OR Today Magazine July 2022

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HDO Sterilization

Temperature Management

Kenesha Bradley

Southwest Steaks

AAMI

SPOTLIGHT ON

MARKET ANALYSIS

RECIPE

LIFE IN AND OUT OF THE OR

JULY 2022

NURSES UNITE E N D I N G I N C I V I L I T Y A N D B U L LY I N G PAGE 36

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OR TODAY | July 2022

contents features

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NURSES UNITE: ENDING INCIVILITY AND BULLYING Fifty percent nurses say they have been bullied by a peer while 42% have been bullied by someone at a higher level of authority. Meanwhile, nearly one in four nurses say they have been physically assaulted at work.

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The temperature management market is

The goal of this article is to provide an

Every time we meet someone, an

projected to reach $3.3 billion by 2026.

introduction to firearm and stabbing

Emotional Bank Account is instantly

injuries and how those concepts relate

established. It’s subconscious, but each

to patient care.

action and attitude displayed is interpreted

MARKET ANALYSIS

CE ARTICLE

EQ FACTOR

as either a deposit or a withdrawal.

OR Today (Vol. 22, Issue #7) July 2022 is published monthly by MD Publishing, 1015 Tyrone Rd., Ste. 120, Tyrone, GA 30290.

POSTMASTER: See address changes to OR Today at 1015 Tyrone Rd., Ste. 120, Tyrone, GA 30290.

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 | July 2022

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contents

PUBLISHER

features

John M. Krieg

john@mdpublishing.com

VICE PRESIDENT

40

Kristin Leavoy

kristin@mdpublishing.com

SPOTLIGHT ON Kenesha Bradley

EDITOR John Wallace

editor@mdpublishing.com

$25

ART DEPARTMENT Karlee Gower

Gift C

ard

Taylor Powers Kameryn Johnson

TWEN TY DOLL -FIVE ARS

ACCOUNT EXECUTIVES Jayme McKelvey Megan Cabot

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Win a $25 gift card!

Southwest Steaks with Creamy Peppercorn Sauce and Parmesan Herb Fries

OR TODAY CONTEST

Emily Hise

RECIPE OF THE MONTH

DIGITAL SERVICES Cindy Galindo Kennedy Krieg

EVENTS

INDUSTRY INSIGHTS

Kristin Leavoy

8 News & Notes 16 HSPA: Tips to Boost Sterile Processing Technician Training & Outcomes 18 AAMI: What’s on the Horizon for HDO Sterilization Guidance?

20 ASCA: ASCA Recognizes Physicians for Outstanding Service 22 CCI: The Use of Competency Assessment Instruments in Credentialing

ACCOUNTING Diane Costea

WEBINARS Callie Dixon

EDITORIAL BOARD

IN THE OR

24 M arket Analysis: Reports Indicate Temperature Management Market Growth 25 Product Focus: Temperature Management 28 CE Article: Knife and Gun Injuries

Hank Balch, President & Founder, Beyond Clean Vangie Dennis, MSN, RN, CNOR, CMLSO, Assistant Vice President, Perioperative Services with AnMed Health System

OUT OF THE OR

40 Spotlight On: Kenesha Bradley 42 Fitness 43 EQ Factor 44 Nutrition 45 Health 46 Recipe 49 Pinboard

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INDUSTRY INSIGHTS

news & notes

Ga. Governor Signs Surgical Smoke Legislation Georgia Governor Brian P. Kemp recently signed several bills designed to benefit health care providers and patients in Georgia. The new laws will also strengthen the state’s health care system, according to a news release.

One piece of legislation signed into law by Gov. Kemp is SB 573. The new law requires hospitals and ambulatory surgical centers to adopt policies to protect patients and health care workers from the hazards of surgical smoke.

Gov. Kemp also signed the following legislation on National Nurses Day: • HB 733, which, among other components, requires insurers who cover diagnostic examinations for breast cancer to treat cost-sharing requirements the same as annual mammograms, furthering access to potentially life-saving health exams and increasing the likelihood of early detection for those tested regularly.

• HB 937, which provides for notification to all eligible recipients of insurance coverage for annual mammograms to women over the age of 40.

• HB 1304, which allows patients to appoint a lay caregiver after discharge from a hospital, thereby improving their quality of care and recovery.

• HB 1069, which provides for a new licensure category for adult mental health facilities and programs, further supporting the mental health reforms signed into law earlier this year by expanding access to mental health facilities for adult treatment.

• SB 341, which empowers patients to receive prior authorization for prescribed conditions requiring ongoing medication therapy for up to a year, cutting red tape for those receiving treatment.

• SB 340, which creates a new accreditation organization for residency programs and removes the 50-resident cap on designated teaching hospitals, strengthening and expanding the workforce pipeline for health care workers.

• HB 1041, which raises the cap on income tax credits for contributions to rural hospital organizations to $75 million per year.

“When I ran for governor, I told Georgians I would focus on bringing innovative solutions to our health care challenges – not just expand a one-size-fits-all, broken government program,” Gov. Kemp said. “The bills I have signed into law today further deliver on that promise, building on the efforts we made during the pandemic to confront that once-in-a-century event and its challenges.”

“I want to thank Representative Tyler Paul Smith, Senator Jason Anavitarte, Representative Darlene Taylor, and Senator Sheila McNeil for their work on HB 733, as

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well as the members of the General Assembly who gave this bill overwhelming, bipartisan support. Our daughters, wives, and mothers will now be better equipped to detect and fight breast cancer, so that it does not take even more of them from us,” he added.

“I also want to thank Representative Sharon Henderson and Senator Gloria Butler for sponsoring HB 937 which further encourages women in Georgia to get their annual mammogram examination, a crucial test that leads to better outcomes for patients.

“I want to thank Representative Lee Hawkins, Senator Dean Burke, and the legislators that voted unanimously to pass HB 1304. Caregivers are a vital part of any recovery, and this legislation helps us ensure patients have a reliable partner by their side when they’re on the mend,” he added.

“One of the challenges the pandemic highlighted was the need for a larger, more robust health care workforce,” he continued. “With SB 340 now law, carried by Senator Kay Kirkpatrick and Representative Sharon Cooper and also having received unanimous support from the General Assembly, we are growing the pipeline for that in-demand workforce so that more doctors, nurses, and health care professionals are able to provide quality care to sick or hurt Georgians in the years ahead.”

“With these commonsense policies now in place, Georgia patients will now have both greater access to health care and a higher quality of care when they or a loved one are in need of medical attention. My thanks to all those who helped make this past session historic by implementing measures that will make Georgia a healthier place to live, work and raise our families,” Gov. Kemp concluded.

All of the legislation signed by Gov. Kemp may be accessed online at tinyurl.com/3kjk2kav.

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INDUSTRY INSIGHTS

news & notes

Healthmark Industries Offers Steriking Pouches for Long Medical Devices Healthmark Industries has added Steriking Pouches for Long Medical Devices to its Steriking Sterilization product line.

Manufactured with heat-sealed upper corners that prevent dust from collecting at the opening seal to reduce the risk of contamination when opened, the Steriking Pouches for Long Medical Devices are designed as packing material for sterilization of long devices by steam and are offered in the following sizes: 7.875 x 31.5 inches and 10 x 35.5 inches.

The single-use Steriking Pouches for Long Medical Devices are constructed of heavy weight 100 gsm paper that is heat-sealed together with a multi-ply PET/PE-plastic laminate. Equipped with strong and durable multiline parallel seams that promote a clean peel, the see-through heat-sealable pouches allow double pouching and have thumb notches at each end, which make the filling and opening of a pack easier.

Banner Health Invests in Atlas Healthcare Partners Atlas Healthcare Partners (Atlas), which specializes in developing and managing ambulatory surgery centers (ASCs) in partnerships with health systems and physicians, announced that Banner Health has invested into Atlas.

“Based on the significant growth and success that Banner and Atlas have achieved together through our Banner Surgery Center network joint venture, it was a logical next step for Banner to invest in Atlas to help the company scale and grow into a larger national partner for other health systems as well,” said Scott Nordlund, Banner’s chief strategy and growth officer. “Banner’s decision to invest in Atlas aligns us at the management company level in addition to the regional joint venture and local ASC levels and creates a unique surgery center management company focused on creating strategic partnerships with health systems includ-

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ing ASC network development, investment and operations.”

Atlas formed a joint venture partnership with Banner in 2018 to develop and operate a network of ASCs in Arizona, Colorado and Wyoming. This strategy has resulted in significant growth over the last three years, expanding from eight ASCs to 26, growing volume 155% and growing revenue by 475%. The Banner Atlas joint venture expects to double in size and own and manage over 50 ASCs by the end of 2025.

“We’re excited to expand our partnership with Banner,” said Atlas Healthcare Partners CEO Aric Burke. “Our multi-level partnership with Banner serves as an innovative model for other health systems seeking to develop and implement a fully integrated ASC strategy that aligns all parties; health system, management company, physicians, patients and communities.”

July 2022 | OR TODAY

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INDUSTRY INSIGHTS

news & notes

Medline UNITE Launches 2 Surgical Products Medline UNITE Foot & Ankle has announced the launch of its FDA cleared Calcaneal Fracture Plating System and IM Fibula Implant. The national launch of these two products will provide surgeons with a comprehensive titanium foot and ankle trauma system to address nearly all fractures requiring ORIF with plate and screw fixation.

“Obtaining FDA clearance and launching these new implant systems comes on the heels of several other recent, successful launches, including the UNITE Jones Fracture Screw System, UNITE Distal Tibia Plating System, and SYNDEX with Constrictor Technology Knotless Syndesmosis Implant System,” said Scott Goldstein, director of marketing at Medline UNITE Foot & Ankle.

“Since Medline UNITE was first established in 2013, we have consistently and intentionally developed systems that offer the latest in implant design and technology, along with unique, bespoke instrumentation, and design rationale continuity across all systems. The result is a complete offering of implants that allows surgeons to treat patients and improve outcomes, with greater intraoperative speed and efficiency in the OR.” Created around the philosophy of intelligent design, the Medline UNITE Calcaneal Fracture Plating System enables surgeons to handle a broad array of fracture patterns, surgical approaches and anatomical variations from a single tray. The system is comprised of multiple implant options, including standard, offset, and extension Sinus Tarsi and Perimeter plates, as well as new, large fully threaded 5.5mm and 7.0mm headed cannulated screws. The system

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OR TODAY | July 2022

also comes equipped with a Sinus Tarsi Extension Plate Inserter, allowing for easy plate insertion and positioning through a sinus tarsi incision, enabling percutaneous screw placement in the posterior tuberosity.

The IM Fibula Implant joins the Medline UNITE Distal Tibia System as a standard option. The novel implant provides surgeons with a new option to treat patients with transverse fibula fractures requiring intramedullary fixation, often associated with distal tibia fractures.

“Unlike a traditional screw, the implant features a special tapered diameter designed specifically to fit within the fibula canal, and a dual-lead thread for faster insertion,” said Scott B. Shawen, MD, of Charlotte, N.C. “It’s also available in lengths ranging from 65 – 150mm and comes standard in the tray, so our hospital and OR staff can avoid the excess cost and inefficiency of needing to locate and pull a separate tray with extralong screws, such as a pelvic fracture set.”

“At Medline UNITE, we are guided by our design team, which is comprised of multiple fellowship-trained surgeons who bring with them decades of expertise and invaluable insights into the needs of their peers within the foot and ankle subspecialty,” Goldstein continued.

“Through our collaboration, we have been able to identify crucial unmet needs and have challenged our engineering and product development teams to help advance clinical performance and improve surgical efficiency through intelligent design.”

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IT’S NOT MAGIC, IT’S CARBON. GE Healthcare, Medtronic Announce Collaboration Providing excellent care inside and outside of the traditional hospital is the new normal for patients, clinicians and payers seeking more choices without compromising excellent outcomes. Recently, GE Healthcare and Medtronic announced a collaboration focused on the unique needs and demand for care at ambulatory surgery centers (ASCs) and office-based labs (OBLs). Under this new collaboration, customers can access extensive product portfolios, financial solutions and exceptional service, according to a press release.

“GE Healthcare interventional imaging solutions are built to help our customers deliver care at a higher level for patients.

With a predicted increase in outpatient cardiology and peripheral vascular procedures over the coming years, industry leaders like GE Healthcare need to understand and meet the unique needs of ASCs and OBLs,” said Jim Rapp, vice president of interventional imaging at GE Healthcare. “Our collaboration with Medtronic is one aspect of our efforts to strengthen efficiency, workflow and clinical outcomes for ASCs and OBLs who work with GE Healthcare.”

While patient needs are increasing, there remain high costs and complexity associated with expanding an existing ASC or building a new one. GE Healthcare and Medtronic seek to help ASCs navigate these challenges, bringing the best of each company to deliver high-quality and cost-effective advanced technology, financial solutions and personal service. For GE Healthcare, this includes consultative planning, construction, a comprehensive suite of equipment (including imaging, monitoring and ultrasound) and exceptional service and digital solutions, including the Edison-powered AutoRight A.I.-based interventional imaging chain, which can help clinicians provide the right image at the right dose automatically for each patient.

For Medtronic, this means providing an extensive portfolio of products for a diverse range of service lines in the ASC and OBL, from cardiac rhythm to pain management, peripheral vascular to kyphoplasty. In addition to products, Medtronic will continue to offer the service that customers have come to expect from their field experts as well as reimbursement support, remote solutions and more.

“As our customers open centers outside of the hospital, they are looking for support beyond the devices used in medical procedures,” said Adam King, senior director of U.S. enterprise accounts and ambulatory surgery centers at Medtronic. “From products and devices to equipment and services, we provide a full range of technologies and solutions. Our collaboration with GE Healthcare was formed to better serve the growth of our ASC and OBL customers with extensive technologies and dedicated teams who have expertise in outpatient services and can address all aspects of this evolving sector.”

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July 2022 | OR TODAY

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INDUSTRY INSIGHTS

news & notes

Study: Patient Response to Surgical Disruption Varies Major surgery and critical illness produce a potentially life-threatening systemic inflammatory response, which is counterbalanced by changes in adrenocorticotrophic hormone (ACTH) and cortisol.

The body’s stress response system, known as the hypothalamic-pituitary-adrenal (HPA) axis, controls the production of these hormones as a vital part of patients’ response to surgery, but researchers have found that there is no simple graded HPA response to cardiac surgery.

Research by experts at the Universities of Birmingham and Bristol, published in Royal Society Interface, shows cardiac surgery causes major dynamic changes in concentration of ACTH and cortisol, as well as their pattern of secretion.

Using novel mathematical techniques, researchers developed a model of HPA axis activity that predicts the physiological mechanisms responsible for different patterns of cortisol secretion.

They found that the HPA axis response can be classified into one of three dynamic phenotypes: single-pulse, two-pulse and multiple-pulse dynamics.

Co-author Eder Zavala, from the Centre for Systems Modelling and Quantitative Biomedicine (SMQB) at the University of Birmingham, said, “We’ve found that cardiac surgery patients experience one of three different patterns of HPA axis responses following surgery, which may reflect individual differences in how people respond to this type of stressor.”

“These patterns may reflect underlying physiological differences in each person’s HPA axis, but inflammation caused by surgery also appears to be contributing to changes in at least one of these patterns, the single pulse phenotype, suggesting that patients showing this dynamic could be experiencing the greatest inflammatory response to cardiac surgery.”

Researchers discovered that the different patterns of HPA axis response could reflect different underly-

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ing physiological changes in adrenal sensitivity, cortisol production and turnover.

Co-author Daniel Galvis, centre fellow at SMQB, said, “We now need further studies to investigate whether and how these patterns are correlated with clinical outcomes. This will be critical in establishing whether we can use the patterns to identify and classify post-surgical risk.”

“Our research also shows the existing model used for diagnosis and prognosis after major surgery and critical illness may not be giving us the full picture. Improved diagnostics based on individual responses could lead to a better, personalized diagnosis and targeted interventions.”

Under normal physiological conditions, ACTH and cortisol are in a state of dynamic equilibration which is disrupted by stressors such as surgery and critical illness.

Dr. Ben Gibbison, consultant senior lecturer in cardiac anaesthesia and intensive care at the University of Bristol commented: “What is really interesting about this study is that for many years, we have thought that the rise in the anti-inflammatory hormone cortisol was triggered by the inflammation itself – our work shows that this is only true in certain cases and individuals. What’s fascinating is that we can see who these people are by the pattern of cortisol that they produce.”

Researchers addressed the question of how the inflammatory and HPA axis responses interact by sampling blood from a number of patients during and after coronary artery bypass grafting (CABG) surgery to generate profiles of ACTH, cortisol and inflammatory mediators.

The profiles were analyzed through repurposed computer algorithms originally developed for facial recognition, while the mechanisms underpinning different dynamic phenotypes were investigated through a mathematical model of HPA axis activity.

A video about the research is available at youtube.com/watch?v=h-SUkCbMIZs.

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Nursing Simulation Lab Creates High School Pipeline into Health Care Federal funding of $850,000 will support the operation, purchase and related infrastructure of a high-fidelity multi-patient nursing simulation lab to provide state-of-the-art training and education to nursing students at Bradley University.

This investment will also allow Bradley University to provide nurse simulation training for local high school students at Manual High School and Peoria (Central) High School, which are part of the Peoria Public Schools system. Students will be invited to participate in a targeted early-learning program using the simulation lab. Bradley anticipates inviting 50-75 students from these high schools on an annual basis.

Dean of the College of Education and Health Sciences Jessica Clark, being a first-generation college student, says her first exposure to the health care discipline was as a high school student, which set the tone for her future.

“That first touchpoint ignited my love for health care. Being able to connect the K-12 system to health professions like nursing, and giving them hands-on opportunities to experience it, will allow us to connect area students to this industry and hopefully inspire them to go on to secondary education in these fields,” she said.

Today’s nurses must be trained to react to the increasingly high-pressure clinical challenges in real-time by utilizing the best technology available. This new simulation lab will allow Bradley nursing students to access the use of high-fidelity nursing manikins that will provide medically immersive, life-like simulated medical scenarios in a controlled environment. This technology will help bridge the gap between the skills and content they learn within the classroom and during onsite clinical rotations. Experiential learning has proven to decrease adverse patient events, such as medication errors.

This funding also supports an overall growing nurse shortage in Illinois. According to data provided by the Illinois Department of Financial and Professional Regulators, approximately 27% of Illinois nurses will retire within the next five years. The nursing shortage in Illinois is further complicated by an aging baby boomer population that will require more complicated health care services.

More recently, the stress on health care providers related to COVID-19 is also deterring health professionals from pursuing careers in health care, causing a further shortage in the nursing profession.

As one of Bradley’s top majors, the nursing program has gained a strong state and national reputation for developing workforceready graduates who consistently score above state and national averages for first-time pass rates of the NCLEX-RN. The high-fidelity multi-patient nursing simulation lab will help the Bradley nursing community stay on that track.

Illinois Senator Dick Durbin joined Bradley President Stephen Standifird and other distinguished guests on campus to announce the recent passage of the fiscal year 2022 appropriations bill, including $850,000 that he secured to enhance Bradley’s nursing program.

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INDUSTRY INSIGHTS

news & notes

Collaboration Reduces HO-CDI A new study published in the American Journal of Infection Control (AJIC), suggests that health care facilities can significantly reduce the incidence of hospital-onset Clostridioides difficile infection (HO-CDI) by establishing interprofessional teams to implement selected, evidence-based infection-prevention interventions.

“Our project showed that interprofessional collaboration and continuous improvement can profoundly impact HO-CDI incidence, and sustain reductions over years,” said Cherith Walter, MSN, RN, Emory St. Joseph’s Hospital, and first author on the published study. “We hope our findings will help other health care teams struggling with this incredibly challenging healthcare-associated infection to improve patient safety and reduce associated costs.”

According to the Centers for Disease Control and Prevention, an estimated 500,000 cases of CDI occur in the United States annually, making it one of the most prevalent healthcare-associated infections (HAI) in the country. Because the cost of caring for patients with HO-CDI, as well as financial penalties levied under the Centers for Medicare and Medical Services’ (CMS) hospital-acquired condition reduction program, these infections have increased the financial burden on the health care system.

To address the HO-CDI incidence at a 410-bed community hospital, which was consistently above the national CMS benchmark, Walter and colleagues created an interprofessional team comprising a clinical nurse specialist, a physician champion, a hospital epidemiologist, an infection preventionist, a clinical microbiologist, unit nurse champions, an antimicrobial stewardship pharmacist and an environmental services representative. The team reviewed HO-CDI events at its facility between 2014 and 2016 to determine causative factors, and then identified appropriate, evidence-based infection prevention interventions. The selected interventions comprised diagnostic stewardship, including the development of a diarrhea decision tree (DDT) testing algorithm with a nurse-

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OR TODAY | July 2022

driven ordering protocol; enhanced environmental cleaning; antimicrobial stewardship, including a system-wide electronic medical record intervention to reduce fluoroquinolone use; and education and accountability, the latter of which focused on encouraging compliance with the DDT algorithm.

After the first year, the project leads recorded a 63% decrease in HO-CDIs as compared to the two years prior (4.72 per 10,000 patient days vs. 12 per 10,000 patient days).

This number improved further to 2.8 per 10,000 days three years after implementation of the selected interventions (a 77% decrease from baseline). The team also saw a decrease in the facility’s standardized HO-CDI infection ratio (the total number of infections divided by the National Health Safety Network’s risk-adjusted predicted number of infections), from 1.11 in 2015 to 0.43 in 2020 – significantly lower than the national benchmark.

Interventions also improved CDI testing practices, increasing testing for appropriate patients within the first three days of hospital admission from 54% in 2014 to 81.1% in late 2019, to support prompt treatment of infected patients. This practice also helped identify and differentiate cases of community-acquired CDI (CA-CDI) from HO-CDI, reducing the financial impact of HO-CDIs on the facility after 2016. Finally, by empowering nurses to hold providers accountable for judicious test ordering and creating a system of “accountability notices” alerting nurses and providers to DDT algorithm deviations, the team successfully increased compliance with the algorithm, from 50% in mid-2018 to 80% in mid-2020.

“These study findings are exciting, because they suggest that professional collaboration to consistently apply known, evidence-based practices can significantly reduce the incidence of HO-CDI, an intractable and costly HAI,” said Linda Dickey, RN, MPH, CIC, FAPIC, and 2022 APIC president. “They are also the first findings demonstrating the impact of education and accountability interventions in reducing HO-CDI incidence and improving compliance with standards of practice.”

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INDUSTRY INSIGHTS HSPA

Tips to Boost Sterile Processing Technician Training & Outcomes

By Tony Thurmond, CRCST, CIS, CHL, FCS terile processing (SP) professionals are in high demand these days due to a mix of retirement, transitioning to other career fields and the so called “Great Resignation” that was largely spurred by the pandemic.

It’s an eye-opening development and one that should make every health care organization take notice because of an essential fact: the critically important work that takes place in the sterile processing department (SPD) remains and must be performed by well-trained, qualified and dedicated professionals.

S

Further compounding the challenges is that many organizations are seeing a slow trickle of new hires, many of whom have little or no SP experience. I applaud any SP manager who is willing to hire inexperienced technicians because there are many individuals who want to work and become key contributors to the department; however, the secret to those employees’ (and the department’s) success lies in proper training and adequate time and attention given to various aspects of professional development.

In some SPDs, inexperienced technicians may be paired with more veteran teammates for training. Other departments may instead (and unfortunately) slowly introduce new hires into the fold in the hopes they will eventually learn and adapt to the discipline’s various roles and responsibilities. Still others may introduce new employees to one area within the department but fail to

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complete dedicated training in other areas of the department. None of these approaches to new employee training are ideal. Focused training is necessary to bring employees up to speed and ensure they have the knowledge and skill sets to become productive members of the team and promote quality customer service and patient safety.

A proper training program involves orientation, initial evaluation, probationary period evaluation, competencies, continued education and annual reviews.

Such a program should also include proper documentation at each interval because training without documentation will not provide proof of proper training.

The Association for the Advancement of Medical Instrumentation’s ANSI/AAMI ST79:2017 and 2020 amendments offer guidance for the education and training of SP personnel. What follows are more details about the various aspects of an effective training program.

Orientation: New employee orientation covers all tasks performed in the SP area. This includes an orientation of the department and review of organizational policies and procedures regarding infection prevention, safety, proper attire, personal hygiene and compliance with state and federal regulations. Failure to start training with this type of orientation could result in failure to protect an employee from unsafe conditions or work practices.

I nitial evaluation: An initial evaluation of one’s skills should be performed within the first week of an employee’s start date. If a new

employee is experienced in the role, it will still be important to assess whether techniques are performed to standards and to focus on any areas where further training is needed. A new employee who is inexperienced in SP, on the other hand, should not be expected to be able to demonstrate how to inspect instrumentation or properly run a sterilizer load. The initial evaluation will allow the leader or educator to document a starting point and allow for the development of a training program to familiarize the new employee with departmental and facility processes. robationary period evaluation: With P any orientation period, there is a probationary period where the new employee received adequate time to demonstrate they are learning the processes and retaining the information. The new technician should not immediately be expected to perform on his or her own or be independent in all tasks. During the probation period evaluation, however, the tasks they are capable of doing well should be documented along with the tasks that will require further training or more experience. Proper and thorough documentation is required and must be filed with the employee’s training records. ompetencies: Competencies are C documented records that demonstrate skills and knowledge; some competencies are required in order to comply with federal regulations or

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INDUSTRY INSIGHTS HSPA

accreditation agency requirements.

Individual competencies are designed to be renewed periodically to assure knowledge (with the intent of reducing or preventing errors). They may also be used to document whether training was successful and to track performance and growth. Competencies can be evaluated by demonstration, written assessment, verbal interview and observation, both announced and unannounced. ontinuing education: SPDs must C provide educational opportunities to staff for continued growth and development. Mandatory education (such as bloodborne pathogens and fire safety) must be completed promptly and updates to regulations and stan-

dards must be delivered as soon as an update is released. Other continuing education opportunities could involve new equipment or instrumentation and their instructions for use (IFU). nnual reviews: Skills attained during A the employee’s training period will be reflected in their evaluation. Did the employee complete their education in a timely manner? Were there tasks that were successful in competencies, but errors that still occurred during the period of evaluation? Annual reviews can be opportunities to identify areas for improvement, but it is recommended that improvement areas be identified and addressed as they happen instead of just during the annual review.

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Conclusion The ever-evolving SP profession provides many training and educational opportunities, and SP leaders must be open to advancements, new information and new methods for increasing technicians’ knowledge and professional growth. These leaders (or dedicated SP educators) must develop comprehensive training and education for their staff members and help prepare their teams for any challenges that may arise. The SPD’s interdisciplinary colleagues and patients will benefit greatly by this commitment to quality training and professionalism.

– Tony Thurmond, CRCST, CIS, CHL, FCS, serves as central service manager for Dayton Children’s Hospital. He is an HSPA pastpresident and currently serves on HSPA’s board of directors.

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July 2022 | OR TODAY

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INDUSTRY INSIGHTS AAMI

What’s on the Horizon for HDO Sterilization Guidance? n this special AAMI Update, the co-chairs of WG 40, the Steam Sterilization Hospital Practices Working Group, describe what the working group has in store for sterile processing professionals and clinicians alike. Co-chair Sara Friedberg is a senior microbiology manager at Stryker, while co-chair Susan G. Klacik, is clinical educator for HSPA.

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Continuous Growth of ST79 A widely recognized standard, ANSI/AAMI ST79, Comprehensive guide to steam sterilization and sterility assurance in health care facilities is used by healthcare delivery organizations (HDOs) for the processing of reusable medical devices. Its content includes processing area design and personnel considerations; handling of contaminated items; cleaning, disinfection, and decontamination steps for soiled items; and packaging and sterilization. It also covers installation and maintenance of sterilizers, process monitoring, quality process improvement and new product evaluation.

ST79 was last updated and revised in 2017. At AAMI Sterilization Standards Week in 2018, the committee met to discuss the revised standard and determine whether any additional changes

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were needed at that time. This led to four new amendments that were added in 2020 in the areas of (1) environmental services, fans, food, and drink; (2) inspection of insulated instruments; (3) modification of content pertaining to frequency of cleaning for routine care of sterilizers; (4) and content about recording biological indicator lot numbers in sterilizer records for sterile processing in HDOs. ST79 is up for full review within the next year. At that point, the standard likely will be fully opened for comments and updates, including the topics that were previously tabled for the next update.

The most notable changes to be reviewed pertain to terminology, water quality, point-of-use-treatment, inspection, and drying. Common issues that have been brought up as a result of research and user feedback may be addressed; these include special techniques for processing ophthalmic instruments, additional packaging considerations, and cleaning equipment.

AAMI TIR79: Guidance on Complying with ST79 In addition to ST79, WG 40 also oversees the AAMI technical information report TIR79, ST79 Selfassessment for health care facilities.

This TIR provides a checklist of specific recommendations contained

in ST79 that HDOs can use to assess and monitor their compliance with the standard, in order to aid in preparing for an accrediting audit.

An update will be made to TIR79 in the near future in order to align it with the four amendments made to ST79 in 2020.

AAMI TIR109 to Address External Transport of Devices WG 40 also recently initiated a project to develop AAMI TIR109, External transport of medical devices processed by health care facilities. This is a much-needed document for the industry. Historically, medical devices to be processed at HDOs were transported from the point of use to the sterile processing department (SPD). This typically involved moving the devices on a cart or in a container through the halls of the HDO, potentially on an elevator, and into the SPD. As HDOs have expanded and begun centralizing operations, this activity can now include transporting devices across a campus to another building, across town to a separate building, or even over a highway several towns away.

This increased transport distance brings up new concerns and issues that are not already addressed in the transport section of ST79. The goal of this new TIR is to introduce best practice guidance for transport-

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INDUSTRY INSIGHTS AAMI

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Nitrile Exam Gloves, Non-Sterile, 5 mil, Blue ing clean, disinfected, sterilized, and soiled devices across longer distances, including addressing requirements for the transport vehicles used to transport the devices. For regular updates about this developing technical information report, check aami.org.

Processing Dental Instruments The guidance in ST79 is focused extensively on medical device processing in HDO settings. Of important note, roughly 80% of dentists practice in small outpatient clinics, and as a result, ST79 has not been widely embraced by the dental profession. AAMI has established a new Working Group, ST-WG 44 (Steam Sterilization Dental Practices) to develop a guidance document for the processing of dental instruments based on the best practices in ST79.

The development of this document will involve a collaboration between AAMI and the American Dental Association (ADA) Standards Committee on Dental Products. WG 44 met for the first time in September 2021 to begin work on this new standard. Members of WG 40 have joined WG 44 in order to provide input on developing the new standard and to ensure that the requirements do not deviate from those detailed in ST79.

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INDUSTRY INSIGHTS ASCA

ASCA Recognizes Physicians for Outstanding Service

By Bill Prentice uring ASCA’s annual conference in Dallas this year, the association recognized two physicians with its 2022 Nap Gary Award for Lifetime Achievement in the ASC Community: Thomas M. Deas Jr., MD, and Peter Daly, MD. Both men exemplify the long-standing dedication to the ASC community, leadership qualities and high moral and ethical standards the award was created to recognize. Each also contributed in unique ways to advancing the ASC care model.

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Deas, a former member of ASCA’s Board of Directors, is board certified in internal medicine and gastroenterology. The list of leadership positions he has held and his accomplishments during his career is long, so I will mention only a few highlights here. In 1991, after a 20-year career in the U.S. Air Force, Deas retired as colonel and began his gastroenterology medical practice in Fort Worth, Texas.

He served as medical director of the Fort Worth Endoscopy Center between 1994 and 2012 and the Southwest Fort Worth Endoscopy Center between 2002 and 2012.

He also served as medical director and president of North Texas Specialty Physicians during many of

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Thomas M. Deas Jr, MD those same years and as president of the American Society for Gastrointestinal Endoscopy from 2012 to 2013. Since 1994, Deas has been an outspoken advocate for the high-quality, cost-efficient care that ASCs provide. He has also been involved in several innovative programs designed to maximize the many benefits ASCs offer. He continues to work part-time as a physician development coach at the TCU School of Medicine.

As he accepted the award, Deas noted that receiving it was a huge honor and receiving it for doing something he loved so much made it an even greater honor. In a nod to the achievements of Daly, Deas talked about how something lifechanging happened to him when he

participated in a medical mission trip with ASCA and Daly’s One World Surgery program in Honduras. He advised everyone, “Let something happen to you.”

Daly is an orthopedic surgeon with Summit Orthopedics in Eagan, Minnesota, and specializes in shoulder, hip and knee conditions.

He and his wife, Lulu, opened the Holy Family Surgery Center in Honduras in 2008 and began organizing four to five medical mission trips to the facility each year. In 2017, they combined with Surgical Care Affiliates Medical Missions to create One World Surgery, where Daly continues to serve as chief medical officer. Recently, One World Surgery opened a second center in the Dominican Republic.

That program builds on the success of the original center in Honduras, bringing life-changing care to an underserved population in a second country. The ASCA Foundation offers a scholarship program for ASCA members interested in medical mission opportunities through One World Surgery in both locations.

Lulu Daly, who is also a pediatric nurse, accompanied Daly as he accepted the award. After acknowledging the important contributions she made in establishing both surgery centers, he thanked her and ASCA for their support.

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INDUSTRY INSIGHTS ASCA

First presented in 2016, the Nap Gary Award recognizes individuals who have made outstanding lifetime contributions to the ASC community. It recognizes longstanding and unwavering dedication to ambulatory surgery as well as qualities like integrity, mentorship, leadership, loyalty, and high ethical and moral standards that the individual has demonstrated over time.

Beall D. “Nap” Gary Jr. proposed the award while serving as past president of the ASCA and ASCA Foundation Boards of Directors. As he was preparing to take part in ASCA’s annual meeting in 2015, he suffered a fatal heart attack on his weekly earlymorning, 13-mile run at his home in White Hall, Virginia. The other board members who served with him elected to name the award in his honor.

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Peter Daly, MD The recognition of these two physicians for their outstanding service and commitment to ASCs was just one part of ASCA’s April conference that attracted nearly

2,000 people from the ASC community to Dallas for three full days of educational sessions and an expansive exhibit hall. In-person networking opportunities included an ASC Celebration Luncheon and a Friday night social event at the Glass Cactus nightclub overlooking Grapevine Lake. After two years of virtual events, attendees were enthusiastic about being together again at the live conference.

ASCA’s next annual conference will be in downtown Louisville, Kentucky, May 17-20, 2023. I hope to see you there.

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

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INDUSTRY INSIGHTS CCI

Use of Competency Assessment Instruments in Credentialing

By James X. Stobinski egarding nursing competency Mika Fukada tells us that, “Competence is an ability acquired through experience and learning.”

(2018, p.1) and that competence is a prerequisite for competency. Fukada describes nursing competency, “… as a complex integration of knowledge including professional judgment, skills, values and attitude …” (2018, p. 1). She also states that competency is a behavioral characteristic which can be measured. Fukada’s statement on measuring competency intersects well with one section of the influential Future of Nursing Report from 2010 (IOM) which speaks to the need for a framework of lifelong learning.

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While Fukada maintains that competency can be measured the use of competency assessment instruments is not common in American nursing practice and the devices are not well-integrated into licensure and credentialing practices. The use of skills checklists, or competencies (used here as a noun), are far more common. The assumption here being that if the skill can be successfully performed that the individual possesses competency. For those who ascribe to a holistic definition of competency, as does Fukada, this

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assumption that the repetition of a skill equates to competency appears flawed and incomplete.

The argument can be made that the measurement of the complex concept of competency could guide lifelong learning. There is an opportunity for those willing to initiate the use of these assessment instruments. But, as Machiavelli so clearly points out, “… there is nothing more difficult to take in hand, more perilous to conduct, or more uncertain in its success, than to take the lead in the introduction of a new order of things.”

(2020). A long-standing assumption in American nursing is that competency is measured when one passes the licensure examination. Competency is then somehow assumed to continue throughout a career unless evidence of some egregious error presents (Tilley).

The use of competency assessment instruments would be disruptive to well-established current systems.

Valid competency assessment instruments have the potential to enhance professional development by identifying areas for improvement. Instruments do exist for the assessment of general nursing competency; the Nurse Competence Scale (NCS) developed by Meretoja being one salient example (2004). The NCS has been used with perioperative nurses but is not specific to the specialty.

The Competency and Creden-

tialing Institute (CCI) has begun the early use of true competency assessment in its certification and recertification processes. A valid and reliable instrument for the selfassessment of perioperative nursing competency does exist, the Perceived Perioperative Competence Scale-Revised (PPCS-R) developed by Gillespie and colleagues.

(Jaensson, 2018). This instrument has been validated for use with American nurses by CCI and is one of the four components of the CFPN credential. The results of a self-assessment using the PPCS-R assists perioperative nurses early in their career to chart their professional development course (Kinlaw, 2021).

CCI plans to begin using the PPCS-R in its recertification programs for other CCI credentials in 2022. Many licensure and credentialing programs default to the very familiar use of Continuing Education (CE) in their programs.

The assumption being that CE will enhance competency. But, the link between CE and competency is not well-supported by research evidence. CCI believes that competency assessment instruments have great potential to enhance perioperative nursing competency if a supporting framework can be fashioned. CCI is accustomed to taking measured risks and in being an early adaptor of new methods. In the future you will see further efforts by

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INDUSTRY INSIGHTS CCI

CCI to integrate the use of specialty-specific competency assessment instruments into the certification and recertification processes. This reconceptualization of competency assessment may well be disruptive in the short term, but we believe the risk is worth taking.

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

References •

Fukada, M. (2018). Nursing Competency: Definition, Structure and Develop-

•

• •

•

ment. Yonaga Acta Medica. 61(1): 1–7. doi: 10.33160/yam.2018.03.001.

Good Reads (2020). Niccolò Machiavelli > Quotes > Quotable Quote. Accessed November 27, 2020 at: https:// www.goodreads.com/quotes/274551it-ought-to-be-remembered-thatthere-is-nothing-more.

Inspirational Stories (2020).

Institute of Medicine. (2010). The future of nursing: Leading change, advancing health. Retrieved from: http:// books.nap.edu/openbook.php?record_ id=12956&page=R1 Jaensson, M., Falk-Brynhildsen, K., Gillespie, B.M., Wallentin, F.Y., Nilsson, U. (2018). Psychometric validation of the Perceived Perioperative Competence Scale-Revised in the Swedish

•

•

•

context. Journal of PeriAnesthesia Nursing, 33(4), 499-511. http://dx.doi. org/10.1016/j.jopan.2016.09.012 Kinlaw, TS, Stobinski, JX, Irvin, SA, Rosenfield, L & Dunn, D. (2021). Professional development in perioperative nursing begins with the certified foundational perioperative nurse (CFPN) credential. Perioperative Care and Operating Room Management. doi. org/10.1016/j.pcorm.2021.100239 Meretoja R, Isoaho H, Leino-Kilpi H. (2004). Nurse competency scale: Development and psychometric testing.

J Adv Nurs. 47(2):124-133.

Tilley S. (2008). Competency in nursing: a concept analysis. Journal of Continuing Education in Nursing, 39(2):58‐64

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IN THE OR

market analysis

Reports Indicate Temperature Management Market Growth Staff report he temperature management market is projected to reach $3.3 billion by 2026 from $2.7 billion in 2021, according to MarketsandMarkets.

This indicates a compound annual growth rate (CAGR) of 3.6% during the forecast period.

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“Factors such as increasing global incidence of chronic conditions and the subsequent increase in the number of surgical procedures,” are expected to fuel growth according to the MarketsandMarkets report. “The growing number of contracts and agreements between market players is also expected to offer a wide range of growth opportunities for market players during the forecast period. However, the high cost of intravascular temperature management systems is restraining the growth of this market.”

MarketsandMarkets goes on to discuss the impacts of the COVID-19 pandemic on the market.

“The COVID-19 has resulted in significant disruption to business and economic activity globally and is expected to show short-term impacts on the temperature management product business,” the report states. “Temperature management products for perioperative care are expected to be impacted to some 24

OR TODAY | July 2022

extent due to the postponement of elective surgeries caused by COVID-19, as governments and authorities seek to ensure the availability of resources for COVID-19 patients. In an effort to reduce the strain on the health care system, decrease disease transmission, and conserve personal protective equipment (PPE), various governments have provided guidelines on elective surgeries.”

“Globally, there has been an increase in the incidence of chronic conditions, such as strokes, cardiac arrests, and neurological diseases such as traumatic brain injury,” the report adds. “Several research studies indicate that survivors of cardiac arrests can suffer from devastating neurological impairments. Temperature management devices are widely used in the prevention of neurological damage after cardiac arrests. The use of mild therapeutic hypothermia is considered to improve neurological outcomes after cardiopulmonary resuscitation. Thus, the increasing incidence of chronic diseases is expected to drive the demand for temperature management systems.”

Grand View Research also predicts growth in the temperature management market.

“The global patient temperature management market size was valued at $3.2 billion in 2021 and is expected to expand at compounded annual growth rate

(CAGR) of 8.8% from 2022 to 2030.

Increasing volume of surgical procedures is one of the significant factors impacting growth of the patient temperature management market,” the report states.

A new market study published by Global Industry Analysts Inc., a market research company, recently released its report titled “Temperature Management Systems – Global Market Trajectory & Analytics.” The report predicts that the global temperature management systems market will reach $3.3 billion by 2026.

The demand for temperature management systems is fueled by an increasing number of surgical procedures and availability of advanced products like battery-powered and standalone devices for temperature management, according to the Global Industry Analysts Inc. report.

“The U.S. market is also augmented by increasing geriatric population along with rising cases of neurological disorders and cardiac arrests in the region. Growth in the Asia-Pacific region is attributed to increasing adoption of advanced medical treatments.

The regional market is anticipated to gain from the sheer size of patient population, increasing number of surgical interventions and rising health consciousness,” according to Global Industry Analysts Inc. WWW.ORTODAY.COM

IN THE OR

product focus

Augustine Surgical Inc.

HotDog Patient Warming System The newest (air-free) HotDog Patient Warming System is so advanced it’s almost magic. The HotDog Temperature Management Controller smartly manages the system’s patented conductive fabric technology that warms above and below the patient to improve normothermia outcomes. Air-free warming enhances patient and staff safety. The Normothermia Partnership Plan overcomes capital constraints and reduces warming costs. Trendelenburg patients are kept warm and secure with WaffleGrip the integrated securement technology that optimizes surgical efficiency and safety. Contact the normothermia experts at Augustine Surgical Inc. for a free demo. It’s never been more important to go air-free.

For more information, visit hotdogwarming.com.

CenTrak Automated Temperature Monitoring CenTrak’s Automated Temperature Monitoring solution offers a reliable, cost-effective way to measure conditions of refrigerators and freezers (-200 C to +125 C) to ensure the safe use of blood products, tissue and other critical items. Real-time alerts and customizable escalation chains enable staff to take immediate action when conditions fall outside of safe parameters. The solution offers graphs and report views, enabling facilities to eliminate manual data collection, analyze data and generate compliance reports. Differential air pressure monitoring may be added to the same system. A single CenTrak customer has measured savings of 10,000 labor hours by automating their temperature monitoring.

For more information, visit centrak.com.

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July 2022 | OR TODAY

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IN THE OR

product focus

Attune Medical ensoETM

Attune Medical’s ensoETM modulates and controls patient temperature through a single-use silicone tube inserted into the esophagus, similar to a standard gastric tube, and connected to an external heat exchange unit. Positioned in the esophagus, next to the heart and great vessels, water circulates inside the closed-loop system to efficiently warm or cool a patient. Unlike surface devices, the ensoETM’s internal placement won’t impede patient access during procedures in the OR, ER, ICU or electrophysiology lab for various temperature management applications. The ensoETM works with existing heat exchangers and is the only device cleared for use in the esophagus for patient temperature modulation.

MAC Medical

Blanket & Fluid Warming Cabinets MAC Medical Inc. is a industry leader when it comes to medical equipment. The highest quality of materials and craftsmanship is used to manufacture all of its products, including the technologically advanced Blanket & Fluid Warming Cabinets. With two styles of warming cabinets to choose from, the D-Series (Data Logging – Data is recorded every 30 minutes and stored for up to two years) and TS-Series (Touch Screen – Ethernet/Wi-Fi capable with remote connectivity) are available in many sizes. MAC Medical is confident in its manufacturing process and offers a “Built to Last” warranty with all its products.

For more information, visit macmedical.com.

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OR TODAY | July 2022

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IN THE OR

product focus

Encompass

Nova Patient Warming Blanket Nova Next-Generation Patient Warming System provides safe, consistent and effective heat to warm patients without air movement, reducing the potential for infection risks associated with forced air. With no moving parts, the Nova System emits no additional noise or heat into the OR environment. Each Nova blanket is easy to apply and to connect to support maintaining the position on the patient. The control unit is intuitive and simple to use, supporting two blankets per patient or potentially two patients while in prep or in post-op. Nova works both passively and actively to support the patient through the entire operative journey; patients arrive in the OR warm and stay warm.

For more information, visit www.encompassgroup.com

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July 2022 | OR TODAY

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CE570 CE710

IN THE OR

continuing education

Knife and Gun Injuries enetrating trauma involves wounding instruments that penetrate the skin and directly injure body tissue. Although there are numerous examples of penetrating trauma — such as a child falling on a pencil that penetrates the globe of the eye or a piece of shrapnel from an explosive device tearing through a limb — two obvious causes of penetrating trauma are firearm wounds and stabbings. This module discusses the mechanism of injury involved in firearm injuries and stab wounds. The healthcare providers should have a baseline understanding of the mechanisms of injury surrounding this form of trauma.

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The goal of this educational program is to provide nurses in acute care settings with an introduction to the biomechanical concepts of firearm and stabbing injuries and an explanation of how those concepts relate to the care of the patient with penetrating trauma.

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Types of Trauma Trauma is divided into two main categories: blunt and penetrating. Blunt trauma is caused by blunt forces external to the body. These blunt forces transmit energy through body tissues.

Examples include motor vehicle collisions, falls, and sporting injuries.

In contrast, penetrating trauma is caused by wounding instruments that penetrate the skin and directly injure body tissue. Penetrating trauma can take many forms and may be accidental or intentional. It may be the result of a mishap with an everyday object or a violent act with a weapon.

Firearms and knives, or other sharp objects, can cause very serious penetrating injuries.

Gun violence is considered by many experts to be a public health crisis, and injury and death related to firearms continues to rise. Deaths attributed to guns increased 20% worldwide between 1990 and 2016 with more than half of those deaths occurring in the U.S. (DynaMed, 2018). One study found that every seven minutes someone is brought to a hospital in the U.S. for a gun-related injury (DiMaggio et al., 2017). This represents a 4% total increase and

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

Goal and Objectives After taking this course, you should be able to: • Calculate the kinetic energy of a moving mass.

• List at least three factors that affect the severity of firearm injuries.

• Describe common injuries associated with stab wounds to the trunk.

• Discuss nursing care for penetrating trauma wounds.

30% increase among children less than 5 years of age.

Overview Injuries related to firearms are the second-leading cause of traumatic death in the U.S., second only to motor vehicle crashes (Tasigiorgos et al., 2015). Even more patients survive

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IN THE OR

continuing education firearm injuries. While close to 90 people die every day from firearms, an additional 160 nonfatal injuries are treated in hospitals around the U.S. Often the visible wounds on a patient with a firearm injury do not reflect internal and less visible damage done by the bullet to underlying structures. If a practitioner has a base knowledge of firearms and ballistics, it may make it easier to anticipate the types of injuries that cannot be seen.

Some factors that may help predict injury patterns and severity of injury when caring for the victim of a firearm injury include: • The type of firearm used • The distance from the firearm to the target • The type of projectile fired from the firearm • The type of tissue through which the projectile passed • The trajectory of the projectile through the body Firearms can be divided into several major categories. Handguns, as the name implies, are small, light, and easy to conceal. For that reason, they are a popular choice for both personal protection and criminal activity in the U.S. Examples of handguns include revolvers and pistols.

Another classification of firearms is long guns, such as rifles and shotguns.

Long guns tend to inflict greater injury than handguns simply because of the length of the barrel. If the barrel of the firearm is longer, the bullet moves faster through the air after it leaves the barrel. With shorter-barreled firearms, such as pistols and revolvers, the projectile has less speed moving forward (Klatt, n.d.). Shotgun injuries can differ from those caused by handguns and rifles when shot ammunition is used (DynaMed, 2018). With greater distance from the intended target, spread of shot pellets is increased; with shorter distance, lethality from this ammunition is greater.

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Distance to the Target Once the projectile leaves the barrel of the gun, there are no influences propelling it forward. In fact, at that point, the atmosphere, gravity, and friction will slow the projectile down.

Gravity will also pull it toward the ground. The farther the projectile must travel between the barrel of the gun and the target, the slower it will go (Holzner, 2011; Klatt, n.d.).

These factors are important to consider because tissue injury is partially related to the velocity of the bullet as it hits the body. Tissue injury is related to the amount of energy exerted on the body. To determine the amount of kinetic energy, one must take the mass of the object involved, half it and then multiply it by the velocity that the object is moving (squared) (Klatt, n.d.; Powers & Delo, 2013):

Kinetic energy = ½ mass × velocity2 As this equation aptly demonstrates, velocity is a major factor in determining the energy and ultimately the wounding potential of a projectile. Knowing the type of firearm used as well as the distance the target was from the wounding instrument can help to predict the types and severity of injuries the patient may sustain.

The Type of Projectile The kinetic energy formula introduced in the previous section familiarized you with the two components that may contribute to energy transfer between objects. The first was velocity, affected by the type of firearm used as well as the distance between the firearm and the target. The second part of the formula involves mass. The heavier an object is, the more kinetic energy it tends to transfer. Therefore, knowing the type of projectile that struck a patient

in a firearm-related injury may help you better anticipate the injuries the patient may have.

A way that bullets are differentiated is by their size. A .22-caliber bullet (this may also be called a “22-gauge”) is a different size than a .45-caliber bullet. The caliber refers to the diameter of the bullet in inches; therefore, a .22-caliber bullet is 22/100 inches in diameter and a .45-caliber bullet is 45/100 of an inch in diameter (Klatt, n.d.; Powers & Delo, 2013). Since mass is part of the kinetic energy formula, the size of the bullet will influence tissue damage, with larger bullets tending to inflict greater damage.

The design of the bullet will also influence its wounding potential.

Softer metals, such as lead, will travel farther and will maintain a higher speed over longer distances. However, soft metals will easily deform when they strike an object and may not penetrate. Heavier metals, such as copper, are less likely to deform but will slow down faster in the friction of the atmosphere. To compensate for this, some bullets are made of softer metals and then coated with a heavier metal. This combination reduces the weight of the bullet so it travels faster, but the tough outer coating minimizes its deformation on contact.

This is called a “full metal jacket.” The tough outer layer allows it to keep its shape as it travels through tissue, and the bullet may pass right through the body (Klatt, n.d.).

Other bullets, sometimes called hollow points or soft points, may not have a heavy metal jacket around the entire outside, and the leading edge of the bullet will be a softer, lighter metal. When these bullets strike the body, the leading edge flattens out, and as the bullet goes through tissue, the larger, flattened leading edge will increase the surface area and significantly increase the tissue damage.

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continuing education This large, flat leading edge will also slow down more quickly in tissue, causing more energy to be transferred from the moving object to the body than a full metal jacket (Klatt, n.d.).

The Type of Tissue As a projectile enters a person’s body, two types of injuries occur. The first is crush injuries directly caused by the path of the projectile through the body. This is referred to as the permanent cavity (Powers & Delo, 2013). The larger the projectile, the larger the permanent cavity will be.

A .45-caliber projectile, for example, will leave a much larger permanent cavity than a .22-caliber projectile.

Similarly, a hollow-point projectile whose leading edge flattens out will have a large diameter leading surface tearing through the body, creating a much larger permanent cavity (Peitzman et al., 2013).

Because of the speed of the projectile, tissue around the permanent cavity will be forced away from the projectile, creating a temporary cavity. The tissue in the temporary cavity is forced away from the moving projectile and essentially suffers the effects of blunt trauma.

Although the tissue in the temporary cavity will generally return to its original state within milliseconds after passage of the projectile, the damage in the structures affected by the momentarily enlarged temporary cavity can be extensive. The size of the temporary cavity can be as much as 10 times the caliber of the bullet (Klatt, n.d.). The stretching can rupture blood vessels, leading to secondary edema and blood loss.

Injury patterns are affected to some extent by the type of tissue that is involved. Highly elastic tissue, such as skeletal muscle and lung, may be deformed by the temporary cavity; however, these tissues are de-

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signed to stretch, at least to a certain degree, and there may be minimal injury to them. Near-water-density tissues, such as the brain, liver, and spleen, are not designed to stretch, and the temporary cavitation may cause significant damage or even cause them to break apart. Similarly, fluid-filled organs, such as the heart, bladder, and intestine, are not designed to stretch and sustain greater damage or may even rupture if the temporary cavity is large enough.

All tissue directly crushed by the projectile will be nonviable and will die regardless of the type of tissue (Klatt, n.d.; Peitzman et al., 2013)

The Path Through the Body Multiple other factors can affect the wounding potential of a projectile.

One is the stability of the bullet. If the bullet enters the body straight on, the size of the permanent cavity will be the same as its diameter. If, however, the projectile wobbles or tumbles before or after it hits the body, it will create a much larger permanent cavity. If, for example, the projectile ends up going through the body sideways (at a 90-degree angle) instead of with its pointed end forward, the amount of resulting crushed tissue can be three times greater (Powers & Delo, 2013).

Another factor that can alter tissue injury significantly is the fragmentation of the projectile. Softer metals are more likely to break apart, especially if they strike bone.

The smaller pieces may continue to move throughout the body, resulting in multiple projectiles instead of a single projectile, each creating its own cavity of destruction (Peitzman et al., 2013).

Stab Wounds Although gunshot wounds and stab wounds are both considered pene-

trating trauma, the injuries are very different. The velocity of a projectile in a firearm injury is responsible for much of the tissue damage that is imparted. In stab wounds, the velocity of the penetrating object (e.g., a knife or screwdriver) is usually much less; therefore, tissue damage may be less. But the surface area of some stabbing instruments, such as a large butcher knife, may be much greater than a firearm projectile, leading to increased size of wounds, both on the surface and in underlying structures.

• Factors to consider when caring for the patient with a stab wound include: • The anatomic area involved • The depth of penetration • The blade length • The angle of penetration Stab wounds to the abdominal area can be deceiving. One-third of these wounds do not even violate the peritoneum, leaving the vital organs and blood vessels intact. A further one-third do penetrate the peritoneum but do not affect the abdominal viscera. When the abdominal viscera is affected, the most common structures to be injured include the small bowel, liver, stomach, colon, and vascular structures (Cox, 2011).

Stab wounds are more common in the upper abdomen than the lower abdomen. Structures at risk in upper abdominal stab wounds include the liver, gall bladder, stomach, duodenum, pancreas, spleen, small/large bowel, omentum, aorta, inferior vena cava, portal vein, and mesenteric arteries. Stab wounds in the lower abdomen more often affect the small/large bowel, bladder, uterus, aorta, inferior vena cava, mesenteric vessels, and the femoral/ external iliac vessels (Corneille et al., 2008). Stab wounds to the abdomen are often not as serious initially as

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continuing education they are days or weeks later. If the stab wound involves disruption of a large blood vessel, the bleeding can be immediately serious. If it involves the underlying viscera, the symptoms of peritonitis and sepsis may be delayed (Corneille et al., 2008; Cox, 2011).

Stab wounds to the left chest are the most fatal because of the location of the heart and great vessels.

Interestingly, victims of stab wounds involving the ventricles are more likely to survive for a longer time than those with stab wounds to the atria because the muscular contraction of the ventricles provides a temporary protective effect (Corneille et al., 2008). Other organs in the chest that can be affected by a stabbing instrument include the lungs, bronchi, diaphragm, and mediastinal structures. Stab wounds to the lungs often have positive outcomes provided the victim receives prompt emergency treatment. The more peripheral the stab wound is to the center of the chest, the less likely it will affect major blood vessels, and the less fatal the wound tends to be. Indications of lung involvement include hemoptysis, subcutaneous emphysema, and signs of a pneumothorax or hemothorax.

When caring for the patient with stab wounds to the trunk, remember that the diaphragm, which separates the abdomen from the thorax, is mobile. During exhalation, the diaphragm may elevate as high as the nipple line, but during inhalation, the diaphragm may extend to the lower rib cage. Therefore, stab wounds of the upper abdomen and lower chest should be evaluated for both abdominal and thoracic involvement. Generally, wounds below the fourth intercostal space on the anterior chest wall and below the scapular tip on the posterior chest wall should be worked up for posWWW.ORTODAY.COM

sible abdominal involvement (Cox, 2011).

Retroperitoneal organs, such as the kidneys, ureters, pancreas, and duodenum, can be injured in up to 40% of stab wounds in the flank or back. It can be difficult to assess for damage to these structures.

Therefore, diagnostic tests such as triple-contrast CT, local wound exploration, ultrasound, and diagnostic peritoneal lavage/laparoscopy may be carried out. Stab wounds to the back also raise the concern of spinal cord involvement, although this is rare because of the thick bony protection of the vertebrae. If the spinal cord is affected, the most common regions are the cervical and thoracic areas. This is because, if the person is stabbed from behind and he or she is bending forward at the time, the vertebrae in these areas separate further, providing greater exposure of the underlying spinal column (Corneille et al., 2008).

Although stab wounds to the neck are rare, they have a higher frequency of being fatal than stab wounds to other parts of the body.

This is because structures such as large blood vessels, the trachea, and the larynx are all close to one another and are only 1/2 to 1 inch below the skin surface. Death is caused frequently by exsanguination, air emboli, or asphyxia due to aspiration of blood (Corneille et al., 2008).

If stab wounds to the neck are deep, the spinal cord can also be affected (Savall et al., 2015).

Isolated stab wounds to the extremities are rarely life-threatening unless catastrophic hemorrhage occurs secondary to disrupted arteries. But extremity stab wounds can have long-term consequences for future functioning of the limb, including lacerations of nerves, tendons, and muscles. Compartment syndrome secondary to intrafascial bleeding is also a potential complication.

The Depth of Penetration and Blade Length One factor that can make assessment of the stab wound challenging is that the external wound does not always equate to the underlying damage. If a screwdriver is used as a wounding instrument, the surface wound may be very small. But if the screwdriver is pushed deep into the body, this seemingly small wound may inflict fatal damage to underlying structures, such as blood vessels and organs. Most stab wounds are deeper than they are wide at the surface.

The depth of a stab wound may be greater than the length of the stabbing instrument when the body surface “dents” from the thrust of the wounding instrument as it is pushed into the body. It is also important to note that because of the elasticity of skin, the shape and width of the wounding instrument does not always match the shape of the visible wound. The wound may be as much as 2-mm smaller than the instrument that caused the wound (Forensic Medicine for Medical Students [FMMS], n.d.).

The Angle of Penetration When caring for a stab wound, remember that the surface trauma may not represent the underlying trauma.

The assailant in a stabbing incident may insert the wounding instrument and then move it around, or the victim may move while the wounding instrument is in the body. In this case, the surface wound will be no larger than the wounding instrument, but the surface area of the underlying trauma may be significantly larger.

Generally, stab wounds to the back are delivered in a downward motion and stab wounds to the front are delivered in an upward motion.

Stab wounds delivered in a downward motion, also known as an “overarm”

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continuing education assault (in which the knife is held in the ulnar aspect of the hand) tend to enter the body at a greater speed and cause deeper and more damage than stab wounds caused by an upward motion, also known as an “underarm” assault (in which the knife is held in the radial aspect of the hand) (Gilchrist et al., 2008).

Assessment and Management A thorough patient and/or witness interview can provide valuable information about the nature of the patient’s injuries. In the case of firearm injuries, ask the patient or any witnesses to the incident how many shots were heard (DynaMed, 2018). If possible, ascertain specifics regarding the type of weapon and ammunition involved in the injury. The distance and position of the patient relative to the shooter are also important, as are the number and location of any known wounds and any treatment that was rendered. Depending on the situation, law enforcement or EMS may provide these details.

If it has not been completed by EMS, the patient’s clothing should be removed to assess injuries. (DynaMed, 2018). Highest priority should be given to injuries located on the head, neck, chest, and abdomen as these present the greatest risk to the life of the patient. Note that for unstable patients with penetrating gunshot or stab wound injuries, immediate surgical treatment may be required as guided by Focused Assessment with Sonography in Trauma (FAST) imaging (DynaMed, 2018a).

Next, perform a primary survey based on the Advanced Trauma Life Support® (ATLS®) algorithm, starting with securing the patient’s airway and assisting ventilations if necessary.

Chest movement should be evaluated for paradoxical motion and lungs auscultated for abnormal, decreased, or absent breath sounds (Kostiuk & 32

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Burns, 2020). Any external bleeding should be managed and intravenous (IV) access initiated (DynaMed, 2018). Crystalloid boluses or blood product transfusions should be administered if indicated for hypotension related to blood loss. If the patient has signs of pneumothorax due to penetrating chest wall injury, it should be addressed at this time by a physician or other Licensed Independent Practitioner (LIP) with thoracostomy (chest tube) placement.

Nursing care includes setting up chest tube drainage systems and documenting output.

A secondary survey is performed after the requirements of the primary survey have been addressed and includes a head-to-toe exam to determine and/or confirm the number and location of all wounds (DynaMed, 2018). It is during and after this assessment that imaging should be performed to attain additional information about internal injuries. Imaging studies can also highlight bullet trajectory and help localize any bullets or bullet fragments still inside the body. Plain films (X-rays) are best suited for this, but CT may be ordered if the patient is stable. Ultrasound using Focused Assessment with Sonography in Trauma (FAST) may also be used. FAST has gained popularity in recent years due to its portability and lack of ionizing radiation exposure for the patient and can be used to detect peritoneal fluid, pneumo- and hemothorax, and hemopericardium. Lab tests often ordered in penetrating trauma cases include complete blood count (CBC), chemistry, blood type and crossmatch, and blood gases (DynaMed, 2018).

Medications Depending on where they work, nurses may administer sedatives and paralytics to assist with establishment of an advanced airway (DynaMed,

2018). Pain control is important, especially in cases of penetrating chest trauma when pain may interfere with effective respirations and clearance of secretions (Jain & Burns, 2020).

Short-acting narcotic analgesics (e.g., fentanyl [Sublimaze] and morphine [Duramorph®]) are typically ordered (DynaMed, 2018; Jain & Burns, 2020). Broad spectrum IV antibiotics (usually ampicillin/sulbactam [Unasyn®], piperacillin/tazobactam [Zosyn®], or Cefotetan [Cefotan®]) are given in the case of abdominal injuries with peritoneal penetration and tetanus vaccines should be updated if indicated (DynaMed, 2018).

Reporting All gunshot wounds and most stab wounds are reportable conditions under federal and state laws (Smallwood, 2020). Gunshot injuries that are intentionally inflicted or injuries obtained during illegal acts such as robberies, must be reported to law enforcement authorities. Gunshot injuries that are considered unintentional must also be reported. Additionally, injuries caused by sharp instruments, like knives, must be reported if they were intentionally inflicted, whether or not they were other- or self-inflicted. Specifics regarding how to report incidents varies by state. Refer to your state’s laws and your institution’s protocols when reporting firearm or stabbing injuries or other criminal activity, such as sexual assault, abuse, and neglect.

Because many penetrating injuries are the result of violence, clinicians must apply the principles of forensics during care. Treat the patient and anything on the patient as a potential crime scene. Be familiar with evidence collection and help law enforcement carry out justice by carefully preserving evidence and documenting meticulously.

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continuing education Summary Now that you have finished viewing the course content, you should have learned the following: • How to calculate the kinetic energy of a moving mass.

• At least three factors that affect the severity of firearm injuries.

• Common injuries associated with stab wounds to the trunk.

• Nursing care for penetrating trauma wounds.

Penetrating trauma from gunshot and stab wounds cause serious and often life-threatening injuries. Knowledge of the physical forces involved in generating these injuries and familiarity with guidelines for patient care and incident reporting will enable you to provide optimal care for your patients.

Course Contributor The content for this course was revised by Carrie Furberg, BSN, RN, CRN. Carrie Furberg, BSN, RN, CRN, has over ten years’ experience in radiology nursing, in vascular and interventional radiology as well as all imaging modalities. She is a Certified Radiology Nurse with clinical expertise in procedural sedation, cardiac CT, and radiation safety, and prior experience in critical care, cardiac stepdown, and emergency care.

She is a member of the Association for Radiologic and Imaging Nursing (ARIN) and RAD-AID International.

Editor’s note: Jeff Solheim, MSN, RN, CEN, TCRN, CFRN, FAEN was the previous author of this educational activity but has not influenced the content of the current version of this course.

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Clinical Vignette Dispatch calls a local trauma unit to indicate that two ambulances are en route, each transporting a patient with gunshot wounds. Ambulance 1 is transporting a law enforcement officer struck in the groin by a .22-caliber full metal jacket bullet fired from a small handgun during a firefight at a robbery scene. The bullet struck the muscles of the upper leg. The second ambulance is carrying the alleged perpetrator, who has three gunshot wounds: two to the anterior chest and one to the central abdominal area. Bullet 1 entered the right lung, bullet 2 struck the right ventricle, and bullet 3 struck the liver. The alleged perpetrator was shot by pistols firing .45-caliber hollow point bullets.

1. Based on the information given, which statement is most accurate?

A. Both patients are likely to have exit wounds.

B. Neither patient is likely to have an exit wound.

C. The alleged perpetrator is more likely to have exit wounds than the law enforcement officer.

D. The law enforcement officer is more likely to have an exit wound than the alleged perpetrator.

Feedback: A heavier metal around a full metal jacket causes it to retain its shape and velocity as it passes through body tissue; therefore, exit wounds are more common with full metal jackets than hollow-point projectiles.

Hollow-point projectiles deform when they hit the body, and this slows them down or even causes deformation; therefore, they are less likely to cause an exit wound.

2. Of the four wounds described, which one was most likely to cause the area it struck to break apart?

A. Bullet 1, which struck the alleged perpetrator in the right lung B. Bullet 2, which struck the alleged perpetrator in the right ventricle C. Bullet 3, which struck the alleged perpetrator in the liver D. The bullet that struck the law enforce-

ment officer in the muscles of the leg Feedback: The temporary cavity caused by a bullet moving through water-dense tissue, such as the liver, spleen, or brain, may cause them to break apart. Muscle tissue and lung tissue are elastic rather than water-dense and are less likely to “break apart.” The heart is a hollow organ and is less susceptible to “breaking apart.”

3. Of the four wounds, which one was most likely to cause the area it struck to rupture?

A. Bullet 1, which struck the alleged perpetrator in the right lung B. Bullet 2, which struck the alleged perpetrator in the right ventricle C. Bullet 3, which struck the alleged perpetrator in the liver D. The bullet that struck the law enforcement officer in the muscles of the leg Feedback: The temporary cavity caused by the bullet moving through a hollow organ, such as the heart, bowel, or stomach, may cause them to rupture. Muscle tissue and lung tissue are elastic rather than hollow and will not rupture.

The liver is a dense organ that may sustain significant damage but will not rupture.

4. If the four bullets in this scenario remain on a straight trajectory through body tissue, which one is MOST likely to cause the smallest permanent cavity?

A. Bullet 1, which struck the alleged perpetrator in the right lung B. Bullet 2, which struck the alleged perpetrator in the right ventricle C. Bullet 3, which struck the alleged perpetrator in the liver D. The bullet that struck the law enforcement officer in the muscles of the leg Feedback: The larger the caliber of the bullet, the larger its diameter. The permanent cavity is caused by crushing of tissue as the bullet moves through tissue; therefore, if all the bullets stayed on a straight trajectory, the smallest bullet (the .22 caliber bullet) would create the smallest permanent cavity. A .45-caliber bullet is larger and will produce a larger permanent cavity.

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continuing education References 1.

Corneille, M. G., Lopez, P. P., Cohn, S. M. (2008) Abdominal trauma. In: Irwin, R. S., & Rippe, J. M. (Eds.), Irwin & Rippe’s Intensive Care Medicine (6th ed., p. 1919). Lippincott Williams & Wilkins.

2.

Cox, W. A. (2011). Sharp-edged and pointed instrument injuries. Forensic Medicine with Dr. Cox. http://forensicmd.files.wordpress.com/2011/07/ sharp-edged-and-pointed-instrument-injuries1.pdf

3.

DiMaggio, C. J., Avraham, J. B., Lee, D. C., Frangos, S. G., & Wall, S. P. (2017). The epidemiology of emergency department trauma discharges in the United States. Academic Emergency Medicine, 24(10), 1244-1256. https://doi.org/10.1111/acem.13223

4.

DynaMed. (2018). Gunshot Wounds - Emergency Management (Record No. T902781). EBSCO Information Services.

5.

DynaMed. (2018a). Penetrating Thoracic Trauma in Adults (Record No. T921446). EBSCO Information Services.

6.

Forensic Medicine for Medical Students (n.d.). Characteristics of stab wounds. Retrieved June 3, 2020 from http://www.forensicmed.co.uk/ wounds/sharp-force-trauma/stab-wounds/

7.

Gilchrist, M. D., Keenan, S., Curtis, M., Cassidy, M., Byrne, G., & Destrade, M. (2008). Measuring knife stab penetration into skin simulant using a novel biaxial tension device. Forensic science international, 177(1), 52-65. https:// doi.org/10.1016/j.forsciint.2007.10.010

8.

Holzner, S. (2011). Physics I for Dummies (2nd ed.). John Wiley & Sons, Inc.

9.

Jain, A., & Burns, B. (2020). StatPearls: Penetrating Chest Trauma. U.S. National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/ NBK535444/

10.

Klatt, E. C. (n.d.). Firearms tutorial. University of Utah Spencer S. Eccles Health Sciences Library. Retrieved June 3, 2020 from http://library.med. utah.edu/WebPath/TUTORIAL/GUNS/GUNINTRO.html

11.

Kostiuk, M., & Burns, B. (2020). StatPearls: Trauma Assessment. U.S. National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/ NBK555913/

12.

Peitzman, A. B., Schwab, C. W., Yealy, D. M., Rhodes, M., Fabian, T. C. (Eds.).

(2013). The Trauma Manual: Trauma and Acute Care Surgery (4th ed.). Lippincott Williams & Wilkins.

13.

Powers, D. B., & Delo, R. I. (2013). Characteristics of ballistic and blast injuries. Atlas of the oral and maxillofacial surgery clinics of North America, 21(1), 15-24. http://dx.doi.org/10.1016/j.cxom.2012.12.001

14.

Savall, F., Dedouit, F., Mokrane, F. Z., Rougé, D., Saint-Martin, P., & Telmon, N. (2015). An unusual homicidal stab wound of the cervical spinal cord: A single case examined by post-mortem computed tomography angiography (PMCTA). Forensic Science International, 254, e18-e21. https://doi. org/10.1016/j.forsciint.2015.06.025

15.

Smallwood, R. (2020). REL-ACU-0-REAMR21: Regulation express: Mandatory reporting [Relias module].

16.

Tasigiorgos, S., Economopoulos, K. P., Winfield, R. D., & Sakran, J. V. (2015).

Firearm injury in the United States: An overview of an evolving public health problem. Journal of the American College of Surgeons, 221(6), 1005-1014. doi: https://doi.org/10.1016/j.jamcollsurg.2015.08.430

Clinical VignettE ANSWERS 1. Answer: D, The law enforcement officer is more likely to have an exit wound than the alleged perpetrator. 2. Answer: C, Bullet 3, which struck the alleged perpetrator in the liver.

3. Answer: B, Bullet 2, which struck the alleged perpetrator in the right ventricle. 4. Answer: D, The bullet that struck the law enforcement officer in the muscles of the leg.

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CE710

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Deadline Courses must be completed by 6/30/2023 3. If the course you have chosen to take includes a clinical vignette, you will be asked to review the vignette and answer 3 or 4 questions. You must answer all questions correctly to proceed. If you answer a question incorrectly, we will provide a clue to the correct answer.

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COVER STORY

NURSES UNITE E N D I N G I N C I V I L I T Y A N D B U L LY I N G

By DON SADLER

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ew would disagree that society has seen growing F levels of incivility and bullying in recent years.

Unfortunately, this incivility has spread to many workplaces, including hospital operating rooms.

In fact, the health care industry experiences some of the highest levels of bullying across all industry sectors. Up to half of all nurses say they have been bullied in some manner in the workplace, according to the American Nurses Association (ANA).

Fifty percent of nurses say they have been bullied by a peer while 42% have been bullied by someone at a higher level of authority, according to ANA. Meanwhile, nearly one in four nurses (25 %) say they have been physically assaulted at work and one in 10 (10 %) say they are concerned about their physical safety at work.

A Dangerous Problem “Incivility in health care has been investigated by researchers and we know it is a problem among nurses in a variety of settings, including the perioperative environment,” says Erin Kyle, DNP, RN, CNOR, NEA-BC, editor in chief, Guidelines for Perioperative Practice for the Association of peri-Operative Registered Nurses (AORN).

“Incivility and bullying in the operating room is a common but dangerous problem,” adds Ruth P. Shumaker, BSN, RN, CNOR, executive director, perioperative services, Regional One Health. She cites an AORN Journal article which notes that 88% of nurses have witnessed physician incivility and 48% of physicians have witnessed nurse incivility.

While serving on the 2021 Task Force for Civility in the Workforce, Shumaker and her colleagues conducted a comprehensive review of the literature.

“Unfortunately, this revealed that incivility is widespread in nursing,” she says.

“While mistreatment in nursing was mentioned in the literature as early as 1980, it really started to surface in the early 2000s and has steadily increased since then.”

Deborah L. Spratt, MPA, BSN, RN, CNOR, CHL, independent perioperative consultant, says that bullying behavior can be physical, emotional, sexual, social, verbal or racial.

“When I first started in the OR almost 50 years ago, I would have attributed the behavior to the perceived difference in status of the various team members,” Spratt says.

“Back in those days, surgeons were held in much higher esteem than other perioperative team members and bad behavior was allowed because they were the money makers,” says Spratt. “To some extent this attitude continues, but there is also now a nurse-to-nurse component, as well as nurses to other team members.”

Based on her literature review, Maria Sullivan, MSN, MMHC, RN, CNOR, says that more than seven out of 10 nurses have experienced incivility.

“The problem of incivility began mainly with perioperative team members, but it has now extended to patients also being uncivil,” Sullivan says.

“Right now, older nurses are retiring and younger nurses are leaving the bedside in droves. New nurses with a healthy self-esteem may just decide to go into another line of work.”

- Deborah L. Spratt

Defining Incivility and Bullying The ANA defines incivility as “one or more rude, discourteous or disrespectful actions that may or may not have a negative intent behind them.” And it defines bullying as “repeated, unwanted harmful actions intended to humiliate, offend and cause distress in the recipient.”

Incivility is often a precursor to bullying. It can take many different forms, some of them subtle: Gossiping and rumor spreading • Eye-rolling and name-calling WWW.ORTODAY.COM

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COVER STORY • • • •

Using a condescending tone Public criticism Refusing to help a coworker Withholding information and sabotage • Social exclusion • Hostile, snide and rude remarks • Passive-aggressive behavior • Scapegoating and backstabbing • Failure to respect privacy Bullying takes incivility to the next level with actions such as: • Hostile remarks • Verbal attacks and threats • Taunts and intimidation • Withholding of support • Harmful actions intended to intimidate • Workplace “mobbing” Kyle says that she has personally witnessed the consequences of incivility and bullying in the OR. “These memories are some of the most vivid from early in my career,” she says. “On the other hand, I have also witnessed civil behaviors that can turn the situation around. The individuals who took the initiative to stop the patterns of incivility made all the difference in those moments.”

“During the span of my nursing career, I have witnessed and/or experienced verbal, and on a more intense level what verged on the threat of physical, harm,” says Shumaker. “Overt aggression, bullying and abusive behaviors are often purposely intended.”

Other personal observations of incivility in the perioperative environment Shumaker has witnessed include shouting, intimating body language, talking down to others, making demeaning remarks and not listening. “I have also observed abuse and misuse of power by leaders and supervisors,” she says.

Spratt tells of a Primary Service Nurse who was known for keeping an instrument in her locker that was always needed for a particular case so that when no one was able to find it, she did and looked like a hero. “I have also seen a scrub nurse send the circulator out of the room for an item later recognized to be on the back table,” she says.

“And once, many years ago, I saw a 38

OR TODAY | July 2022

surgeon throw a knife in frustration,” says Spratt. “That never happened again.”

iar with, causing more stress, burnout and problems with coworkers.”

What Causes Incivility?

Consequences of Incivility

There are many different possible causes of incivility and bullying in the OR. “It could just be the way someone’s day started,” says Sullivan. “Maybe they snapped at the person who came in to help them get their case ready, and that person feels hurt and decides not to bring in the tray that’s in the sterilizer.

This can have a ripple effect and lead to compromises in patient care.”

Kyle cites issues that are common in the perioperative environment as potentially triggering incivility such as high stress, a hierarchical structure and a culture that tolerates incivility.

It’s not surprising that incivility and bullying can have serious consequences on the well-being of health care workers and patients. “Incivility is probably the biggest threat to patient safety in the operating room today,” says Kyle. “This is because perioperative team members who do not feel secure and supported in the practice environment are not able to practice at their best.”

Sullivan also worries about the effects of incivility and bullying on patient safety.

“If you are working with a surgeon or anesthesia team member who has been less than kind to you in the past, you might be reluctant to stop the line and speak up for patient safety,” she says.

“There are also the psychological effects on nurses who have been bullied by other team members,” Sullivan adds.

According to Kyle, perioperative team members who are subjected to incivility and bullying in the workplace report a wide range of physical, psychological and behavioral disturbances including: • Insomnia, dizziness and fatigue • Irritable bowel syndrome • Abdominal and back pain • Hypertension and headaches • Loss of appetite and self-confidence • Rage, aggression and irritability • Anxiety and panic attacks • Depression and PTSD • Inability to relax • Suicidal ideation “In a 2018 study, researchers found that the suicide rate among nurses, especially female nurses, is significantly higher than the general population,” says Kyle.

“I think it would be foolish to ignore the connection between the psychological consequences of incivility and the high rate of suicide among nurses.”

Spratt says that incivility and bullying can increase the risk of “never events” like wrong patient/wrong site surgery, retained foreign bodies, and specimen and medication errors.

“Nurses who are bullied are also more likely to leave the profession,” says Spratt.

“Right now, older nurses are retiring and

“It starts with leadership laying the foundation for the type of workplace they want to foster and then holding all team members accountable for behavior that does not meet that expectation.”

- Maria Sullivan “I believe you can’t change people’s basic personalities,” says Spratt. “Once a bully, always a bully, and you find bullies in all professions. There’s also the stress of time pressure in the OR where time means money, so its push, push to get cases done and start the next case.”

“Incivility in the OR may be caused by a shortage of experienced personnel, extreme work demands, high patient acuity, a lack of teamwork and a lack of respect for coworkers,” says Shumaker. “Also, the pandemic exposed nurses to conditions they weren’t famil-

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younger nurses are leaving the bedside in droves. New nurses with a healthy self-esteem may just decide to go into another line of work.”

Supporting Civility The topic of incivility in the OR is so important that AORN has partnered with the American Association of Nurse Anesthesiology (AANA) and the American Society of PeriAnesthesia Nurses (ASPAN) to create a position statement on workplace incivility.

“Every perioperative team should be aware of the position statement and integrate it into their practice,” says Kyle.

The position statement clarifies that it’s the responsibility of employers and all health care professionals to create an environment that’s free of distracting, disruptive or violent behavior. It also clarifies the difference between incivility and bullying.

Incivility is addressed by transforming culture, according to the position statement, while bullying is commonly addressed in workplace policy and the code of conduct. “The mission, values and code of conduct of a health care setting should address the importance of a healthy work culture,” says the statement.

“Everyone has a role in workplace civility,” says Kyle, who lists a number of steps that can be taken to improve civility in the perioperative environment. Those steps are: • Conduct a full workplace assessment of conflict and disruptive behaviors to inform a workplace violence prevention program as recommended by OSHA. • Make cultivating and maintaining a culture of safety a priority at all levels of the organization by adopting a zero-tolerance policy and providing employee support to address uncivil and bullying experiences.

• Use an interdisciplinary approach when leading teams through education and implementation of workplace civility programs.

“Multidisciplinary team training is a great place to start,” says Spratt.

“Team training in a casual setting, using round tables and with assigned projects, is a great way to break the ice between team members who may not even know each other’s names.”

Some universities are now putting medical and nursing students in the same classes so they can learn to work together right from the beginning, adds Spratt.

“Also be willing to stand up for yourself and your colleagues,” says Spratt. “Don’t participate in the behavior and don’t hesitate to report up the chain of command. If you can’t handle a situation, call for help.

That’s what leadership is there for: to provide an atmosphere that lets you do your job in a safe manner.”

Sullivan concurs.

“It starts with leadership laying the foundation for the type of workplace they want to foster and then holding all team members accountable for behavior that does not meet that expectation,” Sullivan says.

“Leaders are integral in establishing a respectful and positive workplace culture,” adds Shumaker. “Health care institutions must provide a system where employees can report incivility and bullying without fear of retaliation.”

Sullivan sums it up best.

“Be kind and give grace,” she says. “And don’t accept bullying behaviors.

Alert management if they occur so they can be resolved quickly.”

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“Incivility is probably the biggest threat to patient safety in the operating room today. This is because perioperative team members who do not feel secure and supported in the practice environment are not able to practice at their best.”

- Erin Kyle

LIST OF STEPS THAT CAN BE TAKEN TO IMPROVE CIVILITY IN THE PERIOPERATIVE ENVIRONMENT: • Conduct a full workplace assessment of conflict and disruptive behaviors to inform a workplace violence prevention program as recommended by OSHA. • Make cultivating and maintaining a culture of safety a priority at all levels of the organization by adopting a zero-tolerance policy and providing employee support to address uncivil and bullying experiences.

• Use an interdisciplinary approach when leading teams through education and implementation of workplace civility programs.

July 2022 | OR TODAY

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SPOTLIGHT ON

Kenesha

BRADLEY s the director of high reliability and patient safety at Ochsner Medical Center in New Orleans, Louisiana, it’s Kenesha Bradley’s job to know the ins and outs of her department, from the perspectives of patients and clinical staff, the better to drive favorable outcomes for each within the health system. Bradley works to promote evidence-based practices and to evaluate current processes as well as efforts undertaken to improve them. She helps to position her team to take advantage of opportunities to do better in ways that bring everyone along.

A

“As clinical nurse specialists, our job is being the change agents,” Bradley said. “Anybody knows that change is not always welcome and easy. It’s people management, trying to understand the bigger picture, and how to work it into actual work. It’s about recognizing opportunity and how you make those things happen.”

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Bradley is into her 14th year at Ochsner, having begun as a floor nurse working overnight shifts in the medical-surgical unit. The hospital is a community facility within the Ochsner organization, which is the largest non-profit, academic, multispecialty, healthcare delivery system in southeastern Louisiana. Even prior to the rollout of any recommendations for process improvement, Bradley spends a lot of time getting to know staff, onboarding new employees, developing a rapport with them once they’re on the floor, and helping them understand their roles within the system. Much of that work happens one-on-one, the better to help people to consider their experiences and their roles within the system prior to discussions of navigating change. For Bradley, delivering education and asking focused questions about diversity, equity, and inclusion (DEI) issues in the workplace, both for patients and staff, is among the most personally significant efforts in which she’s involved.

“I do a lot of talking with staff to understand their work and what it is to make change,” she said. “My biggest

passion has been in health equity and our work with diversity and inclusion. There’s a lot of work we’re doing internally, [especially around] psychological safety, which has a lot to do with people’s comfort in speaking up and taking care of their patients without fear of harm or anything happening to them.”

Bradley has not only worked on such initiatives at Ochsner, but she’s also brought the lessons from her involvement in DEI issues there to a broader audience via her work with the Academy of Medical-Surgical Nurses (AMSN) and its DEI task force. From the hospital to the clinic, Bradley’s group has met with staff members from housekeeping to the C-suite, discussing their experience of navigating the system from provider and patient perspectives, and how free people feel to speak up when issues of concern arise.

“We talked to just about everyone in our hospital to understand where everybody is coming from,” Bradley said. “That is where my heart is, making sure we’re asking the right questions, making sure we’re not biased in our care, making sure people

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“I knew I wanted to do more, and I couldn’t just continue to work and not have that knowledge or education about how to make change and make things happen.” receive treatment in our facilities that’s equitable, and learning more about how our employees experience work in health care.”

“In med-surg nursing, I always saw opportunities when others said, ‘This is the way we do it; this is how it’s always been,’ in trying to understand the rationale in how this happens,” Bradley said. “I didn’t want to accept the status quo.”

Staffing needs are among the biggest concerns Bradley said have been identified for nurses working in the field. The availability of additional supports from additional hires has become particularly concerning amid the escalating acuity of patient needs in recent years. She believes there’s a disconnect between the work that’s required to deliver high-quality patient care and the number of health care professionals available to provide it.

“Staffing has been such a hardship, and I feel like nurses have been screaming to the rooftops for help,” Bradley said. “They’re trying to do the best with what they have, but I feel like sometimes with the burnout,

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we’re not setting people up for success. It has a lot to do with our ability to affect the things we need to.”

In her career, Bradley had long since done the work of learning what kind of path she would forge for herself in medicine. During her junior year at the University of Louisiana-Monroe, Bradley decided to complete an undergraduate biology degree, but re-routed from a pre-medicine track into a program that would allow her to complete a BSN from the University of South Alabama in Mobile, Alabama.

“I wanted to be able to take care of patients and be in medicine, but not necessarily be a doctor,” she said.

“There are good providers out there, but what I was seeing wasn’t what I wanted to do. I felt like I was going to be at the mercy of whatever organization I was going to.”

“That’s how I ended up in nursing, but still wanting to make it better, help people with their outcomes,” Bradley said. “I knew I wanted to do more, and I couldn’t just continue to work and not have

that knowledge or education about how to make change and make things happen. I definitely saw the opportunities in health care to know more about the operations and the whys behind some of the decisions that may have been made on behalf of staff.”

“That was my driving force,” she said: “to want to make it better instead of complaining and wanting to go somewhere else. When I leave nursing, I want to leave it a little better than when I started.”

When she’s not working to help improve processes, performance and health outcomes at Ochsner, Bradley is a busy mother of three young children, including a set of three-year-old twins. Her self-care routine includes running, and she plans to tackle a marathon before her 40th birthday.

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OUT OF THE OR fitness

Total Body Strength in 3 Moves

By Miguel J. Ortiz hen it comes to strength

W exercises people tend to

keep it simple considering that they are usually lifting heavier weight. However, one unique element about strength training is that primal core strength will lead to distal joint strength. So, if having a stronger core gives you greater distal joint strength then why not do exercises that add a sense of stabilization or even rotation? The following exercises can be used together if your short on time or you can add them into your programming to spice up your training. Either way, these exercises are sure to challenge your entire body in various ways. Let’s dive right in.

Our first movement is a dynamic core exercise known as a Copenhagen Plank with Knee Drive. This exercise targets your core and provides leg and upper body stabilization in order to keep the body balanced. What I love about this movement is that every time you lift your knee up, it makes the stability and strength increase tremendously. The side plank position is already enough of a challenge – let alone being able to lift up one knee. Plank holds, 42

OR TODAY | July 2022

in general, can get a little boring because you are constantly just holding in one position. Don’t get me wrong, it absolutely has its benefits. However, the extra high knee movement really adds another layer of difficulty that will have your core burning.

The second exercise is the Lateral Lunge and Ballistic Kettle Bell Row. This movement requires core stability. It challenges your single leg and arm strength. It also adds an element of coordination to move that kettle bell properly. Because this position requires you to hinge over, your core is challenged the entire time. Your legs will initially carry you through this exercise, but it’s your upper body strength when doing the row that will keep the momentum going. When done properly, you will feel this in several major muscle groups like your lats and back, glutes, quads and adductors. And, because of the straight leg, you will of course feel it in your core.

The last movement is an Elevated Single Leg and Arm Glute Bridge with Dumb Bell Chest Press. This exercise requires you to use your core and legs to stabilize the torso and lower body.

Your upper back is the only part on the bench. Because you will only have one leg on the ground at a time and one dumb bell in

your hand, the counter rotation needed to make sure your hips stay square really adds a higher level of core difficulty. After getting your opposite leg up, to balance out the hips, you can then concentrate on the chest press ensuring your hips never drop or rotate. Do this in order to keep your back straight. Ironically, when doing unilateral work, it’s very difficult to go heavy. The body needs to work significantly harder to stay balanced which makes this exercise perfect for those looking for a great total body challenge.

Give these exercises a try and remember, when it comes to strength training, you don’t always have to lift the heaviest weight.

Simply adding stabilization or doing unilateral work can really go a long way to improving total body strength. Have fun with your movements and stay active.

– Miguel J. Ortiz is a personal trainer in Atlanta, Georgia. He is a Master Trainer for Pain-Free Performance and a Certified Nutritional Consultant with more than a decade of professional experience. He can be found on Instagram at @migueljortiz. You can find videos of the exercises mentioned in this column on his YouTube channel at tinyurl.com/ORTfitness.

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OUT OF THE OR EQ Factor

How to Build Your ‘Emotional Bank Account’

By Daniel Bobinski he term “Emotional Bank Account” was made popular in Stephen Covey’s book, “The 7 Habits of Highly Effective People,” and it provides a solid understanding of how trust is built and maintained, as well as how it can be destroyed.

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An Emotional Bank Account (EBA) is a metaphor for describing the amount of trust that’s been created in a relationship – the amount of safeness or trust we have with another human being and how much they have with us. When EBA levels are high, communication is easy and effective.

When EBA levels are low, communication is more guarded and requires more work.

Here’s the concept. Every time we meet someone, an Emotional Bank Account is instantly established. It’s subconscious, but each action and attitude displayed is interpreted as either a deposit or a withdrawal. Since the building of trust requires ongoing investments, it behooves us to pay attention to the deposits we are making (or not making) when we interact with others.

Actions that constitute deposits: • Seek first to understand • Keep promises • Be kind and courteous • Clarify expectations • Be loyal to the absent • Apologize sincerely if you make a withdrawal • Be open to feedback WWW.ORTODAY.COM

• Attend to the “little” things Withdrawals are actions and attitudes that take away feelings of trust. They include: • Seeking first to be understood • Breaking promises • Being unkind and discourteous • Being disloyal • Being prideful or arrogant • Ignoring the input of others Anyone who wants to become more aware of how different attitudes and actions impact their EBAs can do a simple exercise for a few weeks. Here’s how it works: 1. Obtain four envelopes and a box of paper clips 2. Identify four people with whom you interact daily and assign one envelope to each person 3. Place five paper clips in each envelope Each of the five clips represents an assumed level of deposits each person has made with you. At least once a day, evaluate your interactions with each person. If the person made a deposit into his or her account with you, transfer a clip from the bank (your regular box of paper clips) to that person’s envelope.

For example, if the person kept a commitment, transfer a clip. If the person was open to feedback or apologized after making a mistake, transfer a clip.

Transfer as many clips you believe are necessary to represent the size of deposits that person made in his or her account

with you. Just be sure to be specific about what action or attitude you observed – do not simply transfer clips based on a vague emotional perception. Be specific.

Conversely, if the person made withdrawals, then transfer clips from that person’s envelope back to the bank.

Again, be specific about the reason why.

If the person makes so many withdrawals that you run out of clips in that person’s envelope, create IOUs on small pieces of paper and place them in that person’s envelope.

Do this exercise every day for 2 to 3 weeks at minimum. Then swap the roles by resetting the envelopes and transfer clips based on how you treat those other people. Again, be specific. In a month or two you will be vibrantly aware of ways to build – or diminish – trust.

Daniel Bobinski, who has a doctorate in theology, is a bestselling author and a popular speaker at conferences and retreats. For more than 30 years he’s been working with teams and individuals (1:1 coaching) to help them achieve excellence. He was also teaching Emotional Intelligence since before it was a thing. Reach him by email at DanielBobinski@ protonmail.com or 208-375-7606.

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OUT OF THE OR nutrition

Take Steps Toward a Healthier Lifestyle

By Family Features here isn’t a better time than now to start getting fit with health information and products so easily accessible. Simply incorporate the basics into your daily routine – good nutrition, adequate exercise and a daily supplement – and start down the path toward better health.

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Plan a Nutritious Diet The Dietary Guidelines for Americans describes a healthy diet as one that emphasizes fruits, vegetables, lean meats, poultry, fish, beans, eggs, nuts, whole grains and fat-free or low-fat milk products. It should be low in saturated fat, trans fat, cholesterol, salt and added sugar.

Warm weather makes fresh produce more easily accessible. Eat more fruits and vegetables by setting freshly washed and prepared produce on the kitchen counter or at eye level in the fridge. At every meal, make sure half your plate is made up of fruit and vegetable servings.

One-fourth of your plate at every meal should be made up of grains, such as wheat, rice, oats, cornmeal or barley. People who eat whole grains as part of a healthy diet have a reduced risk of some chronic diseases.

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OR TODAY | July 2022

The remaining one-fourth of your plate should be lean or low-fat cuts of meat, plant-based protein or seafood.

Get Regular Exercise The Department of Health and Human Services recommends an adequate amount of exercise every day.

This guide can point to the right amount of exercise to add to your schedule: • Get at least 150 minutes of moderate aerobic activity every week. For best results, spread the time out over several days.

• Do strength training exercises at least twice a week.

Lifting weights builds muscle, which means the body burns more calories – even at rest.

• It’s important to keep in mind that when people are active, they produce more free radicals. The antioxidants found in supplements can help buffer the negative effects of the workout.

Improving your diet, exercising regularly, taking a daily supplement and getting enough restorative sleep are all important steps to overall wellness. Work to incorporate each step into your daily routine until you reach your goal of good health, and find more healthconscious tips at eLivingToday.com.

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OUT OF THE OR

health

Study Sheds Light on Benefits of Exercise in Fatty Liver Disease xercise supports the treatment of nonalcoholic fatty liver disease by impacting on several metabolic pathways in the body, a new study from the University of Eastern Finland shows.

Regular HIIT exercise over a period of 12 weeks significantly decreased the study participants’ fasting glucose and waist circumference, and improved their maximum oxygen consumption rate and maximum achieved workload. These positive effects were associated with alterations in the abundance of a number of metabolites. In particular, exercise altered amino acid metabolism in adipose tissue. The study was published in Scientific Reports.

E

Non-alcoholic fatty liver disease (NAFLD) is the most common liver disease, affecting approximately 25% of the world’s population. Being largely asymptomatic, the disease may progress from the accumulation of fat in liver cells to liver inflammation and liver cirrhosis. NAFLD is associated with obesity and other characteristics of the metabolic syndrome, such as type 2 diabetes and abnormal blood lipid concentrations. The accumulation of fat in the liver can be reduced by weight loss and a health-promoting diet.

Exercise is an integral part of the treatment of NAFLD. The benefits of exercise may relate not only to weight management, but also to alterations in the metabolites produced by the body and gut microbes, whose role in fatty liver disease remains poorly understood.

In the new study, the researchers comprehensively examined the effects of exercise on metabolism in patients with non-alcoholic fatty liver disease. The randomized controlled intervention study involved 46 subjects diagnosed with NAFLD. They were divided into an exercise intervention group that had a HIIT (high-intensity interval training) session twice a week, plus an independent training session once a week for 12 weeks, and into a control group that did not increase exercise during the study. Neither of the groups sought to lose weight nor changed their dietary habits during the intervention. In addition to conventional medical examiWWW.ORTODAY.COM

nations and laboratory tests performed at the onset and end of the study, the researchers also performed untargeted metabolomics analyses to identity various metabolites and their abundance in adipose tissue, plasma, urine and stool samples.

Based on the results, exercise affected metabolic pathways differently in different tissues.

Exercise had a beneficial effect on fasting glucose concentrations, waist circumference, maximum oxygen consumption rate and maximum achieved workload. These factors were also associated with many of the observed alterations in the abundance of various metabolites in the exercise intervention group. The most significant alterations were observed in amino acids and their derivatives, lipids and bile acids.

In particular, exercise increased the levels of amino acids, which are the building blocks of proteins, in adipose tissue.

According to the researchers, their higher accumulations in adipose tissue may be associated with improved lipid and glucose metabolism, as well as with reduced insulin resistance.

The levels of various gut microbial metabolites were altered as a result of exercise, which is suggestive of changes in the composition of gut microbes, or in their function. Among these metabolites, increased amount of indolelactic acid, for example, can strengthen the intestinal mucosa, immune defence, and glucose balance.

Based on the results, exercise can have a beneficial effect on many factors contributing to disease in patients with NAFLD, even without weight loss and dietary changes. Adipose tissue seems to play a key role in these effects. Exercise improved fasting blood glucose levels and modified the metabolism of amino acids, lipids, and bile acids. However, abnormal blood lipid concentrations were not improved by exercise alone: their treatment requires attention to the quality of dietary fats.

Research article: Babu, A.F., Csader, S., Männistö, V. Tauriainen, M.M., Pentikäinen, H., Savonen, K., Klåvus, A., Koistinen, V., Hanhineva, K. & Schwab, U. Effects of exercise on NAFLD using non-targeted metabolomics in adipose tissue, plasma, urine, and stool. Sci Rep 12, 6485 (2022). https:// doi.org/10.1038/s41598-022-10481-9

July 2022 | OR TODAY

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OUT OF THE OR recipe

Southwest Steaks with Creamy Peppercorn Sauce and Parmesan-Herb Fries INGREDIENTS:

Recipe

Southwest Steak Rub:

the

• 1 tablespoon kosher salt • 1 teaspoon black pepper • 1 teaspoon dried thyme leaves • 1 teaspoon smoked paprika • 1/2 teaspoon ancho chili powder • 1/2 teaspoon ground chipotle pepper • 1/2 teaspoon garlic powder • 1/2 teaspoon cumin

Parmesan-Herb Fries: • 1 package (16 ounces) Omaha Steaks Steakhouse Fries • 1/2 cup Parmesan cheese, freshly grated • 1 tablespoon fresh thyme leaves, minced • 1 tablespoon fresh rosemary leaves, minced • 1 tablespoon fresh Italian parsley, minced

New York Strip Steaks: • 2 Omaha Steaks Butcher’s Cut New York Strips • Southwest steak rub • 1/4 cup grapeseed oil • 2 ounces unsalted butter, cold

Peppercorn Cream Sauce: • 1/2 cup brandy • 3/4 cup beef stock • 1/2 cup heavy cream • 2 teaspoons peppercorn medley, coarsely cracked • salt, to taste • pepper, to taste

By Family Features

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OR TODAY | July 2022

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OUT OF THE OR recipe

A Chef-Worthy Summer Classic elebrating summer with sizzling meals starts with tender, juicy cuts of meat that take center stage when dining on the patio or firing up the grill.

Call over the neighbors or simply enjoy family time with your nearest and dearest by savoring the flavor of warm weather meals.

C

Steak enthusiasts can show off their summer cooking skills with this recipe for Southwest Steaks with Creamy Peppercorn Sauce and Parmesan-Herb Fries from Omaha Steaks Executive Chef David Rose. Thick, juicy, marbled steaks are cooked to tender doneness and complemented by steakhousestyle fries for a meal that screams “summertime.”

Find more summer favorites at OmahaSteaks.com/Summer.

Southwest Steaks with Creamy Peppercorn Sauce and Parmesan-Herb Fries

4.

Remove fries from oven and toss with Parmesan herbs.

5.

To make New York strip steaks: Season steaks generously with Southwest steak rub on both sides.

6.

In cast-iron pan, add grapeseed oil and bring to high heat. Place steaks in pan and sear 3-4 minutes on each side for medium-rare doneness.

7.

Remove steaks from pan and rest 8 minutes; reserve oil in cast-iron pan.

8.

To make peppercorn cream sauce: Add brandy to reserved oil in castiron pan and reduce to 1/3 volume, about 1 minute.

9.

Add beef stock and reduce by 1/3 volume, about 2-3 minutes.

Recipe courtesy of Omaha Steaks Executive Chef David Rose Prep time: 10 minutes Cook time: 25 minutes Servings: 2

1.

To make Southwest steak rub: In small bowl, whisk salt, pepper, thyme, paprika, chili powder, chipotle pepper, garlic powder and cumin until fully incorporated.

2.

To make Parmesan-herb fries: Preheat oven to 425 F. Place fries on baking rack on top of sheet pan; bake 25 minutes, or until goldenbrown and crispy.

3.

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In medium bowl, mix Parmesan cheese, thyme, rosemary and parsley until fully incorporated.

10. Add heavy cream and cracked peppercorn medley to pan, bring to boil and reduce to simmer until thickened. Season with salt and pepper, to taste.

July 2022 | OR TODAY

47

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INDEX

advertisers

ALPHABETICAL AIV Inc.……………………………………………………………… 23

Ecolab Healthcare………………………………………………15

OR Today Webinar Series……………………………… 35

ALCO Sales & Service Co.………………………………… 11

Encompass Group……………………………………………… 11

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

ASCA………………………………………………………………… 48

Healthmark Industries Company, Inc.…………… 5

SIPS Consults………………………………………………………21

C Change Surgical……………………………………………… 4

I.C. Medical, INC.…………………………………………………51

Welmed, Inc.…………………………………………………………19

CIVCO Medical Solutions…………………………………13

Jet Medical Electronics Inc…………………………… 48

Cygnus Medical………………………………………………… BC

MD Technologies Inc.…………………………………………17

CATEGORICAL ASSOCIATION

FLUID MANAGEMENT

REPAIR SERVICES

ASCA………………………………………………………………… 48

Ecolab Healthcare………………………………………………15

Cygnus Medical………………………………………………… BC

CARDIAC PRODUCTS

MD Technologies Inc.…………………………………………17

Jet Medical Electronics Inc…………………………… 48

C Change Surgical……………………………………………… 4

FLUID MANAGEMENT SOLUTION

REPROCESSING STATIONS

CIVCO Medical Solutions…………………………………13

Welmed, Inc.…………………………………………………………19

CIVCO Medical Solutions…………………………………13

Jet Medical Electronics Inc…………………………… 48

GENERAL

MD Technologies Inc.…………………………………………17

Welmed, Inc.…………………………………………………………19

AIV Inc.……………………………………………………………… 23

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

CARTS/CABINETS

Welmed, Inc.…………………………………………………………19

SAFETY

ALCO Sales & Service Co.………………………………… 11

HOSPITAL BEDS/PARTS

Healthmark Industries Company, Inc.…………… 5

ALCO Sales & Service Co.………………………………… 11

SINKS

INFECTION CONTROL

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

ALCO Sales & Service Co.………………………………… 11

SMOKE EVACUATION

CIVCO Medical Solutions…………………………………13

I.C. Medical, INC.…………………………………………………51

Cygnus Medical………………………………………………… BC

STERILIZATION

CIVCO Medical Solutions…………………………………13 Cygnus Medical………………………………………………… BC Healthmark Industries Company, Inc.…………… 5

CS/SPD CIVCO Medical Solutions…………………………………13 MD Technologies Inc.…………………………………………17 Ruhof Corporation…………………………………………… 2,3 Welmed, Inc.…………………………………………………………19

Encompass Group……………………………………………… 11 Healthmark Industries Company, Inc.…………… 5 MD Technologies Inc.…………………………………………17

DISINFECTION

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

CIVCO Medical Solutions…………………………………13

SIPS Consults………………………………………………………21

Cygnus Medical………………………………………………… BC

INSTRUMENT STORAGE/TRANSPORT

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

CIVCO Medical Solutions…………………………………13

DISPOSABLES

Cygnus Medical………………………………………………… BC

ALCO Sales & Service Co.………………………………… 11

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

CIVCO Medical Solutions…………………………………13

ONLINE RESOURCE

Welmed, Inc.…………………………………………………………19

ENDOSCOPY CIVCO Medical Solutions…………………………………13 Cygnus Medical………………………………………………… BC

OR Today Webinar Series……………………………… 35

OTHER AIV Inc.……………………………………………………………… 23

Healthmark Industries Company, Inc.…………… 5

PATIENT MONITORING

MD Technologies Inc.…………………………………………17

AIV Inc.……………………………………………………………… 23

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

Jet Medical Electronics Inc…………………………… 48

Welmed, Inc.…………………………………………………………19

PATIENT WARMING

FALL PREVENTION

Encompass Group……………………………………………… 11

ALCO Sales & Service Co.………………………………… 11

Welmed, Inc.…………………………………………………………19

Encompass Group……………………………………………… 11

POSITIONING PRODUCTS

Cygnus Medical………………………………………………… BC Healthmark Industries Company, Inc.…………… 5 MD Technologies Inc.…………………………………………17

SURGICAL MD Technologies Inc.…………………………………………17 SIPS Consults………………………………………………………21 Welmed, Inc.…………………………………………………………19

SURGICAL INSTRUMENT/ACCESSORIES C Change Surgical……………………………………………… 4 Cygnus Medical………………………………………………… BC Healthmark Industries Company, Inc.…………… 5

TELEMETRY AIV Inc.……………………………………………………………… 23

TEMPERATURE MANAGEMENT C Change Surgical……………………………………………… 4 Encompass Group……………………………………………… 11

WASTE MANAGEMENT MD Technologies Inc.…………………………………………17 Welmed, Inc.…………………………………………………………19

Cygnus Medical………………………………………………… BC

50

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