OR Today Magazine January 2022

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Nursing Competency

Wound Management

Endoscopy

Charlie Lin

CCI

MARKET ANALYSIS

CE ARTICLE

SPOTLIGHT ON

LIFE IN AND OUT OF THE OR

JANUARY 2022

robotic surge PAGE 36

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OR TODAY | January 2022

contents features

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ROBOTIC SURGE There has been a tremendous surge in robotic-assisted surgery in recent years with more than 7 million robotic surgical procedures performed worldwide in 2020.

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The global traditional wound

This course should help professionals

A closer look at Steven Covey’s “7 Habits

management market is expected to

better understand endoscopic procedures

of Highly Effective People.”

exceed $7 billion by 2028.

of the upper and lower GI tract.

MARKET ANALYSIS

CE ARTICLE

EQ FACTOR

OR Today (Vol. 22, Issue #1) January 2022 is published monthly by MD Publishing, 1015 Tyrone Rd., Ste. 120, Tyrone, GA 30290.

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For subscription information visit www.ortoday.com. The information and opinions expressed in the articles and advertisements herein are those of the writer and/or advertiser, and not necessarily those of the publisher. Reproduction in whole or in part without written permission is prohibited. © 2022

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OR TODAY CONTEST

DIGITAL SERVICES

NUTRITION

Cindy Galindo Kennedy Krieg

EVENTS

INDUSTRY INSIGHTS

Kristin Leavoy

8 News & Notes 14 HSPA: SPD/OR Professionals: Do You Understand Enzymatics’ Power in Device Cleaning?

16 AAMI: New Infusion Pump Testing TIR Focuses on Clinically Relevant Metrics & Acute Dialysis Survey Readiness Handbook Gets ‘Tremendous’ Update 18 ASCA: New Medicare Payment Rule and New ASC Legislation Kick Off 2022 20 CCI: The Assessment of Nursing Competency 23 OR Today Webinars: Webinar Provides In-Depth Look at Educator Role

Diane Costea

WEBINARS Jennifer Godwin

EDITORIAL BOARD Hank Balch, President & Founder, Beyond Clean Vangie Dennis, MSN, RN, CNOR, CMLSO,

IN THE OR 24 Market Analysis: Wound Management Market on the Rise 25 Product Focus: Wound Management 28 CE Article: Endoscopy: A View on the Inside

Assistant Vice President, Perioperative Services with AnMed Health System Sharon A. McNamara, Perioperative Consultant, OR Dx + Rx Solutions for Surgical Safety

OUT OF THE OR 40 Spotlight On: Charlie Lin 42 Health 44 Fitness 45 EQ Factor 46 Nutrition 48 Recipe 49 Pinboard

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PROUD SUPPORTERS OF

Health Careers High School

January 2022 | OR TODAY

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INDUSTRY INSIGHTS

news & notes

Health Care Professionals Invited to be AAAHC Surveyor The Accreditation Association for Ambulatory Health Care (AAAHC) encourages experienced and currently practicing health care professionals to apply to become a AAAHC surveyor. Qualified candidates include health care professionals such as doctors, nurses and administrators, all of whom ideally have direct AAAHC accreditation experience. The organization also seeks professionals with health plan and Life Safety Code experience.

Ideal candidates are those who are excited about the opportunity to educate others and benefit health care organizations through knowledge sharing. Individuals who are accepted into the program will attend blended learning sessions, held online and in person, and will support the AAAHC mission of improving health care quality throughout the 1,095 days of the accreditation cycle.

“Using their experience in health care with a collaborative approach to advance the standard of care, surveyors provide peer-reviews for ambulatory organizations, which is fundamental to our 1095 Strong, quality every day philosophy,” said AAAHC Board Chair Timothy Peterson, MD. “The passion we have for empowering health care facilities to adhere to, and exceed, AAAHC Standards is unmatched. This challenging but important role works to keep patients safe in the ambulatory setting through detailed and complex accreditation surveys.”

Within 45 days of application receipt, AAAHC will notify qualified candidates of next steps including a virtual interview.

Candidates who accept job offers are required to participate in a two-day in-person training session scheduled in the first quarter of 2022.

“Our surveyor training program integrates a hands-on approach to drive consistent Standards interpretation, survey process management, and educational consultation that results in a positive learning experience for the surveyed facility that promotes improved patient care,” said Noel Adachi, MBA, president and CEO of AAAHC. “We look forward to reviewing the applications of the highly qualified individuals who are passionate about continuous learning and want to bring our 1095 Strong, quality every day philosophy to life in ambulatory settings nationwide,” noted Adachi.

Intellijoint Surgical Offers Planning Product Intellijoint Surgical has announced a new preoperative surgical planning product for total hip arthroplasty. Intellijoint VIEW is a surgical planning software that provides targets for functional cup position accounting for hip-spine relationship and implant templating to generate targets for leg length inequality and offset restoration without requiring CT imaging. VIEW integrates seamlessly to the Intellijoint HIP navigation system allowing surgeons to access and deliver their plans intraoperatively.

Intellijoint VIEW can be used by clinicians to assess a patient’s spinopelvic mobility with a new feature called the Target Zone Visualizer (TZV) to provide a functional acetabular cup target that is unique to each patient. The feature analyzes X-ray images of a patient in both sitting and standing positions and then applies the novel hip-spine relationship concepts to produce a cup target. VIEW can assist surgeons at identifying at-risk patients from adverse spinopelvic mobility conditions such as “stuck-standing” or “stuck-sitting” postures and with the TZV feature, help plan a patient-specific cup position to accommodate their mobility to help reduce the chance of impingement or dislocation. VIEW also enables implant templating, identifying leg length inequality and offset restoration needs for optimal implant sizing and selection.

Intellijoint Product Manager Lee Preiss states, “We know that over 50% of total hip revisions are avoidable, and with VIEW we can offer surgeons additional value to do both pre-operative implant templating and patient-specific acetabular component position planning, addressing the major contributing factor to these revisions. Now surgeons can enter the OR with a clear and clinically relevant plan that can be delivered confidently with navigation.”

With targeted component positioning, the expectation is a drop in dislocations resulting in revisions. Intellijoint VIEW aids in discovering mobility specific orientation and planning for patient specific needs that can be integrated and delivered during surgery with Intellijoint HIP.

For more details and to apply, visit aaahc.org/surveyors.

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INDUSTRY INSIGHTS

news & notes

Accel Unite Announces Reusable Isolation Gown Accel Unite has announced a new design for reusable isolation gowns that are more cost-effective and provide better protection for the wearer and the environment.

Every year, hospitals and medical facilities use billions of disposable, single-use isolation gowns. It’s a number that only increased with the arrival of the COVID-19. In fact, at the height of the pandemic, some health care institutions were using 10,000 disposable isolation gowns per day. Due to increased demand and supply chain issues from Asia, providers across the country were fearful they would run out of isolation gowns and other PPE. Megan Eddings, founder and CEO of Accel Unite, knew there had to be a better way. She and her team immediately began researching the current offerings for isolation gowns and started working on designing a better gown. After collaborating with Healthcare Infection Control, Eddings and her team designed a new style of isolation gown that is now patent pending

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in 153 countries. Accel Unite is also registered with the FDA. Many reusable gowns tie in the back of the neck, requiring the wearer to put their contaminated sleeves near their face and neck. Accel Unite’s gowns are different. They have a snap behind the neck, enabling the wearer to tug the gown at the chest or shoulders to remove it. They never have to put their contaminated sleeves near their face and neck.

Accel Unite’s gowns also have ties on the side instead of in the back, so they’re easily tied and adjusted. In addition, they include an optional thumb loop, which prevents the gown’s sleeves from riding up.

When testing the gowns, the Association for the Advancement of Medical Instrumentation (AAMI) standards were used. The AAMI standards focus on liquid barrier performance and protection in the critical zones of gowns.

January 2022 | OR TODAY

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INDUSTRY INSIGHTS

news & notes

InnerSpace Offers New Scope Cabinet InnerSpace, a Solaire Medical Company, has announced the launch of its Ventaire Scope Drying and Tracking Cabinet. Ventaire provides real-time tracking capabilities, online scope monitoring and features an automated system that continuously delivers HEPA-filtered pressurized air into endoscope channels to keep scopes dry and avoid reprocessing.

In addition to displaying real-time tracking information like storage durations and expiration times, the Ventaire Scope Drying and Tracking Cabinet generates a report detailing all scope activity.

“Effectively drying and storing endo-

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scopes is critical for ensuring hygiene, prohibiting bacterial growth and potentially lowering infection rates,” InnerSpace Preisdent Ben Barber said. “Ventaire strengthens our position as a leader in medical storage by expanding the capabilities of our scope cabinet offering while providing significant value for health care systems that need to ensure infection prevention and meet industry standards.”

In addition to the scope drying and tracking cabinet, the Ventaire product line includes a scope tracking cabinet, retrofit scope drying and tracking cabinet and tracking units that can be field-installed in

InnerSpace Evolve scope cabinets.

“Our Ventaire scope tracking cabinet offers a cost-effective and efficient way to track scope storage,” Barber said.

A unique aspect of the Ventaire product line is that it allows users to monitor cabinet activity and update scope inventory remotely through the InnerSpace Smart Solutions website.

The Ventaire Scope Drying and Tracking Cabinet system meets the 2021 Multisociety Task Force Scope Storage and Drying Guidelines and works with all major endoscope brands.

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EvaClean Unveils PurExcellence The vision for proactive infection prevention has been realized in the EvaClean solution with proven processes and safer, more effective cleaning technologies. Over time, EvaClean has also become a trusted advisor for infection prevention units and environmental service teams in hospitals, health systems and long-term care facilities, as well as in colleges and universities.

Ultimately, the unique needs of these industry sectors inspired EvaClean to create PurExcellence.

EvaClean’s PurExcellence is a progressive program built on six key pillars – Assessment, Standardization, Education, Safety, Sustainability and Guaranteed Cost Savings – which establish a roadmap to true infection prevention partnerships with health care and higher education.

The first step in the quest for PurExcellence entails a complete site assessment of current protocols, chemistries and applications based on a number of factors specific to each facility.

Kurt Wong, chief experience officer at EarthSafe, EvaClean’s parent company said, “The data is used to develop a comprehensive chemical analysis, then compared against a more standardized approach using safer chemistries, which invariably yields cost savings of at least 30%.”

However, these benefits can’t be realized without ongoing targeted education that ensures proper procedures are implemented on a consistent basis.

“One of the most critical components of PurExcellence is customized training for the life of the partnership,” said Rich Prinz, senior vice president of sales. “Perennial education helps ensure higher levels of safety, compliance and productivity to achieve better outcomes.”

PurExcellence is standardized around EvaClean’s PurOne NaDCC cleaner and disinfectant. Not only does PurOne have the first EPA registered biofilm bacteria kill claim, it also eradicates over 55 organisms on 12 EPA lists, including multi-drug resistant and emerging pathogens. To mitigate cross-contamination, PurOne can also be used with EvaClean’s disposable environmental surface wipes or, alternatively, the wipes system can be used to augment existing programs.

Yet, high level efficacy is only half the safety equation. In addition to protecting patients, students and staff, solutions must also protect the environment. EvaClean’s advanced chemistries are HMIS rated 0/0/0 with a neutral pH, as well as biodegradable and fully OSHA, NIOSH and JCAHO compliant.

Because PurOne and PurTabs, EvaClean’s electrostatic sprayer disinfectant, dilute to different strengths for multi-purpose solutions and are highly effective at lower parts per million (ppm), it takes less chemical to accomplish more. The tablet format also requires less packaging, translating to less shipping, emissions and environmental impact. When strategies include electrostatic disinfection of all touchpoints, chemical consumption is even further reduced.

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January 2022 | OR TODAY

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news & notes

Hologic to Acquire Bolder Surgical Hologic Inc. has signed a definitive agreement to acquire Bolder Surgical, a privately held, U.S.-based company that provides advanced energy vessel sealing surgical devices, for approximately $160 million, subject to working capital and other customary closing adjustments.

“This acquisition will broaden our growing surgical portfolio by adding Bolder’s differentiated advanced vessel sealing and dissection tools that are used in laparoscopic procedures,” said Essex Mitchell, Hologic’s division president, surgical. “We can accelerate growth and improve patient outcomes by leveraging our significant commercial resources and strong relationships with OB/GYNs.” The transaction adds laparoscopic vessel sealing, dividing and dissecting devices to the Hologic portfolio and will enable Hologic to expand the use of Bolder’s devices to OB/ GYN specialists. Hologic estimates that there are five times more laparoscopic procedures in OB/GYN applications than

in pediatrics, where Bolder focuses currently. Bolder’s CoolSeal devices feature slender, dual action jaws, allowing for dissection, vessel sealing and dividing all in one device. The ability to use a combination device improves surgical efficiency by reducing the need for instrument exchanges. In addition, Bolder’s JustRight 3 mm vessel sealer and the JustRight 5 mm stapler are designed for small surgical spaces such as in pediatric cases, which can help reduce the need for larger, overpowered instruments.

The complementary acquisition of Bolder Surgical will add to Hologic’s surgical product line, which includes the NovaSure endometrial ablation system for the treatment of abnormal uterine bleeding, the MyoSure tissue removal devices for the treatment of intrauterine fibroids and polyps, the Acessa laparoscopic radiofrequency ablation system for the treatment of fibroids, and the Fluent fluid management system for streamlining hysteroscopic procedures.

PENTAX Expands Vizient Contract PENTAX Medical has expanded its contract with Vizient to include pediatric endoscopic solutions. The contract provides PENTAX Medical the ability to offer state of the art endoscopes and solutions through the Vizient Pediatric Program to Vizient member hospitals at negotiated pricing.

The agreement also includes value added offerings, education opportunities and best practices, to maximize value while improving clinical outcomes and enhancing experience and satisfaction.

Ojas A. Buch, president of PENTAX Medical Americas

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said, “We are proud to be selected for the Vizient Pediatric Program. We have the most innovative and comprehensive portfolio of slim and small caliber endoscopes to help optimize care for the smallest of patients.”

“The Vizient Pediatric Program is focused on bringing products that are unique to the needs of the smallest patients and making them available in the most cost-effective way,” said Brigitte Chorey, associate vice president of strategic sourcing, partnerships, and programs for Vizient. “We welcome PENTAX to the Vizient Pediatric Program.”

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INDUSTRY INSIGHTS

news & notes

Teleflex Expands Access to Procedural Expertise Teleflex Incorporated is combining its clinical education with the digital platform of Explorer Surgical, a GHX company.

This collaboration will provide urologists expanded access to interactive training and remote learning opportunities for the Teleflex UroLift System.

The Explorer Live cloud-based digital platform communicates critical information through an interactive digital playbook, enabling surgical teams to access customized information for specific team roles. The platform facilitates UroLift System trainer collaboration with urology surgical teams during live procedures from anywhere in the country through remote

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video connectivity.

“Our clinical teams are able to reinforce the best practices and techniques for the UroLift System, and ultimately help clinicians become more proficient with the device so they can achieve better patient outcomes,” said Kevin Hardage, president and general manager of interventional urology at Teleflex. “This innovative platform makes it easy for us to provide support where and when it is needed.”

The UroLift System is a minimally invasive treatment for lower urinary tract symptoms due to benign prostatic hyperplasia (BPH).

January 2022 | OR TODAY

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INDUSTRY INSIGHTS

IAHCSMM HSPA

SPD/OR Professionals: Do You Understand Enzymatics’ Power in Device Cleaning?

By Julie E. Williamson

perating room (OR) and endoscopy suite professionals play a critical role in point-of-use instrument treatment – and the use of enzymatic sprays and detergents can be a powerful tool in the process thanks to their ability to break down clinical soil and make cleaning easier and more effective in sterile processing areas. But many OR, endoscopy and SPD team members aren’t using them consistently and properly and may even lack an understanding of enzymatics’ function and benefits.

O

During his session from the 2021 IAHCSMM Virtual Conference, Craig Wallace, president of Wallace Sterilization Consulting, shared his knowledge about enzymes – including what they are, how they work and essential factors to consider to ensure they are leveraged to their fullest. He explained how enzymes and enzymatic detergents and the soils on instruments and medical devices fall into the biochemistry category and how biological macro14

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molecules are comprised of building blocks [sugars, the building blocks of carbohydrates; fatty acids, the building blocks of lipids; nucleotides, the building blocks of nucleic acids (DNA and RNA); and amino acids, the building blocks of protein] that join together by a link or bond. Enzymes, on the other hand, are proteins that serve as biochemical catalysts, increasing the rate of a chemical reaction without the enzyme itself undergoing any chemical changes itself. Put simply, as they relate to instrument treatment, enzymatic detergents break down the large molecules in the clinical soil to make it easier to wash away during the decontamination process.

“There are millions, perhaps billions, of reactions in cells and all are catalyzed by enzymes to make those reactions happen more quickly,” Wallace said, adding that enzymes are very specific in their work. Most enzymatic detergents sold today have different enzymes for different soil components: protease, lipase and amylase, which break down proteins, lipids/fats, and carbohydrates, respectively.

How enzymatic detergents work (and ensuring proper use) SPDs rely on two types of watersoluble cleansing agents: alkaline detergents that use alkaline pH chemistries to break down and solubilize soils, and enzymatic detergents that rely on enzymes’ lytic action to break down and solubilize soils.

Enzymatic detergents are complex chemistries consisting of enzymes, stabilizers and surfactants, and they are sensitive. They require the correct temperature, pH and concentration to ensure the enzymes stay intact and effective.

“We need to show them respect by following the instructions for use because there are specific reasons behind those [instructions],” he continued.

Recommended usage and conditions for manual and ultrasonic/ automated cleaning methods must be carefully and consistently followed. Many detergents are concentrated and require proper dilution to work effectively. Manufacturer instructions must also be diligently followed to ensure proper temperature ranges (enzymes are sensitive proteins, so “don’t run them too WWW.ORTODAY.COM

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WHERE THERE’S PRESSURE RELIEF, You’ll Find AIRISANA®

hot,” warned Wallace), and proper temperature must also be maintained in storage areas to prevent the enzymatics from losing their efficacy.

He also stressed the need to check expiration dates with every product used, including enzymatic detergents. They shouldn’t be viewed like simple hand soap in a restroom, he said, explaining that stabilizers, for example, may not work after the expiration date.

“These detergents are chemicals designed to chew up biological macromolecules, so they need to be handled, stored and used properly. Follow IFU closely to ensure the enzyme and surfactant chemistries will safely and effectively clean the instruments and devices,” Wallace said.

Author’s note: Enzymatic detergents/sprays may not be suitable for all instrument/devices, so be sure to closely follow manufacturers’ IFU (when in doubt, contact the device and enzymatic manufacturers). Also, while enzymatic sprays can be powerful tools for point-of-use treatment in the OR and other direct patient care areas, they may not be available in some facilities/departments. In the absence of enzymatic sprays or foaming agents, experts agree it is still important to keep instruments moist at point of use to prevent clinical soil from drying and hardening on devices (which can make it more challenging to remove in sterile processing areas and can jeopardize high-level disinfection and sterilization processes). Simply spraying instruments with water or covering them with a water-moistened towel (not saline, which can damage instruments) can be effective.

– Julie E. Williamson serves as Director of Communications and Editorin-Chief for the Healthcare Sterile Processing Association (formerly the International Association of Healthcare Central Service Material Management).

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January 2022 | OR TODAY

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INDUSTRY INSIGHTS AAMI

New Infusion Pump Testing TIR Focuses on Clinically Relevant Metrics new AAMI technical information report (TIR) aims to help product designers and developers apply a more robust testing regime to infusion devices – and, ultimately, improve device, medication and patient safety. AAMI TIR101:2021, Fluid delivery performance testing for infusion pumps, provides guidance on:

A

•

expanded test conditions across the full spectrum of clinical use; • performance measurements translated into clinically relevant metrics; and • standardized testing and disclosure.

With few exceptions, infusion devices have not fundamentally changed over the past decade or more. But infusion practices have “markedly increased in complexity and sophistication of clinical usage,” according to the TIR’s authors. This can result in clinician uncertainty about how these devices will perform across a broad range of conditions that have not been tested.

The international standard that addresses performance testing is IEC

60601-2-24:2012, Medical electrical equipment – Part 2-24: Particular requirements for the basic safety and essential performance of infusion pumps and controllers. The standard is “already pretty old,” said Ben Powers, vice president of infusion systems at Ivenix and co-chair of the AAMI Infusion Device Committee, “and a revision appears to be at least four years away.”

Thus, TIR101 – which has been in development for more than two years – is the first U.S. guidance to define fluid delivery performance test methods to accurately and efficiently align with the intended use of an infusion pump.

Complicated Use Cases Spur A ‘Big Innovation in Analysis’ The international standard largely relies on laboratory test conditions to evaluate infusion device performance. Real-world use cases are more complicated.

“Medications are getting more and more concentrated and they have more kinds of clinical uses,” Powers said. “There are more drugs that have immediate effects – where flow accuracy and continuity are very important. There are also a lot of new biologicals that have higher viscosities.”

In addition, more high-alert medications are used in patient care today. Highalert medications “bear a heightened risk of causing significant patient harm when they are used in error,” according to the Institute for Safe Medication Practices.

“Clinicians need to rely on these pumps a lot more than they have in the past,” Powers said. “Flow rate, viscosity, head height, back pressure and temperature are all external conditions that affect the pump output. Clinicians do not need to understand the science of infusion devices. They do need to know how different clinical conditions affect the output of the pumps.”

Unfortunately, not all instructions for use (IFU) disclose this useful information.

“A lot of the people on the committee have spent a lot of time in labs playing around with this challenge themselves,” Powers said. “It’s a big collaboration of creative ideas from a lot of really talented individuals across the industry.”

TIR101 now provides a standardized approach to disclosure about infusion pump performance in IFU, which will enable a more straightforward understand of which device is suited for which job.

Acute Dialysis Survey Readiness Handbook Gets ‘Tremendous’ Update he Acute Dialysis Survey Readiness Handbook, a valuable resource for anyone responsible for patient safety and outcomes in acute dialysis settings, has undergone significant changes – in-part inspired by the COVID-19 pandemic – with the publication of its second edition.

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‘A Tremendous Amount of Updating’ Glenda Payne, chief compliance officer and co-founder of the National Dialysis Accreditation Commission, wrote the original handbook with the late Jo-Ann Maltais, who served as co-chair for the AAMI’s Renal Disease and Detoxification Committee.

“The first edition was really the only source of information on how to prepare

for a state or accreditation survey of an acute hemodialysis unit, where patients can be at risk,” Payne said. “Jo-Ann really pushed me to do this handbook in the first place, and we were both disappointed when it had to be retired as ‘out of date.’ We were determined to get this revision done; Jean and I found the revision required a tremendous amount of updating.”

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INDUSTRY INSIGHTS AAMI

The overhaul was necessary because “the regulations are ever-evolving towards higher standards of care for our patients to decrease their morbidities and mortality,” said Jean Colaneri, nurse practitioner, clinician, and educator at Albany Medical Center, who co-authored the new edition.

The handbook has been expanded and now includes: • The various accreditation survey processes.

• Updated step-by-step guidance to prepare for a survey, guidelines on risk reduction and examples of auditing tools useful for acute dialysis programs.

• Best practice audit information and case studies for additional assistance for ensuring patient safety, survey preparedness, continued improvement and long-term compliance.

• Frequently asked questions.

• Definitions and abbreviations.

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• Additional emphasis on emergency preparedness.

The primary audiences for this handbook are the nurse and physician leaders and staff who provide acute dialysis services, along with clinician educators. Many others will find it useful as well, including companies that develop dialysis products and the accrediting organizations.

“There are lots of clues in the handbook for how to do a survey, as well as from the point of view of the nurses who provide the services, medical directors, and quality improvement, regulatory, and compliance staff,” Payne said.

“I hope the update will make the regulations more understandable and easier to implement for acute dialysis units,” Colaneri added. “I also hope it will be a practical and readable resource for survey readiness, which really means that we all know how to do things the right way and we do them correctly 100% of the time.”

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INDUSTRY INSIGHTS ASCA

New Medicare Payment Rule, ASC Legislation Kick Off 2022

By Bill prentice oth the Centers for Medicare & Medicaid Services (CMS) and Congress turned their attention to ASCs at the end of 2021. CMS released its final 2022 Medicare payment rule for ASCs and four members of Congress sponsored new legislation promoting patient access to ASCs.

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Under the final payment rule, ASCs received an effective update of 2 percent for 2022, beginning January 1. The amount was determined using a 2.7 percent inflation update based on the hospital market basket minus a 0.7 percentage point productivity adjustment required under the Affordable Care Act. The update is the same amount hospital outpatient departments received and a step toward greater parity in the systems used to determine reimbursements for both settings that ASCA has been requesting for some time.

In other good news for ASCs, CMS adopted a new formula related to device-intensive procedures that is based on ASC rates rather than HOPD rates as in the past. Under the new policy, any procedure for which the device cost is 30 percent of the overall ASC procedure rate will receive device-intensive status. ASCA has long supported 18

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this change. The rule also takes this policy decision one step further, asserting that any device that receives device-intensive status in the HOPD setting will also be device-intensive in the ASC setting.

Unfortunately, in this rule, CMS is removing 255 of the 258 codes it had added to the ASC Covered Procedures List (ASC-CPL) in 2021.

The three codes that will remain are: • 0499T (Cysto f/urtl strix/ stenosis) • 54650 (Orchiopexy (fowlerstephens)) • 60512 (Autotransplant parathyroid) This rule also brings back exclusionary criteria used previously to determine which procedures could be added to the ASC-CPL. These had been eliminated in 2021. This rule also halts the elimination of the inpatient-only (IPO) list that limits the procedures hospitals can perform as outpatient procedures. Although this list does not immediately impact the procedures ASCs can perform, it is of concern to ASCs because procedures often move off the IPO list and, later, into the ASC setting.

Expecting that trend to continue, ASCA was pleased to see that, as ASCA requested, this rule kept three procedures from reverting back onto the IPO list: CPT codes 22630 (Lumbar spine fusion); 23472 (Re-

construct shoulder joint) and 27702 (Reconstruct ankle joint).

On another positive note, the rule finalizes CMS’ proposal to establish a new process that will give professional specialty societies and other external stakeholders an opportunity to nominate new procedures to the ASC-CPL. This, too, is something ASCA has long requested.

This rule also introduced some significant changes to Medicare’s ASC Quality Reporting program that can lead to Medicare payment reductions for ASCs that fail to comply.

Not only are the criteria changing, some of the reporting methodology is changing as well. Some of the changes include: • add a COVID-19 vaccination measure; • resume reporting ASC-1, ASC-2, ASC-3 and ASC4, this time as web-based measures, which will mean facilities will report on all patients, not just Medicare beneficiaries; • require a new cataract-related measure, ASC-11, beginning with the CY 2025 reporting period, a delay from the start date contained in the proposed rule; and • require the Outpatient and Ambulatory Surgery Consumer Assessment of Healthcare

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INDUSTRY INSIGHTS ASCA

Providers and Systems (OAS CAHPS) Surveybased measures beginning with voluntary reporting in CY 2024 and mandatory reporting in CY 2025, also a delay from the start date contained in the proposed rule.

ASCA will continue to advocate for some additional changes in these measures and provide resources to our members to help them comply with the new requirements.

The new legislation, known as the Outpatient Surgery Quality and Access Act of 2021 (H.R. 5818 and S. 3132), would • require the Centers for Medicare & Medicaid Services (CMS) to publish relevant quality data in a way that allows patients to compare quality across sites of service; • eliminate the copay penalty Medicare beneficiaries pay for certain Part B services when they are provided in an ASC; • provide transparency regarding the criteria CMS is using to exclude procedures from the ASC

Covered Procedures List; add an ASC representative to CMS’ Advisory Panel on Hospital Outpatient Payment, which makes decisions that affect both hospital outpatient department (HOPD) and ASC facility fees and eligible procedures; and • align the inflation update and budget neutrality adjustment for ASCs and HOPDs. Demonstrating the bicameral, bipartisan appeal of the bill, Representatives John Larson (D-CT) and Devin Nunes (R-CA) introduced the legislation in the U.S. House of Representatives and Senators Richard Blumenthal (D-CT) and Bill Cassidy, MD (R-LA) introduced the legislation in the U.S. Senate.

ASCA has already begun working to secure support for this legislation from other members of Congress and provides tools and opportunities for ASC physicians, owners and staff to help. If you work in or with an ASC and want to be involved, please contact Stephen Abresch at sabresch@ascassociation.org.

•

Bill Prentice is the chief executive officer of the Ambulatory Surgery Center Association (ASCA).

TAKE GOOD CARE: NURSES • SURGICAL TECHS • NURSE MANAGERS

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INDUSTRY INSIGHTS CCI

The Assessment of Nursing Competency

By James X. Stobinski, Ph.D., RN, CNOR, CNAMB, CSSM(E) he subject of nursing competency is an important consideration for nursing certification programs accredited by either the National Commission for Certifying Agencies (NCCA) or by the Accreditation Board for Specialty Nursing Certification (ABSNC). Nursing specialty certification boards, to maintain accreditation standards, must establish programs that maintain or enhance the competency levels of their certificants.

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The maintenance of competency is also a critical concern for facilities which employ health care workers as their accreditation standards also address competency assessment.

Last month, I spoke to assumptions regarding nursing competency. I would now like to address how accredited certification bodies, such as the Competency and Credentialing Institute, are uniquely positioned to facilitate competency assessment.

Assessing and documenting the competency of staff requires a tremendous commitment of resources.

Licensure and registration programs, for those professions such as nursing which have these programs, make only a cursory and incomplete attempt at documenting competency. It is possible for an employing facility to 20

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assess competency but is a daunting, complex task. Often facilities will use a proxy for competency such as an annual skills fair. From a theoretical perspective competency is composed of three parts – knowledge, skills and attitude. (Tripathi Agrawal, 2014) Even the best of skills fairs assess only one component of competency – skills.

While familiar and commonly used, skills fairs have an issue of both face and criterion validity when used as an assessment of competency (Middleton, 2019).

The use of checklists, often termed competencies, is inherently problematic in the complex setting of the operating room. Wright (2019) states that, “The perioperative environment has so many technical skills and equipment that turn over constantly – if leaders have a competency for every technology, they are not going to make it.” Thus, attempts to measure competency using an endless series of checklists is a futile exercise.

Common in health care facility accreditation standards is a requirement to document the competency of staff members, their training and their ability to deliver safe care. Certifying bodies which administer voluntary credentials, such as the CCI CNOR and CSSM credentials, have a unique position in American health care.

These organizations possess resources and expertise which can be helpful to employers addressing and document-

ing the competency of staff. Certifying bodies administer psychometrically sound, legally defensible, secure examinations of knowledge specific to a role such as perioperative nursing. Passing these exams documents knowledge levels.

Certification bodies may also measure personality factors and soft skills such as critical thinking and adaptability thus covering the second constituent part of competency – attitude. A common criticism of pre-licensure education programs is that graduates do not possess critical thinking skills.

Certification programs, for example the recently launched CFPN credential, can assess these skills, provide feedback to the nurse and then through subsequent reflective learning exercises assist that nurse to develop these skills. And finally, a progressive and innovative recertification program for certified nurses can guide that nurse to refine and document their skills thus serving as an adjunct to skills fairs.

Certification bodies are uniquely positioned to assist both the individual nurse and the employer to fully document all aspects of competency.

Stakeholders such as employers may be well-served by an investment in maintaining the voluntary specialty certification for their health care professionals. Not-for-profit certification boards have the potential to be a great resource. In uncertain, resourceWWW.ORTODAY.COM

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constrained times such as this pandemic it may be helpful for health care facilities to re-examine the benefits of certification for their staff and ultimately for the benefit of their patients and families.

– James X. Stobinski, Ph.D., RN, CNOR, CNAMB, CSSM(E), is CEO of the Competency and Credentialing Institute.

OPERATING ROOM SOLUTIONS Surgical Table Pads, Casters, Mayo Stands and more!

REFERENCES Middleton, F. (2019). The four types of validity. Accessed October 23, 2021 at: https://www.scribbr.com/methodology/types-ofvalidity/#:~:text=There%20are%20four%20main%20types%20of%20 validity%3A%201,to%20a%20different%20test%20of%20the%20same%20 thing%3F Tripathi, K & Agrawal, M. (2014). Competency based management in organizational context: A literature review. Global Journal of Finance and Management. 6(4) pp. 349-356. ISSN 0975-6477. Accessed October 23, 2021 at: gjfmv6n4_10.pdf (ripublication.com)

ALCO has your solution!

Wright, D. (2019). Shift Your Competency Mindset. Accessed September 5th, 2021 at: https://www.aorn.org/about-aorn/aorn-newsroom/periop-todaynewsletter/2019/2019-articles/mindset

800.323.4282 • WWW.ALCOSALES.COM

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When you join us for a FREE webinar.

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OR Today has been approved and is licensed to be a Continuing Education Provider with the California Board of Registered Nurses, License #16623. CBSPD CE credits when12/10/21 applicable.

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INDUSTRY INSIGHTS

WEBINAR SERIES

newswebinars & notes

Webinar Provides In-Depth Look at Educator Role Staff report

he OR Today webinar “An Educator … What Is It Good For” presented by Perioperative Educational Consultant Amanda Heitman, RN, BSN, CNOR, was eligible for one (1) continuing education (CE) hour by the State of California Board of Registered Nursing.

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In the November 11 webinar, Heitman provided attendees – some of which were perioperative nurses considering embarking on the role of educator – with information on the extensive role of the educator for the surgical services areas. Discussion on the scope of the educator role, skill sets, necessary resources and network building expanded the attendees’ knowledge of preparation for the position. An overview of how an educator functions as an intricate cog in the patient/staff safety and quality initiatives was addressed. Heitman also discussed recruitment and retention efforts through an RN residency program in the perioperative arena.

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A question-and-answer session with attendees provided additional insights.

One attendee asked, “You say that you have recruited and had several candidates to choose from.

How do you pick the best one or the right one?”

“Well, that’s a really good question,” Heitman said. “It is sometimes a daunting task because there are a lot of applicants sometimes. But you kind of have to be selective in the questions that you ask them when you’re doing interviews. You want them to know why they want to be in the OR. So, you don’t want to just take somebody that thinks it’s cool because they watch ‘Grey’s Anatomy’ and I wouldn’t really want to do that. And believe me, I’ve been fooled before by these people that say the right things. And it isn’t really what they thought it was.”

“The best thing to do is to find the people that really know that it’s about patient safety, and that that’s the reason they’re doing it and start from there,” she added.

Other questions asked about the high number of travel nurses in the OR, the biggest challenge Heitman faces as an educator, the educational requirement considered appropriate for an LR or RN educator and more.

The webinar drew 87 individuals for the live presentation and an ondemand option is available online.

Attendees provided feedback via a survey that included the question, “How well did the content that was delivered match what you were promised when you registered?”

“Very well. Nice to see that what I do as clinical educator was supported in her lecture,” Clinical Educator G. Young said.

“It was perfect and something I needed at this moment in time,” Nurse Education Specialist M. Hutchcraft said.

“I found the speaker to be well informed and she kept the audience engaged in the conversation,” RN Educator S. Johnson said.

For more information, visit ORTodayWebinars.live.

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IN THE OR

market analysis

Wound Management Market on the Rise Staff report report from ResearchAndMarkets.com’s states that the global traditional wound management market is expected to reach $7.7 billion by 2028 and is expected to expand at a CAGR of 3.7% from 2021 to 2028.

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The rising incidence of chronic diseases, increasing number of accidents and rising number of ambulatory surgery centers (ASCs) are key factors driving for the market.

The global increase in the incidence of chronic diseases such as diabetes, cancer and other autoimmune diseases is one of the key factors for market growth.

Factors such as the adoption of unhealthy and sedentary lifestyles, alcohol consumption and smoking are contributing to the rise in the prevalence of noncommunicable diseases. Cancer has been a global health care burden as it is one of the leading causes of death. Most surgical wounds post-cancer surgery are relatively large in size and deep, producing exudate that requires regular care.

The wound care products such as bandages, medical tapes and gauze help to manage large wounds, significantly reducing the risk of further infection. According to the estimates from the WHO, in 2018, one in five men and one in six women globally develop cancer during their lifetime.

Moreover, as per reports published

by WHO, 18.1 million new cancer cases have been reported in 2018, globally. In addition, it also reported that over 70.0% 24

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of cancer-related deaths typically occur in middle- and low-income countries. Furthermore, the rising prevalence of chronic conditions and the number of surgeries being performed have also increased globally. These factors are anticipated to positively impact market growth over the forecast period.

According to ResearchAndMarkets. com, in terms of revenue, the acute wounds segment held the largest revenue share in 2020 owing to the rising cases of accidents and trauma globally. The gauze segment held the largest share in 2020 owing to its wide range of applicability in various types of injuries and availability of numerous products. The hospital segment dominated the market and held the largest revenue share in 2020 due to the rising cases of burns and surgeries. In Asia Pacific, the market is expected to witness the fastest growth rate over the forecast period owing to the rising number of diabetic patients in this region.

A report from ResearchAndMarkets. com states that the global wound care market size is expected to reach $27.21 billion by 2028 registering a CAGR of 4.1%. A rising prevalence of chronic diseases and growing geriatric population are key factors driving the global market.

An increasing number of ambulatory surgical centers (ASCs) across the globe is also anticipated to boost market growth over the forecast period. Ambulatory surgical centers offer a variety of services, such as surgical care, diagnostics and preventive procedures.

Surgeries for pain management, urology, orthopedics, restorative and gastro-

intestinal (GI)-related surgeries are also performed in ASCs. Earlier, ASCs were only capable of performing GI-related minor surgeries; however, with the rising demand for minimally invasive surgical procedures, services offered by ASCs expanded and grew exponentially. In addition, ASCs are highly cost-effective as favorable reimbursement coverages are provided for ASC services. The chances of contracting post-surgical, hospitalrelated infections are also reduced.

ASCs provide specific instructions to patients regarding post-surgical homecare. According to the U.S. Department of Health and Human Services (HHS) data records of 2014, there were 17.2 million hospital visits. These included invasive, therapeutic surgeries, and ambulatory surgeries. Around 9.94 million (57.8%) of these surgeries occurred in hospitalowned ambulatory surgery settings and the remaining 7.26 million surgeries (42.2%) were conducted in hospitals.

In terms of revenue, the advanced wound dressing segment held the largest share in 2020 owing to the increasing cases of chronic diseases and rising adoption of advanced wound care products, according to the report.

The acute wounds application segment held the largest revenue share in 2020 owing to the increased number of surgeries and burn cases, the report added.

The Asia Pacific region is expected to be the fastest-growing regional market over the forecast period owing to the increasing number of surgeries and burns cases in this region, the report stated.

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IN THE OR

product focus

3M

PREVENA RESTOR AXIO•FORM

PREVENA RESTOR AXIO•FORM Incision Management System delivers negative pressure wound therapy designed to manage post-operative incisions, as well as the surrounding soft tissue envelope. PREVENA RESTOR AXIO•FORM System helps stabilize the incision and surrounding soft tissue, reduce edema, and helps enhance post-operative recovery. This is the third offering in the PREVENA RESTOR Therapy portfolio, launched in 2019, to optimize postsurgical care and expand the company’s specialty surgical offerings. Please refer to the PREVENA RESTOR AXIO•FORM System Instructions For Use for important safety information.

Kerecis

Omega3 SurgiBind The new Kerecis Omega3 SurgiBind is the first-ever fish-skin implantable medical product for use in plastic and reconstructive surgery. The FDA-authorized product is indicated for implantation to reinforce soft tissue where weakness exists, in patients requiring soft tissue repair, or reinforcement in plastic or reconstructive surgery.

Kerecis Omega3 is intact fish skin that, when grafted onto damaged human tissue, recruits the body’s own cells and ultimately is converted into living tissue. SurgiBind helps practitioners better manage the risk of complications and improve outcomes. The fish-skin technology provides rapid incorporation and cell ingrowth, accelerated neovascularization and faster wound closure, all of which speed full tissue remodeling.

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IN THE OR

product focus

Mölnlycke

Mepilex Broder Post-Op Ag

Specifically designed for incisions, Mepilex Broder Post-Op Ag helps medical personnel balance the many demands of incision management and deliver the best possible care. Mepilex® Border Post-Op Ag is a showerproof antimicrobial post-operative dressing that effectively absorbs and retains drainage1,2,3.

The Safetac interface minimizes pain and peri-wound skin damage at dressing removal 4,5,6. The dressing seals the wound edges, preventing drainage from leaking onto the surrounding skin, minimizing risk of maceration6. The flex-cut pad gives high flexibility and good conformability over joints, such as knees or hips, promoting patient mobilization4. The dressing inactivates wound related pathogens within 30 minutes with sustained effect up to seven days7,8,9.

References 1. Feili F, et al. Blood absorption capacity of post-operative wound dressings. Poster presentation at the 5th Congress of WUWHS, Florence, Italy, 25-29 Sep 2016 2. Feili F. et al. Fluid handling properties of antimicrobial post-operative wound dressings. Poster presentation at 5th Congress of the WUWHS, Florence, Italy, 2016.

3. Feili F, et al. A laboratory evaluation of the fluid retention properties of post-operative absorbent dressings. Poster presentation at the 5th Congress of WUWHS, Florence, Italy, 25-29 Sep 2016 4. Bredow J, et al. Randomized clinical trial to evaluate the performance of a flexible self-adherent absorbent dressing coated with a soft silicone layer after hip, knee or spinal surgery in comparison to standard wound dressing. Poster presentation at the 5th Congress of WUWHS, Florence, Italy, 25-29 Sep 2016.

5. Zarghooni K, et al. Is the use of modern versus conventional wound dressings warranted after primary knee and hip arthroplasty? Acta Orthop Belg. 2015;81(4):768-775.

6. White, R. Evidence for atraumatic soft silicone wound dressing use. Wound UK 2005;1:3, 104-109.

7. Mölnlycke Health Care. Report no. 20151026-005. 2015. Data on file.

8. Mölnlycke Health Care. Report no. 20151109-002. 2015. Data on file.

9. Mölnlycke Health Care. Report no. 20151110-007. 2015. Data on file.

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Smith+Nephew

PICO Single Use Negative Pressure Wound Therapy

IN THE OR

product focus

PICO Single Use Negative Pressure Wound Therapy is a negative pressure wound therapy system that raises the level of care: • Indicated for use on closed surgical incisions and open wounds • Manages low to moderate levels of exudate1-3 • Delivers compression-like therapy to the wound, wound margin and periwound4 • Canister-free and portable, which can help improve patient mobility and increase5-6 satisfaction rates7 • Provides therapy for up to 14 days with PICO 14 and 7 days with PICO 7/7Y • Waterproof dressing, allowing patients the ability to shower5 1. Malmsjö M. et al. Biological effects of a disposable, canisterless Negative Pressure Wound Therapy system. Eplasty 2014; 14:e15. 2. Data on File DS/18/015/R. Summary Wound Model Report for Opal PICO 7. January 2018 3. Data on file reference 1102010 – Bacterial Barrier Testing (wet-wet) of PICO dressing with a 7 day test duration against S.marcescens; Helen Lumb, February 2011. 4. Smith & Nephew January 2018. Outcomes following PICO compared to conventional dressings when used prophylactically on closed surgical incisions: systematic literature review and metaanalysis. Internal Report. EO/ AWM/PICO/004/v1. 5. Hurd, T., Trueman, P., & Rossington, A. Use of portable, single use negative pressure wound therapy device in home care patients with low to moderately exuding wounds: a case series. Ostomy Wound Management. Volume 60. Issue 3. March 2014. 6. WMP.11446.UEF/R3 Project Fairbanks Human Factors Summary Report Issue 5. G Walker, May 2017. 7. Kirsner R, Dove C, Reyzelman A, Vayser D, Jaimes H. A prospective, randomized, controlled clinical trial on the efficacy of a single-use negative pressure wound therapy system, compared to traditional negative pressure wound therapy in the treatment of chronic ulcers of the lower extremities. Wound Repair Regen. 2019 Sept;27(5):519-529.

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MolecuLight Inc. MolecuLightDX

MolecuLight Inc. has launched the MolecuLightDX, a new point-of-care device for real-time detection of elevated bacterial burden in wounds.

New features on the MolecuLightDX include comprehensive EMR integration options and patient-centric user interface and workflow for wound tracking. The DX enables rapid digital wound measurement for documentation of procedures and wound progression via a stickerless measurement capability which automatically measures wound area. In addition, all MolecuLight procedures in the U.S. benefit from a reimbursement pathway including two CPT codes for physician work for “fluorescence wound imaging for bacterial presence, location, and load” and facility payment for HOPD and ASC settings through an APC assignment.

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CE103

IN THE OR

continuing education

Endoscopy:

A View on the Inside astrointestinal (GI) disorders have caused human suffering since time in memoriam. The ancient Greek physician Hippocrates documented the symptoms associated with GI conditions such as dysentery, bowel obstruction, and liver disease. William Beaumont was the father of American physiology and gastroenterology (Skroska, n.d.) who also documented GI symptoms. However, both Beaumont and Hippocrates had to rely on the patient’s symptoms to make a diagnosis.

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A Timeline of Invention 1795- First documented use of a sigmoidoscope, a device used to examine the sigmoid colon through the rectum, was by Bozzini.

• 1800s- Kussmaul observed the stomach through a rigid gastroscope.

• 1932- Schindler engineered the first semiflexible endoscope.

• 1957- A new fiberoptic gastroscope revolutionized gastroenterology by producing high-quality images and introducing simplicity and ease of use to these techniques.

(Leung & Gelrud, 2014).

Over the last several decades, many advances in fiberoptic technology have led to more useful instruments. These new and improved endoscopic tools have made it possible for healthcare providers to make accurate diagnoses of upper and lower GI diseases without surgery (Feussner et al., 2015).

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The Scope of the Procedure Endoscopes allow healthcare providers to visualize detailed images of otherwise unreachable portions of the GI tract in a minimally invasive manner. Endoscopes are introduced through natural body orifices, such as the mouth and the anus, eliminating the need for large incisions and long recovery periods. Quick and relatively safe procedures to perform, they can eliminate the need for more invasive modes of care and treatment.

Modern Endoscope The modern endoscope consists of a rigid or flexible tube, a light source, a lens system, an eyepiece, and an additional channel, which allows for the insertion of medical equipment to be passed through the endoscope. The light source directs light internally via an optical fiber system. The control head controls scope maneuverability in all directions, as well as containing valves that regulate air, water, and suction.

The suction/biopsy channel allows for the passage of accessories, such as biopsy forceps or cytology brushes. In 1983, the “chip in the tip” video endoscopy was introduced for GI procedures. However, the technological advances made since that time, especially in the miniaturization of electronics and increase in processing power, have resulted in system performance and functionality that previously were just a dream.

Esophagogastroduodenoscopy During an esophagogastroduodenoscopy (EGD/upper endoscopy), a gastroscope provides direct visualization of the esophagus, stomach, and proximal duodenum, which is the first portion of the

small intestine. If required, an enteroscope, a longer endoscope, can be advanced beyond the ligament of Treitz and into the jejunum. This is called a small bowel enteroscopy (Feussner et al., 2015).

An upper endoscopy can be performed for diagnostic evaluation or therapeutic intervention in the GI tract. Upper endoscopies are performed for the evaluation of noncardiac chest pain; the assessment of nausea and vomiting, dysphagia, and odynophagia; and for the evaluation and treatment of anemia and bleeding originating from the upper GI tract. Upper endoscopies can be performed for the diagnosis of Helicobacter pylori, a type of bacteria commonly discovered in the GI tract that can initiate ulcer disease; the evalu-

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

Goal and Objectives After taking this course, you should be able to: • List the reasons for endoscopic procedures of the upper and lower GI tract.

• Discuss the intraprocedural role of the nurse during an endoscopic procedure.

• List possible complications during and after an endoscopic procedure.

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IN THE OR

continuing education ation of heartburn and gastroesophageal reflux disease (GERD), esophagitis, and gastritis; the investigation of excessive gas and bloating; and the evaluation of peptic ulcer disease. Biopsies can be performed for the determination of malabsorption syndromes, malignancies, and infection.

Strictures can be dilated and foreign bodies can be removed without the trauma of a surgical procedure. Polyposis syndromes can be evaluated. Recent research has demonstrated the efficacy of the treatment and ablation of Barrett’s esophagus with dysplasia and early stage adenocarcinomas (Coman, Gotoda, Forsmark, & Draganov, 2016).

Endoscopy allows the diagnosis, treatment, and documentation of abnormalities of the upper GI tract through the use of manipulators placed through the endoscope to procure tissue samples for biopsy, cells for cytology, and photographic documentation of the visualized areas under evaluation. Therapeutic interventions include polypectomy, electrocautery, laser therapy, thermal coagulation, and dilatation. The provider can also treat esophageal varices through the mediums of banding or sclerotherapy, remove foreign bodies, and insert esophageal stents for the treatment of strictures or duodenal stents for the treatment of gastric outlet syndrome, which addresses and treats intrinsic or extrinsic obstructions of the pylorus or duodenum. Foreign bodies can be retrieved. Bleeding sites can be cauterized. Dysplasia’s and superficial malignancies can be ablated. Gastrostomy tubes can be placed for nutritional support or drainage.

Contraindications to an upper endoscopy include existing coagulopathies and anticoagulant medications the patient is taking. The risk of an embolic event occurring when anticoagulation is interrupted for four to seven days is about 1%, although such an interruption must be considered on an individual basis, as it is not always possible to discontinue anticoagulation (Acosta et al., 2016). However, anticoagulation should be discontinued in light of procedures that present a high risk WWW.ORTODAY.COM

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for bleeding, such as endoscopic mucosal resection, ampullary resection, and banding of esophageal varices.

Additional contraindications, according to American Society for Gastrointestinal Endoscopy (ASGE), include an uncooperative patient, medically unstable patients, and cases in which the risks outweigh the benefits (Bhagatwala et al., 2015). Concerns include the patient in shock. Some centers consider pregnancy a contraindication. Furthermore, the procedure should not be performed when the patient has been nonadherent to NPO guidelines.

Other factors that represent contraindications to the procedure include the patient with severe cervical arthritis or severely altered head and neck anatomy related to prior surgery, radiation, or tumor overgrowth that would result in airway issues that would preclude the safe administration of anesthesia to the patient.

Although standards of care vary between institutions, the ASGE recommends certain basic protocols before an upper endoscopy. These include the availability of an adequately trained staff, functional up-to-date equipment, a cleaning area separate from the endoscopy suite, and personnel who are adequately trained to intervene in the event of an emergency (Calderwood et al., 2014).

Pre-Procedure The patient is commonly instructed to have no solid food by mouth after midnight the day before the procedure.

Guidelines vary between institutions on the amount and timing of clear liquids allowed immediately before the procedure and range from nothing after midnight to clear liquids up to two to four hours before a procedure. The nurse completes an assessment before the patient is brought into the procedure room. This assessment includes a review of vital signs, allergies, current medications, anything taken by mouth on the morning of the procedure, medical comorbidities, pain level, level of consciousness, fall risk, and the reason for the procedure. The physician is notified of any abnormalities in the patient’s pre-

procedural assessment or of any laboratory test results required and drawn. These would include coagulation studies, platelet count, and hemoglobin and hematocrit testing (Pasha et al., 2014).

As a part of the receiving informed consent, the provider who will perform the procedure explains the procedure to the patient, and the patient has the opportunity to ask questions. If sedation will be used, the staff must identify the responsible adult escorting the patient home after the procedure. The discharge instructions should be reviewed with the patient and family/significant other before the procedure. Explain that additional instructions based on the findings of the procedure may be added after the procedure is completed.

An IV line is started per the physician’s order. The patient removes any dentures and partial plates before the procedure.

Antibiotic prophylaxis is addressed on an individual basis and is recommended for patients who are at a higher risk for the contraction of an infection. These include patients who have an underlying highrisk comorbidity, such as an aortic valve replacement or a history of endocarditis, and patients having a high-risk procedure, such as the placement of a biliary stent in the presence of an obstructed biliary tree (Khashab et al., 2015).

Intra-Procedure The patient is placed in the left lateral position, lying on the left side with the knees slightly flexed. A plastic mouthpiece is inserted into the patient’s mouth to relax the jaw and protect both the teeth and endoscope.

A compromised airway is serious complication that can occur during endoscopy.

The nursing priority during the procedure is to monitor the patient, including the airway, vital signs, skin color, and level of pain and consciousness. The nurse should be able to visualize the patient throughout the procedure, and monitoring equipment should be used. The use of monitoring devices is believed to reduce the frequency of complications and improve the overall January 2022 | OR TODAY

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safety of endoscopy (Mahmud & Berzin, 2016). Oxygenation is usually assessed with pulse oximetry to detect hypoxemia.

The nurse should assist the physician by maintaining the patient’s head in a neutral position that is slightly flexed forward.

The patient’s airway is maintained with a slight chin-lift maneuver. Oral secretions are suctioned as required. As the physician advances the endoscope, air is introduced to improve visibility of the GI tract.

Post-Procedure The nurse monitors and documents vital signs as required by institutional policy.

The major complications of an EDG are bleeding, infection, and perforation (Leung & Gelrud, 2014). Observe the patient for abdominal distention, vomiting, or signs of GI bleeding. Also, note any chest pain, palpitations, severe heartburn, or difficulty breathing. Do not allow the patient to have anything by mouth until the gag reflex returns; then, note any difficulty in swallowing. Palpate the abdomen and evaluate bowel sounds. Complications can include pulmonary aspiration and GI or esophageal perforation or hemorrhage.

Endoscopy units may have a policy to discharge the patient if he or she is within a certain range of baseline parameters. Many options exist for discharge criteria, including that the patient should be home ready, awake, and oriented, and have stable vital signs (Calderwood et al., 2014). Other options are based on scoring methodologies during the discharge assessment and on pre-approved clinical criteria (Calderwood et al., 2014). Remove the IV line before discharge. Provide the patient/family with written discharge instructions for followup care.

Colonoscopy: The Bottom Line A colonoscopy is a safe, effective, minimally invasive means of examining the large intestine from the rectum to the ileocecal valve. It is performed for the evaluation and treatment of lower GI bleeding, the detection and excision of colon polyps, the diagnosis of diverticulosis and diverticu30

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litis, and the assessment and treatment of inflammatory bowel disease. It can be used to evaluate areas of abnormality noted on radiological examinations. A colonoscopy can help determine the etiology of symptoms such as diarrhea, chronic constipation, changes in bowel habits, iron deficiency anemia of unclear cause, unexplained abdominal pain, and anemia of unclear origin.

An optical colonoscopy is considered the gold standard for the examination and screening of the large intestine (Beck, 2012). The malignancies most often detected during these screening procedures are adenomatous polyps (Issa & NouredDine, 2017). The common colon cancer screening tool in the United States is the optical colonoscopy (Issa & NouredDine, 2017). However, only 20-38% of the population, about one in three, are current with the mandated screening guidelines (Alberti et al., 2015).

Therapeutic interventions used during a colonoscopy include tissue retrieval for biopsy, polypectomy, hemostasis of bleeding sites, colonic decompression, clip insertion, medication injection, dilation, or stenting. The possibility of performing a biopsy or removing an abnormality via direct visualization of the mucosal wall gives the colonoscopy an important advantage over radiological examinations of the colon, such as the virtual colonoscopy.

Contraindications to a colonoscopy include a known or suspected perforation, fulminant colitis, acute diverticulitis, an uncooperative patient, and cases in which risks outweigh the benefits (Bhagatwala et al., 2015). Additional contraindications include toxic megacolon, peritonitis, a and perforated bowel (Ahlawat & Ross, 2019).

A patient with an inadequate bowel preparation must be rescheduled.

Cancer Screening Even in the absence of suggestive symptoms, colonoscopies are an important component of the diagnostic process in colon cancer screening. In 2008, a multisociety task force reported reductions

in colorectal cancer mortality could be achieved through detection and treatment of early-stage cancers and the identification and removal of adenomatous polyps, the precursors to colon adenocarcinomas (He et al., 2018).

The American Cancer Society [ACS] recommends that people with an average risk of colon cancer begin colon cancer screening at age 45 by one of four methods (ACS, 2018): • Flexible sigmoidoscopy every five years • Colonoscopy every 10 years • Double-contrast barium enema every five years • CT colonography (virtual colonoscopy) every five years People falling in the higher risk grouping, who have a family history of colorectal cancer or adenomatous polyps, should begin their screening protocols at age 40 years. People who have had colorectal cancer and/or adenomatous polyps should be rescreened more often — usually within two to six months after adenoma removal and once again within three years after the polyps are removed. It is recommended that individuals who fall into the very high-risk group begin their screening regimens much earlier (ACS, 2018).

These patients include those with: • Familial adenomatous polyposis diagnosed with or without genetic testing, who should begin screening between 10 and 12 years of age • Those with Lynch syndrome or hereditary nonpolyposis colon cancer, who are at increased risk based upon family history and should begin screening at 20 to 25 years of age or at 10 years before the age of the youngest afflicted individual in their immediate family.

Eight years after it effects the large intestine, inflammatory bowel disease (IBD), such as Crohn’s disease or ulcerative colitis, becomes a significant risk factor for cancer. Those with IBD who WWW.ORTODAY.COM

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develop left-sided colitis after 12 to 15 years are also at significant risk for cancer (ACS, 2018). Also, the American College of Gastroenterology guidelines suggest that African-Americans start the screening process at age 45, as the incidence of colorectal cancer among that population is high (Wang et al., 2015).

Bowel Preparation Before Colonoscopy A good bowel preparation is one of the most important aspects of any colorectal cancer screening regimen, as a well-prepared colon will adequately delineate the colonic mucosa, enabling the physician to thoroughly assess for any abnormalities.

Strict adherence to the physician’s recommended bowel preparation regimen is extremely important; the procedure may have to be suspended before completion in the case of inadequate bowel preparation.

Many options are available for bowel preparation. Ideally, the perfect bowel preparation should reliably empty the colon of all detritus and fecal material in a rapid, convenient, tolerable, and safe manner (Saltzman et al., 2015). That is not the current situation. However, on a brighter note, studies have shown that the split-dose bowel preparation offers a more effective colon cleansing than have the single-dose bowel preparations that have preceded it (Saltzman et al., 2015).

Split dose bowel preparation requires the patient to consume half the dose of bowel preparation the day before and half the day of the procedure.

Poor quality of bowel preparations has been reported in approximately 20-24% of colonoscopies currently performed (Martin et al., 2016). Therefore, approximately 25% of all patients who have this examination are not sufficiently prepared, and consequently, are unable to receive an adequate evaluation of their large intestine. As a result, the ASGE changed to its guidelines for pre-colonoscopy bowel preparations (Saltzman et al., 2015). Aimed at making the preparation safer and more tolerable to patients, the WWW.ORTODAY.COM

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split-dose method has been found to be more effective in cleansing the colon than its earlier counterparts of one dose. Lower in volume than previously, but more effective in cleansing the colon, this bowel preparation requires that the patient drink half of the preparation, typically polyethylene glycol-electrolyte solution, during the evening before the procedure and the other half three to eight hours before the examination (Saltzman et al., 2015).

Research shows that split-dosing increases adenoma detection rates and improves the overall quality of bowel preparations (Radaelli et al., 2017). In addition, both sodium phosphate and magnesium citrate based evacuants are no longer recommended due to the risks they pose for electrolyte and renal imbalances and disruptions (Saltzman et al., 2015).

To increase patient adherence to bowel preparation regimens, a reduced-volume bowel cleansing regimen consisting of 2 liters of the polyethylene glycol-electrolyte solution taken in conjunction with a total of four delayed-release 5 mg bisacodyl (Dulcolax®) tablets was introduced into the marketplace. Studies have found that this preparation cleansed as effectively as the larger volume 4-liter bowel preparations that preceded it (Saltzman et al., 2015).

Bowel preparation solutions may not taste good, and some people may find it easier to drink if the solution is cold. Patients should drink the solution quickly, as drinking slowly will not clean out the colon as effectively or efficiently (Saltzman et al., 2015). Watery stools usually begin within 30 to 60 minutes after the first glass, with the intestines usually completely emptied within four hours.

Patients may find it comforting to know that once the bowel preparation is completed and the colon is clean, they have completed what many regard as the most unpleasant portion of the process.

For a split-dose prep, remind the patient to ask the physician how many hours before the start of the procedure the second dose should be completed.

Although most bowel preparations still require the patient to consume only a clear liquid diet for at least the day before the procedure, the new ASGE guidelines also recommend that a low-residue diet replace the clear liquid diet on the day before the procedure, stating that it has proven to be equally as effective and is preferable to patients Saltzman et al., 2015). A low-fiber diet excludes raw fruits and vegetables, seeds, nuts, berries, and whole grains, but allows refined grains, seedless vegetables that are cooked or canned, soft fruit without the peel, lean meats, and eggs. It has shown to be more tolerable to patients, improving adherence to the bowel preparation and patients’ satisfaction with it (Nguyen, Jamal, Nguyen, Puli, & Bechtold, 2016).

However, regardless of the laxative chosen and the diet consumed, the patient should drink enough clear liquids the day before the procedure to prevent dehydration. The updated guidelines also urge physicians to document the quality of the bowel preparations of patients they have scoped using validated scoring systems, and, if required in the case of an inadequate bowel preparation, to reschedule the patient for a repeat procedure within one year (He et al., 2018).

Of note, patients with chronic constipation, a history of a poor bowel preparation, or on chronic pain medication may require more in-depth bowel preparations.

The patient should be instructed to follow physician guidelines for food and liquid restrictions.

Sedation and Pain Relief A colonoscopy can be safely performed on an outpatient basis without general anesthesia. However, moderate sedation (formerly called conscious sedation) is usually necessary because of the length and discomfort of the procedure. Patients may be concerned that the procedure will be painful. Patients may feel more at ease if the nurse provides information about how the sedating medication helps.

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or sedatives administered through an IV access line (Sonnenberg, 2016).

Fentanyl (Duragesic®) and midazolam (Versed®) are commonly used (Sonnenberg, 2016). Clinicians may want to consider alternatives to meperidine, as adverse neurological effects are possible in some people. Sedation in the endoscopy setting is used to help make the procedure more comfortable and tolerable for the patient.

Sedatives can be used to facilitate amnesia and a decreased level of consciousness, and analgesics can be used to facilitate pain relief. Anesthesia staff will be needed to provide deeper levels of sedation if required. It is safer to sedate patients at a moderate sedation level at which they maintain their protective reflexes.

Propofol (Diprivan®) is gaining widespread use as a safe and effective anesthetic agent in the gastroenterology suite.

It reduces the time between admission and discharge as it shortens the recovery period. Patients who were anesthetized with propofol appeared better sedated and demonstrated higher postanesthesia recovery scores without any increase in post-procedural complication rates (Nishizawa & Suzuki, 2018).

Intra-Procedure Position the patient in the left lateral position (on the left side with the knees slightly flexed) and the head resting on a small pillow. Place a pad under the buttocks. The physician will perform a digital exam. This serves to check for distal masses, dilates the opening, and assesses the distal colon preparation. The distal end of the instrument is then lubricated, and the physician inserts the scope into the rectum and advances it slowly. Once the instrument has been advanced to the desired level, it is withdrawn slowly as the physician meticulously examines the colon on the way out. At this point, a heightened attention to detail and a slow withdrawal are required, as these practices are associated with higher rates of adenoma detection (Rex et al., 2015).

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in applying pressure to the abdomen to prevent the flexible scope from forming loops as it passes through the sigmoid colon; this maneuver is also effective in guiding the instrument through the proximal transverse colon. Initially and throughout the procedure, large amounts of lubricating jelly are applied to the anus to reduce friction, prevent trauma at the anal canal, and facilitate advancement of the endoscope. The nurse must monitor the patient throughout the procedure, noting vital signs, skin color and warmth, distention, possible signs of pain, and level of consciousness (Sonnenberg, 2016).

Per the ASGE and the Society of Gastroenterology Nurses and Associates (SGNA) guidelines, during a procedure under moderate sedation, the nurse may continue with other tasks that can be easily discontinued to quickly attend to the patient’s needs as required. If a deeper level of sedation is desired, however, the monitoring nurse in the room must have no other function except to observe and monitor the patient (SGNA, 2017; Calderwood et al., 2014). If necessary, a nursing assistant may perform the other tasks, which may include repositioning the patient during the procedure, the application of abdominal pressure, and assisting with therapeutic interventions, such as polypectomy and hemostasis. Reassurance and emotional support throughout the procedure will also help ensure the patient’s cooperation.

A nurse may also be responsible for the administration of IV fluids and medications, depending on the customary practice of the diagnosing physician and the protocols of the facility. Oxygen therapy should always be available.

Post-Procedure Monitoring of the patient post-colonoscopy is similar to the care provided after a gastroscopy. Observe the patient’s abdomen for distention. Encourage the patient to pass flatus to relieve abdominal pressure from the insufflation of air during the procedure. In addition, observe for bloody

or tarry stools; vomiting or prolonged heaving; progressive, severe, or colicky pain that persists without improvement; and adverse effects of any medications that have been administered. Make note of any chest pain, palpitations, severe heartburn, or difficulty breathing, fluid shifts, dehydration, or congestive heart failure in association with the prep or the procedure.

Complications can include perforation and/or hemorrhage of the colon.

The Bug in the Ointment Knowledge of the appropriate cleaning, disinfection, and sterilization of equipment is equally as important as being conversant with its use. In our current healthcare environment, when superbugs present an ever-looming obstacle to safe patient care, stringent standards of infection control must be set in place to achieve optimal patient outcomes. Reprocessing of all types of endoscopes must be performed by appropriately trained personnel who are compliant with the standards of infection control relevant to the care and disinfection of the instrument or endoscope being reprocessed. Multiple professional organizations, including ASGE, the Society of Gastroenterology Nurses and Associates, and Association of Perioperative Registered Nurses have developed evidence-based guidelines for the safe reprocessing of GI endoscopes (Peterson et al., 2017). It is the clinician’s role to stringently adhere to these standards and guidelines to maintain a safe and infectionfree endoscopy suite.

A recent research study examined the endoscopy procedures performed in the ambulatory surgery centers (ASC) where associated with infections. “The rates of post-endoscopic infection per 1000 procedures within 7 days were 1.1 for screening colonoscopy, 1.6 for nonscreening colonoscopy, and 3.0 for OGD; all higher than screening mammography (0.6) but lower than bronchoscopy (15.6) and cystoscopy (4.4) (p<0.0001).”

(Wang et al., 2018). This was a much higher number than had previously been WWW.ORTODAY.COM

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assumed (Wang et al., 2018).

The Hidden Depths The small intestine, which comprises a large portion of the GI tract, lies nestled between its upper and lower extremities.

As its length makes it largely prohibitive to visualization with a flexible endoscope, capsule endoscopy provides an accessible means of evaluation of the heretofore hidden recesses of the small bowel: the duodenum, the jejunum, and the ileum. A pill-sized camera travels down the length of the GI tract, recording images along its route. The camera collects data that can provide potential explanations for GI bleeding, the most common reason that this examination is performed. It can be also utilized to detect inflammatory bowel disease, ulcers, tumors, and polyps of the small bowel.

Looking Forward Technology has redefined the field of gastroenterology and endoscopy in the past several decades. The progression from fiberoptic to video endoscopes revolutionized the field. We are entering yet another new age in the field of GI endoscopy, in which the emergence and refinement of new techniques and technologies continue to evolve through the development of advanced imaging techniques, higher endoscopic magnification capabilities, the advancement of nanotechnology, and more enhanced and technologically efficient endoscopes that would make scope manipulation easier and thus allow for a more efficient and safe passage through the GI tract. Just one of these techniques is disposable endoscopy, which would allow for an endoscope to be used on a single-patient basis only, which would potentially reduce the risk of hospitalacquired infection (Baeg et al., 2016).

Technologies are emerging, such as optical polarization, optical phase, and hyperspectral endoscopy, that record images at many different wavelengths (Qi & Elson, 2016). Augmented reality is under discussion, a technique which can WWW.ORTODAY.COM

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be combined with other imaging sources to more accurately ascertain the position of an endoscopic structure or tumor (Mahmud, Cohen, Tsourides, & Berzin, 2015). Procedures are already in place that can act as endoscopic alternatives to bariatric surgeries, or others that allow for endoscopic alternatives to the removal of polyps invading deeply into the mucosal and submucosal linings of the colon wall (Choi & Chun, 2017; Maple et al., 2015).

The future looks exciting and may be full of marvels. What we can be sure of, however, is that we can look forward to greater patient satisfaction and enhanced patient outcomes.

Summary Now that you have finished viewing the course content, you should have learned the following: • List the reasons for endoscopic procedures of the upper and lower GI tract.

• Discuss the intraprocedural role of the nurse during an endoscopic procedure.

• List possible complications during and after an endoscopic procedure.

The content for this course was created or revised by Cathy S Birn, MA, RN, CGRN, CNOR. Cathy S Birn, MA, RN, CGRN, CNOR, practices endoscopy at Memorial SloanKettering Cancer Center in New York. She currently holds a position on the Editorial Board of the Gastroenterology Nursing Journal. She is a former co-chairwoman of the Society of Gastroenterology Nurses and Associates education committee.

This course was edited by Relias staff writer Elizabeth Kellerman MSN RN. Elizabeth Kellerman MSN RN started nursing in 2007 after graduating from Samuel Merritt University in Oakland, California.

While working in a critical care unit at

Sutter Mills-Peninsula Hospital she earned her CCRN and TNCC. Her experience and knowledge led her to nursing education where she taught at a community college while working to receive her Master’s in Nurse Education at Western Carolina University. As a nursing instructor, she spent time in many types of care settings including medical-surgical inpatient and community living centers. Her passion for education and training has led her to a position as a content writer at Relias.

Editor’s Note: Cathy Dykes, MS, RN, CCRC, CCRP, CGRN; Lois Jane Jones, RN; and Maria Morales, MSN, RN, CPAN; past authors of this educational activity, have not had an opportunity to influence the content of this current version.

References American Cancer Society (2018). Guideline for Colorectal Cancer Screening. Retrieved February 6, 2020, from https://www.cancer.org/cancer/ colon-rectal-cancer/detection-diagnosis-staging/ acs-recommendations.html Acosta, R. D., Abraham, N. S., Chandrasekhara, V., Chathadi, K. V., Early, D. S., Eloubeidi, M. A., … DeWitt, J. M. (2016). The management of antithrombotic agents for patients undergoing GI endoscopy. Gastrointestinal Endoscopy, 83(1), 3–16. https://doi.org/10.1016/j.gie.2015.09.035 Ahlawat R, Ross AB. (2019). Esophagogastroduodenoscopy. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-.

Available from: https://www.ncbi.nlm.nih.gov/ books/NBK532268/ Alberti, L. R., Garcia, D. P. C., Coelho, D. L., Lima, D. C. A. De, & Petroianu, A. (2015). How to improve colon cancer screening rates. World Journal of Gastrointestinal Oncology, 7(12), 484. https://doi. org/10.4251/wjgo.v7.i12.484 Baeg, M. K., Lim, C. H., Kim, J. S., Cho, Y. K., Park, J. M., Lee, B. I., … Choi, M. G. (2016). Portable disposable ultrathin endoscopy tested through percutaneous endoscopic gastrostomy. Medicine (United States), 95(48), e5423. https://doi.org/10.1097/ MD.0000000000005423 Beck, D. E. (2012). The importance of colorectal cancer screening. The Ochsner Journal, 12(1), 7–8. Retrieved from http://www.ncbi.nlm.nih.gov/ pubmed/22438774 Bhagatwala, J., Singhal, A., Aldrugh, S., Sherid, M., Sifuentes, H., & Sridhar, S. (2015). Colonoscopy — Indications and Contraindications. In Screening for Colorectal Cancer with Colonoscopy. InTech. https://doi.org/10.5772/61097

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continuing education Clinical Vignette Jason MacBride has been popping antacids for as long as he can remember. A high-pressure job, two kids in college, a big mortgage, and a passion for spicy foods had all conspired against him. Now he belched as he finished the last forkful of his dinner, his wife’s specialty, spicy chili with extra onions. The familiar acid started building in the back of his throat as he rose from the table to lumber over to his favorite recliner to watch television. Feeling his eyes begin to flutter shut several hours later, he heaved his bulk out of the chair and into the bedroom, the acid reflux bubbling up in the back of his throat as he rose.

Jason had had enough and called his physician the next morning about the furnace in his chest and throat and his incessant bad breath. He was directed to a gastroenterologist, for the long overdue colonoscopy he had been putting off since he had turned 50 three years before and for the evaluation of what his primary care physician thought sounded a great deal like gastroesophageal reflux disease (GERD).

Because Jason is 53 and had not had a colonoscopy, the gastroenterologist recommended a colonoscopy as well as upper endoscopy, and the office staff called Jason and gave him the preparation instructions. He listened warily to the diet restrictions and preparation instructions required before a colonoscopy.

Give up nuts? No popcorn? What in the world was he to snack on? Purge his colon with a laxative? Was he going to be able to survive this preparation? He heaved a sigh of exasperation with each new instruction the nurse imparted, such as a clear liquid diet and adequate hydration. Finish the bowel prep to ensure it is successful. Did she really say he had to drink a half-gallon of liquid?

At least she had said he could do it in two divided doses.

He was instructed to take only certain of his medications on the morning of the procedure. Somebody must be with him to take him home. Not looking forward to the procedures that were in his immediate future, he managed to promise the nurse to do his best to cleanse his bowel so the physician would be able to give him an adequate exam. Then he crossed his fingers that he would be able to do so and hung up the phone.

1. What procedure is used to evaluate GERD? a. Colonoscopy c. Esophagogastroduodenoscopy b. Enteroscopy d. Capsule endoscopy 2. What does an esophagogastroduodenoscopy examine? c. The esophagus and the stomach, a. The esophagus, the stomach, and but none of the small bowel the proximal duodenum b. The large intestine and the ileocecal d. The small bowel to the level of the valve jejunum 3. What is the gold standard for the diagnosis of colorectal cancer? a. The fecal occult blood test c. The virtual colonoscopy b. The flexible sigmoidoscopy d. The optical colonoscopy 4. When should a colonoscopy for colon cancer screening be performed? a. Begin at age 40 in patients with no c. Begin at age 45 family history of colon cancer d. Should be performed only after a positive fecal occult blood test b. Be performed only in patients with known malignancies 34

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Calderwood, A. H., Chapman, F. J., Cohen, J., Cohen, L. B., Collins, J., Day, L. W., & Early, D. S. (2014).

Guidelines for safety in the gastrointestinal endoscopy unit. Gastrointestinal Endoscopy, 79(3), 363–372. https://doi.org/10.1016/j.gie.2013.12.015 Choi, H. S., & Chun, H. J. (2017). Recent trends in endoscopic bariatric therapies. Clinical Endoscopy.

Korean Society of Gastrointestinal Endoscopy. https://doi.org/10.5946/ce.2017.007 Coman, R., Gotoda, T., Forsmark, C., & Draganov, P. (2016). Prospective evaluation of the clinical utility of endoscopic submucosal dissection (ESD) in patients with Barrett’s esophagus: a Western center experience. Endoscopy International Open, 04(06), E715–E721. https://doi. org/10.1055/s-0042-101788 Feussner, H., Becker, V., Bauer, M., Kranzfelder, M., Schirren, R., Lüth, T., … Wilhelm, D. (2014). Developments in flexible endoscopic surgery: A review.

Clinical and Experimental Gastroente 8:31-42. doi: 10.2147/CEG.S46584.

He, X., Wu, K., Ogino, S., Giovannucci, E. L., Chan, A. T., & Song, M. (2018). Association Between Risk Factors for Colorectal Cancer and Risk of Serrated Polyps and Conventional Adenomas. Gastroenterology, 155(2), 355-373.e18. https://doi.org/10.1053/j. gastro.2018.04.019 Issa, I. A., & NouredDine, M. (2017). Colorectal cancer screening: An updated review of the available options. World Journal of Gastroenterology.

Baishideng Publishing Group Co., Limited. https:// doi.org/10.3748/wjg.v23.i28.5086 Khashab, M. A., Chithadi, K. V., Acosta, R. D., Bruining, D. H., Chandrasekhara, V., Eloubeidi, M. A., …

Cash, B. D. (2015). Antibiotic prophylaxis for GI endoscopy. Gastrointestinal Endoscopy, 81(1), 81–89. https://doi.org/10.1016/j.gie.2014.08.008 Leung, W. D., & Gelrud, A. (2014). Ushering a new era in gastroenterology: The flexible gastroscope: Commentary on: Gastroscopy with a flexible gastroscope. Digestive Diseases and Sciences</i Mahmud, N., & Berzin, T. M. (2016). Extended Monitoring during Endoscopy. Gastrointestinal Endoscopy Clinics of North America. W.B. Saunders. https://doi.org/10.1016/j.giec.2016.02.006 Mahmud, N., Cohen, J., Tsourides, K., & Berzin, T. M. (2015). Computer vision and augmented reality in gastrointestinal endoscopy. Gastroenterology Report. Oxford University Press. https://doi. org/10.1093/gastro/gov027 Maple, J. T., Abu Dayyeh, B. K., Chauhan, S. S., Hwang, J. H., Komanduri, S., Manfredi, M., … Banerjee, S. (2015). Endoscopic submucosal dissection. Gastrointestinal Endoscopy, 81(6), 1311–1325. https://doi.org/10.1016/j.gie.2014.12.010 Martin, D., Walayat, S., Ahmed, Z., Dhillon, S., Asche, C. V., Puli, S., & Ren, J. (2016). Impact of bowel preparation type on the quality of colonoscopy: a multicenter community-based study. Journal of Community Hospital Internal Medicine Perspectives, 6(2), 31074. https://doi.org/10.3402/jchimp. v6.31074 Nguyen, D. L., Jamal, M. M., Nguyen, E. T., Puli, S.

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How to Earn Continuing Education Credit R., & Bechtold, M. L. (2016, March 1). Low-residue versus clear liquid diet before colonoscopy: A meta-analysis of randomized, controlled trials. Gastrointestinal Endoscopy. Mosby Inc. https://doi.org/10.1016/j. gie.2015.09.045 Nishizawa, T., & Suzuki, H. (2018). Propofol for gastrointestinal endoscopy. United European Gastroenterology Journal. SAGE Publications Ltd. https://doi.org/10.1177/2050640618767594 Pasha, S. F., Acosta, R., Chandrasekhara, V., Chathadi, K. V., Eloubeidi, M. A., Fanelli, R., … Cash, B. (2014). Routine laboratory testing before endoscopic procedures. Gastrointestinal Endoscopy, 80(1), 28–33. https://doi. org/10.1016/j.gie.2014.01.019 Petersen, B. T., Cohen, J., Hambrick, R. D., Buttar, N., Greenwald, D. A., Buscaglia, J. M., …Eisen, G. (2017). Multisociety guideline on reprocessing flexible GI endoscopes: 2016 update. Gastrointestinal Endoscopy, 85(2), 282-294.e1. https://doi.org/10.1016/j.gie.2016.10.002 Qi, J., & Elson, D. S. (2016). A high definition Mueller polarimetric endoscope for tissue characterisation. Scientific Reports, 6. https://doi. org/10.1038/srep25953 Radaelli, F., Paggi, S., Hassan, C., Senore, C., Fasoli, R., Anderloni, A., …

Repici, A. (2017). Split-dose preparation for colonoscopy increases adenoma detection rate: A randomised controlled trial in an organised screening programme. Gut, 66(2), 270–277. https://doi.org/10.1136/ gutjnl-2015-310685 Rex, D. K., Schoenfeld, P. S., Cohen, J., Pike, I. M., Adler, D. G., Fennerty, M. B., … Weinberg, D. S. (2015). Quality indicators for colonoscopy.

Gastrointestinal Endoscopy, 81(1), 31–53. https://doi.org/10.1016/j. gie.2014.07.058 Saltzman, J. R., Cash, B. D., Pasha, S. F., Early, D. S., Raman Muthusamy, V., Khashab, M. A., … Acosta, R. D. (2015). Bowel preparation before colonoscopy. Gastrointestinal Endoscopy, 81(4), 781–794. https://doi. org/10.1016/j.gie.2014.09.048 Skroska, P. (n.d.). The William Beaumont papers: a life in letters. Missouri Medicine, 111(5), 419–423. Retrieved from http://www.ncbi.nlm.nih.gov/ pubmed/25438364 Society of Gastroenterology Nurses and Associates. (2017) Statement on the use of sedation and analgesia in the gastrointestinal endoscopy setting. Retrieved from https://www.sgna.org/Portals/0/Practice/Sedation/Sedation_FINAL.pdf?ver=2017-10-09-110940-983 Sonnenberg, A. (2016). Sedation in Colonoscopy. Gastroenterology & Hepatology, 12(5), 327–329. Retrieved from http://www.ncbi.nlm.nih. gov/pubmed/27499716 Wang, A., Shaukat, A., Acosta, R. D., Bruining, D. H., Chandrasekhara, V., Chathadi, K. V., … Dewitt, J. M. (2015). Race and ethnicity considerations in GI endoscopy. Gastrointestinal Endoscopy, 82(4), 593–599. https:// doi.org/10.1016/j.gie.2015.06.002 Wang, P., Xu, T., Ngamruengphong, S., Makary, M. A., Kalloo, A., & Hutfless, S. (2018). Rates of infection after colonoscopy and osophagogastroduodenoscopy in ambulatory surgery centres in the USA. Gut, 67(9), 1626–1636. https://doi.org/10.1136/gutjnl-2017-315308

Clinical VignettE ANSWERS 1. Answer: C. Esophagogastroduodenoscopy 2. Answer: A. The esophagus, the stomach, and the proximal duodenum 3. Answer: D. The optical colonoscopy 4. Answer: C. Begin at age 45 WWW.ORTODAY.COM

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By Don Sadler

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hen they hear the term “robotics,” W many people think of sci-fi movies or TV shows set many years in the future. But

robotics are very much a part of the modern day operating room.

In fact, there has been a tremendous surge in robotic-assisted surgery in recent years. It’s estimated that more than 7.2 million robotic surgical procedures were performed worldwide in 2020.

More Frequent Usage “Robotic surgery is definitely being used on a more frequent basis in general surgery, neurosurgery and orthopedics,” says Christopher Gazdick, RN, MSN, NE-BC, administrative director of perioperative services at Hackensack Meridian Health.

“Many of the robotic applications have stemmed from the general surgery arena but other specialty areas have also increased their footprint,” Gazdick adds.

In the U.S., tele-surgical robotic systems are most frequently used in urology, gynecology and general surgery procedures, notes Renae Wright, DNP, RN, CNOR, perioperative practice specialist with the Association of periOperative Registered Nurses (AORN).

“Applications for robotic surgical systems are continuing to expand,” says Wright. “These currently include cardiothoracic and head and neck surgery as well as orthopedic, neurologic and spine surgery.”

Wright says we’re also starting to see some robot-assisted procedures move to the ambulatory surgery side. “This is especially evident in minimally invasive surgery and total joints where robotic systems are gaining traction for elective minimally invasive procedures and hip and knee replacement procedures,” she says.

According to Rice University robotics expert Marcia O’Malley, robotics is also making inroads in new areas. For example, robots are capable of guiding cameras in colonoscopies and endoscopies, implanting electrodes in the brain, performing microsurgeries inside the eye and providing rehabilitation therapy for stroke patients.

“Capsule robots no larger than a pill are now helping diagnose gut diseases and semi-autonomous robots already routinely perform preprogrammed tasks, including taking X-rays,” says O’Malley.

“Improved sensing and control schemes allow rehabilitation robots to detect how stroke patients intend to move their arms and wrists,” she adds. “Using that information, the robots can help direct the patient’s movement, offering the right amount of assistance in every repetition of a therapy session.”

What is Robotic Surgery?

The term robotic surgery often conjures up images of robots in the OR performing surgeries, but this isn’t the case. Surgeons still do the procedures, but they use robotic arms to control miniaturized instruments

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“ Capsule robots no larger than a pill are now helping diagnose gut diseases and semi-autonomous robots already routinely perform preprogrammed tasks, including taking X-rays.” Marcia O’Malley that are inserted into tiny incisions like with other minimally invasive techniques.

Erin Keeney, MSN, RN, CNOR, director of perioperative services at Anmed Health, defines robotic surgery as “minimally invasive surgery where the surgeon has 3DHD vision of the surgical field. It uses wristed instruments that mimic the natural movement of the hand without manipulating the trocar site.”

“Robotic-assisted surgery is a technological advancement in surgery that merges insights, execution and performance,” adds David Taylor, MSN, RN, CNOR, the president of Resolute Advisory Group LLC. “This gives surgeons a less invasive option to open or other minimally invasive types of surgery.”

According to Taylor, robotic surgery combines the benefits of laparoscopic and open techniques by using a minimally invasive approach along with the supplementary benefit of a threedimensional, magnified image. “It also offers surgeons improved ergonomics and dexterity compared to traditional laparoscopy,” he adds.

Wright points out that not all robotic systems are used for what have historically been thought of as a minimally invasive approach – or in other words, surgery through small incisions.

“Some procedures, like total joints, still require larger incisions for exposure,” Wright says. “But the use of the robot allows surgeons to be more accurate with their cuts and remove the minimal amount of bone or tissue needed for an implant or joint prosthesis to fit just right, with minimal disruption to surrounding tissue.”

RALP and the SMART Technique David B. Samadi, MD, the director of urologic oncology at St. Francis Hospital in Long Island, N.Y., was one of the pioneers in performing robotic-assisted 38

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laparoscopic prostatectomy (or RALP) in the U.S. 20 years ago. Since then, he has performed more than 9,000 of these procedures.

Samadi has devised his own custom RALP: the Samadi Modified Advanced Robotic Technique, or SMART. Using this technique, he has achieved a 90 percent patient satisfaction rate with prostate cancer treatment decisions more than a year after surgery.

In addition, 96 percent of Samadi’s patients regain urinary control within two to three months of surgery and 85 percent regain sexual potency within 12 to 24 months of surgery.

“If the surgeon is experienced in robotics, there is no longer any reason not to perform the surgery robotically,” says Samadi. “I believe that the era of open prostate surgery has ended.”

Gazdick says the staff at Hackensack University Medical Center has trained staff to do robotic surgery 24/7. “This was a massive undertaking when it comes to the cost of training and the schedule demands,” he says. “However, it allows for more flexibility when scheduling cases.”

University Medical Center started off with just a couple of robots five years ago but has six robots today. “The volume of the service has grown exponentially and is a driver to the general surgery and urology volume of the organization,” says Gazdick.

“With the advent of particular robotic programs like the Intuitive Iris system and the Zimmer Biomet systems, we are able to overlay or conform the surgery to the actual patient,” Gazdick adds. “This allows for better outcomes and surgeries that are specific to each patient’s condition.”

The surgeons at Anmed Health have embraced robotic surgical technology with ease, says Vangie Dennis, MSN, RN, CNOR, CMLSO, assistant vice president,

perioperative services at Anmed Health.

“The robotic arm has a high degree of dexterity, which allows surgeons to operate in very tight spaces in the body that would otherwise only be accessible with an open surgery,” says Dennis.

“Robotic technology also gives surgeons a better vision of the surgical field, which allows them to access areas within the surgical field that were inaccessible previously,” adds Keeney. “And surgeons aren’t as fatigued.”

Benefits of Robotic Surgery Using robotic-assisted surgery can result in a host of benefits for patients and OR personnel. Patient benefits include: • Shorter surgery times and hospital stays • Reduced pain and discomfort • Faster removal of catheter (as soon as one week after prostate surgery) • Higher rates of regained urinary control and sexual potency after prostate surgery • More comfortable and faster recovery time and return to normal activities • Smaller incisions, resulting in reduced risk of infection and faster healing • Reduced blood loss and need for transfusions • Minimal incision, scarring and trauma “Robotic surgery is better for patients because it decreases length of stay and post-op pain,” says Keeney. “Now we can do procedures as outpatient that would normally require an overnight stay.”

Meanwhile, the benefits of roboticassisted surgery to surgeons and perioperative nurses include: • Improved surgical visualization and interoperative imaging • Greater precision and accuracy WWW.ORTODAY.COM

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•

Enhanced dexterity with tremor reduction • Improved ergonomics • Fewer surgical complications Using smoke evacuation technology during robotic surgery also improves visualization of anatomic structures, says Wright.

“This benefits everyone in the OR by reducing the risk of disease transmission and exposure to the harmful chemicals found in surgical smoke,” she says.

According to Wright, robotic surgical systems vary in the amount of control the surgeon has during the procedure.

“At one end of the spectrum, the robot may be used for preoperative surgical planning or to provide intraoperative navigational guidance while the surgeon operates,” she says.

sizes of the patients,” says Dennis.

Wright also points to communication and teamwork challenges among staff with robotic-assisted surgery.

“Reliance on verbal communication is essential in robotic surgery,” she says.

“This is especially the case with tele-surgical robotic systems where the surgeon works at some distance away from the perioperative team and loses the ability to participate in the nonverbal aspect of communication.”

Distractions and failures in communication have been identified in the literature as contributing factors to medical errors and adverse events, says Wright.

“The AORN Guidelines for a Safe Environment of Care and Team Communication offer recommendations that address barriers to effective communica-

investment in a collaborative approach that the organization commits to it.

“Not just the initial cost of purchasing a robotic system or its annual costs, but the commitment of a team centered around the system and the surgeons who will use it,” says Taylor. “This includes training and education, mentorship and support.”

Gazdick agrees.

“Collaboration and transparency are the keys to success,” he says. “It’s best for everyone to speak openly and honestly and emphasize the good of the program overall versus individual program needs.”

“From a perioperative nursing perspective, success in robotic surgery means keeping patients safe during these procedures,” says Wright. “The perioperative nurse’s role in this ranges from providing

“ From a perioperative nursing perspective, success in robotic surgery means keeping patients safe during these procedures.” Renae Wright, DNP, RN, CNOR

“And some robots are designed to hold items like retractors or cutting guides during the procedure,” Wright adds. “These items may be manipulated by the surgeon or programmed to follow a pre-specified plan.”

At the opposite end of the spectrum are autonomous robots. “With these, the surgeon supervises the execution of an operative plan that is carried out by the robot,” Wright explains.

Challenges and Keys to Success Not surprisingly, surgeons and perioperative nurses usually face challenges when adopting robotic surgery for the first time.

“New staff and surgeons obviously take more time to do a case,” says Gazdick. “This can lead to time overages that impact the schedule or make robotics less useful in comparison to standard laparoscopic surgery.”

Patient positioning is another challenge. “Proper positioning and docking of the robot is definitely an issue because of the different types of procedures and

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tion. These include specific strategies to reduce distractions, noise and interruptions,” says Wright.

Another potential challenge to OR staff that are new to robotics is skepticism about how robotic surgery will be beneficial to patients, clinicians and the organization.

“They may feel unsure of the impact that robotic surgery will have on their workflow and how they care for patients,” says Wright. “Leaders can support staff through this by listening to their concerns and communicating the vision for the robotic surgery program, as well as the benefits the program will bring to the patient community.”

Of course, cost is also an issue with robotic-assisted surgical systems. “The only negative for us would be the cost of the unit,” says Keeney.

“Cost seems to be the major obstacle with the system, and volume increase has not yet made a difference in the delta,” adds Dennis.

Taylor believes the success of a robotic-assisted surgical system lies with the

direct patient care in the OR to having a seat at the table in the boardroom where decisions regarding robotic programs are being made.”

Positioned for Growth Taylor believes that the robotic surgical market is positioned to grow even faster in the coming years.

“Intuitive Surgical’s da Vinci system has been the dominant robotic platform for years in general surgery, but new entrants to the market like TransEnterix’s Senhance system are nibbling at their market share,” says Taylor. “The future is limitless as companies leverage advances in the technology to include those related to bionics, disease discovery and rehabilitation.”

While exciting, Samadi reminds that robotics ultimately are just a tool.

“It’s a piece of equipment,” he says.

“But in the hands of a skilled and experienced surgeon, robotics can result in extremely high levels of patient satisfaction.”

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Spotlight ON

Top photo: Charlie Lin and an ear surgery patient give a thumbs up.

Bottom photo: Charlie Lin and a team of health care professional performed surgeries as part of a medical mission trip. Photo on second page: Charlie Lin lost his mother to breast cancer which inspired him to become a nurse.

harlie Lin has spent the past two years of his health care career as a pediatric otolaryngology nurse practitioner at Stanford Children’s Hospital in Palo Alto, California, and is a clinical assistant professor in the Stanford University Physician Assistant program. Lin is also an adjunct faculty member at the RN First Assistant program at Delaware County Community College in Media, Pennsylvania, and chairs two specialty assemblies within the national Association of periOperative Registered Nurses (AORN), where he made the organization’s Forty Under 40 list.

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Racking up that long list of accomplishments is a considerable achievement for any nurse, let alone one who’s still in his thirties. But what it took Lin to get there, and what he experienced along the way, makes those achievements all the more remarkable.

Lin was born in Taiwan, and grew up in the United States.

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under the care of an aunt and uncle in Plano, Texas, who made it clear to him that at age 18, he would be required to find his own way in the world. At a time when many of his peers were still concerned with the trivialities of youth, Lin needed to dedicate himself to a career path that would allow him to forge his own future.

He settled on nursing because his high school offered the opportunity to participate in clinical rotations and test for his nursing assistant and emergency care assistant certifications. Lin, who planned on attending medical school to become a neonatologist, thought he’d earn a nursing degree while applying to medical school so that he’d have a nursing career to work while he continued his studies.

While many of his friends were working in food service or retail, he was holding down a hospital job as a patient care technician, earning more and working fewer hours to do it.

“It was really funny, but in light of all of it, it was great exposure, a great experience, and I realized I could handle blood, guts and gore,” Lin said of his highschool clinical rotations.

Along the way, life presented him with an additional complication. Throughout his teenaged years, Lin struggled with what his doctors told him was a benign growth on his neck. But it wasn’t until after high school, when his family sent him to Taiwan for a thorough physical evaluation that Lin was diagnosed with thyroid cancer.

The process was overwhelming; when the physicians in Taiwan aspirated Lin’s neck with a needle, they discovered he was facing papillary thyroid cancer, and required a thyroidectomy. Lin opted for a partial removal of his thyroid, but a subsequent examination revealed that he’d need to excise the entire organ. Eighteen hours after the second surgery, he was rushed back to the hospital after his jugular vein opened up.

“I didn’t lose consciousness, so I knew everything that was going on,” Lin said. “I knew more than the average 18-year-old kid, but that didn’t make it any less scary.”

So for the first two years of college, Lin battled symptoms that raged and subsided, underwent repeated radioactive iodine treatments, and waited while his thyroid replacement medication was better regulated.

He leaned on the grants and scholarships he’d earned for college to supplement the costs of his treatments and physician follow-up visits.

As much as any of that, however, he leaned harder on his social circle from high school and church.

“I had a great group of friends,” Lin said. “They were super-supportive.”

Even when his health issues were in the rearview mirror, Lin still faced challenges to his plan of becoming a physician. At the University of Texas-Arlington, the demands and baseline criteria kept him out of nursing school when he first applied. Lin changed majors, angling to become a physician assistant, but then re-thought it, and decided to give nursing another shot. He was accepted into a program at West Texas A&M University in Canyon, Texas, which Lin described as “the middle of nowhere.”

“In hindsight, it could not have been better for me,” he said. “In that WWW.ORTODAY.COM

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small environment, I had more opportunity to focus on my studies than if I’d stayed in Dallas, where a lot of my friends were. That small group made it easier for me to get to know my professors and be able to learn from them. It even helped when I went back for my master’s to become a family nurse practitioner. Five years after graduation, some faculty still remembered me as a student.”

Lin graduated with honors, as class president, and earned a place in the international honor society for nursing. His clinical rotations, in Amarillo, Texas gave him exposure to the kinds of cases that were common in rural areas – like tractor injuries and falls – but less so in urban emergency rooms, and he credits the experience with helping prepare him for dealing with the variety of demands his first assignment as a trauma/ ER nurse presented.

A couple years later, Lin joined a medical mission trip to Haiti as a recovery room nurse, and found his understanding and love of the surgical world deepen so much that he picked up a job at a surgery center. Three months in, when the facility needed someone to step into the OR and be an otolaryngology nurse, he learned to expand his preop and recovery skills to support those assignments — and he did most of it on his own, until he connected with his local AORN chapter.

“I had to learn all the equipment by myself; there was no one to train me,” Lin said. “On the days that I was there, I didn’t have back-up. So, I found an AORN chapter in North Texas, and got hold of some resources there. I got to network with a lot of nurses, and after I joined my local chapter I saw this bigger net.”

Lin’s love for otolaryngology stayed with him when he accepted a position in Connecticut, spending a year and a half as a nurse practitioner and RN first assistant in an academic adult otolaryngology practice. Afterwards, he continued in the otolaryngology field, and began taking on pediatric patients at his current assignment in Palo Alto.

“Now I am able to do certain procedures myself without physician oversight because I’ve demonstrated my competence to do so,” Lin said. “I assist with a lot of ear reconstruction; a lot of pediatric airways, especially tracheostomy for babies. I see a lot of general ENT patients as well as patients with chemosensory dysfunction; I might also see ear reconstruction patients for post-op wound care checks.”

“I have a pretty interesting type of practice at this point,” he said.

“Our tracheostomy families in our hospital have come to know me, and when there’s a problem, they know they can call me because they know I will likely respond more quickly, or they’ll see me in clinic sooner.

Many of the families call me ‘Uncle Charlie.’ I have a great relationship with the family because I see these patients whenever they’re admitted in the hospital or in my clinic.”

When he’s not working, or teaching, or coaching some of his former students, Lin is still involved in medical missions (he’s done more than 20 in all, and will lead another this month), and his church. He enjoys playing volleyball, singing, food adventures, travelling, Broadway plays and volunteering.

“I went into this with the intention of being a provider,” he said. “I want to take care of my patients. All in all, I still get to keep doing what I want to do. Professionally, I don’t think there’s much else but to inspire others to chase their aspirations.”

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Scientists ID Mechanism that May Influence Infectivity of SARSCoV-2 Variants By family features cientists at the National Institutes of Health have found that a process in cells may limit infectivity of SARS-CoV-2, and that mutations in the alpha and delta variants overcome this effect, potentially boosting the virus’s ability to spread. The findings were published online in the Proceedings of the National Academy of Sciences. The study was led by Kelly Ten Hagen, Ph.D., a senior investigator at NIH’s National Institute of Dental and Craniofacial Research (NIDCR).

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PHOTO CAPTION: Creative rendition of SARSCOV-2 virus particles with spike proteins dotting their surfaces. Image not to scale. NIAID

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Since the coronavirus pandemic began in early 2020, several more-infectious variants of SARS-CoV-2, the virus that causes COVID-19, have emerged. The original, or wild-type, virus was followed by the alpha variant, which became widespread in the United States in early 2021, and the delta variant. The variants have acquired mutations that help them spread and infect people more easily. Many of the mutations affect the spike protein, which the virus uses to get into cells. Scientists have been trying to understand how these changes alter the virus’s function.

“Throughout the pandemic, NIDCR researchers have applied their expertise in the oral health sciences to answer key questions about COVID-19,” said NIDCR Director Rena D’Souza, D.D.S., Ph.D. “This study offers fresh insights into the greater infectivity of the alpha and delta variants and provides a framework for the development of future therapies.”

The outer surface of SARS-CoV-2 is decorated with spike proteins, which the virus uses to attach to and enter cells. Before this can happen, though, the spike protein must be activated by a series of cuts, or cleavages, by host proteins, starting with the furin enzyme. In the alpha and delta variants, mutations to the spike protein appear to enhance furin cleavage, which is thought to make the virus more effective at entering cells.

Studies have shown that in some cases protein cleavage can be decreased by the addition of bulky sugar molecules – a process carried out by enzymes called GALNTs – next to the cleavage site.

Ten Hagen’s team wondered if this happens to the SARS-CoV-2 spike protein, and if so, whether it changes the protein’s function.

To find out, the scientists studied the effects of GALNT activity on spike protein in fruit fly and mammalian cells. The experiments showed that one enzyme, GALNT1, adds sugars to wild-type spike protein, and this activity reduces furin cleavage. By contrast, mutations to the spike protein, like those in the alpha and delta variants, decrease GALNT1 activity and increase furin cleavage.

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OUT OF THE OR health

overcome this effect, allowing furin cleavage to go unchecked.

Further experiments supported this idea. The researchers expressed either wild-type or mutated spike in cells grown in a dish. They observed the cells’ tendency to fuse with their neighbors, a behavior that may facilitate spread of the virus during infection. The scientists found that cells expressing mutated spike protein fused with neighbors more often than cells with the wild-type version. Cells with wild-type spike also fused less in the presence of GALNT1, suggesting that its activity may limit spike protein function.

“Our findings indicate that the alpha and delta mutations overcome the dampening effect of GALNT1 activity, which may enhance the virus’s ability to get into cells,” said Ten Hagen.

To see if this process might also occur in people, the team analyzed RNA expression in cells from healthy volunteers. The researchers found wide expression of GALNT1 in lower and upper respiratory tract cells that are susceptible to SARS-CoV-2 infection, indicating that the enzyme could influence infection in humans. The scientists theorized that individual differences in GALNT1 expression could affect viral spread.

“This study suggests that GALNT1 activity may modulate viral infectivity and provides insight into how mutations in the alpha and delta variants may influence this,” Ten Hagen said.

The knowledge could inform future efforts to develop new

interventions.

This research was supported by the NIDCR Division of Intramural Research. Support also came from the intramural program of the National Institute of Environmental Health Sciences.

Disclaimer: This press release describes a basic research finding.

Basic research increases our understanding of human behavior and biology, which is foundational to advancing new and better ways to prevent, diagnose and treat disease. Science is an unpredictable and incremental process – each research advance builds on past discoveries, often in unexpected ways. Most clinical advances would not be possible without the knowledge of fundamental basic research. To learn more about basic research, visit https://www.nih.gov/news-events/basic-research-digitalmedia-kit..

For more information, visit www.nih.gov.

References Zhang L, et al. Furin cleavage of the SARS-CoV-2 spike is modulated by O-glycosylation. PNAS. Published online November 3, 2021. DOI:10.1073/pnas.2109905118 (link is external)

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3 Moves Everyone Should Do More This Year

By Miguel J. Ortiz ne very important thing I learned when going through rehab and physical therapy is that after strengthening and lengthening I had to coordinate my movement with the rest of my body. It was a building process that I was not expecting to be very difficult, but it absolutely required a lot of focus and taught me a great deal about movement.

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When it comes to exercise, it’s great to look good. However, to move well and feel good while doing it is just as, if not more, important when it comes to longevity. In order to do that, we need to maintain our normal exercise routine while also doing exercises that will improve our general movement patterns. The following three total body exercises will challenge your flexibility. They will also improve your core balance, coordination and strength.

The first movement is the gorilla squat (youtu.be/oNxM7zC-iPI). This exercise, right off the bat, will challenge your hamstring, shoulder, hip and lower back flexibility. You want to start the exercise as low as possible.

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a higher position (knees) and then work your way down. Try to bend the knees while driving wide and keeping your arms straight. If possible, maintain a neutral spine on bottom and top. This exercise can easily be used as part of a warm-up routine or slowed down for a yoga pose. It can also be used at the end of a workout to crush your hamstrings. Either way, be sure to add this one to your routine. Do three rounds of 10 reps.

The second movement will challenge your total body core strength and balance. It is the single leg touchdown to balance with a curl and press (youtu.be/JCZW2GuXuTA).

While balancing on one foot, hover the other in the air, perform a single leg squat while reaching your right hand to balancing your left foot. If you cannot reach your foot, start at highest position and work your way down. After coming upright, perform a high knee with a curl then a shoulder press. This movement has many fundamental patterns that will help develop general athleticism. It’s a great warm up before going into a strength phase of training or for improving core strength and joint stability. Do three rounds of 6-8 reps a side. Be sure you can control the weight through every phase of motion.

Lastly, we have a great total body movement that can be done with just body weight or be turned into a solid total body strength exercise. It is a kettlebell goblet hinge to squat (youtu.be/yBaTZNMZc-Q). If done with body weight before starting to exercise place your hands behind your head to focus on scapula retraction and spinal alignment. If done with a kettlebell this exercise will challenge your core and leg strength as well as your hip, knee and ankle mobility. The strength development throughout the legs and core can be helpful as a body weight movement to warm up before leg day. It may also be used as a great strength exercise built into a leg or exercise routine. Either way, it’s a great total body movement you don’t want to omit from your program.

Have fun with these new movements and continue to stay active.

– 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.

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OUT OF THE OR EQ Factor

Making Proactivity a Habit By daniel bobinski, M.Ed. ne book that’s mandatory reading for all my coaching clients is Steven Covey’s “7 Habits of Highly Effective People.” First published in 1989, the book has been translated into 52 languages and has sold more than 25 million copies.

Because its concepts dovetail with the emotional intelligence model, I even made “7 Habits” required reading when I taught management at Idaho State University.

O

Despite the book’s popularity, when people speak with me about their workplace issues, I discover that most people fall into one of three camps: 1. Heard of the book but never read it 2. Read the book but can’t name any habits 3. Read the book, but can name only one or two habits As I stated, the concepts in the book complement the EQ model, so consider this the first installment in a series that outlines the 7 habits. I’m a firm believer that Covey was right: If people habitually do these seven things, they will be more effective.

The first habit identified by Covey is “Be Proactive,” and we should note that he differentiates this from being reactive.

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In simple terms, reactive people wait for problems to occur, then they react to the problems. Proactive people keep an eye out for potential problems and then act to prevent the problems from occurring – or at least minimize their impact.

As an example, a client once had an employee we’ll call Lorinda. Lorinda was knowledgeable, but not much of a team player. She would stand around as problems unfolded, and after the fact she would say, “I could have told you that was going to happen.” Her teammates were often frustrated, wondering why she didn’t speak up ahead of time or do something to prevent or minimize problems before they occurred.

After Lorinda finally quit, Kelly came on board, and the difference was night and day. Kelly paid attention to the projects and tasks of her teammates, and when she had ideas for how to make things more effective or efficient, she openly shared them. Also, when Kelly saw somebody needed a hand, she didn’t wait to be asked.

Everyone saw Kelly’s proactivity as a refreshing spark of energy, and it impacted the entire team for the better.

Bonus: The organization’s productivity went up after Kelly came onboard.

Alternative phrase Some clients tell me the phrase “take initiative” resonates better with them

than “be proactive.” I say memorize whichever phrase works best for you because the outcome is the same: If you see something needs to be done, don’t wait for someone else to do it.

Being proactive/taking initiative is a key attribute for success in the self-management quadrant of the EQ model.

A word of caution, though. Covey is clear to point out that we should take initiative only in areas where we have authority to act – or at least in areas where we have some level of influence.

If we put our efforts and energy in to trying to change things over which we have no control or influence, we are usually just wasting our time.

Daniel Bobinski, M.Ed. is a best-selling 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 him through his website at MyWorkplaceExcellence.com or call his office at 208-375-7606.

January 2022 | OR TODAY

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OUT OF THE OR pinboard nutrition

We All Need Help Sometimes

By Kirsten serrano re you reflecting on your health in the new year and not where you want to be? If so, it may be time to find help.

A

Before you start to look, define your goals. Be careful here because we are programmed to define that goal as weight loss. Weight loss can absolutely happen with a solid nutrition plan and it may be fine to have that as a goal, but the real prize is health. I urge you not to fall for the next weight loss scheme or fad diet.

The goal is to learn skills and gain resources to nourish yourself, not go on and off erratic eating plans chasing a clothing size.

Take the time to really think about your personal goals. Health – what does that mean for you?

When I was very sick, some of my immediate goals were get restful sleep, move without pain, stop my hair loss, have enough energy to enjoy my life and to get my brain back. Those were very specific and motivating goals. Some of my clients’ goals have been to banish daily digestive distress, have the energy to enjoy their hobbies, feel confident about food choices and get rid of 46

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arthritic pain. Really taking the time to define your goals allows you to better evaluate potential help.

Taking the time to find the right kind of help is key. Unfortunately, there is a lot of “wellness industry” junk science and cruddy advice to be had. It can be overwhelming, but great help is out there.

As you sift through your options, look for a person and program that is: • Built upon solid science. This may be the hardest element to evaluate. The “shake in a can” diets are pretty darn easy to see through, but most programs will show you some “science.” Anecdotes and stats can be found to prop up just about anything. My advice is to ask questions. Do a little research.

• Skill-, tool- and resourcebased. You are the one going home and doing all the work. It is fine to be told what you need to do, but you need to build the skills and learn to use available tools and resources to make change possible. Otherwise, what is the point?

• Whole food-based. Any plan

that has you gobbling large amounts of supplements, processed foods, and any other magic shakes and potions is a waste of your time. Nutrition magic is in real foods.

• An education. If you are not being taught why, you are not building a foundation for a lifetime of health. Expect and demand substance.

• Personalized. You need an eating approach that works for YOU. A one-size-fits-all approach does not exist.

• An investment of time in you. Real transformation takes a time investment – on your part and on the part of whomever you choose to work with. Find someone who is accessible and gets to know you.

• Real about food and farm quality. Any approach that does not teach you about food quality is bankrupt. A really good program will also teach you about the realities of farming and food quality.

• About shopping smarter. Sourcing quality, nutrient-dense food is vital to improving your WWW.ORTODAY.COM

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SUBSCRIBE

IT’S FREE Subscribe to OR Today and stay up to date on industry trends, news, webinars and more! health. Find a program that really teaches you how to do that (and stay on a budget).

• Nutrient focused. You don’t have to go into a program expecting to come out of it with a nutrition degree, but you should expect to learn about nutrition, not just calories and macronutrient ratios.

• Honoring your emotions. Mindset and complex feelings are usually a large part of the work. Make sure you are getting someone who can talk through that with you in a way that is respectful and productive.

• About whole-body health. Make sure you are working with someone who can help you maneuver lifestyle as well as food. Food can be the centerpiece of overall health, but you deserve real, transformative help!

Overall, demand substance. Hire someone you can have a real conversation with and that listens to you. Look for a teacher and a guide, not a dictator. Lifelong change only happens when you dig in and commit to learning so find someone who can teach.

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Kirsten Serrano is a nutrition consultant, chef, farmer, food literacy educator and the best-selling author of “Eat to Your Advantage.” You can find out more about her work at SmallWonderFood.com.

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OUT OF THE OR

bacon wrapped haliBut

recipe

INGREDIENTS:

Recipe

• 4 halibut fillets (6 ounces each), skin removed • salt, to taste • pepper, to taste • 8 slices Coleman Natural Bacon • 1 tablespoon canola oil • cooked rice or other grain (optional) • salad or other vegetable (optional)

the

Put Fish on the Family Menu By family features hen meals at home get stale

W and boring, adding some

excitement back to family dinners can be as simple as a protein swap.

Despite fish being a no-go for picky eaters in some families, there’s a flavorful solution for adding it to the menu in your home.

If you’re hoping to introduce kids (or a picky spouse) to fish for an at-home shakeup, try wrapping it with a flavorful favorite.

This Bacon-Wrapped Halibut recipe calls for lightly seasoned fillets wrapped with allnatural bacon served alongside your favorite

Bacon-Wrapped Halibut Servings: 4 1.

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OR TODAY | January 2022

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Season halibut with salt and pepper, to taste, then wrap each fillet along shorter side with two bacon slices, tucking ends underneath to hold in place.

grains and vegetables – an easy yet tasty way to put seafood on the table.

Sourced from American Humane Certified family farmers that raise animals 100% crate-free with no antibiotics or added hormones, the Coleman Natural bacon in this 20-minute dish contains no artificial ingredients or preservatives so you can feel good about feeding your family better. Plus, with no sugar, it’s paleo-friendly and perfect for those looking to reduce sugar intake.

Find more family-friendly recipes at ColemanNatural.com/Recipes.

2.

In large, nonstick skillet, heat oil over medium-high heat. Add fish and cook, turning once, until bacon is crisp, about 5 minutes on each side.

3.

Serve fish with rice or salad.

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January 2022 | OR TODAY

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INDEX

advertisers

ALPHABETICAL AIV Inc.………………………………………………………………… 11

Encompass Group………………………………………………15

Ruhof Corporation…………………………………………… 2,3

ALCO Sales & Service Co.…………………………………21

Healthmark Industries Company, Inc.……………51

SIPS Consults………………………………………………………17

AORN………………………………………………………………… BC

Jet Medical Electronics Inc………………………………15

TBJ Incorporated………………………………………………… 5

ASCA………………………………………………………………… 43

MD Technologies Inc.………………………………………… 4

C Change Surgical………………………………………………13

OR Today Webinar Series……………………………… 22

CATEGORICAL ASSOCIATION

HOSPITAL BEDS/PARTS

SINKS

AORN………………………………………………………………… BC

ALCO Sales & Service Co.…………………………………21

Ruhof Corporation…………………………………………… 2,3

ASCA………………………………………………………………… 43

INFECTION CONTROL

TBJ Incorporated………………………………………………… 5

CARDIAC PRODUCTS

ALCO Sales & Service Co.…………………………………21

STERILIZATION

C Change Surgical………………………………………………13

Encompass Group………………………………………………15

Healthmark Industries Company, Inc.……………51

Jet Medical Electronics Inc………………………………15

Healthmark Industries Company, Inc.……………51

MD Technologies Inc.………………………………………… 4

CARTS/CABINETS

MD Technologies Inc.………………………………………… 4

TBJ Incorporated………………………………………………… 5

Ruhof Corporation…………………………………………… 2,3

SURGICAL

ALCO Sales & Service Co.…………………………………21 Healthmark Industries Company, Inc.……………51 TBJ Incorporated………………………………………………… 5

CS/SPD MD Technologies Inc.………………………………………… 4

SIPS Consults………………………………………………………17 TBJ Incorporated………………………………………………… 5

INSTRUMENT STORAGE/TRANSPORT Ruhof Corporation…………………………………………… 2,3

MD Technologies Inc.………………………………………… 4 SIPS Consults………………………………………………………17

SURGICAL INSTRUMENT/ACCESSORIES C Change Surgical………………………………………………13

Ruhof Corporation…………………………………………… 2,3

ONLINE RESOURCE

Healthmark Industries Company, Inc.……………51

DISINFECTION

OR Today Webinar Series……………………………… 22

TELEMETRY

Ruhof Corporation…………………………………………… 2,3

OTHER

AIV Inc.………………………………………………………………… 11

DISPOSABLES

AIV Inc.………………………………………………………………… 11

TEMPERATURE MANAGEMENT

ALCO Sales & Service Co.…………………………………21

PATIENT MONITORING

C Change Surgical………………………………………………13

ENDOSCOPY

AIV Inc.………………………………………………………………… 11

Encompass Group………………………………………………15

Jet Medical Electronics Inc………………………………15

WASTE MANAGEMENT

MD Technologies Inc.………………………………………… 4

PATIENT WARMING

MD Technologies Inc.………………………………………… 4

Ruhof Corporation…………………………………………… 2,3

Encompass Group………………………………………………15

TBJ Incorporated………………………………………………… 5

FALL PREVENTION

REPAIR SERVICES

ALCO Sales & Service Co.…………………………………21

Jet Medical Electronics Inc………………………………15

Encompass Group………………………………………………15

REPROCESSING STATIONS

FLUID MANAGEMENT

MD Technologies Inc.………………………………………… 4

MD Technologies Inc.………………………………………… 4

Ruhof Corporation…………………………………………… 2,3

GENERAL

TBJ Incorporated………………………………………………… 5

AIV Inc.………………………………………………………………… 11

SAFETY

Healthmark Industries Company, Inc.……………51

Healthmark Industries Company, Inc.……………51

50 OR TODAY | January 2022

2201_ORT-Mag_new.indd 50

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