INDUSTRY INSIGHTS NEWS & NOTES
LIFE IN AND OUT OF THE OR
PRODUCT FOCUS INSTRUMENT TRACKING SYSTEMS
CE ARTICLE CARDIAC INVASIVE PROCEDURES
OUT OF THE OR WHAT YOU NEED TO KNOW ABOUT YOUR THYROID
REDUCING MEDICAL PAGE 38
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OR TODAY | August 2020
COVER STORY: REDUCING MEDICAL ERRORS Medical errors continue to be a leading cause of death in the United States. Experts share insights and advice to prevent errors in the surgical arena.
REPORTS PREDICT GROWTH IN INSTRUMENT TRACKING MARKET Reports predict growth in the instrument tracking market through 2026.
EXERCISING THROUGH EMOTIONAL STRESS Stress relief can be an important part of any fitness routine.
STAYCATION IDEAS THAT WON'T BREAK YOUR BUDGET A staycation can be the perfect solution for the summer blues before the school year starts.
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9 News & Notes 18 IAHCSMM: AI and Machine Learning Changing the Health Care Landscape 20 CCI: The Concept of Modular Credentials 22 ASCA: Reopening to the New Normal 24 Avante: Why Air Disinfection Systems are Becoming an Increasingly Vital Component of Patient Care 26 Webinar: How to Resolve Multiple IFUs
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IN THE OR
28 M arket Analysis: Reports Predict Growth in Instrument Tracking Market 29 Product Focus: Instrument Tracking Systems 32 CE Article: Cardiac Invasive Procedures: Pre- and Postprocedure Care
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OUT OF THE OR
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INDUSTRY INDUSTRY INSIGHTS INSIGHTS news & notes
Osso VR Delivers Exactness to Improve Global Surgical Outcomes Osso VR, a validated virtual reality (VR) surgical training platform, is rolling out a new training experience in VR with an exceptional level of visual exactness surrounding every aspect, from anatomical detail to the OR environment. This novel immersive experience is a result of Osso VR’s unique creative team makeup, consisting of an Oscar-winning art director and a large medical illustration team with alums from Electronic Arts, Microsoft and Apple. For the first time, big-budget film and game studios are bringing their capabilities to medical VR to deliver solutions that are clinically accurate, preparing an entire generation to train in a new way while improving health care outcomes around the world. Osso VR’s training platform is designed for surgeons, sales teams and other trainees to address complexities in learning new procedures and to use novel medical devices by providing realistic, haptic-enhanced interactions in an immersive training environment that is repeatable. “We’ve reached a level of detail in the anatomy, surgical tools and the OR environment within the platform that was not previously possible. This will improve our ability to accomplish our mission, improving patient outcomes, driving the adoption of high-value technologies and democratizing access to surgical education globally,” said Justin
Barad, MD, CEO and co-founder of Osso VR. Jonathan Sabella, art director for Osso VR, has contributed to some of the most prominent content in entertainment, including films, games and VR. The central driving force in his work is his expertise in human and comparative anatomy, which he has used to bring to life memorable characters and performances for modern cinematic universes, including Marvel and Star Wars. “We are dedicated to bringing the virtual medical training experience to life, leaving no detail untouched. The colleagues I have the privilege of working with here are some of the most talented and professional I’ve had the opportunity to collaborate with,” said Sabella. “I’ve spent my career fascinated with anatomy and the chance to work directly with medical illustrators, engineers and leading doctors in the field to help save lives is something I cherish greatly.” Osso VR’s technology is being used by more than 20 leading teaching hospitals and eight top medical device companies in 20 countries and has been shown to improve surgical performance by 230% in a peer-reviewed study in the Journal of Surgical Education. Focused on increasing access to hands-on training that improves patient outcomes and increases the adoption of higher value medical technology, Osso VR provides an immersive, repeatable environment to safely work up surgical learning curves. •
AUGUST 2020 | OR TODAY |
news & notes
Altapure’s Technology Achieves High Level Disinfection of N95 Safety Masks Altapure LLC, a technology and manufacturing company dedicated to providing high-level disinfection products to medical and long-term care facilities, has announced new data evaluating two of its devices for the disinfection of personal protective equipment (PPE). Two studies demonstrated the effectiveness of the company’s ultrasonic disinfection technology for the rapid decontamination of large numbers of N95 respirators. Both products generate submicron droplets of peracetic acid (PPA) and hydrogen peroxide and have been shown to be highly effective in eliminating microorganisms in patient treatment spaces and on portable equipment. One study, published in Pathogens and Immunity, found that the high-level disinfection cabinet, a product that will be available later this year pending FDA 510k approval in high-level disinfection, was more effective than ultravioletC (UV-C) light and provided greater reductions on both outer and inner surfaces of N95 respirators with a single cycle. Regarding the UV products, the author stated, “However, the levels of reduction did not meet our pre-established criteria for decontamination (i.e., >3 log10 reduction on inoculated respirators), and moreover would not have met a >2 log10 reduction requirement for decontamination. Thus, the level of reduction would not be adequate to allow shared use of respirators by different individuals.” “There remains an urgent need for an effective N95 respirator disinfection process that will allow on-site reprocessing with rapid turnaround times, ease of use with existing personnel and expertise, and flexibility and scalability to process large quantities of respirators,” said Altapure President Carl Ricciardi. “Given the efficacy of the Altapure’s process, the study findings have important implications for facilities that are considering decontamination of PPE as a strategy to maintain adequate supplies in the current COVID-19-related public health crisis, and also have potential application for broader decontamination needs.” The study examined the effectiveness of three methods,
10 | OR TODAY | AUGUST 2020
including UV-C light, a high-level disinfection cabinet that generates aerosolized PPA and hydrogen peroxide and dry heat at 70°C for 30 minutes. The decontamination of three commercial N95 respirators, inoculated with methicillinresistant Staphylococcus aureus (MRSA) and several bacteriophages, including an enveloped RNA virus used as a surrogate for coronaviruses, was assessed. UV-C administered as a one-minute cycle in a UV-C box or a 30-minute cycle by a room decontamination device reduced contamination but did not meet criteria for decontamination of the viruses from all sites on the N95s. The high-level disinfection cabinet was effective for decontamination of the N95s and achieved disinfection with an extended 31-minute cycle. Dry heat at 70°C for 30 minutes was not effective for decontamination of the bacteriophages. Currently in pre-print publication, a separate multiinstitutional study was conducted by researchers at University Hospitals Cleveland Medical Center (UHCMC), Case Western Reserve University (CWRU), National Aeronautical and Space Administration (NASA) Glenn Research Center and the Cleveland Veterans Affairs Medical Center (VAMC) to evaluate the technology for whole-room disinfection of a large number of respirators and evaluated the impact of the treatment on mask performance. “We found that the PAA room disinfection system was easy to set up, operate and was effective for disinfection of N95 respirators with a total cycle time of 1 hour and 16 minutes. Using multiple methods, we did not detect any adverse effects on filtration efficiency, structural integrity, or strap elasticity after 5 treatment cycles,” said author Curtis J. Donskey, M.D., professor of medicine, Case Western Reserve University, and staff physician, infectious diseases section, Louis Stokes Cleveland VA Medical Center. “These results suggest that the PAA room disinfection system provides a scalable solution for in-hospital decontamination of N95 respirators to meet the needs of health care workers during the SARS-CoV-2 pandemic.” •
news & notes
Colibri Endoscopy System Granted FDA Clearance 3NT Medical, a privately held corporation dedicated to developing single-use specialized endoscopes for the diagnosis and treatment of ear, nose and throat (ENT) disorders, has announced the FDA 510(k) clearance for the Colibri Micro ENT Scope, the world’s first single-use endoscope specifically designed for otology. The Colibri endoscopy system incorporates a lightweight ergonomic hand piece, a 2.2mm diameter tip and built-in suction to enable two-handed functionality in a single device. Furthermore, this sterile endoscope enhances safety for patients and medical staff by eliminating the risk for cross contamination, which is a concern when reprocessing multi-use devices. “Colibri enables me to use both hands to perform surgery, returning to the familiar otologic position, and at the same time provides the benefits of endoscopic visualization and illumination,” said Dr. Daniel I. Choo, director, division of pediatric otolaryngology at Cincinnati Children’s Hospital. “I look forward to using Colibri in my surgical practice.” One in seven Americans report some degree of hearing loss,
with more than 4 million office visits annually attributed to chronic ear disease. Ear surgery is successful in addressing the disease burden and stabilizing or improving hearing, but traditional microscopic approaches may require large skin incisions and time-consuming bone drilling. Colibri allows for a minimally invasive, endoscopic transcanal approach, and provides an excellent, wide angle view of hidden middle ear structures. Colibri endoscope can also be used in an endoscope-assisted microscopic approach. “We are excited to make this new, single-use endoscope available for select surgeons in the U.S.,” said Ehud Bendory, CEO of 3NT Medical. “This is a critical first step toward our strategic objective of commercializing a full portfolio of single-use endoscopes designed with the specific needs of otolaryngologists in mind. We expect our family of products will enable surgeons to improve clinical outcomes and patients’ quality of life, while eliminating cross infection risk associated with using and cleaning multi-use devices.” •
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AUGUST 2020 | OR TODAY |
news & notes
AAAHC Report Identifying High Compliance Areas, Improvement Opportunities AAAHC recently released its 2020 Quality Roadmap report, which provides a thorough analysis of data from 1,488 surveys conducted in 2019. Health care organizations can utilize this tool to identify themes that deserve special attention as they pursue ongoing quality improvement throughout the accreditation period. While most deficiencies are comparable to previous years’ findings, given the COVID-19 pandemic, the report underscores the need to address standards related to infection prevention, safe injection practices and emergency preparedness. “The AAAHC Standards focused on infection prevention and control have never been more important. Today, health care organizations need to be even more vigilant about adherence to these practices to promote employee and patient safety,” said Noel Adachi, MBA, president and CEO of AAAHC. “The Quality Roadmap, along with other AAAHC resources such as educational programs and webinars, is designed to help organizations integrate best practices at their facilities throughout the 1,095 days of the accreditation term.” The 2020 AAAHC Quality Roadmap examines accredited organization compliance ratings for current AAAHC Standards based on onsite surveys conducted January 1-December 31, 2019. Organizations surveyed include ambulatory surgery centers, Medicare Deemed Status ASCs, office-based surgery practices, and primary care settings. The cumulative findings suggest that facilities continue to face challenges related to quality improvement studies and documentation. The most common documentation deficiencies include missing information in the patient clinical record on allergies/sensitivities and no evidence that medication reconciliation was performed. The analysis further indicates that other top deficiencies cited in more than 10% of survey ratings were consistent with previous years, including those related to credentialing and privileging, infection prevention/safe injection practices, and emergency preparedness. AAAHC’s analysis shows that AAAHC-accredited organizations demonstrated high compliance with several
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standards. The facilities surveyed showed improvement in several key areas, which are organized by Non-Medicare and Medicare Deemed Status Standards, including: Non-Medicare Deemed Status Standards � Supporting ongoing professional development � Transferring a patient’s care from one health care professional to another � Educating operators of newly acquired devices or products to be used for patient care � Maintaining strict confidentiality on records that contain clinical, social, financial, or other data about a patient, except when otherwise required by law � Ensuring pharmaceutical services are directed by a qualified licensed provider Medicare Deemed Status Standards � Implementing preventive strategies targeting adverse patient events � Improving the professional competence, skill, and performance of health care professionals � Providing convenient access to reliable, up-to-date information pertinent to the clinical, educational, administrative, and research services � Encouraging health care professionals to participate in educational programs and activities � Ensuring that concern for the cost of care is present throughout the organization “In line with AAAHC’s 1095 Strong, quality every day philosophy, which promotes ongoing commitment to quality improvement and patient safety, the 2020 Quality Roadmap can help ambulatory providers better develop and strengthen their policies, procedures, and practices,” said Adachi. “This requires a team effort. We encourage organizations to review and discuss the Quality Roadmap findings and work together to drive collaboration and help all team members focus on improving the quality of care they provide.” • To download the 2020 AAAHC Quality Roadmap, visit www.aaahc.org/quality/aaahc-quality-roadmap/.
BD Announces New Thin-Walled Guiding Sheath BD recently announced the launch of the Halo One ThinWalled Guiding Sheath, designed to perform as both a guiding sheath and an introducer sheath, for use in peripheral arterial and venous procedures requiring percutaneous introduction of intravascular devices. Halo One Thin-Walled Guiding Sheath consists of a thin-walled (1 French wall thickness) sheath made from braided single-lumen tubing, fitted with a female luer hub at the proximal end and a formed atraumatic distal tip. The thin-walled design reduces the size of the arteriotomy compared to standard sheaths of equivalent French size, which is designed to help minimize access site complications. Halo One Thin-Walled Guiding Sheath’s broad size offering provides the only thin-walled sheath with lengths suitable for distal peripheral intervention as well as sizes for alternative approaches such as tibiopedal or radial access sites. “The introduction of the Halo One Thin-Walled Guiding Sheath embodies our dedication to innovation, which for so long has centered on minimally invasive devices,” said Steve Williamson, worldwide president of BD Peripheral Intervention. “With Halo One Thin-Walled Guiding Sheath, we’re focusing on where those interventions begin, at the point of access. It effectively downsizes the access profile of peripheral procedures compared to standard sheaths, making it a valuable complement to our innovative portfolio of peripheral artery disease interventional devices.” A stainless-steel braid construction fortifies the design for extra support, and benchtop testing of comparable 5F sizes, showed that Halo One Thin-Walled Guiding Sheath demonstrated 107 percent higher compression resistance, four-times better kink resistance, and 100 percent smoother tip transitions (measuring dilator to sheath transition) than a leading competitive thin-walled sheath. Halo One Thin-Walled Guiding Sheath provides the versatility to fit physicians’ everyday needs with a broad size offering that includes 4, 5 and 6F sizes with shaft lengths of 10 cm and 25 cm. Additionally, shaft lengths of 45, 70 and 90 cm are available for 4F and 5F sizes. •
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AUGUST 2020 | OR TODAY |
news & notes
Philips’ New Acute Care Patient Monitoring Solutions Granted EUA Royal Philips has announced that the U.S. FDA has issued an Emergency Use Authorization (EUA) for Philips’ IntelliVue Patient Monitors MX750/ MX850 and its IntelliVue Active Displays AD75/AD85, for use in the U.S. during the COVID-19 health emergency. These patient monitoring solutions support infection-control protocols and remotely provide critical patient information for caregivers, capabilities that are much needed when caring for hospitalized COVID-19 patients. Philips’ IntelliVue Patient Monitors MX750/MX850 and IntelliVue Active Displays AD75/AD85 received CE mark in 2019 and are already being used in hospitals across Europe. The EUA allows Philips to start delivering the new remote patient monitoring solution to hospitals in the U.S., and the company is committed to submitting a 510(k) to FDA for this acute care solution in the course of 2020. As countries across the globe continue to combat COVID-19, while gradually resuming elective care, Philips is significantly increasing its patient monitor production to address the demand for increased intensive care unit (ICU) capacity. Hospitals and health systems are increasingly relying on health technology to better manage the influx of COVID-19 patients they
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are seeing in emergency rooms (ERs) and ICUs. To minimize staff exposure to the virus that causes COVID-19 while still delivering quality care, there is a critical need for patient monitors that enable clinicians to remotely monitor a patient’s condition. “As the world continues to battle against COVID-19, we’re committed to ramping up production of all critical solutions that can help in this time of crisis,” said Peter Ziese, general manager, monitoring and analytics at Philips. “This FDA EUA for our MX750 and MX850 monitors and IntelliVue AD75 and AD85 Active Displays allows us to do that for these remote patient monitoring solutions, which are of vital need in the ICU. At Philips, being able to provide the right information at the right time to caregivers has always been a top priority. Now more than ever, there’s an urgent need to make sure those on the frontline have all the available resources at their disposal.” The IntelliVue Patient Monitors MX750/MX850 and IntelliVue Active
Displays AD75/AD85 offer advanced functionality and clinical decision support capabilities such as Philips’ IntelliVue Horizon Trends information view, which shows deviations in vital signs (for example, CO2 and heart rate) to contextualize a patient’s condition, while also supporting infectioncontrol protocols and access to key information both remotely and at the bedside. Features such as Philips’ Alarm Advisor and Alarm Reporting help to reduce alarm fatigue for caregivers, while the smooth glass surfaces, rounded edges and special surface material of the monitors and displays facilitates cleaning and disinfection. The MX750 and MX850 monitors are the latest additions to Philips’ portfolio of integrated patient monitoring solutions to support improved clinical and operational workflows. The MX750 and MX850 also include updated features, including enhancements to monitor and assess clinical and network device performance, and additional functionalities to strengthen cybersecurity. •
Quality Improvement Initiative Certifies Surgical Residents as Bilingual Speakers Communication between patients and health care professionals is essential to the safe and effective delivery of health care. More than 60 million residents of the United States speak a language other than English at home, with approximately 22% self-identifying as either speaking English “not well” or not speaking English “at all,” according to the U.S. Census Bureau. A new improvement brief in the June issue of The Joint Commission Journal on Quality and Patient Safety details a quality improvement initiative to identify general surgery residents proficient in a non-English language and have each attempt the Clinician Cultural and Linguistic Assessment (CCLA) to become qualified bilingual staff speakers. In the study “Surgical Residents as Certified Bilingual Speakers: A Quality Improvement Initiative,” general surgery house staff at Johns Hopkins Hospital in Baltimore were asked to self-identify as proficient in a language other than English. All residents responded to the initial survey, with 18 out of 65 reporting a non-English language proficiency. Of the 12 residents who sat for the CCLA exam, nine (75%) passed, with five certifying in the most commonly spoken non-English languages at the academic medical center. The number of certified residents increased from one to 10. Fees for the exam were waived and each resident was excused from clinical duties to complete the exam. “Residents care deeply about the patients they care for, yet are often very busy. Speaking to patients with limited English proficiency in their own languages helps residents build rapport with patients and saves time. This study demonstrates how this can be done in a safe and standardized fashion. Lowering the barriers to certification without lowering the standards for certification helps residents promote culturally sensitive, high quality and equitable patient care. Resident quality improvement projects are key components of their education and can help lead to change for institutions,” says Elliott R. Haut, MD, PhD, FACS, vice chair of quality and safety for surgery and co-author of the paper. “Initiatives like this one are an important piece of a larger puzzle that must include multiple complementary modalities for language access with both clinic- and systems-level components, including qualified interpreters to be able to offer limited English proficient (LEP) patients a consistently high standard of care,” notes Lisa C. Diamond, MD, MPH, in an accompanying editorial.
AUGUST 2020 | OR TODAY |
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AI and Machine Learning – Changing the Health Care Landscape But Don’t Exclude Sterile Processing from Key Discussions By David Taylor, MSN, RN, CNOR ncient papyrus revealed Egyptian medical practice was highly advanced and doctors performed the first surgery more than 3,500 years ago (2750 BC).1, 2 Since then, medicine has seen significant advancements, but none like we are poised to see over the next decade. As the technology sector had merged with medicine, significant advancements have been made in computing, artificial intelligence (AI), machine learning (ML), sensors, robotics and genomic sequencing – and it is touching all aspects of human health. The convergence of these technologies and its integration with medicine aspires to change and even eliminate disease as we know it.3
Not long ago, patients were admitted to the hospital days or even weeks before surgery. Those procedures often required large incisions and weeks of recovery. Today, cutting-edge technologies (laparoscopic/minimally invasive procedures) and advances in anesthesia allow many patients to arrive the morning of their surgery and be discharged home far more quickly, often within hours after their procedure. Those patients also experience far simpler recoveries due to these advancements.
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The not-so-distant future of surgery will offer amazing collaborations that will include advanced robotics. NASA has been working with a U.S.based medical company to develop a robot weighing 0.4kg, which can be placed inside a patient’s body (through the umbilicus, while the patient is in space), and controlled remotely by a surgeon from planet earth.4 And it is not just NASA looking at cutting-edge technologies. Dr. Rafael Grossman, MD, FACS, a surgeon, educator and health care futurist who practices in Maine, was part of a team performing surgery using medical virtual reality (VR). He was the first doctor to use Google Glass live in surgery and is an outspoken proponent for innovative technologies and applying those technologies to improve the quality of care.5 Advanced technologies and the willingness of providers and health systems to employ them for patient care can elevate the precision and efficiency of surgeries. When looking at the growth in the advanced surgical technology segment, it’s little surprise that surgical robotic sales are expected to nearly double to $6.4 billion.6
Ensure SP professionals have a seat at the table Before adopting advanced surgical
technology, however, it is essential that health care organizations take into consideration all departmental stakeholders that will be affected by the change, including those in the sterile processing department (SPD). And because robotic technology will increasingly be used throughout health care facilities, not just in the operating room, it’s prudent that sterile processing (SP) professionals are part of those product evaluation and purchase decision-making processes if the technology or any of its components will require cleaning, disinfection or sterilization by SP technicians. Although new technologies may produce tremendous efficiencies and increase surgical case volumes, all could be lost if leaders do not understand the time, equipment and other resources that may be needed behind the scenes to clean and sterilize these new products/technologies. Many of the nation’s SPDs are already under tremendous pressure to produce more with less, without jeopardizing quality and safety. Advanced technologies may require special equipment, training or more manpower to keep up with demand, so it’s essential to know all that early on and ensure the facility has the proper resources to ensure it can be used safely and effectively. WWW.ORTODAY.COM
Conclusion Technology will drive health care in more dramatic ways than anything we can imagine. In a time when every nation is experiencing shortages in health care providers and increased patient demand, advances in technology may be the only solution that extends a provider’s ability to reach more patients. Providing exceptional care to all those who need it will depend not only on providers but also on functional, dependable technology that enhances the patient care experience. There is no telling where advanced technologies will be in our near future, but the prospects seem endless. Before health care organizations jump onto the advanced technology bandwagon, however, it will remain important to ensure all essential departmental representatives are part of the process when evaluating new solutions and determining whether purchasing and implementing them makes sense for the health care organization.
References 1. Ancient Egyptian medical knowledge revealed by 3,500-year-old texts https://www. cnn.com/2018/08/31/health/ancient-egyptmedical-knowledge/index.html
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2. Ancient Egyptian Medicine https://www. crystalinks.com/egyptmedicine.html 3. Medicine Will Advance More in the Next 10 Years Than It Did in the Last 100 https:// singularityhub.com/2016/10/26/medicine-willadvance-more-in-the-next-10-years-than-it-didin-the-last-100/ 4. Surgery in Space: Nasa helps develop matric-
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AUGUST 2020 | OR TODAY |
INDUSTRY INSIGHTS CCI
The Concept of Modular Credentials By James X. Stobinski, PhD, RN, CNOR, CSSM (E) ecently, during the question and answer period following a presentation, I was asked how the Competency and Credentialing Institute (CCI) is evolving in response to the COVID-19 pandemic. The context for this question was how licensing and credentialing bodies could assist in the competency development of their stakeholders.
At CCI the largest part of our work, at present, is administering certification programs for perioperative nurses. I have presented and written on this topic of competency assessment for many years beginning with a 2008 article in the AORN Journal.1 The short answer is that the business of CCI is changing and the pandemic and its sequelae will likely accelerate the pace of that change. How CCI will change in the nearterm future will be guided in part by the development of new concepts such as microcredentials. Microcredentials are described by BloomBoard as competency-based, personalized, self-directed demonstrations of new or existing expertise.2 Jon Marcus3 on the Wired website speaks to the concept of stackable credentials. Marcus describes how diverse education providers to include Western Governors University, edX and Brigham Young University-Idaho are all offering programs where a collection of microcredentials can be earned in sequence and then stacked together to eventually result in a degree. CCI, as I have described in previous columns, is now administering microcredentials. The traditional model of certifi-
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cation has been for decades that a candidate passed a knowledge-based examination to earn a credential and then recertified that credential by documenting continuing education (CE) activities. That model was widely used in many occupations but was firmly rooted in the nursing profession. Professional meetings were built around the need to earn CE to fulfill recertification and renewal of licensure requirements. In this context CE became a commodity of sorts but a necessary part of the licensure and credentialing component of professional nursing. With the pandemic we can assume that health care facilities will predictably slash education and professional development budgets to meet budget shortfalls. Many of our industry partners will have less money to spend on trade shows and exhibits but the continuing professional development (CPD) needs of perioperative nurses will remain. The need for CPD in the technology intensive, dynamic field of perioperative nursing is clear.4 CCI believes that microcredentials can fill some of this CPD need in a costeffective manner. We envision that microcredentials, such as the current CCI offering in strategic management, can fill a variety of purposes. We see microcredentials as modular components in the larger ecosystem of credentialing. Microcredentials, when considered from a modular perspective, could be used in a variety of ways. The potential for microcredentials lies in first developing a suite of offerings which are meaningful and useful to perioperative nurses. Once that resource is established nurses could earn microcredentials to fulfill eligibility criteria for a
certification, to fulfill recertification requirements or simply as documentation of expertise or competency in a defined field. The use of microcredentials, based in adult learning principles allow considerable autonomy for perioperative nurses to chart their own CPD path. At CCI, we are currently working with several industry and nonprofit partners to develop a suite of microcredentials based upon a consensus of the work of perioperative nurses. I do not foresee that professional meetings and trade shows will end abruptly or that nursing will no longer use CE. However, I do believe that in unsettled times with tight budgets, nurses and other health care professionals will appreciate having flexibility and additional choices to fulfill their CPD needs. The CCI team looks forward to working with perioperative professionals to develop education materials which can meet those needs.
References 1. Stobinski, J. X. (2008) Perioperative nursing competency. AORN Journal (88)3. pp. 417-436. 2. BloomBoard (2019). What are Microcredentials? [webpage}. Accessed June 2, 2020 at: https://bloomboard.com/what-are-microcredentials/ 3. Marcus, J. (2020). More Students are â€œStackingâ€? Credentials en Route to a Degree. [webpage]. Accessed June 2, 2020 at: https:// www.wired.com/story/students-stackingcredentials-route-degree/ 4. Stobinski JX. (2020). [guest editorial]. Continuous Professional Development in Perioperative Nursing. AORN J. 111(2):153-156. doi: https://doi.org/10.1002/aorn.12944 WWW.ORTODAY.COM
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INDUSTRY INSIGHTS ASCA
Reopening to the New Normal By Bill Prentice rom early March through the end of April, it seemed that almost everyone I talked to used the word “coronavirus” or “COVID-19” at some point in our conversation. ASCA staff worked seven days a week during that time, conferring with federal and state officials to determine the best ways for ASCs to participate in their community’s response. They were collaborating with our professional colleagues and state ASC leaders to make certain ASCs had access to the best guidance possible. They were collecting, analyzing and distributing the information ASCs needed to make wise decisions for their centers.
If you work in an ASC and have not visited our online COVID-19 Resource Center, I encourage you to visit that site (www.ascassociation.org/ covid-19). We continue to update it as new information becomes available. Today, along with the rest of the country, ASCs are focused on what is next. How do we move forward? For ASCs, that means finding the best ways to provide our patients with the services they need while keeping them and their families safe. After canceling non-emergent surger-
22 | OR TODAY | AUGUST 2020
ies for several weeks this spring while the country focused its resources on caring for those affected by the virus, ASCs are, once again, performing elective surgery. The first reports we are getting indicate that many patients are anxious to get the surgery they postponed earlier and most are happy to comply with the new policies and procedures ASCs are putting in place to provide additional safety for their patients. As one ASC administrator reminded me recently, the term “elective surgery” can be misleading. Often when people who are not health care professionals hear that word, they think it means cosmetic surgery or some procedure that has nothing to do with a patient’s physical well-being. In reality, a patient in need of an elective surgery could be coping with a significant amount of pain or discomfort. The only aspect of the procedure those patients consider elective is the exact timing of the surgery, not whether to have it done. Some of the new policies ASCs have put in place in response to COVID-19 include requiring everyone who enters the ASC to wear a mask or face covering of some kind, enforcing social distancing recommendations and asking the friends and family members who accompany patients to the center to wait somewhere outside the facility while surgery is performed – mak-
ing exceptions for pediatric patients and special circumstances, of course. With these new processes in place, one ASC administrator I talked to recently reported returning to about 80% of his ASC’s regular caseload in just one week. Another indicated that her ASC was at nearly 100% after two weeks. “We have always sterilized our ORs in between patients, so there is nothing new there,” she said. What can take a little longer, other ASC managers tell me, is creating the schedules and additional space needed to adhere to the social distancing guidelines and spending additional time reviewing the new policies with patients. As ASCs adjust to the new normal, ASCA is adjusting too. Back in March, when COVID-19 was being reported in new places across the country several times a week – we postponed ASC Advocacy Day. That event brings ASC staff and physicians, and others who work with ASCs, to Washington, D.C., to meet with their members of Congress to discuss key ASC policy concerns. It has been a critical component of ASCA’s advocacy program for many years. As I write this message, ASCA has moved that event into late September and is still working to determine if the new date will be viable. If so, we are considering what sort of meetings members of Congress WWW.ORTODAY.COM
and their staff will prefer. For the most current information on that event, please see ASCA’s website (www.ascassociation.org/nationaladvocacyday) or contact ASCA Manager of Grassroots and Political Affairs Adam Parker at email@example.com.
ASCA Conference When it became clear that the May date for ASCA’s 2020 Annual Conference & Expo was no longer an option, ASCA got to work converting that program into a virtual conference that included special interactive events in the expo hall. It included sessions that attendees could join live – with presenters on hand to answer questions – on July 9 and 10 or watch on-demand recordings through October 31. The virtual conference delivers all the same great educational content ASCA events are known for, with two significant benefits. First, the new
format allows participants to attend more sessions, so they can earn up to 26, instead of 18, nursing contact hours, administrator education units (AEU) and/or infection prevention credit hours (IPCH). Second, all conference participants have access to the recorded sessions through October 31. If you did not sign up for the conference earlier, you can still register today and access the entire program. For more information, visit the ASCA 2020 website at www. ascassociation.org/asca2020.
COVID-19 Resources Earlier this year, as ASCA reached out to federal and state officials to help coordinate the ASC community’s response to the pandemic and developed and disseminated the COVID-19 resources ASCs needed, I heard from many ASCs of all specialties and sizes thanking ASCA for the work we were
doing and the tools and information we were providing. Many recognized that no other organization was delivering the kind of comprehensive services ASCA was providing. None of that work would have been possible without the support of our members. As we head into the next chapter of our “new normal,” I am encouraging everyone who works in an ASC to make sure your ASC is a member. If you don’t know if your facility is a member or need help signing up, please contact Mykal Cox at mcox@ ascassociation.org. With so much uncertainty surrounding so much of what we took for granted before, it is more important than ever for ASCs to be represented in Washington, D.C., and their state legislatures and to speak with a united voice. Please, if you work in an ASC, help support the work ASCA is doing and get involved with ASCA today.
AUGUST 2020 | OR TODAY |
SPECIAL ADVERTISING SECTION
INDUSTRY INSIGHTS Avante
Why Air Disinfection Systems are Becoming an Increasingly Vital Component of Patient Care By Brent Kramer edical facilities are incorporating air filtration systems to help safeguard patients and staff from coronavirus transmission.
As coronavirus restrictions ease across the United States, medical facilities are gradually opening their doors for nonurgent exams and procedures. In their preparations to see patients, creating and maintaining a sanitized environment is paramount. Clinicians are reexamining and reformatting every stage of patient care for maximum infection control. From the operating room, to the waiting room, exam suite and staff areas, medical staff is making sure their practices adhere to standards from the Centers for Disease Control and Prevention (CDC) and other agencies. The CDC recommends social distancing, virus testing and surface sanitation protocols that are proven to control the risks of infection. While these methods are certainly effective in the fight against the coronavirus, more and more facilities are using active air disinfection filtration systems in addition to other proven safety measures to provide staff and patients with an extra layer of infection control. As we are all familiar, COVID-19 is primarily spread as an aerosol that can stay in the air for hours and travel up
24 | OR TODAY | AUGUST 2020
Brent Kramer Medical Supplies Manager to 160 feet. Treating the air in medical facilities is a vital component in stopping the spread of viruses and bacteria. While many air purification products on the market today help to reduce virus transmission, some are more effective than others. For example, Novaerus products from WellAir Solutions provide continuous air purification reducing both viral and bacterial loads in the surrounding air. Novaerus air disinfection systems use patented plasma technology that is proven to destroy airborne viruses. Any virus or particle that passes over the patented plasma coil barrier will be killed immediately at the DNA level. The technology’s effectiveness has been shown in independent laboratory trials around the globe, including at the NASA Ames Research laboratory. In addition to a variety of bacterial and viral agents, this technology has also been tested to reduce MS2 Bacteriophage, a commonly used sur-
rogate for SARS-CoV* (Coronavirus) by 99.99%. The systems offer this high level of infection control without releasing any harmful chemicals into the air. Unlike other airborne infection control methods including photocatalytic oxidation and sanitation misting, the Novaerus system is safe to run 24/7 while still offering a 99.99% Log 4 reduction rate. Each model is sleek and compact with a minimal footprint, offering air purification without disrupting the floor plan of the surgery suite. For example, the Protect 900 model weighs only 10.4 pounds but can filter up air up to 1,200 square feet. With their reusable filters, the systems also provide low ownership and maintenance costs. Clinicians must simply replace the reusable filter as needed, and the device will keep working as intended. Novaerus technology is currently available in three different units, allowing facilities to select the right configuration for their unique needs. All units can be easily positioned and plugged in where they are needed most including surgical suites, waiting rooms, patient areas, staff areas and hallways. � Protect 900: medium-sized spaces � Defend 1050: larger, high-risk spaces � Protect 200: small spaces WWW.ORTODAY.COM
news &Avante notes
As clinicians ready their facilities and resume non-urgent patient care, an increasing number of them are implementing air disinfection technology to help safeguard patients and staff from the coronavirus. Novaerus systems from WellAir Solutions are available from Avante Health Solutions, your one source to maximize capital equipment performance. For more information, visit avantehs.com/air. Brent Kramer is the Medical Supplies Manager for Avante Health Solutions’ Louisville Center of Excellence. With over 10 years of experience in the medical equipment industry, he works every day with clients to find the right medical supplies to suit their clinical needs and their budget. *2010 – Evaluation of filters for the sampling and quantification of RNA Phage Aerosols, Louis Gendron et al.
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news & notes webinars
Webinar: How to Resolve Multiple IFUs Staff report he OR Today webinar “Resolving Multiple IFUs: Navigating the Long and Winding Road of Medical Device Reprocessing” was eligible for one (1) continuing education (CE) hour by the State of California Board of Registered Nursing.
The webinar featured David Jagrosse, president of David Jagrosse Consulting LLC. Jagrosse is also a consultant to oneSOURCE Document Site. In the session, Jagrosse discussed how a manufacturer’s instructions for use (IFUs) are a critical part of today’s health care settings. Staff are often involved in scenarios where multiple devices can have their own independent instructions for use that may or may not concur with one another. This session explored the latest AAMI guidelines and guided users to better understand how to resolve these conflicts. Real world examples were explored and glimpses of what the future may bring were covered. More than 200 people attended the live presentation and even more have watched a recording of the webinar online. Several attendees shared positive feedback via a post-webinar survey. “The OR Today webinars are always pertinent to what’s happening in the
26 | OR TODAY | AUGUST 2020
"The OR Today webinars are always pertinent to what’s happening in the real world. I always learn something new or reinforce what I already know, giving me confidence in my experience." - L. Farabaugh, infection preventionist real world. I always learn something new or reinforce what I already know, giving me confidence in my experience. As an infection preventionist, the OR can be an intimidating world to enter. But OR Today webinars give me the knowledge and skills needed to push through those OR doors. Thank you,” said L. Farabaugh, infection preventionist, Northwest Hospital. “I think education is the key to success in this ever-changing industry! If it’s informative and relevant to your job ... listen,” shared R. Worden, CST, CRCST, CHL, CIS, Northern Michigan Surgical Suites. “Information presented was very informative and thought provoking. Examples of the multiple IFUs and how to use critical thinking skills to solve challenges presented at individual facilities is a very timely subject. Thank you for providing solutions to difficult real-life situations,” wrote E. Vane, SPD practicum/health science teacher, Health Careers High School. “David Jagrosse is very knowledgeable. I appreciate his years of experience and his guidance in this area of IFUs. This webinar was very timely as
it seems each year more IFUs conflict with each other. Webinar went quickly and didn’t drag,” said K. Hughes, central processing manager, Good Samaritan Hospital. “Many thanks for continuous infection prevention practices. It’s important we remember every item we process affects a patient’s outcome. My father’s rotator cuff instrument tray was not sterilized following practice, and he lost use of his arm due to severe infection. I vowed to do all I can to prevent this event from happening again,” said R. Serrato, SPD Tech III, St. Mary Medical Center. For more information about the OR Today webinar series, including recordings of previous webinars and registration for upcoming sessions, visit ORToday.com and click on the “Webinars” tab.
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IN THE OR
Headline Headline Deck Reports Predict Growth in Instrument Tracking Market Staff report everal reports call for continued growth in the surgical instruments tracking systems market. At least one research firm calls for the market to exceed $536 million in the near future.
Reportlinker.com recently announced the release of its report on the surgical instruments tracking systems market. “The global surgical instrument tracking systems market size is expected to reach a value of $536.0 million by 2026,” according to Reportlinker.com. “It is anticipated to expand at a compound annual growth rate (CAGR) of 19.9% during the forecast period.” The report adds that the rising incidence of retained surgical foreign bodies in the body during surgery is expected to boost the growth. In the U.S., around 4,500 to 6,000 items of surgical equipment are left in surgical sites, annually, leading to the requirement for an additional surgery to remove that equipment from the body, the report states. Thus, there is an increasing demand for operating instrument tracking products. Reportlinker.com also states that an increasing need for inventory management and implementation of Unique Device Identification (UDI) regulations by the Food and Drug Administration (FDA) are some of the major factors supporting market growth. The U.S. FDA has proposed a rule requiring UDI for medical devices to encounter the requirements of the FDA Amendments Act, to improve medical
28 | OR TODAY | AUGUST 2020
devices safety and reporting of devicerelated adverse events. According to UDI regulations, surgical instruments would essentially have to be UDI marked on the device to modernize post-market surveillance and the patient safety of various surgical instruments. Thus, favorable government regulations for implementation of tracking solutions is projected to boost the market growth. According to a new research report published by MarketsandMarkets, the surgical instrument tracking systems market is projected to grow at a CAGR of 14.1% during the forecast period to reach $312 million by 2024 from $161 million in 2019. The MarketsandMarkets report states that factors such as the need to meet FDA UDI mandates, the requirement for better inventory and asset management practices, along with the growth of the surgical instruments market are all expected to drive market growth. The hospitals market segment accounted for the largest share of the surgical instrument tracking systems market, according to MarketsandMarkets. “Based on end user, the market is segmented into hospitals and other end users. The hospitals segment accounted for the larger share of the surgical instrument tracking systems market in 2018. The growth of the hospitals segment is attributed to high patient inflow as compared to other end users in the market. Hospitals also use more equipment and instruments on an average than other health care providers and carry out a greater number of surgical procedures.
This has ensured a sustained demand for tracking solutions in hospitals,” the report states. Grand View Research also issued a report that predicts continued market growth. The global surgical instruments tracking systems market size was valued at $128.3 million in 2018 and is projected to expand at a CAGR of 19.9% over the forecast period (2019-2026), according to the report. Grand View Research agrees that the increasing incidence of retained surgical instruments in the human body after surgery and instrument misplacement are major factors contributing to market growth. “According to the National Center for Biotechnology Information (NCBI), the fatality rate of retained surgical objects is around 2.0%. Thus, the need for advanced technologies such as 2D barcodes and RFID to track the retained instruments while the patient is still in the operation theater, is rising. This factor is projected to propel the market,” the report states. High adoption of instrument tracking products by hospitals is another major factor driving the market growth. “Tracing medical devices and inventory management during work cycle including surgery, post-surgery, storage and sterilization procedures are some of the major problems faced by hospitals. Thus, they are adopting innovative technologies to track these equipment and systems, which in turn is expected to propel the market,” Grand View Research adds. WWW.ORTODAY.COM
IN THE OR
UNIFIA, Olympus’ reprocessing documentation and asset management system, utilizes the proprietary, built-in RFID technology of Olympus endoscopes and OER-Pro reprocessors to track an endoscope’s movement throughout the GI lab. Wireless scanners, used to track an endoscope’s journey, collect information on the asset’s real time location, patient interactions and user performance. This tracking creates a permanent electronic reprocessing and location record that associates patient, user and endoscope data together in a single system. Data can be used in Unifia’s Infection Prevention and Materials and Asset Management modules to identify areas for improvement, including accuracy of reprocessing documentation, staff performance, asset utilization and repair history. •
oneSOURCE is a leading healthcare management solution that enables facilities to stay in compliance 24/7 through its robust online platform equipped with the world’s most updated IFUs (instructions for use) and its ability to integrate instrument tracking platforms like CensiTrac so everything a sterile processing department would need is in one central hub. The instrument tracking integration allows practitioners to document every stage of the sterile processing workflow including who worked on the instrument – from the OR room to decontamination to assembly. When the instrument is scanned into the system it can direct the practitioner to the necessary IFU in order to complete the proper sterilization procedures. • For more information, visit onesourcedocs.com.
AUGUST 2020 | OR TODAY |
IN THE OR
CenTrak’s Location Services platform streamlines the tracking and management of soiled utensils and trays by location and where they are in the sterilization process. An electronic monitoring system, like CenTrak’s Real-Time Location System (RTLS), increases safety with an automated alert to staff if a step of the sterilization process is missed, helping to eliminate a number of potential infection risks. CenTrak’s DuraTag is fully waterproof and withstands harsh highlevel disinfection chemicals. The tag is compatible with CenTrak’s Clinical-Grade RTLS, enabling facilities to continually monitor assets locations to optimize workflow and utilization, meet compliance requirements and prevent shrinkage. •
Surg-I-Band Data Matrix Color Coding Barcode Scanlan Surg-I-Band Data Matrix Color Coding Barcode offers hospitals an excellent system to organize and track surgical instrumentation and devices. Combining the benefits of Surg-I-Band color coding with the technology of bar coding, Surg-I-Band Data Matrix provides a fast, easy and precise organizational system. The EASY-TAG Mini is designed to answer the need for a cost-effective, easy, secure method of tracking instruments, trays, equipment and repairs through cleaning, decontamination and sterilization processes. • For more information, visit www.scanlaninternational.com.
30 | OR TODAY | AUGUST 2020
IN THE OR
Cardiac Invasive Procedures: Pre- and Postprocedure Care By Joanne McGlinchey MSN, RN-BC, PCCN usan, an RN on a telemetry unit, received a shift report for two patients scheduled for procedures in the cardiac catheterization lab.
Raymond, a 76-year-old retired truck driver, was admitted with a diagnosis of congestive heart failure and was scheduled for diagnostic cardiac catheterization at 8:00 a.m. After recovery in the holding area, he was expected to return to the telemetry unit. Patti, a 68-year-old retired office manager with known coronary artery disease, was scheduled for an angioplasty at 10:00 a.m. She will go to the cardiac procedure recovery unit (CPRU) for specialized care after the procedure. While Susan made rounds, Alan, an ED RN, was caring for Jason, a 42-year-old teacher with unstable angina who needed an emergency catheterization with possible intervention. The CathPCI Registry collects data from approximately 90% of cardiac catheterization labs in in the United States. This data is a representation of treatments received with consideration to patient populations as well as procedural settings.1 These procedures involve physicians evaluating for potential blockages or lesions and, if needed, approaching them through the lumen of coronary arteries to restore coronary artery blood flow to the myocardium of the heart.2 Percutaneous coronary intervention (PCI) may include: � Percutaneous transluminal coronary angioplasty (PTCA) (balloon dilation) � Atherectomy (plaque cutting and removal) � Thrombectomy (clot extraction) � Rot ablation (drilling and pulverizing
32 | OR TODAY | AUGUST 2020
of hard plaque) � Laser-assisted angioplasty (ablation of atherosclerotic plaques) � Stent placements (“scaffolding” of interior lumens of diseased arteries) Stents are used in more than 90% of PCI procedures.2 Coronary stents are made of metal, and some deliver antiproliferative medication directly at the site.3 These drug-eluting stents are useful for lesions at high risk for thrombosis. Indications for PCI can be found in the 2015 ACC/AHA/SCAI focused update on primary PCI.4 Cardiac catheterizations are performed via a percutaneous approach that involves the use of an introducer needle, guidewire, and catheters.5 The radial artery approach is gaining popularity because there is less risk of vascular complications and bed rest postprocedure is reduced.5, 6 Heparinized solutions may be used to maintain the catheter’s patency. Through the catheter, radiopaque contrast materials are injected into coronary arteries and the left ventricle to track coronary artery and ventricle-toaorta blood flow. X-rays of the contrast flow are recorded digitally to facilitate subsequent review of the anatomy and diagnosis of an abnormality.7 Indications for cardiac catheterization: � Evaluate chest pain. � Confirm presence of heart disease. � Evaluate function of the heart muscle. � Determine the need for further treatment. Radiopaque contrast exposes blockages or lesions, which can be treated with interventional procedures that use dilation balloons, rot ablation drills, or vacuum-extraction devices to restore circulation.2 The catheter sizes 5FR and 6FR are most common.7 The size of the
Relias LLC guarantees this educational program free from bias. The planners and authors have declared no relevant conflicts of interest that relate to this educational activity. See Page 37 to learn how to earn CE credit for this module.
Goal and objectives The goal of this percutaneous coronary interventions continuing education course is to enhance nurses’ care of patients undergoing cardiac-invasive procedures. After studying the information presented here, you will be able to: •
List factors that increase the risk for vascular complications in patients undergoing cardiacinvasive procedures.
Discuss common sensations and anxieties experienced by patients undergoing cardiacinvasive procedures.
Describe nursing pre- and postprocedural care for patients undergoing procedures in the cardiac catheterization laboratory.
catheter is dictated by procedural need and body weight. Clinicians may insert a femoral vein sheath for fluid and drug administration as well as a temporary pacing catheter, when needed, that is advanced to the right ventricle. In patients with compromised femoral arterial circulation or morbid obesity, percutaneous or surgical “cutdown” of the brachial or even radial artery may be used.7 Before arterial access is established, WWW.ORTODAY.COM
IN THE OR
continuing education palpation or a Doppler device is used to evaluate pulses distal to the proposed site to determine the appropriateness of the site and a baseline for postprocedure comparisons. If the radial approach is planned, Allen’s Test determines if the ulnar artery can provide adequate blood flow to the hand in the event of radial occlusion. The predictability of ischemic complications using this technique is questionable, and it is not performed before all transradial approaches.8
Preparing for Diagnostic Cardiac Catheterization Susan interviewed Raymond and reviewed his chart to determine his readiness for the 8:00 a.m. diagnostic cardiac catheterization procedure. She noted a record of his medical history and physical examination, signed procedure and operative consent, current lab study results, ECG, and chest x-ray. Baseline blood urea nitrogen and creatinine levels had been obtained for later comparison with postprocedure values because iodinated radiopaque contrast could exacerbate pre-existent renal insufficiency. Susan also reviewed the baseline hemoglobin and hematocrit so she could monitor for changes that might indicate bleeding. She noted that the prothrombin (PT) and partial thromboplastin (PTT) times, as well as the international normalized ratio (INR) were within normal limits. Elevated PT, INR, and PTT values may increase the risk of bleeding during and/ or after the procedure and may cause the physician to delay the catheterization procedure. Oral anticoagulants should be withheld and the INR should be less than 1.8 before the procedure to avoid an increased risk of bleeding.5 Susan noticed that the patient’s oral hypoglycemic medication and metformin hydrochloride had been discontinued for 48 hours before the procedure. It will continue to be withheld for 48 hours after the procedure and until the creatinine level is stable, as this medication could cause renal failure if taken concomitantly with iodinated contrast material.9 WWW.ORTODAY.COM
Patients who have a documented allergy to contrast medium should receive prednisone or hydrocortisone 12 hours before and immediately prior to the procedure. Cimetidine and diphenhydramine may also be prescribed.5 Measures to help reduce the incidence of contrast-induced nephropathy include:9 � Adequate IV expansion with an isotonic crystalloid (0.9% saline or Ringer’s lactate) � Certain medications, such as: - Acetylcysteine - Sodium bicarbonate - Statins - Ascorbic acid The antioxidant acetylcysteine can be administered orally before the procedure to reduce the incidence of contrast mediainduced nephropathy.10 A systematic review and meta-analysis concluded that the greatest reduction in contrast-induced nephropathy was seen with acetylcysteine plus IV normal saline and with statins plus acetylcysteine plus IV normal saline.11 An attendant completed Raymond’s groin skin clipping preparation, and Susan noted that the IV was patent during the preoperative assessment. The physical assessment included lung auscultation and evaluation of radial and pedal pulses, which are documented for later comparison. On the postprocedural clinical pathway record, Susan noted potential variations such as shortness of breath, diaphoresis, pulse irregularities, or chest pain that might occur related to pre-existing conditions of diabetes, allergies, and congestive heart failure.
Patient Teaching Despite seeing a patient education film and reading a preparation booklet, Raymond admitted he was nervous. Studies have shown that patients undergoing cardiac catheterization develop anxiety and increased stress as the result of the unknown experience of the procedure and the uncertainty of the results.12 Susan knew that this anxiety could have an adverse effect on Raymond’s recovery, so she held his hand and acknowledged his
feelings. She assured him that he would receive medication in the lab to help him relax. She told his wife where to wait during the procedure, cautioning that delays could occur that might vary the waiting time but that personnel would keep her updated about her husband’s progress. Patient descriptions of cardiac catheterization range from “a piece of cake” to “worse than a root canal.” Some patients may perceive cardiac catheterization as a threat to one’s health status, and arousal of the autonomic (sympathetic) nervous system can elicit negative physiological and psychological human responses as a reaction to this perceived threat. A Brazilian study examining patients’ perceived knowledge of the cardiac catheterization found that expectations of the unknown generated worry, anxiety, fear, and restlessness.13 A randomized controlled study at a specialized heart institution in Jordan explored the use of an educational video for lowering preprocedural anxiety. The researchers concluded that the intervention was more effective in reducing preprocedural anxiety than the brief verbal instructions that nurses and physicians routinely provide.14 Nurses who take the time to ask patients to describe their feelings can individualize their instruction to help ease patients’ anxiety. Some patients may not want to be told everything, while others feel they need to know it all. While preparing patients for catheterization procedures, explaining sensations associated with them may relieve some anxiety by addressing the fear of the unknown.13 Nurses should inform patients that: � The arterial access may be uncomfortable but not painful. Although local anesthetic is always used, it stings. � Back discomfort related to the flat procedure table is a common complaint, but analgesics and positioning with pillows can provide comfort. � Patients can enhance their comfort by bringing pillows, wearing warm socks, and using their hearing aids and dentures. � Someone, specifically the “circulator,” AUGUST 2020 | OR TODAY |
IN THE OR
continuing education will be assigned to meet the patient’s needs. � Feelings of “fluttering” in the chest caused by dysrhythmias and catheter manipulation are common and expected. � Chest pressure or angina from transient coronary ischemia caused by contrast administration into the coronary arteries may occur during angiograms, while the patient may experience a hot flush feeling during an angiogram of the left ventricle. Chest discomfort should be reported so that medication, oxygen, or simply a “rest period” can be prescribed. � Angina experienced during interventional procedures may be evaluated on a scale of one to ten for possible treatment with narcotics, nitrates, and oxygen. � Rot ablation therapy may produce vibrations and burning sensations due to friction from the device spinning in the coronary artery. The patient may hear “drilling” sounds during atherectomy, embolectomy, and rot ablation procedures. After Raymond’s procedure was finished, Susan prepared Patti for a coronary angioplasty. Her physical preparation should be similar to that of Raymond’s, but she needed more preoperative teaching preparation. The patient’s major concern, however, was that her daughter, who had not arrived at the hospital, would not be able to find her after the procedure. Susan called the patient information desk to make sure hospital personnel would direct Patti’s daughter to the cardiovascular preparation and recovery unit and informed Patti of the steps taken to ensure that her daughter would find her. Meanwhile, in the ED, as Alan prepared Jason for an emergency cardiac catheterization, the dispatcher announced the impending ambulance transfer of another man with chest pain. Alan knew that “time is muscle” and that reperfusion with PCI should occur within 90 minutes of a patient’s arrival to the ED, which is the “gold standard” according to
34 | OR TODAY | AUGUST 2020
the American Heart Association and the American College of Cardiology.15 To see how your hospital performs in meeting this goal, visit https://www.medicare.gov/ hospitalcompare/search.html. Alan gathered several consents for Jason’s procedure because hospital policy mandates consents for intra-aortic balloon insertion; intervention by angioplasty, atherectomy, or stent; administration of IV antiplatelet or thrombolytic drug therapy; and emergency coronary artery bypass surgery for all patients with unstable angina who go to the cath lab. Because Jason was so uncomfortable, his wife signed the documents and received most of the teaching. Assessment and preparation of Jason was like that of Raymond, except a blood type and cross screen was added in case immediate bypass surgery was indicated, when blood might be required.
Care After Diagnostic Versus Interventional Procedures Susan came back from escorting Patti to the catheterization lab to find that Raymond had returned from his diagnostic procedure. “It was a piece of cake!” he said, smiling, as she walked into his room. Susan initiated a standard assessment protocol of frequent, periodic assessments of groin insertion sites, peripheral pulses, and vital signs. Assessing for vascular complications, such as hematomas, pseudo aneurysms, or retroperitoneal bleeding, she was particularly vigilant for ecchymosis, bleeding, and swelling at the groin sites, as well as complaints of back pain. She advised Raymond to notify the nursing staff immediately if they occured.2, 16 A pseudoaneurysm, which can develop after the arterial wall is punctured during the procedure, is a palpable, pulsatile mass of solidified blood outside of the vessel wall.5, 17 The first signs of a retroperitoneal bleed are often vague, which make early detection difficult and the mortality rate high.18,19 Susan also told him that coughing, sneezing, or laughing could initiate bleeding. “Remember, Raymond, first aid for bleeding is direct pressure,” Susan explained. She advised him to restrict his
activities as indicated by the prescribed order, usually two to four hours of bed rest.19 Reminding Raymond to keep his leg straight, Susan offered a urinal and instructed Raymond to increase his fluid intake today to help his kidneys excrete the contrast medium. Compared with patients undergoing diagnostic catheterization, patients undergoing cardiac interventional procedures are at greater risk for complications due to the use of large-bore catheters and sheaths, prolonged placement of sheaths, and lengthy procedures.2 The use of anticoagulant, thrombolytic, and antiplatelet therapies; multiple invasive studies during the same hospitalization; and punctures from multiple attempts to access the common femoral artery are associated with greater potential for postprocedure bleeding complications.2 A retrospective study found the following risk factors for vascular complications: increased age, female gender, hypertension, large sheath size, prolonged sheath time, renal failure, and excessive use of anticoagulation.20 Unfractionated heparin is the most commonly used anticoagulant during PCI and can be reversed with protamine. Antiplatelet therapies, such as aspirin, P2Y12 receptor inhibitor (e.g., clopidogrel, prasugrel, and ticagrelor), and glycoprotein IIb/IIIa inhibitors (abciximab, eptifibatide, and tirofiban), generally are used during procedures requiring interventions.21 The resulting platelet inhibition, which lasts from four to 48 hours after the drug is discontinued depending on the agent used, necessitates added postprocedural vigilance for vascular complications, including:22, 23 � Re-bleeding at the insertion site � Hematoma formation � Retroperitoneal bleeding � Arteriovenous-fistula formation � Arterial occlusion (assess for the five Ps of neurovascular compromise: pain, pallor (pale color), pulselessness, paresthesia (i.e., a tingling sensation, “pins and needles” or leg has “fallen asleep”), and paralysis � Nerve damage or neuropathy � Pseudoaneurysm formation WWW.ORTODAY.COM
IN THE OR
continuing education Although any of these complications need to be reported immediately to the physician who performed the procedure, hemostasis is a nurse’s first concern. A growing pulsatile mass or frank bleeding requires immediate direct pressure on the artery 2 cm above the site until bleeding stops. Guided compression repair of pseudoaneurysm is possible with the use of ultrasonography.24 Patients undergoing interventional procedures are also at risk for coronary restenosis and related cardiac complications, such as myocardial infarction. Many patients return from the catheterization lab with mild chest discomfort, but any increase in chest pain requires the attention of the physician. Most patients who have coronary interventional procedures transfer postoperatively to specialized units where their cardiac status can be monitored. Sheaths may remain sutured in place until clotting times are normal, as indicated by a PTT or an activated clotting time (ACT) of 150 to 200 seconds. Specially trained personnel are assigned to remove the sheath. Institutional policies and protocols can vary on the removal procedure and should be followed. Manual compression of the puncture site after sheath removal is performed to achieve hemostasis. An alternate approach is the removal of the sheath in the catheterization lab, using a vascular sealing device to achieve hemostasis. Current approaches include collagen plugs, clip closure systems, and suture-mediated closure devices.25, 26 Sheath removal may produce vasovagal syncope, which is an exaggerated vasovagal response caused by the parasympathetic nervous system due to pain, fear, or tissue injury. The vasovagal response can occur during arterial access, venipuncture, or, occasionally, before anticipated painful procedures. The vasovagal reaction begins with the slowing of the heart rate followed by a decreased blood pressure. Early signs may include pallor, diaphoresis, nausea, and yawning. Treatment consists of discontinuing nitrates, administering a fluid bolus, and placing the patient in a modified Trendelenburg position by WWW.ORTODAY.COM
elevating the legs 20 degrees. These measures enhance blood return to the heart and raise the blood pressure. Atropine sulfate, 0.5 mg to 1 mg IV, may be given at five-minute intervals until the baseline blood pressure is regained, or a total of 3 mg of IV atropine is administered.27
Follow-Up Patti had an angioplasty with stent insertion; the stent was placed after coronary artery dissection following balloon inflation. The stent provides a scaffold to maintain patency and blood flow. Patti, who experienced severe chest pain during the procedure, was transferred to a critical care unit with sheaths sutured in place and a pressurized saline solution infusing into a femoral arterial line to maintain patency. This flush line allows 3 mL/hour of the solution to flow automatically when the pressure bag is inflated to a level higher than the patient’s systolic pressure. An inline pressure transducer on the femoral arterial flush line also provided arterial waveform monitoring. A heparin drip was also infusing, as well as a nitroglycerin solution, which will continue postprocedure to help control chest discomfort associated with hypertension. The IV antiplatelet infusion initiated in the catheterization lab was infusing as well. Patti’s daughter learned from the cardiac prep and recovery unit nurses that her mother went to the coronary care unit, where her condition could be monitored more closely, and that she will be able to see her 30 minutes after she is returned to the CPRU. Patti is assigned to Leah, a CCU nurse who noted the postcardiac interventional procedure orders, as follows: � Titrate nitroglycerin drip to maintain systolic blood pressure less than 150 mmHg. � Start aspirin 81 mg once a day. � Start ticagrelor 90 mg twice a day. � Administer an oral analgesic for back discomfort. � Remove sheaths when ACT is less than 180 seconds. � Maintain bed rest until sheaths are removed.
� Return the patient to routine post heath activity orders. An increase in chest pain is to be reported immediately to the cardiologist as angina may indicate thrombus formation, reocclusion, or restenosis of the coronary artery. When the prescribed parameters were met, Leah arranged for Joanne, a CPRU nurse certified in sheath removal, to discontinue the sheaths. After Joanne removed the sheaths, pressure was applied to the groin site for the prescribed half hour. Leah, who had assisted with femoral sheath removals on several occasions, observed for a vasovagal syncope response. Leah noted that Patti was becoming pale and diaphoretic, and was saying she felt nauseous, which is symptomatic of the vasovagal syncope response. Joanne maintained pressure, while Leah turned off the nitroglycerin drip, increased the IV fluid rate, and elevated the patient’s legs with pillows. Atropine was on standby but not required because Patti responded quickly to accurate, timely assessment and immediate treatment.
Discharge Instructions Patti was discharged home directly from the CCU the next day. Her angina subsided, and she did not have any vascular complications other than minimal ecchymosis at her groin. Upon questioning, Leah addressed patient concerns about the groin site condition and provided Patti with verbal and written discharge instructions about the signs and symptoms of local and systemic infection, when to seek medical attention, how to recognize bleeding and what to do about it, prescription information, activity protocols, and her next medical appointment. Raymond went home on the day of his procedure. Although his right coronary artery had been totally occluded, collateral circulation supplied that area of his heart. He was treated with medication. In addition to the postcatheterization discharge instructions, Susan discussed heart healthy lifestyle changes with Raymond. AUGUST 2020 | OR TODAY |
IN THE OR
continuing education Jason had triple coronary artery bypass surgery and stayed in the cardiovascular CCU for 24 hours. He was discharged home after five days with five days of home care visits prescribed. Technologies advance regularly in the catheterization lab. As an example, promising interventional procedures include transcatheter aortic valve replacements, pulmonary vein isolation for treatment of atrial fibrillation, and percutaneous closure of patent foramen ovale for cryptogenic stroke. Advancing technologies generate challenges for nurses providing patient care and instructions. For instance, hemostatic puncture closure devices achieve postprocedural hemostasis by the insertion of a collagen plug directly into or over the artery, replacing the application of manual pressure for 20 minutes.25 This may require revising the site and dressing care instructions for patients because some of these devices present additional complications, such as occlusion or stenosis of femoral arteries. Although puncture closure devices allow position changes earlier during bed rest and provide greater comfort for patients, patients with peripheral vascular disease or poor hygiene may not be candidates for these devices. A large observational cohort study found a significant reduction in vascular complications and transfusion need with the use of vascular closure devices, but there was a small increase in the more serious risk of retroperitoneal bleeding.25
opportunity to influence the content of this version.
7. Popma JJ, Kinlay S, Bhatt DL. Coronary arteriography and intracoronary imaging. In: Bonow RO, Mann DL, Zipes DP, Libby P, eds. Braunwald’s
Joanne McGlinchey, MSN, RN-BC, PCCN, is a registered nurse who has practiced at the bedside for more than 20 years. She holds certifications as a cardiac vascular nurse and progressive care nurse and is a clinical instructor.
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NCDR Cath PCI Registry: a US national perspective on care and outcomes for percutaneous
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Nurses in cardiovascular units and home care settings encounter patients undergoing invasive cardiac procedures and are in a crucial position to assess and positively affect patient responses to these procedures. As nurses sharpen their skills by remaining current in information and practice, they can improve patient outcomes.
Cardiovascular Angiography and Interventions.
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EDITOR’S NOTE: Mary Ann Degges, DNP, RN, CNL, CCNS, and Evelyn Korjack, RN, RCIS, past authors of this educational activity, have not had the
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1. Read the Continuing Education article. 2. Go online to ce.nurse.com to take the test for $12. If you are an Unlimited CE subscriber, you can take this test at no additional charge. You can sign up for an Unlimited CE membership at https://www.nurse.com/ sign-up for $49.95 per year.
Deadline Courses must be completed by 10/1/2022 3. If the course you have chosen to take includes a clinical vignette, you will be asked to review the vignette and answer 3 or 4 questions. You must answer all questions correctly to proceed. If you answer a question incorrectly, we will provide a clue to the correct answer. 4. Once you successfully complete the short test associated with the clinical vignette (if there is one), proceed to the course posttest. To earn contact hours, you must achieve a score of 75%. You may retake the test as many times as necessary to pass the test. 5. All users must complete the evaluation process to complete course. You will be able to view a certificate on screen and print or save it for your records.
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By Don Sadler
N A PERFECT WORLD, MEDICAL ERRORS WOULD NOT OCCUR AND NO ONE WOULD EVER DIE AS A RESULT OF THEM. UNFORTUNATELY, THE WORLD WE LIVE IN IS FAR FROM PERFECT. According to a study conducted by researchers at Johns Hopkins Medicine that was published in 2016, medical errors are the third leading cause of death in the United States, responsible for up to 250,000 deaths each year. This is up considerably from an estimated 98,000 deaths each year that were attributed to medical errors in the landmark report, “To Err Is Human,” which was published in 1998.
38 | OR TODAY | AUGUST 2020
Problem is Worsening Despite an increased awareness of the prevalence of medical errors – including surgical errors occurring in the OR – and the toll they’re taking in terms of human lives, these statistics seem to indicate that the problem is getting worse, not better. “The reality is that surgery is a complex, dynamic and stressful environment that serves as a catalyst
for error,” says Susan K. Banschbach, MSN, RN, CNOR, a former surgical services executive director (retired) and current contracting consultant. “Errors in surgery do not just happen,” adds David L. Taylor, MSN, RN, CNOR, an independent hospital and ambulatory surgery center consultant and principal of Resolute Advisory Group LLC. “They develop from a series of interactions between mulWWW.ORTODAY.COM
“Errors in surgery do not just happen. They develop from a series of interactions between multiple people and equipment used on a particular surgical intervention.” – DAVID L. TAYLOR, MSN, RN, CNOR
tiple people and equipment used on a particular surgical intervention.” Taylor divides surgical errors into two main categories: errors of omission that occur as a result of actions not taken by the assigned staff, and errors of commission that occur as a result of the wrong action taken. Examples of the former include things like not securing the patient properly to the surgical bed or not stabilizing a gurney prior to patient transfer to that bed, Taylor explains. Examples of the latter include things like the administration of a medication improperly labeled or administering a medication to which the patient has a known allergy. Other causes of surgical errors listed by Taylor include: � Distractions in the OR setting such as music and digital devices � Incomplete or missing pertinent imaging information, which forces a reliance on memory � Incomplete pre-operative assessments, such as failing to note abnormal pre-op labs or tests (like EKGs) � Time pressures that result in OR staff taking shortcuts or not following established infection prevention recommendations or safety precautions � An attitude that a surgeon’s decisions should not be questioned WWW.ORTODAY.COM
Impact of Communication Failures Alexander A. Hannenberg, M.D., principal consultant-anesthesiology with OR Dx + Rx Solutions for Surgical Safety, believes that the overarching source of medical errors in health care, including surgery, is poor communication among the many providers typically involved in patient care. “The Joint Commission has estimated that between 70 percent and 80 percent of adverse events are related to communication failures,” says Hannenberg. “In addition, more than a third of malpractice actions identify this as an underlying cause of the event.” Medication errors and missing information in patient handoffs are the two most frequently cited manifestations of communication failure, Hannenberg adds. “Each of these drives mishaps with a range of severity, including death,” he says. Bill Greene, M.D., F-IDSA, FSHEA, senior quality and patient safety consultant with OR Dx + Rx Solutions for Surgical Safety, concurs. He emphasizes the importance of standardized work – or in other words, using policies, forms, prompts and reinforcement – to minimize variation from best practices. “Two areas of standardization are especially important,” says Greene.
“Pre-operative risk assessment and medical optimization (or pre-habilitation), and perioperative or surgical safety checklists.” One type of medical error that Greene says is not usually characterized as an “error” is the failure to communicate to the surgeon or other practitioner data and analytics relating to the quality and safety of his or her work. “The prevention of medical errors is enabled by the collection and use of data by the department or institution to measure performance related to quality and safety,” he says. Examples of this type of data include patient/family or staff complaints about a staff surgeon or other provider; objective, risk-adjusted surgical process and outcome indicators; and surgery-specific and surgeonspecific “dashboards” that are formatted for clarity and shared with relevant supervisors and the surgeon.
Top Sentinel Events Amber Wood, MSN, RN, CNOR, CIC, FAPIC, senior perioperative practice specialist with the Association of periOperative Registered Nurses (AORN), cites data from The Joint Commission indicating that the top two sentinel events in the surgical setting are: 1) unintended retained foreign objects and, 2) wrong-patient, wrong-site, AUGUST 2020 | OR TODAY |
"[Perioperative team members are] ethically and morally obligated to protect patients by preventing medical and surgical errors.” – AMBER WOOD, MSN, RN, CNOR, CIC, FAPIC
wrong procedure events. The prevention of both of these types of errors requires a multi-disciplinary approach, says Wood. “For unintended retained foreign objects, the approach includes accounting for surgical items, preventing retention of device fragments, reconciling count discrepancies, and using adjunct technologies to supplement manual count procedures,” she says. “For wrong-patient, wrong-site, wrong procedure events, the approach includes pre-procedure verification that includes site marking, time out procedures, a standardized briefing process and use of a standardized surgical safety checklist,” Wood adds. Each year, AORN sponsors a National Time Out Day in June to keep this issue top of mind for perioperative personnel, notes Banschbach. “Consistency, redundancy, clear communication and speaking up are the keys to success,” she says. Taylor believes that creating the right patient safety culture is one of the biggest keys to reducing medical errors. “This culture should work toward recognizing safety challenges and implementing viable solutions rather than harboring a culture of blame, shame and punishment,” he says. “Health care organizations need
40 | OR TODAY | AUGUST 2020
to establish a culture of safety that focuses on system improvement by viewing medical errors as challenges that must be overcome,” Taylor adds. “All individuals on the health care team must play a role in making the provision of health care safer for patients and health care workers.” Banschbach stresses the myriad safety procedures that have been implemented to prevent what are referred to as “never events.” “One of the most significant is the use of the Comprehensive Surgical Checklist,” she says. “The list covers three phases of patient care: preoperative, intraoperative and postoperative. “Caregivers in all three phases depend on the list to confirm that everything is accurate and complete,” Banschbach adds. “Intraoperatively, it is used in conjunction with a surgical time out prior to the incision or beginning of a less-invasive procedure.” Banschbach acknowledges that convincing members of the surgical team to support and comply with safety protocols can sometimes be challenging, at least at first. “But over time, as team members overcame the awkwardness of the time out and site marking, things became much less difficult.”
It Starts at the Top Taylor believes strongly that improving patient safety by reducing medical and surgical errors starts at the top of the health care organization. “Executive leaders who make safety part of their mission, vision and values realize better outcomes,” he says. “Accountability and culture also matter. Designing safe systems that are easily followed helps minimize errors and allow detection before harm begins.” Wood believes that perioperative team members are “ethically and morally obligated to protect patients by preventing medical and surgical errors.” Aside from this ethical obligation, Wood notes that health care organizations face serious ramifications resulting from these errors. “These include financial penalties, legal consequences, mandatory reporting, erosion of trust and potentially irreparable damage to their reputations,” she says. Hannenberg notes that the industries health care most often seeks to emulate, such as aviation and nuclear power, long ago embraced investments in teamwork and communication training in order to prevent human errors. “Reducing medical and surgical errors moves health care closer to the ultimate goal of high reliability,” he says. WWW.ORTODAY.COM
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By Matt Skoufalos
hen Vivian Watson graduated nursing school in 1957, life had already prepared her for the unpredictable pace of the health care field. Born to a family of Mississippi sharecroppers in 1935, Watson entered into a difficult upbringing made harder by a cleft lip and palate. The congenital issue is one that children the world over still experience, but at the time of her birth, surgeons only repaired pediatric patients’ lips. She was to have had the palate surgery at five, but the doctor who’d done the repairs was killed in a car accident by then, and her father wouldn’t allow her to travel to New Orleans or to Mobile, Alabama to have the surgery out of fears for her safety. Neither was it easy for them to care for Watson’s specific needs while working the fields and raising her four siblings, so she was sent to live with her aunt in Waynesboro, Mississippi. Even with the support of her aunt, school was difficult because of her physical appearance. The teacher wouldn’t call on her, and other children bullied her, but she never spoke about it to her aunt for fear of getting in trouble.
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“I just lived with it,” Watson said. By the early 1940s, the United States had entered World War II, and her fellow Mississippians were shipping out. Watson still holds a vivid memory of seeing a convoy of doughboys whistling and waving as they drove by her aunt’s home. “I was playing under a tree with my doll,” she said. “When I asked Aunt Bertie where were all those boys going, she said, ‘They’re serving their fellow man; they’re going to war.’” “I said, ‘I want to serve my fellow man; I’ll be a nurse,’ ” Watson recalled. “She sat me down and told me I was born different, and the patients would not be able to understand what I was saying. She said I’d have to give up my dream and do something else.” By the time she was 10, her parents came to reclaim Watson from her aunt’s home, as she was old enough to contribute on the farm, and her labor was required. When she came home to Jones County, she learned to plow, to draw water from a well, and to help her mother care for her brothers. At school, however, Watson was no longer left to her own to deal with bullies. “If anybody laughed at me, my brothers would beat them up,” she said. “They were football players; I was good at basketball.”
Watson didn’t give up on her education, but her dream of becoming a nurse still seemed out of reach. In her senior year of high school, her English teacher overheard her telling a friend that her cleft palate could disqualify her from her chosen profession, and interceded. “She said, ‘Vivian, you have too good of a mind to waste. You can be a nurse,’” Watson said. Her teacher gave her the name and number of a vocational rehab facility in Soso, Mississippi, and told her to keep it to herself until after graduation. When that day came, “I did what she asked me to do,” Watson said. “We didn’t have a telephone; we lived 10 miles out of town,” she said. “I got up and put on my tennis shoes and my blue jeans and my flour sack shirt, and I pulled out the name of that Mr. Matthews, and I walked seven miles to the highway, and I thumbed a ride.” When she got into town, Watson called the number, and was received by the Mississippi Director of Vocational Rehabilition, who invited her into his office, and gave her a stack of papers to fill out. “It took me almost two hours,” Watson said. “It was sort of like the ACT or the SAT. I turned it into him, and they put me in the waiting room, and WWW.ORTODAY.COM
all I heard in my mind was, ‘They’ll never help you; you’re not worthy.’” Instead, the man returned to her and said, “Whatever you want to do with your life, we have already arranged for it to be done.” He signed her papers in loco parentis, and arranged for Watson to be seen by James Harvey Hendrix Jr., the first plastic surgeon in Mississippi. “He will accept you as a patient, and he will do all of your plastic surgery, and turn you back over to us, and we will educate you on whatever you want to do,’” Matthews told her. It took a full year and four separate surgeries for Hendrix Jr. to repair Watson’s palate, including repairs to her lip, the addition of a bone in her nose to form her iliac crest, and extensive dental work. She was all of 18 years old, and he did the work gratis. From there, she attended Mississippi College in Clinton, and graduated from the school of nursing at Baptist Medical Center in Jackson, Mississippi at 21. Thus began a nursing career that took her from the surgical floor to the emergency room within six years. “Then they sent me to Dallas to learn how to open an ICU,” Watson said. “I set it up real good, but I never had enough people to work it. I never gave up on anybody, the patients loved me, and I never met a patient I didn’t love.” In all, Watson spent decades in the emergency room and ICU before she went into the operating room at Baptist to work a daytime shift while she was having her third baby. “I wound up being in charge,” she said. “We had the largest operating room in Mississippi, and that was in the day when patients were all in-house patients. We had about 150 people and we did about 75 cases a day.” After she retired and remarried in her fifties, Watson was only out of work for about eight or nine months before the University of Mississippi Medical Center invited her to return as a teaching nurse. She promised WWW.ORTODAY.COM
them five years, and had intended to retire again thereafter, but the passing of her father drew Watson back to her family again. So in the 1990s, she spent another decade working at an outpatient cath lab in Laurel, Mississippi, and another three-and-a-half at Oxford Hospital after that. “Then I came home and said, ‘No more – and then somebody else called, and wanted me to open up the fourth floor of a clinic in Hattiesburg to do outpatient urology,” Watson said. “I went for two years, and I remodeled that place to meet Joint Commission standards.” Just for good measure, Watson then spent another three years at Methodist Hospital as an OR nurse educator. She became active with the Association of periOperative Registered Nurses (AORN), presiding over its Mississippi state chapter, and becoming its first ombudsman, while also delivering seminars on nursing education. She also wrote a memoir with advice for OR nurses entitled, “A Passionate Journey: Overcoming Adversity, Realizing a Dream,” and continues to share her experiences with other nurses across the world, thanks to the support of Chuck Hughes of HIGHPOWER Validation Testing & Lab Services. “I’ve had a wonderful life,” Watson said. “I love the operating room. Everybody said I had a real heart for my patients.”
Vivian Watson overcame obstacles to achieve her dream of being a nurse.
AUGUST 2020 | OR TODAY |
OUT OF THE OR
How to navigate a crisis and come out stronger By Family Features hen life, or the people in
W your life, push your limits,
the emotional load may feel insurmountable. Making sense of the chaos in your life can allow you to rediscover peace and joy, but circumstances like a world crisis can complicate the process of emotional healing. “Almost nobody is trained on what to do with their emotions in times of crisis and stress, and most of us are never taught how to manage our emotions in normal times,” said Eric Paskel, who holds a master’s degree in clinical psychology and is a licensed marriage, family and child therapist. “If you’ve ever admired someone who was cool under pressure then you know it’s possible to emotionally survive, and even thrive, in a crisis.” Paskel, an author and motivational speaker, has spent 34 years exploring how human beings can rise above their dysfunctional tendencies and control their emotions. He has developed a series of resources to help individuals prevent their emotions from owning them in a crisis, allow people to do more observing and less reacting and take decisive actions to help themselves and their loved ones. Learn how to take charge of your emotional health with these practical and effective tips, adapted from Paskel’s Emotional Survival Kit, a free online video course on personal crisis management.
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OUT OF THE OR
Be Open to Learning During a crisis is when personal growth is most possible. During adversity and crisis, there are always lessons to be learned and shared. Sometimes growth comes as the result of overcoming the pain of a crisis, but there are other sources of growth. To accelerate your growth, begin by recognizing you need help then be willing to accept that help. It may come in the form of advice from a professional or it may be simply listening to the perspective of others with similar experiences.
Look for Opportunity A simple change in perspective like a crisis or a forced change, such as having to work from home, is both a challenge and an opportunity, although the challenges and benefits will likely be different for each individual person. Some people will benefit from the isolation, which they’ll see as solitude. Some will be challenged by a noisy home while others will be thrilled to have the company of family or roommates all day. The key is to find a way to turn those challenges into gold. Begin by identifying your challenges. Then find the silver lining. What are the benefits that come with these challenges? It may be that your rigorous travel schedule allows more time at home or that you’ve been able to tackle a long-standing list of lowerpriority tasks. Then choose to focus on the positive and find ways to adapt to the challenges. Use your former commute time to practice yoga or exercise. Buy noise-cancelling headphones to reduce distractions. Find different strategies that work for you.
Embrace Self-Sufficiency Being self-sufficient is critical to your personal and emotional freedom and a crisis can serve as an opportunity to become more self-sufficient. Being WWW.ORTODAY.COM
self-sufficient means you’re able to manage yourself and have sovereignty over your body and mind. It means your thoughts and emotions do not control you; you control them. Consider the example of an ending relationship. If you’re codependent, the end of that relationship is more likely to devastate and destroy you. If you’re self-sufficient, as painful as the end of a relationship or a life situation may be, you can let it go and move on to the next chapter in your life.
Find Joy You can always find joy, even in the midst of change, confusion, chaos or crisis. Celebration comes from the way one chooses to see, perceive and be in the world. However, you may have trepidation about celebrating and having joy when others are focusing on negativity or you see suffering in the world around you. Confetti flying and champagne bottles popping isn’t what defines joy; joy comes out of positivity. Celebration comes out of acknowledgements and affirmations, and out of your sense of freedom and purpose. Finding joy is not just for joyous moments. Embracing joy and celebrating in challenging
times can help reframe your mentality about what challenges really are and help provide longer-lasting positive effects on your body and mind.
Know You’re Not Alone You may think you’re alone, especially during hard times, but when you understand it’s a matter of creating relationships and making connections, you’ll never feel truly lonely again. Whatever it is, the difficulty you’re going through isn’t unique to just you. Once you understand that other people have been through your problem, you will be able to understand that you have a large pool of connections and help. Just connecting with other people who’ve had the same experiences can give you an emotional tailwind to push you forward. Recognize that feeling alone is a warning sign that you need to reach out to loved ones. Daily maintenance, contact, connection and working on relationships can help keep you from feeling disconnected from the world around you. Learn how to manage your way through troubling times and become part of the solution at ericpaskel.com. AUGUST 2020 | OR TODAY |
OUT OF THE OR fitness
Exercising Through Emotional Stress By Miguel J. Ortiz long with vigorous planning to change your lifestyle to support new healthy behaviors, it’s important to remember that there will be distractions that can take you off your path or slow your journey.
As we stay as strong and disciplined as we can with our goals, life can have a unique way of forcing change. The emotional shifts that tend to disturb our inner peace may cause disturbances in a workout or two. This is very common. It’s also very common for the gym to turn into a place of peace for many because it provides time for one to focus on themself. To ensure efficiency during training and workouts, let’s look at three important behaviors that can help focus the mind to better the body. For starters your warm-up is absolutely vital to the type of workout you may have planned. A quality warmup should be about 8-10 minutes. This is a great opportunity for you to settle the mind or re-focus. Taking five minutes to stretch and five minutes for a light cardio warm-up can change the heart rate and allow one to focus on what’s right in front of them. Even the lightest, but consistent, movement
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patterns and a slightly escalated heart rate can do the trick. So, whether you’re doing some general strength and stabilization exercises or you’re doing a kickboxing workout with some jump rope intervals, you should be focused and ready to go. Use your warm-up as a tool to set up your body and mind for success. Second, we may want to try a couple of different breathing techniques to achieve focus. They can be extremely helpful. Just as exercise and training have specific breathing routines, practicing daily breathing techniques throughout the day have been shown to lower stress and assist the body and mind. I won’t go into detail regarding all the different breathing techniques. Instead, I encourage you to discover some on your own. However, before you do that, I invite you to try a simple one called focused breathing. It is important to determine the best time for you to do this throughout the day. You may want to try it first thing in the morning and/or before you go to bed. Start by inhaling through the nose, hold the breathe and count to 7, and then exhale through the mouth. As you practice, start to focus on letting something go or focus on something
you want to accomplish, etc. Then, you can start applying a conscious thought to the breathing. Lastly, mixing up your exercise routine can greatly help reduce stress. Yes, you have strength, endurance or weight loss goals that call for demanding work. But, does all your work have to be so vigorously? I’m not saying you have to take up yoga. I know certain routines aren’t for everyone. However, consider trying Qigong, active recovery, a simple dance class, a walk down the street or light cardio. These can really help keep the body active and the mind focused. It can also possibly reduce stress at the same time. So, have fun with your training and always remember, warming up is very important. Utilize breathing techniques to your advantage and not just for exercise, but throughout the day. And, don’t be so hard on your body. It’s not necessary to always do your most strenuous workout. Miguel J. Ortiz is a personal trainer in Atlanta, Georgia. He is a member of the National Personal Trainer Institute and a Certified Nutritional Consultant with more than a decade of professional experience. He can be found on Instagram at @migueljortiz. WWW.ORTODAY.COM
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OUT OF THE OR health
What You Need to Know About Your Thyroid By Family Features ichele Adams is quick to say, “I don’t want to throw anyone under the bus,” but it took her being hit by a car for her thyroid disease to finally be diagnosed.
Adams has always been an active person, but for a few years, she had felt tired and had a constant tightness in her throat. She was diagnosed with post-nasal drip but did not feel relief after a year of treatment. “I thought this exhaustion, hoarse voice and lump in my throat were just my new normal,” Adams said. “I’d accepted it, and I shouldn’t have.” During this time, Adams went on a bike ride in northeastern New Jersey – something she still does frequently. However, on this day, Adams was struck by a car as she was biking. The incident resulted in an MRI scan. Adams was not seriously injured, but doctors noticed something unexpected. The scan revealed nodules in her lower neck, which suggested thyroid disease. “I now realize I had symptoms of a thyroid condition for years,” Adams said. “I’d had it up to here with not feeling like myself. Once I had the MRI results, I knew to seek out a thyroid expert, and I found an endocrinologist.”
What you probably do not know about your thyroid Thyroid disease is more common than WWW.ORTODAY.COM
Photo courtesy of Getty Images.
diabetes and heart disease, but more than half of Americans with thyroid disease are unaware, according to the American Association of Clinical Endocrinologists (AACE). This lack of awareness can endanger a person’s health and well-being. The thyroid is a butterfly-shaped gland located low in the front of the neck below the Adam’s apple. It produces thyroid hormones that influence almost every cell, tissue and organ in the human body. Common signs of thyroid diseases include: � Unexplained changes in weight � Depression, anxiety or feelings of irritability � Changes in memory or ability to concentrate � Joint or muscle pain or weakness � Fatigue or trouble sleeping � Fast or irregular heartbeat � Irregular menstrual periods Cheryl Rosenfeld, D.O., is a thyroid expert and AACE member. Rosenfeld is also the physician who treated Adams’ thyroid disease. “If the thyroid does not function correctly, it can affect every possible aspect of a person’s life,” Rosenfeld said. “Remember that thyroid conditions can cause changes in mental health, including depression. I’ve also spoken to patients who’ve experienced an inability to concentrate, which seriously affected their performance at work.”
Several disorders can arise if the thyroid produces too much hormone (hyperthyroidism) or not enough (hypothyroidism). Other thyroid diseases include: � Nodules � Thyroid cancer � Graves’ disease � Hashimoto’s thyroiditis � Thyroid eye disease Undiagnosed thyroid issues can also place a person at increased risk for heart disease, osteoporosis, infertility and other serious conditions.
What to do if you are ‘up to here’ with not feeling like yourself “Once I was placed on treatment for Hashimoto’s and hypothyroidism, my life changed completely,” Adams said. “My throat is no longer sore, and I’m able to go out with my family or spend time at the gym without feeling completely drained of energy.” The first step to ensure your thyroid gland functions properly is to speak with a health care provider about your symptoms and whether a thyroid test is needed. An endocrinologist is a specially trained doctor who is qualified to diagnose and treat hormone-related diseases and conditions, including thyroid cancer and all other diseases related to the thyroid gland. For more information, visit thyroidawareness.com. AUGUST 2020 | OR TODAY |
OUT OF THE OR EQ factor
The Different Ways People Give to Others By daniel bobinski hat motivates you to
W give? Do you give for the
satisfaction of being generally helpful, or do you give for specific reasons? This article is the fourth in a series about the six learned (extrinsic) motivators. The first installment examined the different ways people are motivated by knowledge. Then we looked at how tangible things – including money – may or may not motivate us. Following that we looked at how we are driven by our surroundings. This time we’re looking at different ways people are motivated to give to others.
The motivational spectrum of community The community spectrum is about how we help others. At one end of the scale are people we call altruistic, and at the other end are those we call intentional. Altruistic people are driven to help other people just for the sake of being helpful. They give generously of their time, talent, and resources with no expectation of personal return. They have a drive to give because they enjoy being supportive. Intentional people also give, but their drive is to give in specific ways. They are selective in how and what they give because they want their giving to
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have specific application. All people value others in their community, but they will demonstrate it in different ways.
Traits of an altruistic person People in the altruistic camp tend to notice when others need help and often step up to volunteer. They believe everyone should have the opportunity to be the best they can be and may even sacrifice their own personal gain to help someone else. They get energized by being supportive of other people. Those with strong tendencies in this area often enjoy volunteering for or even leading community outreach or assistance programs (such as blood drives or food drives), and often advocate that coworkers participate in those activities.
Traits of an intentional person People on the intentional side of the community spectrum are driven by the desire to help others for a specific purpose, not just for the sake of being helpful. As such, they tend to be selective about who they help, when they help, and how they provide that help. As the label states, their help is intentional. To illustrate the difference between the two drivers, think back to Hurri-
cane Harvey, which flooded the city of Houston in 2017. An altruistic person sees the devastation and might immediately write a $500 check to the Red Cross. An intentional person will not do that, because he or she does not know how the money will be used. But if the person’s neighbor is filling a U-Haul with diapers and blankets and personal hygiene items so he can drive to Houston and personally distribute those items to churches and daycare centers, the intentional person might write a check for $500 to support that effort, because that giving is intentional. As I said, all people place value on their community, they’re just driven to give back in different ways. Daniel Bobinski, M.Ed. is a bestselling author and a popular speaker at conferences and retreats. For more than 30 years he’s been working with teams and individuals (1:1 coaching) to help them achieve excellence. He was also teaching Emotional Intelligence since before it was a thing. Reach Daniel through his website, MyWorkplaceExcellence.com, or his office: (208) 375-7606.
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OUT OF THE OR nutrition
Cooking Inspiration By Charlyn Fargo e still are not yet operating
W at the “normal” we all knew
before COVID-19. You may be at a stalemate for what to cook, what to buy and how to continue fixing your meals at home. Here are some tips to help you continue to navigate this new lifestyle with your family. � Continue to plan your meals. Focus on the foods you have in your freezer, your pantry and your refrigerator. Not only will you save money, but you’ll also prevent spoilage and make room for new purchases. � Chop up leftover meats and vegetables for soups, salads or sandwiches. Make a hearty salad with hard boiled eggs or canned fish, or add vegetables and leftover poultry to beans, and wrap in a corn or whole-wheat tortilla for tacos. You can even use leftover quinoa spiced with taco seasoning in a taco.
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� Get healthy. This is a great time to take control over what you’re eating. Choose fruits, vegetables, whole grains, lean proteins and lowfat dairy in every meal. � Make a meal with tomorrow in mind. If you make a soup or casserole, portion out some of it to freeze for a lunch or dinner later. � Use your fruit – fresh, frozen or canned – to whip up a smoothie with low-fat or fat-free milk, yogurt or a nondairy alternative. A parfait with fruit, yogurt, a sprinkling of granola or a spoonful of nut butter can serve as a snack or as part of a quick breakfast. � Try a new recipe – or one you haven’t made for ages. It’s fun to look back through a cookbook or recipe box and think about the reason you loved a recipe enough to write it down. � Keep your time at the grocery store to a minimum by organizing your
list by sections of the store. Group together produce or frozen items so you minimize backtracking. And be sure to follow state guidelines for using face masks. Most stores offer disinfectant wipes or hand sanitizers to clean carts and basket handles. It’s also important to practice social distancing, even while shopping. My favorite grocery store offers arrows to help keep traffic flowing smoothly. � Be sure to wash your hands when you come home. There is no evidence to suggest that COVID-19 can be transmitted through food or food packaging, according to the Centers for Disease Control and Prevention and the U.S. Department of Agriculture. Charlyn Fargo is a registered dietitian with SIU Med School in Springfield, Illinois. For comments or questions, contact her at email@example.com. WWW.ORTODAY.COM
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AUGUST 2020 | OR TODAY |
OUT OF THE OR recipe
Greek Yogurt Bark INGREDIENTS: • 3 cups plain non-fat Greek yogurt
• 1/3 cup honey, plus additional for drizzling (optional) • 1 teaspoon vanilla • 1/2 cup strawberries, sliced into rounds • 1/2 cup blueberries • 1/2 cup raspberries, halved
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Dairy: Did You Know? Dairy foods can add taste and versatility to your plate, but they also deliver a unique package of essential nutrients important for good health. � Milk has a unique combination of nine essential nutrients: protein; calcium; potassium; phosphorus; vitamins A, D and B12; riboflavin and niacin. Each of these nutrients is a key ingredient of milk and they all work together to help keep bodies healthy. � Milk, cheese and yogurt are good sources of high-quality protein, which is essential for growth and maintenance of muscle and other proteins within the body. � Enjoying dairy foods like milk, cheese and yogurt as part of a healthy diet is associated with many health bonuses, including reduced risk of heart disease, Type 2 diabetes and high blood pressure. WWW.ORTODAY.COM
OUT OF THE OR recipe
Super Snacking Let kids get hands-on with healthy, easy treats By Family Features nacks are a way of life for people of all ages, but especially children, who consume about 25% of their daily calories from snacks, according to research published in the Journal of Nutrition Education and Behavior. Providing nutritionally balanced snacks for your children at home can make for a happy and healthy day.
Planning snacks that are as delicious as they are healthy is a winning solution, and snacks are a simple way to add more nutrition to your child’s diet. For example, low-fat and fat-free dairy foods are essential to children’s growth and overall wellness. They provide calcium and vitamin D, two nutrients kids don’t get enough of, according to the 2015 Dietary Guidelines for Americans. The guidelines recommend 2-3 servings of low-fat and fatfree dairy foods every day, depending on the child’s age. Giving kids a role in the preparation can give them added incentive to enjoy healthy treats, and some recipes are easy enough that kids can make them on their own (or with minimal assistance). Giving your kids the ability to play a role in the kitchen and create is a gift that can last a lifetime. The culinary skills they develop early in life can give them the confidence and know-how to cook nutritious meals for themselves as teens and adults. Get more ideas to get kids cooking and snacking smart at milkmeansmore.org.
Greek Yogurt Bark Prep time: 5 minutes Servings: 12 1. In medium mixing bowl combine Greek yogurt, 1/3 cup honey and vanilla. 2. On parchment paper-lined baking sheet, spread Greek yogurt mixture to 1/4-inch thickness. Press strawberries, blueberries and raspberries into yogurt. Freeze at least 3 hours. Break into pieces upon removing from freezer. WWW.ORTODAY.COM
AUGUST 2020 | OR TODAY |
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YEAR OF THE NURSE OR Today magazine joins the World Health Organization in celebrating the 200th anniversary of Florence Nightingale’s birth and the Year of the Nurse in 2020. As part of the celebration, OR Today wants to feature nurses in a new contest! Every entry wins a gift card! To enter the contest, share a time when a nurse served as an inspiration to you or your team. This can be a peer, a mentor, an educator or anyone from the nursing profession. Help us shine a spotlight on these individuals. Please share your brief (1 to 3 sentences) contest entry at ORToday.com/Contest. One gift card per individual.
H QUOTE OF THE MONT
ur problems, but yo l al e lv so t o n ay m “A positive attitude rth the effort.” o w it e ak m to le p peo it will annoy enough right – Herm Alb
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STAYCATION IDEAS THAT WON’T BREAK YOUR BUDGET By Family Features
amily vacations are a great way to bond and take a step back from the hectic schedules that accompany everyday life, but sometimes time or money (or both) make planning an elaborate trip a non-starter. However, a staycation – a vacation you take right in your hometown (or nearby) – can be much less expensive and fit into nearly any amount of available time with the added bonus of skipping out on potentially stressful travel. Consider these staycation ideas to take advantage of your local area’s attractions and prove you don’t have to go far to spend quality time together. •V isit local landmarks. Just because it’s not a traditional vacation doesn’t mean you can’t pretend to be tourists. Start by visiting the places you recommend to friends and family from out of town or pick up a city guidebook to uncover hidden spots you may not even know exist. Make a plan to seek out historic sites, visit local landmarks like museums or try an out-of-the-way restaurant (or two) you’ve never eaten at before.
•C amp out in the backyard. Camping doesn’t have to be done far from home. In fact, it can be done right in your own backyard. Pitch a tent to sleep under the stars and plan a night full of traditional camping activities like roasting s’mores, telling spooky stories by flashlight and trying to identify stars and constellations. •S et up a picnic in the park. Pack a basket with sandwiches, fruit and other treats and head to the park. You can enjoy a casual meal then take advantage of the open space for a family walk or game of tag before retreating to the playground to let the little ones expel any leftover energy. •H ave a home spa day. If you’re looking for some relaxation but don’t want to splurge on the full spa treatment, plan an at-home oasis instead. Light some candles, run a bubble bath and break out the facial masks and fingernail polish. Find more tips and tricks for enjoying family time together at eLivingtoday.com.
AUGUST 2020 | OR TODAY |
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Cygnus Medical……………………………………………………31 Healthmark Industries Company, Inc.…………… 4 MD Technologies Inc.……………………………………… 48 Ruhof Corporation……………………………………………… 2 Total Scope, Inc……………………………………………………13
Ruhof Corporation……………………………………………… 2 TBJ Incorporated……………………………………………… 59
GelPro…………………………………………………………………… 11 Healthmark Industries Company, Inc.…………… 4 TIDI…………………………………………………………………………16
International X-Ray Brokers………………………………19
Cygnus Medical……………………………………………………31 Ruhof Corporation……………………………………………… 2 ALCO Sales & Service Co.……………………………… 53
MD Technologies Inc.……………………………………… 48 Ruhof Corporation……………………………………………… 2 TBJ Incorporated……………………………………………… 59
Innovatus Imaging…………………………………………… 43 MedWrench……………………………………………………… 47 MedWrench……………………………………………………… 47 OR Today Webinar Series…………………………………51
International X-Ray Brokers………………………………19
Cygnus Medical……………………………………………………31 Healthmark Industries Company, Inc.…………… 4 MD Technologies Inc.……………………………………… 48 TBJ Incorporated……………………………………………… 59
MD Technologies Inc.……………………………………… 48 SIPS Consults…………………………………………………… 23 TIDI…………………………………………………………………………16
Action Products, Inc.…………………………………………19
Cygnus Medical……………………………………………………31 Healthmark Industries Company, Inc.…………… 4
ALCO Sales & Service Co.……………………………… 53 Encompass Group………………………………………………15
OTHER: FLOOR MATS
MD Technologies Inc.……………………………………… 48
PATIENT DATA MANAGEMENT
AIV Inc.………………………………………………………………… 5
MAC Medical, Inc………………………………………………… 8
ALCO Sales & Service Co.……………………………… 53
ALCO Sales & Service Co.……………………………… 53 Cygnus Medical……………………………………………………31 Encompass Group………………………………………………15 Healthmark Industries Company, Inc.…………… 4 MD Technologies Inc.……………………………………… 48 Ruhof Corporation……………………………………………… 2 SIPS Consults…………………………………………………… 23 TBJ Incorporated……………………………………………… 59 TIDI…………………………………………………………………………16 TIDI…………………………………………………………………………16
AIV Inc.………………………………………………………………… 5
AIV Inc.………………………………………………………………… 5 USOC Medical………………………………………………………21
Action Products, Inc.…………………………………………19 Cygnus Medical……………………………………………………31
PRESSURE ULCER MANAGEMENT
Action Products, Inc.…………………………………………19
Cygnus Medical……………………………………………………31 Doctors Depot………………………………………………… 27
58 | OR TODAY | AUGUST 2020
AIV Inc.………………………………………………………………… 5 USOC Medical………………………………………………………21
Encompass Group………………………………………………15 MAC Medical, Inc………………………………………………… 8
Jac-Cell Medical……………………………………………… 25
Innovatus Imaging…………………………………………… 43
MAC Medical, Inc………………………………………………… 8
MD Technologies Inc.……………………………………… 48 TBJ Incorporated……………………………………………… 59
Innovatus Imaging…………………………………………… 43 International X-Ray Brokers………………………………19
NEW FEATURED PRODUCT
WE ONLY MAKE ONE SINK… THE BEST ONE FOR YOU DESIGNED BY YOU!
TBJ’s SurgiSonic® 1211X features a patented dual hook up method for pre-cleaning da Vinci® instruments utilizing a filtered, independent flushing system combined with ultrasonic action. The unit is independently tested for cleaning effectiveness and exceeded AAMI TIR 30. Three instruments can be pre-cleaned simultaneously.
TBJ sinks are designed specifically for the pre-cleaning of surgical instruments and endoscopes. All of our sinks are custom made to order to enable you to design a system around your specific needs. A wide range of optional features and accessories enable you to tailor a design that puts the tools you for efficient, effective and ergonomic pre-cleaning right at your fingertips.
The system is also ideal for other types of non-robotic submersible tubular instruments as six instruments can be pre-cleaned simultaneously. Available in an economical counter top unit or floor standing unit with automatic water filling and automatic drain control.
OPTIONAL FEATURES INCLUDE Integrated Ultrasonic System
Air and water pistols
Auto Fill System
Automated Lumen and Scope Flushing
Additional Options not shown: Push-button Height Adjustment - Auto sink bowl filling | Heated Sink Bowls | Custom Sink Bowl sizes | DI/RO faucets | Integrated Sonic Irrigator | Etched sink gallon markings | Storage shelves and drawers | Deck mounted Eyewash | Stainless steel peg board storage system
717.261.9700 firstname.lastname@example.org www.tbjinc.com
WITH BD CHLORAPREP™ PATIENT PREOPERATIVE SKIN PREPARATION WITH STERILE SOLUTION AND AN ALL-NEW STERILITY ASSURANCE LEVEL OF 10 –6.* At BD, patient health is an unrelenting priority. It’s why we’ve introduced a whole new level of sterility assurance for BD ChloraPrep™ Patient Preoperative Skin Preparation, the solution that more hospitals count on than any other brand. As pioneers in skin antiseptics, we are raising the performance bar above and beyond FDA skin prep requirements, making our market-leading solution even better. Because when it comes to patient health, no other option gives you more peace of mind. Now you can rely on the lowest risk of intrinsic contamination commercially available in the United States, with a sterility assurance level of 10 –6—reducing the risk of antiseptic solution contamination to less than one in a million.*1 Discover the confidence of BD ChloraPrep™ Applicators. Discover the new BD. *The SAL level indicates there is less than one in a 1,000,000 chance (1000x greater than the minimum requirement) that a sterile ChloraPrep™ applicator containing a sterile solution will contain a single (viable) microorganism following terminal sterilization of the ampules through the new manufacturing process of BD. 1 Degala S, McGinley CM II, Thurmond KB, inventors; CareFusion 2200 Inc., assignee. Systems, methods, and devices for sterilizing antiseptic solutions. US patent 9,078,934. July 14, 2015.
Discover peace of mind in your antiseptic solution at bd.com/One-Trust BD, the BD Logo and ChloraPrep are trademarks of Becton, Dickinson and Company or its affiliates. © 2019 BD. All rights reserved. 0819/3397