical……………………………………………… 9 D. A. Surgical……………………………………………… 67 Innovative Medical Products…………………… 68 Kapp Surgical Instrument, Inc………………… 62 Medi-Kid Co.………………………………………………… 33

AIV Inc.………………………………………………………… 20 Capital Medical Resources………………………… 53

RENTAL/LEASING

INFECTION CONTROL

REPAIR SERVICES

Cygnus Medical……………………………………………… 9 Diversey …………………………………………………………17

66 | OR TODAY | MARCH 2018

Avante Health Solutions……………………………… 6 Capital Medical Resources………………………… 53 Cygnus Medical……………………………………………… 9

C Change Surgical……………………………………… 13 Cincinnati Sub-Zero…………………………………… 18 Encompass Group……………………………………… 58

WARMERS

Cincinnati Sub-Zero…………………………………… 18

WASTE MANAGEMENT

MD Technologies inc.………………………………… 43 TBJ Incorporated…………………………………………… 5

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