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The Aligning practice with policy to improve

patient care

Volume 7, Issue 2

Special Breast Cancer Awareness Issue!


Ways to Improve Surgical Outcomes


Malignant Hyperthermia ARE YOU PREPARED?


Get into the Groove!



Covered Arms Are Compliant Arms Look what’s new! Long-sleeve scrubs. The latest AORN and OSHA guidelines recommend that OR nurses who aren’t in gowns should wear long sleeves. PerforMAX scrubs added an inner sleeve to keep arms covered without dangling cuffs—like on jackets—to contaminate sterile fields. These sleeves are like the finest athletic undergear: cool, supportive and totally breathable. And because they’re PerforMAX, you get a fashionable layered look that’s comfortable and functional all shift long. Talk to your facility’s Medline rep or visit to find out more about PerforMAX scrubs.

Standard scrub top

Pink Glove Dance photo winners. OR nurses from University Medical Center of Princeton

greensmart™ is not a third-party certification. The use of the greensmart™ trademark is determined by Medline Industries, Inc. through an internal review process of environmental claims. ©2012 Medline Industries, Inc. PerforMAX and greensmart are trademarks and Medline is a registered trademark of Medline Industries, Inc.

MKT1219116 / LIT139R / 30M / QG5

2012 Pink Glove Dance Competition Page 84


11:13 PM 8/8/03 SharpsSafety_posterFINAL.qxd

This fun group of perioperative nurses from the University Medical Center of Princeton at Plainsboro, in Plainsboro, NJ, took first place in Medline’s Pink Glove Dance Photo Contest at the 2012 AORN Conference in March. From left to right, Lori Mozenter, BSN, CNOR, RNFA, Staff Nurse; Mary Zegarski, RN, CNOR, Staff Nurse and Vice President of AORN Chapter 3109; Fe Moreo BSN,CNOR, Staff Nurse and Patricia Lum, RN, BSHA, CNOR, CMLSO, Perioperative Educator/Interim OR Manager.

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Aligning practice with policy to improve patient care 107

Editor Sue MacInnes, RD


Senior Writer Carla Esser Lake Creative Director Michael A. Gotti Clinical Team Jayne Barkman, BSN, RN, CNOR Lorri Downs, BSN, MS, RN, CIC Margaret Falconio-West, BSN, RN, APN/CNS, CWOCN, DAPWCA Joan Ferrara, BA, RN, CNOR Kimberly Haines, RN, Certified OR Nurse Rebecca Huff, MSN, RN Angel Trichak, BSN, RN, CNOR Perioperative Advisory Board Garry Crawford, MS, RN, CNOR Norman Regional Health System, Oklahoma Evangeline Dennis, RN, BSN, CNOR, CMLSO Spivey Station Surgery Center, Georgia Linda Groah, MSN, RN, CNOR, NEA-BD, FAAN Association of PeriOperative Registered Nurses, Colorado


Something Wicked This Way Comes. Patient safety expert and author Atul Gawande comments on the Supreme Court decision to uphold Obamacare.


Communication Dynamics and Patient Safety in the Operating Room. Solutions to communication difficulties and lateral violence among perioperative personnel.


Pink Glove Dance Video Competition 2012. Are you in it to win it? New ways to promote your Pink Glove Dance Video.

Darvina L. Heichemer, BSN, CNOR Gwinnett Medical Center – Duluth, Georgia Vivienne P Kaplan, RN Anaheim Regional Medical Center, California Colleen Mattioni, MBA, RN, CNOR Hospital of the University of Pennsylvania, Pennsylvania Julieann McIntyre, MSN, RN, CNOR South Shore Hospital, Massachusetts Susan A Miller, MSN, RN, CNOR St. Luke’s Hospital, Missouri Susan S Phillips, MSH, RN, CNOR UNC Hospitals, North Carolina Jo Quetsch, MA, RN, NE-BC Providence Sacred Heart Medical Center, Washington Eleonora Shapiro, BSN, MHA, CNOR Mount Sinai Medical Center, New York Pat Thornton, MS, RN, CNOR Southern Regional Medical Center, Georgia Judith A. Townsley, MSN, RN, CPAN Christiana Care Health System, Delaware Pat Thornton, MS, RN, CNOR Southern Regional Medical Center, Georgia



In the Heat of the Moment: Malignant Hyperthermia Calls for Action. Ways to make sure your operating room is prepared to intervene when patients develop malignant hyperthermia.

Judith A. Townsley, MSN, RN, CPAN Christiana Care Health System, Delaware About Medline Medline, headquartered in Mundelein, IL, manufactures and distributes more than 100,000 products to hospitals, extended care facilities, surgery centers, home care dealers and agencies and other markets. Medline has more than 800 dedicated sales representatives nationwide to support its broad product line and cost management services. ©2012 Medline Industries, Inc. The OR Connection is published by Medline Industries, Inc. One Medline Place, Mundelein, IL 60060. 1-800-MEDLINE.

Aligning practice with policy to improve patient care 3

Patient Safety

6 Three Important National Initiatives for Improving Patient Care 24 Communication Dynamics and Patient Safety in the Operating Room 28 In the Heat of the Moment: Malignant Hyperthermia Calls for Action 48 Quantification of Anesthesia Providers’ Hand Hygiene in a Busy Metropolitan Operating Room: What Would Semmelweis Think?

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OR Issues

10 13 36 43 58

Surgical Safety News Five Ways to Improve Surgical Outcomes Greening the OR Lean Isn’t Just for Diets Anymore Another Article About Safety Scalpels? Yes, But There’s New Data 70 So You Really Think That Surface Is Clean?

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"The Canvas” by Michelle DeMeo. See page 67. Special Features

9 Medline Acquires Medisiss 11 Communication Between Surgical Services and Sterile Processing 14 Something Wicked This Way Comes 63 Sterile Processing – A Lifetime Passion: Q&A with Michele DeMeo 67 The Canvas: Portrait of a Life Well-Lived 80 Emma and SCIP Celebrate Breast Cancer Awareness Month 84 Pink Glove Dance Video Competition 2012 Caring for Yourself

76 89 92 98

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Get Rid of Worry Once and For All Cooking Pink Breast Cancer Myths Healthy Eating: Lillian Stafford’s Oriental Broccoli Forms & Tools

101 102 103 104 105 107


The OR Connection

Now You See It, Now You Don’t Emergency Therapy for Malignant Hyperthermia Malignant Hyperthermia Drill Your 5 Moments for Hand Hygiene Caring for Your Surgical Incision at Home Sharps Safety Begins with You

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The OR Connection Letter from the Editor

Dear Reader, Last year, at AORN’s 59th Congress in New Orleans, more than 1,000 OR nurses danced to Pink’s hit single, “Raise Your Glass” ... at 5:00 in the morning. Picture a ballroom at the Hilton New Orleans filled with people dancing, laughing, singing ... and even some standing on chairs encouraging their peers to “let their hair down” and dance ... that was the scene at Medline’s 5th annual Breast Cancer Awareness Breakfast. I was sitting at a table in the front of the room and a friendly looking woman asked me if she could take the seat beside me. Her roommate at Congress went to the breakfast, encouraging her to join in. But my new neighbor said ... ”I just couldn’t get out of bed that early.” Then she said, something stirred inside her ... her roommate had lost a friend to breast cancer and she felt she needed to get herself out of bed and at least make an effort. Although a bit late (which is probably why she ended up in the front of the room looking for an empty seat), she was grateful to be in attendance, and I was the fortunate recipient of her company. As the choreographer went through the moves of the “live dance” there was a section where you needed a dance partner. My “new friend” asked me if I would be her partner. We howled with laughter as we went through the moves over and over again, each time with more animation and energy. At the conclusion of the dance, my friend asked for my contact info. It wasn’t long before she contacted me to tell me that she was having a meeting with the staff at her hospital to show them the dance and talk about the breakfast and the incredible support of the many attendees. This was last March. She still stays in contact, and now, her hospital is doing a video for the Medline 2012 Pink Glove Dance Video Competition. Recently, she asked if I would visit her facility and talk to her staff. This from the woman who wanted to stay in bed but later decided to “get up and get moving and support something good.”

Several months ago, the perioperative director of a large and prestigious hospital on the East coast contacted me about a friend who had a terminal illness. This friend had written a book, and he was wondering if I could help the friend communicate the book to peers. The terminal illness was ALS (Lou Gehrig’s disease) and the “friend” was Michele Demeo ... who is now my friend also. You know, “nobody gets out of here alive” ... but the things we do to save lives and the things we do to support others through tragedy of loss give us greater meaning than “a job.” I especially want to recognize the four women on the cover of this issue of The OR Connection and the many people who stood in line to have their pictures taken! Each vote you received was another acknowledgement and show of support to breast cancer victims and survivors alike. I support my fabulous table partner at the AORN breakfast, I am thankful that the perioperative director of that huge acute care facility took the time to email me about his friend, and I salute and thank Michele DeMeo, who wants to live the rest of her days doing meaningful tasks and contributing. Tragedy is always tragic ... but the spirit and soul of each healthcare worker is much like a blessing ... nurturing others, helping others and delivering care to both patients and co-workers. I salute you all,

Sue MacInnes, RD Editor

Aligning practice with policy to improve patient care 5

Three Important National Initiatives for Improving Patient Care Achieving better outcomes starts with an understanding of current patient-care initiatives. Here’s what you need to know about national projects and policies that are driving changes in care.


IHI Improvement Map

Origin: Purpose:

Launched by the Institute for Healthcare Improvement (IHI) in January 2009 To help hospitals improve patient care by focusing on an essential set of processes needed to achieve the highest levels of performance in areas that matter most to patients.

Hospitals sign up through IHI and can choose to implement some or all of the recommended interventions. IHI provides how-to guides and tools for all participating hospitals. The IHI Improvement Map covers the entire landscape of outstanding hospital care to help hospitals make sense of countless requirements and focus on high-leverage changes to transform care. There are 73 processes grouped into three domains: leadership and management, patient care and processes to support care.

2 Origin: Purpose:

Joint Commission 2012-2013 National Patient Safety Goals The development and updating of the National Patient Safety Goals (NPSGs) is overseen by the Patient Safety Advisory Group. The NPSGs were established in 2002 to help accredited organizations address specific areas of concern regarding patient safety.

Joint Commission-accredited organizations are evaluated for compliance with these goals. The Joint Commission offers guidance to help organizations meet goal requirements.

3 Origin:

Purpose: Goal:

Surgical Care Improvement Project (SCIP) Initiated in 2003 as a national partnership. Steering committee includes the following organizations: CDC, CMS, ACS, AHRQ, AHA, ASA, AORN, VA, IHI and the Joint Commission To improve patient safety by reducing postoperative complications To reduce nationally by 25 percent the incidence of surgical complications by 2010

SCIP aims to reduce surgical complications in three target areas. Participating hospitals collect data on specific process and outcome measures. The SCIP committee believes it could prevent 13,000 perioperative deaths and up to 300,000 surgical complications annually (just in Medicare patients) by getting performance up to benchmark levels.


The OR Connection

IHI Improvement Map: 73 Processes to Transform Hospital Care The Improvement Map aims to help:  t Make care safer  t Make patient care transitions smoother  t Lead improvement efforts effectively  t Reduce costs and increase quality

Helping hospitals improve in nine core focus areas identiďŹ ed by Partnership for Patients 1. Adverse Drug Events 2. Catheter-Associated Urinary Tract Infections (CAUTIs) 3. Central Line-Associated Bloodstream Infections (CLABSIs) 4. Injuries from Falls and Immobility

5. Obstetrical Adverse Events 6. Pressure Ulcers 7. Surgical Site Infections 8. Venous Thromboembolism 9. Ventilator-Associated Pneumonia

To learn more about the IHI Improvement Map and the 73 processes to transform hospital care, go to


t 6OJWFSTBM1SPUPDPMGPS1SFWFOUJOH8SPOH4JUF  Wrong Procedure, and Wrong Person Surgery.™ - Conduct a pre-procedure veriďŹ cation process. - Mark the procedure site. - A time-out is performed before the procedure. Effective January 1, 2013: Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections (CAUTI).

To learn more about National Patient Safety Goals, go to

Surgical Care Improvement Project (SCIP): Target Areas 1. Surgical infections t"OUJCJPUJDT CMPPETVHBSDPOUSPM IBJSSFNPWBM QFSJPQFSBUJWF temperature management t3FNPWFVSJOBSZDBUIFUFSPO1PTU0QFSBUJWF%BZ 10% PS 2. Perioperative cardiac events t6TFPGQFSJPQFSBUJWFCFUBCMPDLFST 3. Venous thromboembolism t6TFPGBQQSPQSJBUFQSPQIZMBYJT Visit

Aligning practice with policy to improve patient care 7

Contributing Writers Katie Beam, DNP, RN, ACNS-BC, CWS Katie Beam is an ANCC Board-Certified Adult Clinical Nurse Specialist and American Academy of Wound Management Certified Wound Care Specialist supporting the Emergency, Intensive Care, Oncology, Medical Surgical, Pediatric and Maternal Child departments at Woodland Healthcare. She received her Associate Degree in Nursing from Shasta College in 1985, her BSN and MSN from California State University, Sacramento, and her Doctorate in Clinical Nursing Practice from the University of Colorado, Denver. She has been with Dignity Health since 1985. Beth Boynton, MS, RN Beth Boynton is an organizational development consultant specializing in issues that affect nurses and other healthcare professionals. She is a national speaker, coach, facilitator and trainer for topics related to communication, conflict management, teambuilding and leadership development and author of the book, Confident Voices: The Nurses’ Guide to Improving Communication & Creating Positive Workplaces.

Michelle DeMeo Michele DeMeo is an expert in the sterile processing field who is highly regarded for her management techniques, product development and contributions to various healthcare associations and professional publications. She is now tackling another important role – learning to live well in the face of a terminal illness.

Joan Ferrara, BA, RN, CNOR Joan Ferrara has 31 years of experience in various roles in the operating room, including serving as assistant vice president of surgical services, perioperative services director, OR nurse manager and OR staff nurse. She has also served as a certified surgical technologist.

Atul Gawande, MD Atul Gawande is a surgeon, writer, and public health researcher. He practices general and endocrine surgery at Brigham and Women’s Hospital in Boston. He is also Professor of Surgery at Harvard Medical School and Professor in the Department of Health Policy and Management at the Harvard School of Public Health. He has written several books, including The Checklist Manifesto and serves as lead advisor for the World Health Organization’s Safe Surgery Saves Lives program, which developed the Safe Surgery Checklist. Wolf Rinke, RD, CSP Keynote speaker, seminar leader, management consultant, executive coach and editor of the free electronic newsletter Read and Grow Rich, available at In addition he has authored numerous CDs, DVDs and books including Make It a Winning Life: Success Strategies for Life, Love and Business, Winning Management: 6 Fail-Safe Strategies for Building High-Performance Organizations. Reach him at


The OR Connection

Breaking News

Medline Acquires Medisiss Surgical Instrument Reprocessing Company Medline is pleased to announce that we are continuing to expand our business with the acquisition of Medisiss, a leading surgical instrument reprocessing company with whom we’ve successfully partnered for the last two years. With this acquisition, we hope to expand and strengthen our business with OR teams in both the hospital and surgery center markets. Medisiss will retain its brand identity and company name and will operate as a wholly owned subsidiary of Medline headquartered in Redmond, Oregon.


Our Commitment to You 1 Employ the highest environmental safeguards to ensure that optimum infection and decontamination control processes underscore our reprocessing of your medical devices.

6 Become one of your most trusted providers of SUDs, substantially improving your bottom line and overall patient care in the process.

2 Maintain the highest industry standards to provide reprocessed SUDs at half the cost of new devices without sacrificing level of performance.

With every customer we strive diligently to: 5 Assist you in your efforts as both a conscientious health provider and a good steward of the environment.

3 Offer you the opportunity to save operating capital while reusing devices that would otherwise be discarded.

4 Continue to demonstrate to you that reprocessed devices are as safe and functional as brand new ones.

greensmart™ is not a third-party certification. The use of the greensmart™ trademark is determined by Medline Industries, Inc. through an internal review process of environmental claims.

Surgical Safety News

Safety Organizations Recommend Blunt-Tip Suture Needles1 The Food and Drug Administration (FDA), Centers for Disease Control and Prevention (CDC), Occupational Safety and Health Administration (OSHA) and the National Institute of Occupational Safety and Health (NIOSH), are strongly encouraging healthcare professionals to use blunt-tip suture needles instead of standard suture needles to suture fascia and muscle. Using blunt-tip suture needles decreases the risk of needlestick injury and exposure to bloodborne pathogens such as hepatitis B, hepatitis C and HIV. Published studies show that using blunt-tip suture needles cuts the risk of needlestick injuries by 69 percent. Although blunttip needles cost about 70 cents more than standard suture needles, the benefits of reducing bloodborne infections justify the extra expense.

Past Skin Infections Can Predict SSIs2 A new study by researchers at Johns Hopkins School of Medicine shows that people who have a single skin infection are three times more likely to develop a surgical site infection. The increased risk suggests there are underlying biological differences in the way individuals respond to skin cuts that need to be better understood in order to prevent SSIs. Even when all of the proper procedures known to prevent SSIs are followed — from administering preoperative antibiotics to using the correct antiseptic to prepare the skin during surgery — some patients appear to be much more susceptible than others to contracting an infection. Although the research does not establish a cause-and-effect relationship between a past skin infection and SSI, the research team says the association between them is strong and should not be ignored. In the study, researchers analyzed information before, during and after surgery for 613 patients, with an average age of 62. Twenty-four patients developed an SSI within 180 days of surgery, and five of them died from the condition. Another 15 died from noninfectious causes. Of those who had a history of skin infection, 6.7 percent got an SSI compared with 3.9 percent of those without a history of skin disease. It made no difference whether the skin infection was recent or had occurred years earlier. Researchers also took into account and adjusted for other known risk factors for SSI, including the patient’s age, a diagnosis of diabetes and certain medications they were taking.

References 1. McGraw M. FDA recommends blunt-tip suture needles. Outpatient Surgery E- Weekly. June 5, 2012. Available at: eweekly/2012/06/05#1. Accessed July 19, 2012. 2. Surgical site infections more likely in patients with history of skin infection [press release]. Baltimore, MD: Johns Hopkins Medicine; May 29, 2012. Available at: http:// in_patients_with_history_of_skin_infection. Accessed July 19, 2012.

10 The OR Connection

Sterile Processing Corner

Communication Between Surgical Services & Sterile Processing by Michele DeMeo

Sometimes the most common words and definitions are the hardest to convey or apply. The topic of “communication” is discussed frequently, but often executed poorly. Many believe they speak, write or even give direction in the clearest way. However, people are unique, and as unique as every person is, so are their styles of communication. Unfortunately, at some of the most critical times, breakdowns in communication make matters worse.

Here are a few tips to consider when trying to deal with miscommunication with the sterile processing department: Before reacting, consider for a moment, “What could the other person have been thinking?” There could be a very logical reason for their action or statement. It just may not be logical to you. Allow for the possibility that the communicator had good intentions, but the outcome was less than favorable because perception or understanding of instructions were not clear due to differences in communication style, experience, education, environment or various other circumstances.

This is especially true when there are barriers in the way, such as differing educational levels or experience. Communication can be hampered when we are unable to see the other person’s perspective for any number of reasons. For example, miscommunication commonly occurs between surgical services and the sterile processing department. If your department has a sound communication system in place, that’s terrific. If it could use some work or tweaking, consider making some improvements. Ignoring trouble will foster more of the same. Implementing even a single change just might become the impetus for long-lasting, incremental improvement. And that’s just when successful partnerships become not just possible, but probable! Editor’s Note: This is the first in a series of 8 columns written by Michele DeMeo, a sterile processing expert with more than 20 years of experience in this field.

Mitigate the risk for future communication mishaps by being proactive now. Invite sterile processing employees to your morning huddles to give them a real visual and audio impression of your stress and environment. This can also serve as a means for members from both teams to ask questions or convey any impromptu scheduling or case changes. Consider holding joint educational sessions. The same type of information isn’t always needed by both units, but it helps add depth to the other party’s understanding of each others’ responsibilities and the complexities of their work. Surgical services staff would benefit from firsthand understanding of the conditions, challenges and complex tasks faced by sterile processing and vice versa. Consider creating a quarterly newsletter or memo written jointly by the two department managers. The newsletter could include tips, congratulations and system wide initiatives. It might just engage the groups to begin to help see each other as peers and become a support a system for collaboration.

Aligning practice with policy to improve patient care 11

Join 280,000 other nurses for FREE CE courses at

Medline University Š 220 courses Š 22 curriculum tracks Š Interactive competencies Š Flexible access: PC, iPhone, iPad Š Free registration

©2012 Medline Industries, Inc. Medline and Medline University are registered trademarks of Medline Industries, Inc.

Quiet, please!

Soothing tunes When Frank Sinatra, Vivaldi or Beethoven were played during surgical procedures performed under local anesthesia, patients had less anxiety and lower respiratory rates.1

General surgery residents made major surgical errors during eight of 18 simulated procedures when they were interrupted by questions or sidebar conversations in the OR. 2


Ways to Improve Surgical Outcomes

Speak up and reduce SSIs Empowering OR team members to use a simple safety checklist and encouraging them to speak up if something seems wrong reduced surgical site infections by one-third.3

Use eyewear only once Disposable protective glasses are a must in the OR, but they should be discarded after every case. Wearing glasses a second time raises the risk for pieces of the glasses flaking off and entering the sterile field.5 The glasses also may have lingering pathogens on them from the previous case.

Know your antibiotics Improving the timing and selection of antibiotics prior to skin incision can reduce the rate of surgical site infections by up to 50%.4

References 1. Buxman K. Turn up the tunes in the operating room: studies show that music improves surgical outcomes. Outpatient Surgery Magazine Online. July 2012: 75. Available at: Accessed August 14, 2012. 2. Feuerbacher RL, Funk KH, Spight DH, Diggs BS, Hunter JG. Realistic distractions and interruptions that impair simulated surgical performance by novice surgeons. Archives of Surgery. 2012 Jul 16:1-5. [Epub ahead of print]. Available at: http://www.ncbi.nlm. Accessed August 14, 2012. 3. Johns Hopkins Patient Safety Pilot Program slashes colorectal surgical site infections (SSIs) by 33 percent: researchers estimate similar interventions nationwide could save

more than $100 million annually [press release]. Baltimore, MD: Johns Hopkins Hospital; July 30, 2012. Available at: releases/johns_hopkins_patient_safety_pilot_program_slashes_colorectal_surgical_ site_infections_ssis_by_33_percent. Accessed August 14, 2012. 4. World Health Organization. 10 Facts on Safe Surgery. Available at: features/factfiles/safe_surgery/en/index.html. Accessed August 15, 2012. 5. DiNobile C. 6 pieces of the barrier protection puzzle. Outpatient Surgery Magazine Online. January 2012: 26-29. Available at: <> . Accessed August 16, 2012.

Aligning practice with policy to improve patient care 13

14 The OR Connection


WICKED THIS WAY COMES by Atul Gawande June 28, 2012 The New Yorker

A few days ago, while awaiting the Supreme Court’s ruling on President Obama’s health-care law, I called a few doctor friends around the country. I asked them if they could tell me about current patients whose health had been affected by a lack of insurance. “This falls under the ‘too numerous to count’ section,” a New Jersey internist said. A vascular surgeon in Indianapolis told me about a man in his fifties who’d had a large abdominal aortic aneurysm. Doctors knew for months that it was in danger of rupturing, but since he wasn’t insured, his local private hospital wouldn’t fix it. Finally, it indeed began to rupture. Rupture is an often fatal development, but the man—in pain, with the blood flow to his legs gone—made it to an emergency room. Then the hospital put him in an ambulance to Indiana University, arguing that the patient’s condition was “too

complex.” My friend got him through, but he’s very lucky to be alive. Another friend, an oncologist in Marietta, Ohio, told me about three women in their forties and fifties whom he was treating for advanced cervical cancer. A Pap smear would have caught their cancers far sooner. But since they didn’t have insurance, their cancers were recognized only when they caused profuse bleeding. Now the women required radiation and chemotherapy if they were to have a chance of surviving.

Copyright © 2012 Conde Nast. All rights reserved. Originally published in The New Yorker. Reprinted by permission.

Aligning practice with policy to improve patient care 15

Tens of millions of Americans don’t have access to basic care for prevention and treatment of illness.

A colleague who practices family medicine in Las Vegas told me about his clinic’s cleaning lady, who came to him in desperation about her uninsured husband. He had a painful rectal fistula—a chronically draining infection. Surgery could cure the condition, but hospitals required him to pay for the procedure in advance, and, as unskilled laborers, the couple didn’t have the money. He’d lived in misery for nine months so far. The couple had nowhere to turn. Neither did the doctor. The litany of misery was as terrible as it was routine. An internist in my Ohio home town put me on the phone with an uninsured fifty-five-year-old tanning-salon owner who’d had a heart attack. She was now unable to pay the bills for the cardiac stent that saved her and for the medications that she needs in order to prevent a second heart attack. Outside Philadelphia, there was a home-care nurse who’d lost her job when she developed partial paralysis as a result of a rare autoimmune complication from the flu shot that her employers required her to get. Then she lost the insurance that paid for the medications that had been reversing the condition. Tens of millions of Americans don’t have access to basic care for prevention and treatment of illness. For decades, there’s been wide support for universal health care. Finally, with the passage of Obamacare, two years ago, we did something about it. The law would provide coverage for people like those my friends told me about, either through its expansion of Medicaid eligibility or through subsidized private insurance. Yet the country has remained convulsed by battles over whether we should implement this plan—or any particular plan. Now that the Supreme

16 The OR Connection

Court has largely upheld Obamacare, it’s tempting to imagine that the battles will subside. There’s reason to think that they won’t. In 1973, two social scientists, Horst Rittel and Melvin Webber, defined a class of problems they called “wicked problems.” Wicked problems are messy, ill-defined, more complex than we fully grasp, and open to multiple interpretations based on one’s point of view. They are problems such as poverty, obesity, where to put a new highway—or how to make sure that people have adequate health care. They are the opposite of “tame problems,” which can be crisply defined, completely understood, and fixed through technical solutions. Tame problems are not necessarily simple—they include putting a man on the moon or devising a cure for diabetes. They are, however, solvable. Solutions to tame problems either work or they don’t. Solutions to wicked problems, by contrast, are only better or worse. Trade-offs are unavoidable. Unanticipated complications and benefits are both common. And opportunities to learn by trial and error are limited. You can’t try a new highway over here and over there; you put it where you put it. But new issues will arise. Adjustments will be required. No solution to a wicked problem is ever permanent or wholly satisfying, which leaves every solution open to easy polemical attack. Two decades ago, the economist Albert O. Hirschman published a historical study of the opposition to basic social

advances; “the rhetoric of intransigence,” as he put it. He examined the structure of arguments—in the eighteenth century, against expansions of basic rights, such as freedom of speech, thought, and religion; in the nineteenth century, against widening the range of citizens who could vote and participate in government; and, in the twentieth century, against governmentassured minimal levels of education, economic well-being, and security. In each instance, the reforms aimed to address deep, pressing, and complex societal problems—wicked problems, as we might call them. The reforms pursued straightforward goals but required inherently complicated, difficult-to-explain means of implementation. And, in each instance, Hirschman observed, reactionary argument took three basic forms: perversity, futility, and jeopardy. The perversity thesis is that the change will not just fail but make the problem worse. The futility thesis is that the change can’t make a meaningful difference, and therefore won’t be worth the effort. We hear both of these lines of argument against the health-care-reform law. By providing coverage for everyone, it will drive up the system’s costs and make health care unaffordable for even more people. And, some say, people can get care in emergency rooms and through charity, so the law won’t do any real good. In fact, a slew of evidence indicates otherwise—from the many countries that have both universal coverage (whether through government or private insurers) and lower per-capita costs; from the major improvements in health that uninsured Americans experience when they qualify for Medicare or Medicaid. The reality is unavoidable for anyone who notices what it’s like to be a person who develops illness without insurance. The jeopardy thesis is that the change will impose unacceptable costs upon society—that what we lose will be far more precious than what we gain. This is the sharpest line of attack in the health-care debate. Obamacare’s critics argue that the law will destroy our economy, undermine health care for the elderly, dampen innovation, and infringe on our liberty. Hence their efforts to persuade governors not to cooperate with the program, Congress not to provide the funds authorized under the law, and the courts to throw it out altogether. The rhetoric of intransigence favors extreme predictions, which are seldom borne out. Troubles do arise, but the reforms evolve, as they must. Adjustments are made. And, when people are determined to succeed, progress generally happens. The reality of trying to solve a wicked problem is that action of any kind presents risks and uncertainties. Yet so does inaction. All that

leaders can do is weigh the possibilities as best they can and find a way forward. They must want to make the effort, however. That’s a key factor. The major social advances of the past three centuries have required widening our sphere of moral inclusion. During the nineteenth century, for instance, most American leaders believed in a right to vote—but not in extending it to women and black people. Likewise, most American leaders, regardless of their politics, believe that people’s health-care needs should be met; they’ve sought to insure that soldiers, the elderly, the disabled, and children, not to mention themselves, have access to good care. But many draw their circle of concern narrowly; they continue to resist the idea that people without adequate insurance are anything like these deserving others. And so the fate of the uninsured remains embattled—vulnerable, in particular, to the maneuvering for political control. The partisan desire to deny the President success remains powerful. Many levers of obstruction remain; many hands will be reaching for them. For all that, the Court’s ruling keeps alive the prospect that our society will expand its circle of moral concern to include the millions who now lack insurance. Beneath the intricacies of the Affordable Care Act lies a simple truth. We are all born frail and mortal—and, in the course of our lives, we all need health care. Americans are on our way to recognizing this. If we actually do—now, that would be wicked.

Aligning practice with policy to improve patient care 17

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Illustrations and content provide general description only and may be subject to change. Integra, the Integra logo and Miltex are registered trademarks of Integra LifeSciences Corporation or its subsidiaries in the United States and/or other countries. Copyright © 2012 Integra LifeSciences Corporation Medline OR Connection Ad 5/2012 PM11168

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Emma the perioperative nurse is empowered to speak up respectfully to her teammates when she sees or hears something that may not be right. She also watches to ensure everyone on the OR team uses aseptic technique and safe practices.

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Educational Resources to Enhance Surgical Safety Adverse events occur more often in surgery than in any other specialty. A staff that feels confident that safety precautions are in place to help them do their jobs without fear of making a mistake will perform at their best. Medline offers a variety of educational resources that address some of the most critical issues facing OR staff today.

Speak Your Truth I


t Kathleen Bartholomew, RN, MN t John Nance, JD Why are people often afraid to tell the truth in the OR? A compelling discussion on the communication tools surgical staff can employ to openly communicate with colleagues and leadership in the OR.

Coming Soon! Speak Your Truth II t Kathleen Bartholomew, RN, MN t John Nance, JD Learn new ways to effectively communicate with colleagues, how to build an effective OR team, establish leadership among surgeons and clinicians and better understand the culture that prevents staff from speaking up in the OR.

To participate in these programs contact your Medline sales representative, or call 1-800-MEDLINE

* The AORN Seal of Recognition confirms that the content has undergone thorough review by AORN and meets the guidelines set forth in AORN’s Recommended Practices and Standards. While not a product endorsement, the Seal of Recognition demonstrates that the promotional and informative material related to your product or service has met AORN standards for excellence in safe patient care. ©2012 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

Martie Moore (far right) and colleagues, Providence St. Vincent Medical Center, Portland, OR

New! Culture of Safety in the Operating Room t Martie Moore, R.N., MAOM, CPHQ, Chief Nursing Officer, Providence St. Vincent Medical Center

t Rick Waller, MD, Chief of Surgery (retired) t Cyndi Owens, RN, MA, CNOR, Director of Surgical Services t Nancy B. Church, RN, BSN, MT (ASCP), CIC, Manager, Infection Prevention and Control and Wound/Ostomy Departments How does a culture of safety in the OR dramatically improve patient care? This compelling roundtable discussion uncovers the complexities in establishing a cultureof safety and trust among hospital colleagues, ultimately enhancing care for surgical patients.

New! The Joint Commission Center for Transforming Healthcare: Wrong Site Surgery Project t Mark Chassin, President t Melody F. Dickerson, RN, MSN, Master Black Belt, Robust Process Improvement t Ana Pujols McKee, MD, Executive VP and CMO A comprehensive approach to addressing wrong site surgery, wrong patient and wrong procedure. This course addresses everything from root causes of wrong site surgery to solutions and resources available to prevent this “never event.”



24 The OR Connection

AND PATIENT SAFETY IN THE OPERATING ROOM Insights for surgeons, nurses, patient advocates and administrative leaders

By Beth Boynton, MS, RN Self-reflection, ownership and respectful communication are examples of “soft” skills that are extremely hard to develop and practice. Yet, the surgeon or nurse manager who can teach the right way of doing something without humiliating a team member will show everyone that respect is guaranteed, skills and knowledge are required to work in the OR, and passive aggressive behavior will not be rewarded with alignment. Not long ago in preparing an interactive workshop on communication and assertiveness for a chapter for the Association of periOperative Registered Nurses (AORN), I asked their educational committee to share their most common communication challenges so that we could make our time as meaningful as possible. They replied with four scenarios. These scenarios reveal layers of interwoven relationship patterns that are fraught with horizontal and vertical violence. Add to that more innocent unawareness about individual behaviors and their impact on others, along with lack of skills in self-reflection and expression, and the complexity of interactions and ramifications begins to emerge.

Do these scenes sound familiar?


Your teammate purposefully holding back information about a surgery to make you look bad in front of the surgeon.


Surgeon yelling that s/he wants someone in the OR who “knows what they are doing.”


Purposeful negative discussion about you in the operating room by other team members without including you in the conversation.


Surgeon compromises patient safety either by surgical technique, not wanting to wait for “TimeOut” or not wanting to wait for counts at the end of the procedure (especially when counts are incorrect), and ignores or becomes angry when you request him or her to consider the information presented.

Continued on page 27

Aligning practice with policy to improve patient care 25

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Team members vying for approval and leaders who are somehow gratified by giving or withholding approval are participating in relationship patterns that contribute to adverse events.

Team members vying for approval and leaders who are somehow gratified by giving or withholding approval are participating in relationship patterns that contribute to adverse events. Withholding information, setting up a colleague to work in a position without appropriate training and experience or using humiliating language and tone are not in the patients’ best interests. As human beings, I believe we all want and deserve to feel respected and have a sense of power. Yet in our culture, some members and professions are valued more than others. This imbalance chips away at everyone’s self esteem and contributes to complex feelings and behaviors involving frustration and resentment. In addition, relentless stress, gender, ego and self-esteem factors help set the stage for such aggressive, passive-aggressive or passive ways of obtaining power. I hate to think of my colleagues in the nursing and medical professions behaving in these ways, yet I also feel a little defensive. I know how I feel along the course of a highly stressed shift as a per diem RN on an Alzheimer’s unit. I can practically watch my best self disintegrate with relentless alarms, interruptions, dementia behaviors, changing priorities and chronic understaffing. I’m pretty good at owning and apologizing for any irritability, but that may be after a sarcastic or short-tempered remark. Despite the fact that I can empathize with poor conduct, I passionately believe that individuals and organizations can do better. Even under pressure, a mistake requiring an immediate substitution of staff can be handled with respect. A statement such as, “I need trained OR assistance, now!” is quite different from, “Get someone in here who knows what they are doing!” They both get the same problem addressed, but the first statement brings up an organizational responsibility regarding training, while the second is more blaming of the individual. Making sure the situation is followed up as soon as possible after surgery by debriefing with the surgeon, nurse manager and staff will identify train-

ing problems, seek solutions and practice giving and receiving constructive feedback. Whenever I hear about situations like these, I look for individual and organizational factors. Solutions that consider less blaming are more likely to lead to long-term, meaningful change. Administrative leaders have a responsibility to advocate for resources required to focus on communication training, opportunities to practice skills and recognizing learning curves. Individuals have a responsibility to seek help, acknowledge limitations and develop their skills. Not everyone is cut out to work in the OR, (or on an Alzheimer’s unit) and career coaching and/or discipline also may be necessary. I don’t know exactly what respectful communication looks like in the operating room, but I suspect there is a unique opportunity for peri-op professionals to define, develop and practice it. Facilitated discussion among OR staff about the following questions could be a rich process.

Consider these questions


What does respectful communication look like in the OR?


What makes it challenging or different here?


What do we need to do to practice it?

Positive outcomes such as creating new norms, safer surgery, increased collaboration, personal and professional growth and improved morale are all possible!

Aligning practice with policy to improve patient care 27

28 The OR Connection

CE ARTICLE Visit and login or create an account. Choose your course to take the test and receive 1 FREE CE credit. Course is approved for continuing education by the Florida Board of Nursing and the California Board of Registered Nursing.

IN THE HEAT OF THE MOMENT Malignant Hyperthermia Calls for Action

by Katie Beam, DNP, RN, ACNS-BC, CWS

Clinicians, particularly nurses, working with patients during or after surgery understand that an emergency situation with a patient who has malignant hyperthermia (MH) instantly can become a matter of life or death. As a result, nurses should be aware of the signs and symptoms that identify malignant hyperthermia and know how to respond immediately and appropriately.1 The challenge for these clinicians, then, is assessing accurately which patients may have or be susceptible for having this rare condition and preparing adequately to handle any case of malignant hyperthermia before it becomes catastrophic for a patient and his or her family. The information in this article provides an overview of malignant hyperthermia, describes how nurses can prepare an effective malignant hyperthermia cart for use in their facilities and encourages nurses to connect patients and their families with appropriate resources about MH. Familiarity with this type of knowledge is crucial for staff members caring for patients who have received general anesthesia.1

Aligning practice with policy to improve patient care 29

MANAGING MALIGNANT HYPERTHERMIA at Dignity Health Woodland Healthcare, Woodland, CA Fortunately, we have not had a malignant hyperthermia (MH) case at Woodland for more than ten years. Nevertheless, we perform several drills every year and require nurses in the Perioperative, Emergency Department, Maternal Child and Intensive Care Unit (ICU) to complete 90 minutes of an annual MH Competency training that includes hands-on mixing of Dantrolene, and observation of a mock drill video from MHAUS. We also keep one fully stocked MH cart in our surgical services department and another one in our outpatient surgery center, which is located in a separate building adjacent to the hospital. The two carts are set up exactly the same way and each drawer of the MH cart is standardized to provide quick and easy access for needed supplies in an MH emergency. A laminated copy of the cart contents is kept on the top of each MH cart for reference and the drawers are labeled on the outside to assist the staff, and minimizes confusion. This is because many staff float between the surgery center and the main hospital OR. In addition, Dignity Health recently implemented the identical MH cart, educational program, policies, and procedures at their sister hospitals in the greater Sacramento/San Joaquin region of California. When a malignant hyperthermia (MH) episode occurs, we make an announcement on the overhead page system, “Your attention please, Malignant Hyperthermia Alert (location)” which prompts the nurse supervisor to locate the MH cart and bring it to the patient location within five minutes. Although MH often occurs in the OR, it could also

30 The OR Connection

occur in the emergency department (ED), intensive care unit or in the maternal/child unit in mothers who have Cesarean sections. We recently performed a drill with a mock MH patient in the ED, and the nursing supervisor arrived with the MH cart in two minutes and 45 seconds. Our next drill this year will involve a mock patient in the surgery center. The drill will involve the use of the MH cart for a patient in the recovery area of the surgery center and then test our system of communication and teamwork after stabilization from the initial MH event and transporting the patient to the emergency department at the hospital. From there, the MH patient will be admitted to the ICU for observation because 25 percent of patients who experience MH can have a spontaneous recurrence within 48 hours of the first episode. For this reason, all patients with MH must stay in the ICU for at least 48 hours after being treated and stabilized. Getting Dantrolene to our patient within the five-minute window, and making certain that our staff feels confident in recognizing and treating MH is a priority to our organization because treating MH is all about speed. MH occurs suddenly and affects multiple body systems simultaneously; the muscles, the heart, the brain, and the kidneys. Knowing how to recognize MH, how to prioritize treatments, understanding their roles in the care of the patient and how important it is to get Dantrolene on board quickly to reverse the hypermetabolic state that initiates the deadly MH cascade, will give our patients their best chance for survival.

Drawer 1

Woodland Healthcare MH Cart Contents




Drawer 3





Drawer 4 5



Aligning practice with policy to improve patient care 31

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Recognizing malignant hyperthermia

The Malignant Hyperthermia Cart

Malignant hyperthermia is a genetic disorder and a hypermetabolic, or biochemical chain reaction, response.2,3 Susceptible patients undergoing surgery may exhibit signs of malignant hyperthermia if they are exposed to the “trigger” muscle relaxant succinylcholine and select inhalation agents such as desflurane, enflurane, halothane, isoflurane, and sevoflurane.2-4

Health care facilities that use general anesthesia that could trigger MH must have a kit or a cart that contains all of the items needed to manage MH readily available.1,6,9 A basic MH kit or cart should include the following items1,6: Dantrolene, sterile water sufficient to dilute Dantrolene, D50, antiarrythmics, calcium chloride, sodium bicarbonate, insulin and furosemide.

The symptoms of MH can be very specific and include muscle rigidity, increased CO2 production, and fever escalating to 105 degrees F or higher.3,5 Masseter spasm, which manifests as jaw muscle rigidity and corresponds with limb muscle flaccidity after succinylcholine has been given, often is the first sign of malignant hyperthermia.6 It is important for clinicians to know that all patients who have had even mildly increased jaw tension should be observed carefully for signs of MH for at least 12 hours.6 Non-specific symptoms of MH can include tachycardia, tachypnea, metabolic and respiratory acidosis and hyperkalemia.3,5 Severe complications associated with MH include cardiac arrest, brain damage, internal bleeding or failure of other body systems, and even death.3

In addition, the items needed for patient monitoring include EKG, blood pressure, temperature, pulse oximeter and capnograph. It is also helpful to have an ice machine, a refrigerator, cooled intravenous fluids and cool blankets close at hand so these items can be used quickly to help lower the patient’s body temperature.1,6,9

How common is malignant hyperthermia? It is estimated that for every 5,000 to 50,000 patients who are given anesthetic gases, one patient may have malignant hyperthermia.7 Malignant hyperthermia is inherited in an autosomal dominant pattern,3,7 which means that an affected person usually inherits the altered gene from a parent who also is at risk for malignant hyperthermia.7 Carriers of the gene for MH may be unaware they have this risk unless they are aware of whether any of their family members has experienced MH after receiving anesthesia in the past.3 If malignant hyperthermia is suspected, it is essential for the nurse to get a thorough history of a patient’s experiences with anesthesia as well as any notable experiences that the patient’s close family members may have had with anesthesia.8

To practice how to use the items on the cart efficiently, it can be helpful for facilities to plan annual staff education to refresh their knowledge on MH and the procedures for recognizing and treating MH, and implementing a series of regular, planned mock “MH drills” that involves many health care team members. These drills enable all of the team members to practice providing the urgent care needed for a patient experiencing MH before an emergency arises.6 Because it can be difficult to dilute Dantrolene, especially on the first attempt at doing so, all staff members should be given an opportunity to practice diluting Dantrolene by using outdated vials of the drug during an MH drill.6 Staff members should check the MH cart routinely to remove expired supplies and replace them.1 The Malignant Hyperthermia Association of the United States (MHAUS) is an organization whose mission is to promote optimum care and scientific understanding of malignant hyperthermia and related disorders. MHAUS offers posters and wallet cards containing concise protocols that can be disseminated to staff or used during a drill or an educational session.1 The MH drill could mimic an MH crisis, which would require the staff to call the MH 24-hour hotline (emergencies only): 1-800-644-9737 (United States) or 00+1+303+389+1647 (outside the United States). Also, the drill could incorporate practicing the START emergency therapy for MH Acute Phase Treatment, as recommended by MHAUS.9

Aligning practice with policy to improve patient care 33

MH Drill Protocols Get help. Get Dantrolene. Notify surgeon.

Inject Dantrolene sodium 2.5 milligrams/ kilogram rapidly intravenously through a large-bore IV, if possible.

Provide a bicarbonate for metabolic acidosis.

Cool the patient.

Address dysrrhythmias: usually respond to treatment of acidosis and hyperkalemia.

Address hyperkalemia.

Resources for patients and families affected by malignant hyperthermia MHAUS has a variety of patient resources that can be accessed online or by attending a support group or meeting.11 Patients and families who have faced malignant hyperthermia, or who may recently have learned that they carry the gene for MH may find helpful information through this organization6 and by reading about and connecting with others who have experienced situations with MH. MHAUS manages a registry that keeps records of the family health histories and test results of patients with MH; the organization uses these data to conduct relevant research about malignant hyperthermia.11 Today’s techno-savvy patients and family members are always looking for reliable sources of medical information online. To help these patients find the type of electronically engaging yet technically sound information they are seeking, nurses might want to suggest that patients and family members view the videos about MH that MHAUS has posted on its website. 12 By watching these videos, patients and their families will learn valuable information; also, it is interesting to note that MHAUS highlights the important role that nurses play in caring for patients with MH.12

Follow this testing sequence: ETOC2, electrolytes, blood gases, CK, serum myoglobin, core temperature, urine output and color, and coagulation studies.

REFERENCES 1. Mitchell-Brown F. Malignant hyperthermia: turn down the heat. Nursing 2012;42(5):39-44. 2. Kaplow R. Care of postanesthesia patients. Crit Care Nurse 2010;30(1): 60-62. 3. Malignant Hyperthermia Association of the United States. What is MH? Accessed July 28, 2012. 4. Rosenberg H, Sambuughin N, Dirksen R. Malignant hyperthermia susceptibility. 2003 Dec 19 (updated 2010 Jan 19). In: Pagon RA, Bird TD, Dolan CR, et al., eds. GeneReviews [Internet]. Seattle: University of Washington; 1993-. Accessed July 27, 2012. 5. Medline Plus, U.S. National Library of Medicine, National Institutes of Health. Malignant hyperthermia. htm. Accessed July 27, 2012. 6. Greco RJ. Malignant hyperthermia: what are the first signs? The ASF Source; 2008;Summer:1,10.

34 The OR Connection

7. Genetics Home Reference, a service of the U.S. National Library of Medicine. Malignant hyperthermia. malignant-hyperthermia/show/. Accessed July 27, 2012. 8. Rosenberg H, Davis M, James D, Pollock N, Stowell K. Malignant hyperthermia. Orphanet J Rare Dis 2007;2(1):21. 9. Hutton D. Malignant hyperthermia: part 1. Plast Surg Nurs 2011;31(1):23-26. 10. Malignant Hyperthermia Association of the United States. Healthcare Professionals: During an MH Crisis. Accessed July 28, 2012. 11. Malignant Hyperthermia Association of the United States. Patients and families. Accessed July 27, 2012. 12. Malignant Hyperthermia Association of the United States. Videos. www. Accessed July 28, 2012.

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Reference 1 Saint S, Kaufman SR, Thompson M, Rogers MA, Chenoweth CE. A reminder reduces urinary catheterization in hospitalized patients. Jt Comm J Quality Patient Saf. 2005; 31(8): 455-462 2 Patient Safety Quality Measures for the Surgical Care Improvement Project (SCIP). Health Services Advisory Group. Available at: Accessed December 7, 2010. 3 Guideline for Prevention of Catheter-associated Urinary Tract Infections, 2009. Centers for Disease Control and Prevention. Available at: Accessed December 7, 2010. ©2012 Medline Industries, Inc. Medline is a registered trademark and InserTag is a trademark of Medline Industries, Inc.

Greening the

OR 36 The OR Connection

Greening the OR Can Yield Cost Savings and Healthier Communities By Francesca Olivier

Background Pollution is a serious public health concern that affects everyone, but it especially affects vulnerable populations such as the elderly, sick, children and the poor. At Medline we feel that preserving a healthy planet for future generations is not only the right thing to do, but it is our responsibility as leaders in the healthcare industry to do our part. Going green in the OR is one area of critical importance to Medline. We have developed the greensmart™ Program, a unique environmental training and education initiative designed to help health care facilities reduce costs, increase patient care and build healthier communities. A significant component of the program is a comprehensive roadmap that will help facilities develop a baseline for OR energy use and waste streams. The roadmap also provides facilities solutions on how to improve performance.

The Problem Operating rooms generate an enormous amount of trash – about 20-30% of a hospital’s total waste – and account for 86% of total hospital disposal costs. Since so much of a hospital’s waste is generated in the OR, it is not a surprise that many hospital green teams begin with OR nurses. In the chaos of the OR, packaging and general trash often end up in regulated medical waste (RMW), or red bag waste, even though it doesn’t need to be there. A Johns Hopkins study found that as much as 90% of what is thrown in red bag waste does not actually meet the criteria for regulated medical waste (RMW).

This represents an enormous opportunity not only for improved environmental impact, but also for cost savings through reduced RMW. Because of the sheer volume of supplies that pass through the OR, small incremental changes can add up to significant overall impacts. These impacts are both environmental and economic. Waste reduction reduces both immediate and ongoing disposal costs, while it reduces carbon emissions and the need for landfills and their associated risks.

The Approach With Medline’s greensmart™ sustainability program health care facilities have options in addressing sustainability challenges: facilities can execute the program on their own with the greensmart™ Roadmap and support of an expert in the field; they can employ an expert to complete a sustainable OR assessment; or, facility staff can be trained on how to complete the assessments and conduct follow-up evaluations. Regardless of the path taken, the result of the efforts will be measurable, both financial and environmental, and can help gain support for more sustainability efforts throughout the hospital. The recommended steps to reduce waste are: 1. Measure your Baseline To determine the opportunity for waste reduction and cost savings at your facility, the first step is to measure your baseline. Work with your housekeeping department to find out the annual volume of RMW disposed of every year by your hospital and the cost per pounds for that waste. Next, conduct a waste sort.

Continued on page 39

Aligning practice with policy to improve patient care 37

Program for Healthcare One-on-one sustainability guidance and services The greensmart approach for reaching your unique goals:

Measure Your Baseline

1 2

From calculations to benchmarking, your greensmart RoadMAP provides all the tools you need to green your OR, Housekeeping, Laundry, Food Services and Patient Rooms.

Receive One-on-one Consultation You will receive personal assistance from your dedicated greensmart Program Manager.

Identify Green Products and Strategies


With the help of your Program Manager, you will identify products, services and education that are right for your facility.


Monitor and Promote You are given the tools to not only monitor your progress, but to promote your success.

ONE CALL STARTS YOU ON YOUR WAY TO BECOMING GREENSMART Francesca Olivier, Medline’s corporate sustainability manager, is ready to work with you no matter where your facility is on your sustainability journey. Call her at (847) 643-3821 or email

©2012 Medline Industries, Inc. greensmart is a trademark and Medline is a registered trademark of Medline Industries, Inc. greensmart™ is not a third-party certification. The use of the greensmart™ trademark is determined by Medline Industries, Inc. through an internal review process of environmental claims.

Green Solutions for the Operating Room The Problem Disposable Forced-Air Patient Warming Blankets t$PTUFBDI t5ISPXOBXBZBGUFSFWFSZ QSPDFEVSF t$POTVNFBMPUPGFOFSHZ t-FUPVUIFBUJOUPUIF03










Aligning practice with policy to improve patient care 39

Going green in the OR will yield cost savings, increased patient satisfaction and a healthier community.

A waste sort is a means of cataloging what actually is put into red bag bins, and the weight of each item. This will tell you the level of compliance with your hospital’s RMW policies, as well as the cost savings opportunity through improved waste segregation practices. Through Medline’s greensmart™ program you can not only have this assessment completed for you, you can also be trained in the process so that you can complete your own follow-up evaluations to measure your progress. 2. Implement Environmentally-Friendly Products and Strategies There are several strategies that a hospital can take to reduce the waste generated by the OR. Remember – what comes into the OR must go out. By eliminating disposables and moving towards products with a longer life you not only reduce your contribution to the landfill, but reduce the costs associated with waste disposal. Here are some examples: 3. Market your Success Improving performance in health care is a significant accomplishment for a facility and should be communicated to patients, staff and the community. Going green in the OR can help a facility communicate efforts being made to improve efficiencies for staff, improve patient care and illustrate how a facility is reducing their carbon footprint. There are myriad

ways to promote such success through basic communication efforts including: t 6TFUIFJOUSBOFU CSFBLBSFBTBOEPUIFSJOUFSOBMSFTPVSDFT to communicate the successes to staff. t 6TF UIF JOUFSOBM UFMFWJTJPO OFUXPSL  XFCTJUF BOE PUIFS resources to communicate the successes to patients. t 8PSL XJUI ZPVS DPNNVOJDBUJPOT UFBN UP XFBWF UIFTF successes into the facility’s overall public relations plan. Conclusion The greensmart™ program is a strategic four-pronged approach that can help facilities: measure the baseline of their environmental impact; identify opportunities for environmental cost savings; monitor and report on progress; and, garner marketing assistance and education. By employing this comprehensive approach in the OR, hospitals will experience significant environmental outcomes and look at their ORs in a whole new light. Going green in the OR will yield cost savings, increased patient satisfaction and a healthier community. About the Author Francesca Olivier manages Medline’s sustainability program. She previously worked at the U.S. Environmental Protection Agency Region 5, in the Office of Enforcement and Compliance Assurance. Francesca received her bachelor’s degree from Loyola University, New Orleans, and a master’s degree in Environmental Management and Sustainability from the Illinois Institute of Technology.

greensmart™ is not a third-party certification. The use of the greensmart™ trademark is determined by Medline Industries, Inc. through an internal review process of environmental claims.

40 The OR Connection

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ANYM An introduction to the LEAN Process Improvement Methodology

E by Joan Ferrara, RN, BA, CNOR


Aligning practice with policy to improve patient care 43

Lean is a process improvement methodology developed by UIF5PZPUB$PSQPSBUJPO8IZBQQMZDBSNBOVGBDUVSJOHNPEFMT to providing surgical care? Thatâ&#x20AC;&#x2122;s a fair question that has been answered by many success stories across the country. Health care is an industry that is undergoing tremendous change. (PWFSONFOUT  SFHVMBUPSZ BHFODJFT MJLF UIF +PJOU $PNNJTTJPO and the public are holding healthcare providers to a higher TUBOEBSEUIBOFWFSCFGPSF3FJNCVSTFNFOUJTUJFEUPPVUDPNFT BOEQBUJFOUTBUJTGBDUJPO%PNPSFXJUIMFTTJTBNBOUSBJONBOZ 03T CVUIPXDBOJUCFEPOFXIJMFLFFQJOHQBUJFOUTTBGFBOE happy? The answer comes from industry. The aviation industry CFDBNF UIF HPME TUBOEBSE GPS QBUJFOU TBGFUZ $IFDLMJTUT XFOU GSPN UIF DPDLQJU UP UIF PQFSBUJOH SPPN "OE MFBO IBT NPWFE from automotive factories to hospitals, making small changes that result in big differences.

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What is lean all about? Just like trimming the fat from your meat, the goal of lean is to hold on to those things that have value and to get rid of the XBTUFUIBUBEETOPWBMVFUPBQSPDFTT3FEVDJOHXBTUFJTUIF cornerstone of Lean. Lean is frequently implemented along with 4JY4JHNB XIJDIJTBQSPDFTTJNQSPWFNFOUNFUIPEPMPHZUIBU TUSJWFT UP SFEVDF WBSJBUJPO -FBO BOE 4JY 4JHNB DPNQMFNFOU FBDIPUIFS1PPSMZEFTJHOFEQSPDFTTFT PSUIFMBDLPGBEFmOFE process, can waste time, steps or supplies. Leadership training is essential before beginning a lean project. 5IFPSHBOJ[BUJPONVTUJOWFTUJOGPSNBMUSBJOJOHPGLFZQFPQMFXIP will become the experts in the lean method. The leader of a lean team must be familiar with the methodology, and the team should include front line workers who live with the current practice and DBODPOUSJCVUFJEFBTGPSDIBOHF1SPKFDUTBSFJEFOUJmFE SFBMJTUJD goals are set, and the Lean methodology begins.


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44 The OR Connection




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place or does the cleaner have to leave the room and disrupt the work? How are the supplies for the next case gathered? "SFUIFZSFBEJMZBWBJMBCMFUPUIFSPPNTUBGG )PXNBOZUIJOHT need to be opened? How does the staff know what the surgeon OFFET GPS UIF OFYU DBTF  "SF UIFZ MFBWJOH UIF SPPN UP HFU TVQQMJFTPODFUIFTFUVQIBTCFHVO *TUIFOFYUQBUJFOUSFBEZ  )PXEPFTUIF03TUBGGLOPX 4PNBOZGBDUPSTQMBZJOUPHFUUJOH POFQBUJFOUPVUPGUIF03BOEUIFOHFUUJOHJUSFBEZGPSUIFOFYU The questions are answered and the process is documented in as much detail as possible. This step requires discussion and PCTFSWBUJPO&WFSZKPCDBUFHPSZJOWPMWFEJOUIFQSPDFTTTIPVME be represented on the team.


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46 The OR Connection

UIFTVSHFPO XIJDIJOUIF03JTBGUFSFWFSZDBTFXIFOBOPUIFS is to follow it. Then comes Perfection. This doesnâ&#x20AC;&#x2122;t mean the process is QFSGFDU *U NFBOT UIBU DPOTUBOU BUUFOUJPO JT NBEF UP GVSUIFS perfect the process. Little tweaks along the way adjust things BT DIBOHF IBQQFOT JO UIF 03 PS XIFO UIJOHT CFHJO UP TMJEF The lean methodology requires continuing attention even after a HPBMJTNFU$POUJOVFUPSBJTFUIFCBSBOETFUOFXHPBMT -FBOIBTQSPWFOUPCFWFSZFGGFDUJWFJOIFBMUIDBSF.JMMJPOTPG EPMMBST BSF TBWFE XIFO -FBO JT BQQMJFE UP UIF 4VQQMZ $IBJO  BOEUIF03JTHFOFSBMMZUIFMBSHFTUDPOTVNFSPGTVQQMJFT.BOZ PSHBOJ[BUJPOT DPNQMFUFMZ SFBSSBOHF TVQQMZ TUPSBHF BGUFS B -FBOBTTFTTNFOUJTQFSGPSNFE5IFCFOFmUUPUIFPSHBOJ[BUJPO is obvious in increased revenue, decreased spending, happy QBUJFOUTBOEIBQQZTVSHFPOT#VUXIBUBCPVUUIFTUBGG -FBO doesnâ&#x20AC;&#x2122;t advocate â&#x20AC;&#x153;do more with less.â&#x20AC;? Lean helps staff work TNBSUFS OPUIBSEFS*GBOVSTFDBOFMJNJOBUFUISFFGSBOUJDUSJQTUP the sterile core while starting a case, she will be more relaxed and less distracted from her most important task of taking care of the patient, less tired at the end of the day, and will feel a TFOTF PG DPOUSPM BOE BDDPNQMJTINFOU *G BMM NFNCFST PG UIF team work together, knowing what to expect of each other, the work day becomes less stressful and more productive. Who wouldnâ&#x20AC;&#x2122;t want that? *GZPVS03IBTOUHPOFMFBOZFU JUQSPCBCMZXJMM-FBOJTIFSFUPTUBZ

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48 The OR Connection

QUANTIFICATION of anesthesia providersâ&#x20AC;&#x2122; HAND HYGIENE in a busy metropolitan OPERATING ROOM: What would Semmelweis think? By Chuck Biddle CRNA, PhD & Jagdip Shah, MD

Background:)BOEIZHJFOF )) JTQPPSJOUIFIFBMUI care environment representing a major public health concern. HH compliance is poorly studied in anesthesia providers who contribute extensively to nosocomial infection. The rate of HH opportunities and compliance by these providers was studied using embedded, clandestine observers. We aimed to quantify HH behaviors BOEUBYPOPNJ[FGBJMVSFTMethods: Following intensive USBJOJOH PCTFSWFSTNBTRVFSBEJOHBTOVSTJOHTUBGGJO an academic center, observed the HH of anesthesia providers over a 4-week period throughout the periopFSBUJWFQFSJPEVTJOHB8PSME)FBMUI0SHBOJ[BUJPOUPPM HH opportunities and HH failures were recorded and

DBUFHPSJ[FE VTJOH B RVBMJUBUJWF DPOUFOU BOBMZTJT 3FTVMUT /FBSMZ   )) PQQPSUVOJUJFT XFSF PCTFSWFE ))PQQPSUVOJUJFTBWFSBHFEUPIPVSBOEQFBLFE TFWFSBMUJNFTBUIPVS"HHSFHBUFGBJMVSFSBUFXBT XJUIBSBOHFPGUPCZQSPWJEFSHSPVQ$PODMVsion: HH was very poor among anesthesia providers. The task density of anesthesia care may conspire with an intrinsic HH failure rate to create great opportunity GPSIPSJ[POUBMBOEWFSUJDBMWFDUPSTGPSOPTPDPNJBMJOGFDUJPO 0VS PCTFSWBUJPOT IBWF MFE UP BHHSFTTJWF FEVDBtional and ergonomic interventions at our facility. Given the task density of anesthesia care, and the observed failure rates, novel approaches to HH should be inves-

Aligning practice with policy to improve patient care 49

Recently investigators have focused attention on HAIs in the anesthesia workstation, demonstrating very clearly that pathogenic, drug-resistant organisms are regularly transmitted to and from patients via a variety of mechanisms during the technically challenging and task-dense period associated with anesthetic administration during surgical procedures.

5IFXPSLPGUIF7JFOOFTFPCTUFUSJDJBOBOETVSHFPO4FNNFMXFJT GSPNTPNFZFBSTBHPJTXJEFMZBDLOPXMFEHFEBTUIFmSTUUP promote handwashing as the simplest and most effective interWFOUJPO GPS SFEVDJOH OPTPDPNJBM JOGFDUJPO %FTQJUF UIF QBTTBHF PG UJNF  IPTQJUBMBDRVJSFE JOGFDUJPOT )"*T  DPOUJOVF UP PDDVS BU BOBMBSNJOHSBUF BGGFDUJOHQFSIBQTPGIPTQJUBMJ[FEQBUJFOUT  representing a true public health crisis, decried in both professional and lay publications. Whereas many factors contribute UP)"*T SFDFOUSFTFBSDIBOEFEJUPSJBMTJOQSPNJOFOUQVCMJDBUJPOT TUSPOHMZTVHHFTUUIBUMPXIBOEIZHJFOF )) SBUFTTIPVMEOPMPOger be viewed as simply a systems problem but rather a matter of personal accountability.&TUJNBUFTPG)"*TJOEJDBUFUIBU million occur each year with nearly 100,000 deaths resulting in the 6OJUFE4UBUFTBMPOF &WFOUIJTOVNCFSNBZVOEFSFTUJNBUFUIF problem because of the perplexing problem of under-reporting. /VNFSPVTTUVEJFTIBWFSFWFBMFEBOBQQBMMJOHMZMPXSBUFPG))CZ health care providers. These studies are most often limited by the OBUVSFPGUIFPCTFSWBUJPOTUIBUJT PCTFSWFSTBSFWJSUVBMMZBMXBZT positioned in an obvious manner, and even if the providers are not GVMMZBXBSFPGUIFPCTFSWFSTQVSQPTF UIFFGGFDU MJLFMZBOJNQSPWFNFOUJOUIFUBSHFUCFIBWJPST DBOOPUCFEJTDPVOUFECFDBVTFPG expectancy and the Hawthorne effect. 3FDFOUMZ JOWFTUJHBUPST IBWF GPDVTFE BUUFOUJPO PO )"*T JO UIF anesthesia workstation, demonstrating very clearly that pathogenic, drug-resistant organisms are regularly transmitted to and from patients via a variety of mechanisms during the technically challenging and task-dense period associated with anesthetic administration during surgical procedures. Whereas good HH is the cornerstone in preventing nosocomial disease transmission in the hospital setting, a growing body of literature suggests that anesthesia providers may contribute to the ongoing problem PG)"* We executed an observational study of the HH of anesthesia providers in a major, metropolitan medical center, using embed-

ded, highly trained, clandestine observers that to our knowledge SFQSFTFOUFEUIFmSTU VOJRVFMZWBMJEBOESFMJBCMFRVBOUJmDBUJPOPG HH during anesthesia delivery without any potential of observer JOnVFODF0VSHPBMXBTUPRVBOUJGZUIFSBUFPG8PSME)FBMUI 0SHBOJ[BUJPO 8)0 EFmOFE))CFIBWJPSTJOBSBOHFPGBOFTUIFsia providers during the real-time care of patients over the continuum of perioperative care. .&5)0%4 'PMMPXJOHJOTUJUVUJPOBMBQQSPWBMCZUIF$PNNJUUFFGPS1SPUFDUJPO PG)VNBO4VCKFDUTBU7JSHJOJB$PNNPOXFBMUI6OJWFSTJUZ.FEJDBM $FOUFS PCTFSWFSTUSBJOFEUPVTFB8)0))PCTFSWBUJPOGPSN and assessment inventory and masquerading as surgical nurses undergoing routine employee orientation to the operating room 03  XFSF SBOEPNMZ QMBDFE JO WBSJPVT QFSJPQFSBUJWF BSFBT PWFS the course of a 4-week period. The observers were savvy about UIF03NJMJFV BMMXFSF3/TOPUFNQMPZFECZUIFJOTUJUVUJPO BOE XFSFUSBJOFEVTJOHBTFSJFTPGmMNFEWJHOFUUFTPGUIFBDUJWJUJFTPG anesthesia providers as well as demonstrations conducted in a simulation laboratory and then rated the observed HH using the 8)0JOWFOUPSZ5IFUSBJOJOHQFSJPEXBTDPOUJOVFEVOUJMBL was achieved on observed HH opportunities and failures, requirJOHBQFSJPEPG IPVSMPOHTFTTJPOTPWFSBXFFLUJNFGSBNF 0CTFSWFSTXFSFBTTJHOFEBSPPNSBOEPNMZ XJUIPVUSFHBSEGPSUIF provider type they would be observing to avoid any clues of their purpose. Given the nature of the anesthesia and surgical process where a single team of surgical and anesthesia providers follows a given patient through the perioperative process, the study observers were able to continuously observe the anesthesia providers from UIFUJNFUIFZmSTUFODPVOUFSFEUIFQBUJFOU QFSGPSNJOHBIJTUPSZ and physical, placing intravenous lines and blood draws, obtainJOHDPOTFOU UISPVHIUIFFOUJSFJOUSBPQFSBUJWFQFSJPE BOEJOUPUIF recovery period where the provider eventually performed a handoff to the postanesthesia care unit staff. Throughout this period, the PCTFSWFSTSFDPSEFEPQQPSUVOJUJFTGPS))BOERVBOUJmFEBNJTTFE PQQPSUVOJUZBTB))GBJMVSF ))' VTJOHUIF8)0SFDPSEJOHUPPM Continued on page 52

50 The OR Connection



Exceeds FDA Requirements1

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©2012 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc. Sterillium is a registered trademark of Bode Chemie GmbH

Examples of a HH opportunity included, but were not limited to: t Hand cleansing prior to first interacting with the patient; t hand cleansing, gloving prior to arterial or IV line placement or other invasive procedure; t hand cleansing after any invasive procedure; t hand cleansing after manipulation of the airway (e.g.,.artificial airway placement, suctioning); t hand cleansing after hanging a blood product; t hand cleansing after touching the patient for surgical positioning; t gloving before and hand cleansing after suctioning of the airway; t hand cleansing after patient handoff; and t hand cleansing after retrieving a soiled or dropped item off the OR floor.

To avoid over penalizing a provider for a HHF, we elected to count a failure only once in a given sequence, that is, if a provider failed to perform HH after manipulating the airway or otherwise contaminating his/her hands and then began touching the anesthesia equipment (e.g., agent vaporizer, flowmeters, stethoscope, drug syringes, warming devices, and others), they were only counted for 1 HHF (i.e., a “missed opportunity”). This provided the most consistent and most conservative quantification of HHF rate but would, however, underestimate the degree of secondary contamination targets.

were thus accessible to the anesthesia provider. During the intraoperative phase, sinks with running water and soap were available immediately outside the OR, and alcohol-based hand scrub was available within easy reach of the anesthesia provider. During the immediate postoperative phase, sinks with running water and soap were available within 10 to 30 feet of each patient, and alcohol-based hand scrub was available within easy reach of the anesthesia provider. No signage or verbal “prompts” to perform HH were used over the course of the perioperative observation period.

The ORs at the study institution are typical of any large, metropolitan academic center providing services over the full range of surgical procedures with a diverse representation of patient morbidity. The anesthesia care providers include attending anesthesiologists, physician anesthesiology residents, off-service residents and medical students doing anesthesia rotations (neither were observed), certified registered nurse anesthetists, and student registered nurse anesthetists. Attending anesthesiologists provide medical direction to every surgical case and work in an anesthesia care team model as they oversee (most commonly) 2 operative suites with the varied providers.

As a condition of the institution’s human subjects committee, the observed behaviors of the various provider types were recorded in the aggregate. There was concern by the board that should differences in rates of failed HH occur between or among groups, that interdepartmental provider conflict might arise. Therefore, only descriptive statistics were performed with no inferential statistical analysis to ascertain provider group differences in HH behavior. Using a qualitative content analysis, we reduced the HH failures into mutually exclusive but all-encompassing categories.

Throughout the perioperative period, disposable gloves were available within easy reach of the provider. During the preoperative phase (examination, IV start, and other), sinks with running water and soap were available within 10 feet of each patient and

RESULTS Over the course of the 4-week period, 7,976 HH opportunities among the anesthesia providers actively engaged in clinical practice were observed, recorded, and electronically archived. Likewise, missed opportunities for HH were observed, recorded, and electronically archived.

Continued on page 54

52 The OR Connection


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Table 1

Taxonomy of hand hygiene failures by anesthesia providers Category of failure


Moving among patients during the perioperative assessment phase

Contacts patient during examination or IV start and goes on to contact another patient without appropriate HH

Before, during and after pain service

Placing a nerve block using “relaxed” aseptic technique. Failed HH before and after perioperative nerve block

Keyboard use with soiled hands when using electronic medical record-keeping

Keyboard use with soiled gloves on. Failure to perform HH before touching keyboard and other charting aides

Placement of IV lines and blood draws

Not wearing gloves during procedure. Failed HH before and after procedures involving vascular access

Preparing drugs and equipment

Drawing up drugs, preparing airway devices, IV fluid sets and other equipment with soiled hands for the next scheduled case with the case still in progress

Soiled gloves left on after airway access

Intubating or otherwise accessing the airway and failing to remove soiled gloves or perform HH before touching other items such as keyboard, flowmeters, and others

Soiled gloves left on after Foley catheter or central/arterial line manipulation

Touching the urinary collection bag or central/arterial line connection or access site without proper HH


Catch-all category for HH behavior such as picking up something that fell to the floor and using it (e.g., suction catheter, roll of tape, and others). Touching another room provider (e.g., shaking hands) with soiled hands. Opening sterile packages or opening anesthesia cart drawers with soiled hands.

HH, hand hygiene; IV, intravenous

t 5IFPWFSBMMGBJMVSFPG))SBOHFEGSPNUPCZ provider group with a mean aggregate failure rate of 82%. t %FQFOEJOHPOUIFQIBTFPGUIFQSPDFEVSF JOEVDUJPO  maintenance, emergence), we found indications occurring for HH at a rate that averaged 34 to 41 events per hour, especially at induction and emergence) and at times were as high as 54 per hour in certain types of cases (e.g., extensive blood loss, patients with particularly challenging airway issues, periods of high task density such as complicated emergence from anesthesia, and others). t 5IFNBKPSDBUFHPSJFT 5BCMF PG))GBJMVSFPDDVSSFEJOUIF following manner: 1. Moving between/among patients during the preoperative assessment phase; 2. before, during, and after pain service interventions (e.g., placing perioperative nerve blocks); 3. keyboard use with soiled hands when using electronic medical record keeping; 4. during the placement of IV and blood draws;

5. preparing drugs and equipment for the case to follow with soiled hands; 6. soiled gloves left on after airway manipulations such as endotracheal intubation, suctioning of the airway, laryngeal mask airway insertion, and others; 7. soiled gloves left on after Foley catheter or central or arterial line manipulation; and 8. other: picking up something off the floor (e.g., pen, tape roll, tongue blade, suction catheter) and using it. DISCUSSION Other researchers in multiple disciplines have demonstrated a significant failure rate in HH among health care workers using observational approaches that are likely to significantly influence provider behavior. The current study is unique in that it quantified the HH behaviors of anesthesia providers in a busy operating room in a large, metropolitan medical center using observers who were embedded in the operating room with easy visual access of the anesthesia providers throughout the perioperative course of care and whose intent was totally obscured from those observed.

Continued on page 95

54 The OR Connection


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56 The OR Connection



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Aligning practice with policy to improve patient care 57

58 The OR Connection

Another Article about

Safety Scalpels? Yes, but there’s new data by Natalie J. Mach, RN

How many articles have you read in the last decade about safety scalpels? How many safety scalpels has your OR trialed in the last decade? Hospital ORs and surgery centers have attempted to standardize on safety scalpels – with little success! There are a vast number of reasons or explanations, especially from surgeons, such as: T “I want to continue to use the blade I’m used to using.” T “It doesn’t feel the same.” T “I’ve never been stuck. Why should I use a safety scalpel?” (Note: This is predominantly true. It’s the surgical techs and nurses who get stuck according to national statistics.1) T “The plastic cartridge covering the blade obscures my vision.” T “This safety scalpel affects how I perform surgery.” All that being said, new data strongly suggest an increase in sharps injuries in surgical settings versus non-surgical settings since the national Needlestick Safety and Prevention Act was passed in 2000. Since the legislation was enacted, injury rates dropped 31.6 percent in non-surgical settings, but increased 6.5 percent in surgical settings. Most of the injuries were caused by suture

needles (43.4 percent), followed by scalpel blades (17 percent) and syringes (12 percent). Seventy-five percent of the injuries occurred during the use or passing of devices. Surgeons and residents were most often the original users of the injury-causing devices; nurses and surgical techs were typically injured by devices originally used by others.1 In addition, the Massachusetts Department of Public Health (MDPH) surveyed 99 facilities in 2004 specific to sharps injuries in the operating room. Some of their findings are as follows:  T Devices without safety features accounted for more than 78 percent (812) of sharps injuries in Massachusetts ORs in 2004  T 32 percent (1,038) of sharps injuries reported by Massachusetts hospitals occurred in the operating room  T Three categories of devices: suture needles, scalpels, and hypodermic needles, accounted for approximately 75 percent of all OR injuries Based on the Massachusetts data, opportunities exist for reducing sharps injuries within operating rooms. As sharps data is presented, it is always important to emphasize that underreporting remains a significant issue that varies according to occupation and facility. It is reasonable to assume, therefore, that these data underestimate the problem.

Aligning practice with policy to improve patient care 59

The 2010 data is alarming, but what conclusions can be drawn? In those areas where safety devices have been implemented, sharps injuries have decreased. In the operating room, where safety devices/safety scalpels largely have not been implemented, sharps injuries have risen. Many surgeons are still clinging to standard scalpels rather than making the conversion to safety scalpels. OSHA can ďŹ ne facilities a minimal amount up to ďŹ nes as high as $72,000 for â&#x20AC;&#x153;willfulâ&#x20AC;? violations.3 What if one of your family members became a sharps injury statistic? Would you feel any differently about safety products not being used in the workplace? The answer is obvious. The evaluation, use and standard practice of safety scalpels is only one piece of a total program concerning sharps safety. It is important for operating rooms to implement some, or all of the following to reduce and/or eliminate sharps injuries: 1. Safety scalpels 2. Passing trays 3. Neutral zones (elimination of hand-to-hand passing of scalpels or with other sharps) 4. Conscientiousness, consistency and commitment to reduce sharps injuries by the entire perioperative team. There are several resources available for employers and employees with regard to occupational exposures to blood and OPIM. First, of course, is the OSHA Bloodborne Pathogens Standard (29 CFR 1910.1030). Also available are â&#x20AC;&#x153;CPL 2-2.69 (November 2001). Enforcement Procedures for the Occupational Exposure to Bloodborne Pathogens, and many other related documents. To access this information, as well as information from OSHAâ&#x20AC;&#x2122;s Consultation and State Plan State OfďŹ ces, visit OSHAâ&#x20AC;&#x2122;s website at or call 1-800-321-OSHA. References  +BHHFS +  #FSRVFS 3  1IJMMJQT &,  1BSLFS (  (PNBB "& *ODSFBTF JO TIBSQT JOKVSJFT JO surgical settings versus nonsurgical settings after passage of national needlestick legis MBUJPO+PVSOBMPGUIF"NFSJDBO$PMMFHFPG4VSHFPOT  "WBJMBCMFBU  IUUQXXXODCJOMNOJIHPWQVCNFE"DDFTTFE+VMZ  2. Sharps injuries in the operating room. Massachusetts Sharps Injury Surveillance System Data, 2004. Occupational Health Surveillance Program, Massachusetts Department of Public Health. April 2008. Available at: UJPOBMIFBMUITIBSQTJOKVSJFTPQFSBUFSPPNEPD"DDFTTFE+VMZ  3. US Labor Departmentâ&#x20AC;&#x2122;s OSHA cites Paradise Park Assisted Living in Lake Zurich, Ill., with safety and health violations after needle stick injury [news release]. Lake Zurich, Ill: US Department of Labor OfďŹ ce of Public Affairs: May 3, 2011. Available at: http://  JE"DDFTTFE+VMZ 

60 The OR Connection


Children’s Activities

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Sterile Processing

Q &A

Michele with DeMeo

Sue MacInnes, editor of The OR Connection, recently had the opportunity to interview Michele DeMeo, a sterile processing professional who is considered an expert by her peers and the FDA. She was nominated and approved by the FDA as the single sterile processing expert on their overarching device committee and as SGE or special government employee for her work in helping with national and international standards development. She has also written columns for major healthcare publications and developed soft goods and statistical tools. She is a sterile processing consultant, IAHCSMM-approved instructor, course developer and chair of several national and international committees for major healthcare associations. Michele has authored over 100 articles, drafted textbook chapters, and has written three books on topics outside of the sterile processing field. She also received IAHCSMM’s highest award, Educator of the Year for 2011 and AAMI’s first Shining Star Annual Award. She was listed in Infection Control Today magazine in 2011 as one of the top 25 Who’s Who to know in Infection Prevention. Michele was diagnosed with amyotrophic lateral sclerosis (ALS, also known as Lou Gehrig’s disease) in 2010, and she readily accepts that the diagnosis is terminal, giving her only three to five years to live.

Aligning practice with policy to improve patient care 63

Sue MacIn nnes:


Miche ele De eMeo: Twenty years is a long time but, sterile processing has been my longest love and greatest passion. The specialty caught my eye about 22 years ago as a technician, and I still cannot shake my interest in it. Some habits become so ingrained in us we have no choice but to go along for the ride. Seriously, there was something missing when I was a UFDIOJDJBO 5JNFT GPS UIF TUFSJMF QSPDFTTJOH EFQBSUNFOU 41%  and the OR were much different 20 years ago compared with UPEBZ 41% XBT OPU SFTQFDUFE  BOE NBOZ IPTQJUBMT TUJMM XFSF OPUBMMPXJOH41%UFDIOJDJBOTUPUPVDI IBOEMFPSQSPDFTTiUIFJSw JOTUSVNFOUT5IFJOTUSVNFOUTXFSFCFJOHTFOUTJNQMZUPiCFQVU JOUPUIFTUFSJMJ[FSw5IFSFXBTBGBMTFTFOTFUIBUJGBOVSTFXBT QVUUJOHUIFJOTUSVNFOUTUPHFUIFSBOE41%UFDIOJDJBOTXFSFiKVTU TUFSJMJ[JOHw UIFN  UIFZ XPVME CF TBGF GPS VTF 5IF TUFSJMJ[BUJPO QSPDFTTJTTPNVDINPSFDPNQMFYUIBOTJNQMZMPBEJOHBDBSU  QVTIJOHJUJOUPUIFTUFSJMJ[FSBOEQSFTTJOHTUBSU I suppose, to better answer your question, the challenge of changing the worldâ&#x20AC;&#x2122;s perception of what we could provide in UFSNT PG TFSWJDF BOE UIF DPNQMFYJUZ PG UIF TUFSJMF QSPDFTTJOH job itself are the things that have kept my interest. My goal has been to try to chip away misperceptions person by person, hospital by hospital, and year after year to work toward shared ownership and peer relationship development between surgical services and sterile processing.

SM: 8IBU JT ZPVS JNQSFTTJPO PG UIF DVSSFOU SFMBUJPOTIJQ CFUXFFOUPEBZT03TBOE41% BOEXIBUEPZPVFOWJTJPOGPS UIFGVUVSF MD: The work of many pioneers before me made the greatest JNQBDUJODSFBUJOHBOFXEBZ TPUPTQFBL GPS41%BOETVSHJDBM services. I have always been interested in relationship mending or building right alongside improving both administrative and UFDIOJDBM FOWJSPONFOUT XJUIJO 41% BOE TVSHJDBM TFSWJDFT 4P  for me, I have witnessed and sometimes contributed to clearer boundaries, more transparency, and better intra-dependency. 'SBOLMZ SFDPHOJ[JOHUIFiJOUSBEFQFOEFODZwJTBUXPXBZQBUI 41% BOE TVSHJDBM TFSWJDFT DBOOPU GVODUJPO JOEFQFOEFOU GSPN each other without something or someone being compromised in some fashion.

64 The OR Connection


The challenge of changing the worldâ&#x20AC;&#x2122;s perception of what we could provide in terms of service and the complexity of the sterile processing job itself are the things that have kept my interest.â&#x20AC;?


We owe o it to our patients to encourage and support every person who touches the very instruments that can either help or harm surgeons and patients.â&#x20AC;?


SM: How will passage of this bill beneďŹ t the OR, especially, TJODFJUNBZNFBOBEEJUJPOBMDPTUT





Yes, without a single doubt. But it is not a simple TJUVBUJPO UP DPSSFDU 0VS 41% UFDIOJDJBOT VTVBMMZ BSF OPU BT respected in facilities. By this I mean that educational funds VTVBMMZBSFOPUBMMPUUFEUP41%BUUIFTBNFMFWFMBTPUIFSVOJUT or the OR. Resources, in general, are tight, and with a lack of full VOEFSTUBOEJOHPGUIFEJGmDVMUUBTLTBOEUJNFQSFTTVSFT41%TBSF put through, change and improvement in skills will have some road bumps. However, they are not at all insurmountable. In fact, I believe we can learn many lessons from each other by partnering more with our surgical units and allowing more personal interface between the two departments at the staff level.



Funny you should ask. I helped draft the language of a sterile processing bill sitting with State Representative Maureen (JOHSJDI JO 1FOOTZMWBOJB 5IF *OUFSOBUJPOBM "TTPDJBUJPO PG Healthcare Central Service Materials Management (IAHCSMM) later was brought in and added considerably to the subsequent drafts. The bill is now being co-sponsored by the U.S.

Department of Health and Human Services. My hope is that 1FOOTZMWBOJB JT UIF UIJSE TUBUF JO UIF 6OJUFE 4UBUFT UP SFRVJSF certiďŹ cation.

There is plenty of free or low-cost continuing education available for sterile processing technicians to maintain their certiďŹ cation. The cost of this education is a fraction of the cost of a single surgical infection that could be linked to a poorly QSFQBSFEUFDIOJDJBOQSPDFTTJOHDPNQMFYJOTUSVNFOUBUJPO 8F PXF JU UP PVS QBUJFOUT UP FODPVSBHF BOE TVQQPSU FWFSZ person who touches the very instruments that can either help or harm surgeons and patients. The only sticking point is in mOEJOHGVOEUPNBLFUIJTIBQQFO8FXBTUFTPNVDINPOFZ PO PUIFS SFTPVSDFT XF SBSFMZ VTF PS CFOFmU GSPN JG TPNF PG those practices stopped or decreased, then allocation of funds could be shifted differently to beneďŹ t more critical stakeholders. Sterile processing technicians deserve the same level of funding for education as any surgical department. They are no less responsible for outcomes than surgical personal. They simply QSPWJEF UIF UFDIOJDBM FMFNFOU WFSTVT UIF DMJOJDBM CVU CPUI elements go hand-in-hand. That means both deserve the same opportunities for improvement, because they both ultimately affect each and every surgical patient.


Aligning practice with policy to improve patient care 65


Allow for more interaction between the units, not just when an error has been made or in the midst of a crisis. Instead, DPOTJEFSJODMVEJOH41%JOFWFSZEBZPQFSBUJPOBMBDUJWJUJFT5IJT JT UIF POMZ XBZ 41% UFDIOJDJBOT BSF HPJOH UP CF BCMF UP USVMZ understand the type of pressure OR nurses and physicians FYQFSJFODFFWFSZEBZ*BNBIVHFBEWPDBUFPGIBWJOHBNFNCFS PG 41% BUUFOE NPSOJOH 03 HSPVQ NFFUJOHT BOE SBOEPN BOE EBJMZ03TVJUFiSPVOEJOHwUPDIFDLJOXJUIUIFDJSDVMBUJOHOVSTFT and charge nurse and even doctors to ask about schedule DIBOHFTPSBEEJUJPOTUIBUXJMMJNQBDUXPSLnPXXJUIJO41%*GUIF ORâ&#x20AC;&#x2122;s needs change, and those needs are not communicated, UIF 03 TUBGG XJMM OPU SFDFJWF XIBU UIFZ OFFE GSPN 41% * TFF this as a shared responsibility for open communication to occur CFUXFFO41%BOEUIF03 Building better communication and collaborating on projects in the future, together, will help, too, not just putting out ďŹ res in the moment. Identify risks as a joint effort and mitigate them together as a team. Neither group, alone, will have the correct BOTXFS JU XJMM MJF TPNFXIFSF CFUXFFO UIF UXP QPJOUT PG WJFX and best practices for both specialties.


I understand that our readers will be hearing more from ZPV1MFBTFTIBSF


Yes, I thought I was retired, but it seems I am not so ready to relinquish everything. Everyone needs a purpose, and I pitched an idea for a short column in The OR Connection. 4P XIFO*UIPVHIU*XPVMEIFBSiXFXJMMUIJOLBCPVUJU wBOE* BDUVBMMZIFBSEiXFMPWFUIFJEFB w*LOFX*TUJMMIBEBQVSQPTF* believe people should give all they can give. I am not done yet, and where else can someone with a love of surgical services and sterile processing best ďŹ t that with you. Turn to page to read the ďŹ rst article in my new sterile processing column. Yes, I do have ALS, a terminal disease, but I believe that is all the more reason for me to write the column. I have lots to say and likely little time to share all my ideas, hopes and dreams for the sterile processing profession. I have completed many future articles to ensure my ideas get printed long after I may be gone. Every nurse knows you need a contingency plan. They have taught me well!

Read Michele DeMeoâ&#x20AC;&#x2122;s Inspiring Book

The Beauty of a Slow Death There is no question, in her 39 years, Michele DeMeo has truly lived. In her book, she shares that in some ways, her life really began when she was diagnosed with amyotrophic lateral sclerosis (ALS), a terminal disease. Some might question why a person nearing the end of life would consider spending time writing a book. But GPS .JDIFMF  QVUUJOH IFS FYQFSJFODF JOUP XSJUJOH XBT OPU KVTU B DBUIBSUJD FTDBQF  but rather a way to help others learn to live in a more deliberate, thoughtful and meaningful way.

Proceeds go to the International Association of Healthcare Central Service Materiel Management (IAHCSMM).

5IF CPPL JODMVEFT BO i"GUFSXPSEw XSJUUFO CZ .JDIFMFT QBSUOFS  +PIBOO #FDLFS )FSFJTBOFYDFSQUi8FIBWFTIBSFEUIJTKPVSOFZUPHFUIFSBOE*XJMMDPOUJOVFSJHIU by her side. Already sheâ&#x20AC;&#x2122;s fading around the edges. Itâ&#x20AC;&#x2122;s okay, because sheâ&#x20AC;&#x2122;s given NFUIFCFTUHJGUFWFSoUIFBXBSFOFTTUIBUTIFTMJWFEBMJGFPGQVSQPTFyw The Beauty of a Slow Death is available at

66 The OR Connection

Portrait of a Life Well-lived The Canvas is a painting created by Michele DeMeo, who believes in passion, improvement and beauty, even in the darkest times. Sheâ&#x20AC;&#x2122;s created The Canvas as a legacy to her life and her dedication to the sterile processing ďŹ eld.

Aligning practice with policy to improve patient care 67

a Journey to It began as a blank white stretched canvas to be MBZFSFEXJUIDPMPSFEPJMQBJOUEFQJDUJOHBYJODI abstract rendition of the circle and progression of life showing that people can build themselves up, make their own way to ďŹ nd contentment and create a space literally or ďŹ guratively where peace can be found by sheer determination. Michele wanted a symbol to outlast her, and so with brushes taped to her ďŹ ngers, The Canvas was born. It is a traveling piece of art on a year long journey to some of the best and most important places Michele thought it should be displayed. Most of the locations along the way are related to Micheleâ&#x20AC;&#x2122;s lifelong career in sterile processing. At the end of its journey, The Canvas will reside permanently at the International Association of Healthcare Central Service Materiel Management (IAHCSMM) headquarters in Chicago, where Michele is donating the piece.

Memorial Hospital :PSL 1" Memorial Hospital was selected because it shares my values in care and I have the utmost respect for its mission, vision and leadership led by an incredible, gifted, LJOEIFBSUFEBOETLJMMGVMXPNBO 4BMMZ+%JYPO

The Food and Drug Administration (FDA) Silver Spring, MD The Food and Drug Administration (FDA) is an PSHBOJ[BUJPOUIBUIBTUIFBCJMJUZUPNBLFSFBM change here in the United States. I accepted the nomination to be on their team because UIFSFXFSFOPPUIFSTUFSJMFQSPDFTTJOHFYQFSUT I felt it was a duty. I believe it is working toward complete device improvement and taking input from surgical services and sterile QSPDFTTJOHFYQFSUTTFSJPVTMZ

68 The OR Connection

Locations Key Surgical &EFO1SBJSJF ./ Key Surgical is a great company and a TJHOJmDBOUiCBDLFSwGPSThe Canvas and pledged enough to earn the opportunity to choose one of the locations.

Gabrielâ&#x20AC;&#x2122;s at The Ashbrooke Inn 1SPWJODFUPXO ." For personal reasons, Gabrielâ&#x20AC;&#x2122;s was chosen since it has been my second home for 23 years. It has been my private refuge at least once a year for a long time. There is no other place in the world like it and it is one of the only places I vacation and always will be. There is a sense of both magic and peace within the compound. Iâ&#x20AC;&#x2122;ve watched this 15-year-old inn morph from a work in progress into an oasis, without losing its soul.

The World Health Organization (WHO) (FOFWB 4XJU[FSMBOE 5IF8PSME)FBMUI0SHBOJ[BUJPOTFSWJDFT so many countries and is diverse in its FYDFMMFODF*CFMJFWFJOJUTQVSQPTF

AORN Denver, CO The Association of peri-Operative Nurses "03/ JTBOPSHBOJ[BUJPOEFBSUPNZIFBSU*UT QVSQPTF NJTTJPOBOEFYFDVUJPOPGPCKFDUJWFT JTVOQBSBMMFMFE*TFSWFEGPSUIJTPSHBOJ[BUJPO because I see sterile processing and surgical services as a team

The Hospice Foundation of America 8BTIJOHUPO %$ The moment I heard the voice of Hospice Foundation CEO Amy Tucci, I knew I had to include the Hospice Foundation in the year long journey of The Canvas. Hospice is pivotal to those who are terminal, but not just for the last few days of a personâ&#x20AC;&#x2122;s life. Rather, hospice is a program and service that can help ease patients and families through the sometimes long journey of tough news and death.

Advanced Sterilization Products (ASP) Irvine, CA "41TQBSLFEBOJOUFSFTUJONFGPSTUFSJMF processing from a job I had as a teen into a lifelong career. Thank you, Cynthia Spry.

The Seaver Center for Autism, Mount Sinai School of Medicine New York, NY The Seaver Center is a premier autism facility that worked closely with me during my diagnosis and subsequent studies.

The ALS Clinic at Hershey Medical Center )FSTIFZ 1" I selected this facility for its team of professionals with heart and incredible skill. The team helped me navigate my way through the most challenging news in my life with kindness, great resources and leadership HVJEFECZFYQFSUJTFPOBMMMFWFMT

Association for the Advancement of Medical Instrumentation (AAMI) Arlington, VA I could not leave off the MJTUUIFPOFPSHBOJ[BUJPO that I had worked with for years helping to shape standards, draft articles and lending a hand in developing a useful and needed tool for the world to look to as a widely WJFXFEiTUBOEBSEw in best practices for sterile processing and TUFSJMJ[BUJPO*IBWFUIF utmost faith in AAMIâ&#x20AC;&#x2122;s ability, goals, vision and leadership.

Betty Hannaâ&#x20AC;&#x2122;s Home Chicago, IL Betty, well, there are not enough words to say why The Canvas had to visit Betty Hannaâ&#x20AC;&#x2122;s home. She leads the International Association of Healthcare Central Service Materiel Management (IAHCSMM). I look up to her and I believe in her, and I am proud of what she has accomplished for our profession with such kindness and a soft approach. Her style of leadership sings to me, and I believe it reaps longer lasting results.


Aligning practice with policy to improve patient care 69

So You Really Think That Surface Is Clean? by Lorri A. Downs RN, BSN, MS, CIC

Healthcare professionals often ask..... â&#x20AC;&#x153;Is that room or reusable piece of medical equipment clean?â&#x20AC;? How do you know? Infection prevention starts with hand IZHJFOF IPXFWFS  XIBU BCPVU UIF IFBMUIDBSF FOWJSPONFOU  $MFBOJOH BOE EJTJOGFDUJPOJTDSJUJDBMJOFWFSZTFUUJOHGSPN the physicianâ&#x20AC;&#x2122;s ofďŹ ce, ambulatory surgery centers to hospitals and long-term care. Surface cleaning and disinfection can help reduce the risks of healthcareacquired infections. Improved hand hygiene and better JTPMBUJPO QSBDUJDFT IPXFWFS  IBWF UIFJS limits. A plethora of evidence points to the importance of proper cleaning and disinfection. Eight recent studies have conďŹ rmed that patients occupying rooms previously occupied by patients with Vancomycin-resistant enterococcus (VRE), MRSA, Clostridium difďŹ cile (C. diff.) and Acinetobacter baumannii JOGFDUJPOT  PS DPMPOJ[BUJPO  IBWF on average a 73 percent increased risk of acquiring that same pathogen than patients not occupying such rooms. i'JWF TUVEJFT IBWF SFDFOUMZ TIPXO UIBU improved routine disinfection cleaning QSBDUJDFJTBTTPDJBUFEXJUIBOBWFSBHF percent decrease in transmission of VRE, .34" BOE"CBVNBOOJJw1

70 The OR Connection


for Cleaning and Disinfecting Healthcare Settings

1. Purchase EPA-labeled healthcare grade disinfectant products and apply per the manufacturer’s label. 2. Know the “wet contact time,” which means the amount of time the surface must remain wet (with the chemical) to disinfect that surface. 3. More is not better. Use exactly the amount of cleaning and disinfection product needed to get the job done.

4. Know how to clean and disinfect each piece of reusable medical equipment with the appropriate product to avoid damaging the equipment or voiding the warranty. 5. Always provide and use appropriate personal protective equipment prior to performing any cleaning activities.

Key culprits of healthcare-acquired infections can survive on dry surfaces for varying amounts of time, as shown below.


Length of time survives on surfaces

Methicillin resistant Staphyloccocus aureus (MRSA)

1-56 days 2

Clostridium difficile (C diff.) spores

15 mins up to 5 months 3

Vancomycin resistant E. coli (VRE)

7 days to 4 months 4

Acinetobacter baumannii

29 days 5

High touch or high risk objects (side rails, call lights, light switches, door knobs, toilet handles, telephone, chairs, commodes, bedside tables, and bedside trays) certainly need attention due to the repeated contamination from patients or healthcare workers hands when assisting with patient care. The term “high risk areas” is not scientifically defined, so it is important to remember all areas of the environment to effectively clean and disinfect. Cleaning and disinfection “best practices” usually involve a onestep method using a detergent-disinfectant. No pre-cleaning is necessary unless a spill or gross contamination has occurred.

6. Maintain a current list of all approved cleaning and disinfection products your facility purchases and prohibit staff from bringing products from home. 7. Select cleaning products that are a detergent and disinfectant in one. 8. Set a “regular “ (daily, weekly, monthly) routine cleaning schedule (depending on items and areas that are being cleaned ), and then train and assign staff to complete.

Best Practices for Daily Cleaning and Disinfection6 ■ Perform hand hygiene and apply gloves ■ Place wet floor sign at door ■ Discard disposable items and remove waste and soiled linen ■ Disinfect (damp wipe) all horizontal, vertical and contact surfaces with a cotton (or microfiber) cloth saturated with a disinfectant-detergent solution ■ Spot clean walls (when visually soiled) with disinfection-detergent and windows with glass cleaner ■ Clean and disinfect sink and toilet ■ Stock soap and paper towel dispensers ■ Damp mop floor with disinfectant-detergent ■ Inspect work ■ Remove gloves and wash hands

Continued on page 73


Intelligent Room Sterilization

A room can look clean, but looks can be deceiving. Powerful, Safe and Intelligent Powerful IRiS emits UV-C rays that produce a 3 to 6 log reduction in colony-forming units.1

Safe IRiS has redundant safety features to help prevent inadvertent exposure to UV-C. IRiS is chemical-free, so there’s no need to cover windows or seal heating/ ventilation systems. It’s even safe to view from outside the room.

Motion Sensors – on IRiS and for anging on roomaccess door handles.

Intelligent Dose Assurance – With special sensing technology, IRiS automatically determines the perfect UV-C dose for any room size. Steri-Trak™ Service Documentation – Advanced patent-pending technology provides real-time documentation of all disinfections. Steri-Trak is customizable and Web-based for maximum convenience. ©2012 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

Additional Considerations 6

Properties of an Ideal Disinfectant 6

■ Use EPA-registered disinfectant-detergent (if prepared on site, document correct concentration)

■ Broad-spectrum antimicrobial

■ Clean surfaces should appear visibly wet and should be allowed to air dry at least one minute ■ Change mop water containing disinfectant every three rooms and after every isolation room ■ Change cotton mop heads after isolation room cleaning and after blood borne pathogen spills (change microfiber after each room) ■ Clean from the cleanest areas to the dirtiest areas (the bathroom would be cleaned last followed by the floor)

■ Fast acting-should produce a rapid kill ■ Not affected by environmental factors-active in the presence of organic matter ■ Nontoxic-not irritating to user ■ Surface compatibility-should not corrode instruments and metallic surfaces ■ Residual effect on treated surface-leave an antimicrobial film on treated surface ■ Easy to use

■ Change cleaning cloths after every room and use at least three clean cloths per room, but typically five to seven clean cloths

■ Pleasant odor or odorless

■ Do not place cleaning cloths back into the disinfectant solution after using to wipe a surface. Change to a clean cloth instead.

■ Soluble (in water) and stable (in concentrate and use dilution)

■ Daily cleaning of certain patient equipment is the responsibility of other healthcare practitioners (often nursing) ■ Surfaces should be wiped with a clean cloth soaked in disinfectant

■ Economical-cost should not be prohibitively high

■ Nonflammable

Innovation in products and processes to help with surface disinfection are rapidly entering the marketplace. Three which have emerged to help facilities ensure consistent and effective cleaning and disinfection are: 1. Ultra violet (UV) light

Now that we have reviewed how to clean, let’s review how to select the ideal disinfectant.

2. Microfiber products 3. Adenosine triphosphate (ATP) bioluminescence tests

In 1995 Dr. Rutala published a list of properties in an ideal disinfectant. Listed in the box are the ideal properties from their collective research. Consideration of this list will help you as you evaluate your chemical disinfectants.

In today’s healthcare arena the environment cannot be overlooked. Maintaining a clean and sanitary environment is the responsibility of everyone who works in every healthcare setting. Aligning practice with policy to improve patient care 73

ATP (adenosine triphosphate) bioluminescence tests Ultra Violet (UV) Light Irradiation 7 (No touch surface disinfection) UV light irradiation has been used to control pathogenic microorganisms in a variety of applications, such as control of legionellosis, as well as disinfection of air, surfaces, and instruments. UV light at certain wave lengths will break the molecular bonds in the DNA, there by destroying the organism. The efficacy of UV irradiation is a function of several different parameters, such as intensity, exposure time, lamp placement, and air movement patterns. This technology supplements but does not replace standard cleaning and disinfection because surfaces must be physically cleaned of dirt and debris

This technology helps to monitor adequacy of surface cleaning. ATP testing uses a chemical that gives off light when it reacts with ATP (adenosine triphosphate). A swabbed sample is placed in the chemical and inserted into the hand held unit. The light detector determines the amount of ATP present in the sample. ATP is found in all animal, plant, bacterial, yeast and mold cells. Blood and bioburden contain large amounts of ATP. Microbial contamination contains ATP, but in smaller amounts. If the surface was cleaned adequately, then ATP levels should be significantly reduced. This new testing can help managers measure the effectiveness of the cleaning and disinfection of reusable medical equipment throughout the healthcare organization.

Microfiber Microfiber is a strong, lint-free and ultra fine material with a dense matrix. These properties make it an idea cleaning tool. Microfiber cleaning materials are a blend of microscopic polyester and polyamide fibers. These fibers form microscopic “hooks” that scrape up and hold dust, dirt, and grime. They are 1/16 the thickness of a human hair and can hold six times their weight in water.8 The positively charged fibers attract the negatively charged dirt and dust.

References 1. National Institute for Occupational Safety and Health (NIOSH). How to protect yourself from needlestick injuries. Available at: Accessed March 9, 2012. 2. Pyrek KM. Study raises ongoing issue of passive vs. active safety-engineered sharps devices. November 2, 2010. Available at: Accessed March 9, 2012. 3. American Nurses Association. 2008 Study of Nurses’ Views on Workplace Safety and Needlestick Injuries. Available at: (ANA/Invira) 4. Centers for Disease Control and Prevention. Workbook for Designing, implementing, and Evaluating a Sharps Injury Prevention Program. Available at: Accessed March 9, 2012. 5. O’Connor D. The most dangerous job in surgery? Outpatient Surgery Magazine. March 7, 2012. Available at: Accessed March 9, 2012.

74 The OR Connection

Medline Safety Syringes

Protect yourself and patients from needlestick injuries Safety features so you wonâ&#x20AC;&#x2122;t get stuck

To Prevent Transmission of Infections in Healthcare

A staggering 74 percent of nurses report being stuck by a contaminated needle,1 which can lead to infection with Hepatitis B and C, HIV, and other dangerous bloodborne pathogens. Avoid needlesticks with Medline Safety Syringes. After injection, slide the safety shield forward and simply twist clockwise. Once you hear a click, the needle is fully protected and the syringe is ready for safe and proper disposal. Medline Safety Syringes also feature: t-PXEFBETQBDFEFTJHOUPSFEVDF medication waste and expense

Injection Safety is Every Providerâ&#x20AC;&#x2122;s Responsibility


Š2012 Medline Industries Inc. Medline is a registered trademark of Medline Industries, Inc.

Reference 1. American Nurses Association. 2008 Study of Nursesâ&#x20AC;&#x2122; Views on Workplace Safety and Needlestick Injuries. Available at: Accessed March 16, 2012.

WO Once Wolf J. Rinke, PhD, RD, CSP

To me worrying is like backward goal-setting. Because when you worry you are vividly imagining all of the things you do not want to have happen! And boy, do we like to worry. According to one study four out of five Americans said that they worry. (That’s 80 percent of us doing the backward goal-setting thing.) The poll, conducted by Barna Research, asked adults what are “the most pressing challenges and difficulties you

76 The OR Connection

face.” Among those who worried, 28 percent said that they worried about finances, 19 percent identified health, 16 percent mentioned career issues, followed by parenting concerns (11 percent), family relationship issues (seven percent) and goal accomplishment challenges (seven percent). Research further indicates that women tend to worry more than men. For example, in a study of 1,044 women in the U.S. conducted by Bruskin Audits and Surveys Worldwide, 50

RR and for all percent reported that they experience anxiety symptoms and worry for a period of more than six months. In addition, one out of 10 women describes herself as having “unrealistic” or “excessive worry.” What makes these findings startling is that most of us appear to have little to worry about. In fact, 78 percent of the Barna Research poll’s respondents rated themselves as completely or mostly satisfied with their lives.

I find our propensity for worrying particularity perplexing, since only eight percent of our worries are “legitimate”—that is, they are under our control. The other 92 percent are “worthless worries” also known as the coulda, shoulda, woulda syndrome. That’s when you engage in “catastrophizing” convincing yourself that a stomachache means that you have an ulcer and an “angry” look by your spouse means that you are about to get a divorce. Worthless worry is when we try to solve what can’t be

Aligning practice with policy to improve patient care 77

solved because it has already happened, will never happen or is simply not under our control. According to psychiatrist Edward M. Hallowell, worry can depress us, destroy our relationships, and sap our energy and joy of living. Struggling with perpetual “what if” scenarios can make us physically sick with back pain, recurring headaches and digestive disorders. It may even weaken the immune system, leading Dr. Hallowell to conclude that chronic, persistent worry is just as dangerous as high blood pressure.

Not to worry -pun intended -- I have delineated an eight-step process to help you get rid of worries once and for all:

Step 1 Clarify what it is that you are worried about. The best way to do this is to write it down, because it gets it out of your head. Step 2 Ask yourself if there is anything you can do to affect the situation. If not, it’s a worthless worry -skip to Step 8. If you can affect the situation, go to the next step. Step 3 Identify the worst possible outcome. Step 4 Ask yourself if you can live with the worst possible outcome. If so, go to Step 6. If not, go to the next step. Step 5 Do everything in your power to solve the problem right now. Step 6 Make an action plan that will solve the problem entirely or minimize its bad consequences. Step 7 Take action. Step 8 Quit worrying. Either it’s too late or worrying won’t make a bit of difference.

78 The OR Connection

Of course you can do what I do, and reduce this 8-step “Worry Buster” process down to 2 steps:

Step 1 What will happen if I worry about this really well? If the answer is “nothing,” quit worrying. If on the other hand, you can impact the outcome, go to step 2. Step 2 Do something—anything—now. Then quit worrying! If you still need more help, here are seven “Action Steps” that will help you take getting rid of worries to the next level:

1. Share Your Worry with Others When worries seems to go out of control, talk them through with a trusted friend, a mentor or even your pet — hey, at least your pet won’t talk back. Be sure to reciprocate so that your worry support team is there for you when you need them. 2. Realize That Certainty is a Myth Recognize that the only certainty is death. Given that most of us are not very interested in that option, make a commitment to get comfortable with uncertainty. Focus your mental energies on the joy you get from uncertainty and begin to celebrate it as part of the unique human experience. Just think, how boring life would be if everything was certain. 3. Make Worrying a “Snap” If you find that all of the above still don’t work, start wearing a rubber band on your left wrist. When you find yourself worrying, snap the rubber band—it’ll remind you, in a somewhat painful way, to quit worrying. Another technique that seems to work real well for one of my coachees is that when she gets stuck in a serious worry phase she records her worries on an oldfashioned tape recorder. (Yes they are still around.) Then she takes the tape out of the recorder, goes to her husband’s workshop, finds a big hammer and smashes the tape -- getting rid of those worries once and for all. (Hey, tapes are cheaper than wasting your precious brain power.) 4. Take a Worry Break Still not working? Set a timer for a specified time—let’s say 10 minutes—and now worry “real good.” Play the “what if” game to the max. Get it all out of your system. When the 10 minutes are up, refocus your energy on something that will disconnect you from your worries.

Done it all, and still worrying? Just say no -I mean just let go. Let go of the feeling that you have to be in control -- you are not!”

5. Disconnect Disconnect yourself from worrying by doing something that will totally absorb you. Try jogging, meditation, yoga, tai chi, getting a massage, playing a game of tennis, deep breathing, taking a walk, going to the movies--anything that disconnects you from your worries and allows you to totally relax. 6. Just Let Go Done it all, and still worrying? Just say no--I mean just let go. Let go of the feeling that you have to be in control--you are not! Realize that the harder you try, the less likely that will happen. Make a commitment to “go with the flow.” Convince yourself by re-evaluating prior worries; you may find that ultimately things do tend to work out for the best. 7. Laugh If all else fails make yourself laugh. Here is a bit of humor to make that happen:

Why Worry? There only two things to worry about; either you are well or you are sick. If you are well, there is nothing to worry about; If you are sick, there are only two things to worry about; either you will get well or you will die. If you get well, there is nothing to worry about. If you die, there are only two things to worry about; either you will go to Heaven or you will go to Hell. If you go to Heaven, there is nothing to worry about. If you go to Hell, you will be so busy shaking hands with friends, you will not have time to worry.

Dr. Wolf J. Rinke, RD, CSP is a keynote speaker, seminar leader, management consultant, executive coach and editor of the free electronic newsletter Read and Grow Rich, available at www. In addition he has authored numerous CDs, DVDs and popular books including Make It a Winning Life: Success Strategies for Life, Love and Business, Winning Management: 6 Fail-Safe Strategies for Building High-Performance Organizations; Don’t Oil the Squeaky Wheel and 19 Other Contrarian Ways to Improve Your Leadership Effectiveness; and Leadership: Helping Others to Succeed, available at His company also produces a wide variety of quality pre-approved continuing professional education (CPE) self-study courses, such as Beat the Blues--How to Manage Stress and Balance Your Life, (28 CPEUs) from which this article was excerpted. CPE courses are available in both print and electronic formats at Reach him at

© 2012 Wolf J. Rinke

Aligning practice with policy to improve patient care 79

Emma and SCIP

Celebrate Breast Cancer Awareness Month





t0YZ1BTTIPFT 09:1"48)5

80 The OR Connection









Top 5

Breast Cancer Awa reness Activities for Octobe r 1

Schedule a mammogram and remind a friend to do the same.


Join a breast cancer walk in your local area.


Cook pink! (See page 89)


Wear pink gloves and other pink attire.


Sign up for Medlineâ&#x20AC;&#x2122;s Daily Dance inspirational emails at

Breast cancer awareness fashions available at and Questions? Call 1-800-MEDLINE or contact your Medline representative

Aligning practice with policy to improve patient care 81

PGD 2012 Pink Glove Dance II Video Competition

Voting begins October 12! Win a Donation to Your Favorite Breast Cancer Charity* tFirst Place: $10,000 tSecond Place: $5,000 tThird Place: $2,000 Deadline for submissions: September 28 Winners announced: November 2

Complete contest instructions are available at

*Subject to review and approval by Medline Industries, Inc.

82 The OR Connection

Some of last yearâ&#x20AC;&#x2122;s PGD Video contestants!

Gwinnett Medical Center, Duluth, GA

Lexington Medical Center, West Columbia, SC

Highland Hospital, Rochester, NY

San Juan Medical Foundation, Farmington, NM

Victoria Hospital, Prince Albert, SK, Canada

Aligning practice with policy to improve patient care 83

Pink Glove Dance








I am very honored that Medline and Providence St. Vincent Hospital used my song “Down” to promote and support Breast Cancer Awareness. Jay Sean

84 The OR Connection



The 2012 Pink Glove Dance Video Competition is in full swing, and there’s still time to enter by the September 28 deadline. Choose from new songs, new artists and new social media that we hope will bring the competition to the next level.

This year, the competition will embrace old favorites like “Down” by Jay Sean (the song in the original Pink Glove Dance) and “You Won’t Dance Alone” by The Best Day Ever (the song in Pink Glove Dance: The Sequel). New tunes include “Part of Me” by Katy Perry, “Evacuate the Dance Floor” by Cascada, “This One’s for the Girls” by Martina McBride, and “Let Yourself Go” by Emily, a local artist. Medline is grateful to these artists with heart who are supporting the cause and providing great dance beats. BY THE BEST DAY A EVER

The thanks are going both ways. “It’s very cool,” said Tonya Puerto, of Capitol Records, who is excited about Katy Perry’s music being used for the second year in a row. Singer Jay Sean said, “I am very honored that Medline and Providence St. Vincent Hospital used my song “Down” to promote and support Breast Cancer Awareness. I like that such a fun and light hearted approach was taken to create awareness for a serious disease that can be cured if caught early. The positive response and reaction that the ‘Pink Gloves’ video has received has been incredible, and coming from a medical background myself, I hope that we are able to keep a spotlight on this illness until we reach a cure!”

Aligning practice with policy to improve patient care 85

The Pink Glove D ance co great wa mpetitio y f o r n was a Lexingto show th n Medic e world a our hosp l Center commitm ital and to ent to th o ur stead e treatm fast ent of b reast ca ncer. L e x in g ton Medic 2011 First al Center Place Pink Glove D ance Winn


Emily Rosenberg, of Highland Park, Ill. and a sophomore at Berklee College of Music in Boston, donated the rights to use her song the Pink Glove Dance. When asked why, she responded, “I’m so thrilled to be involved in the Pink Glove Dance. These videos bring such joy and laughter to the people who deserve it most. Breast cancer affects so many people — both the patients and their loved ones. The more awareness we can raise the better, and we might as well do it in such a fun way! I’m ecstatic that my music will be used for something that makes people so happy. That’s the goal of making music: to improve lives. That’s the dream, and I’m so grateful that the Pink Glove Dance is helping make it come true.” Lexington Medical Center, the facility that won the 2011 Pink Glove Dance Competition, loved dancing pink last year. “The Pink Glove Dance was a wonderful experience for Lexington Medical Center,” said Jennifer Wilson, Lexington Medical Center public relations manager. “We are so grateful to the people from around our community, country and the world who viewed our Pink Glove Dance video and voted for us. To date, our video has received more than 150,000 You Tube views. The Pink Glove Dance competition was a great way for Lexington Medical Center to show the world our hospital and our steadfast commitment to the treatment of breast cancer, a disease that affects 1 in 8 women in her lifetime.”

86 The OR Connection

What started as a crazy fun way to raise awareness about early detection of breast cancer has become an international dancing phenomenon, including 21,000 total Pink Glove Dancers, 13,608,658 (and counting!) views of the original Pink Glove Dance, and more than one million page views of To get the message out there as much as possible, Pink Glove Dance this year has enhanced its presence on the web through new social media including Facebook, Twitter, Pinterest, Tumblr and Flickr. These social media sites are more important than ever, and not only get the Pink Glove Dance out there, but are a great resource for competition participants to spread the word as well. Medline hopes to keep spreading smiles and awareness by promoting the Pink Glove Dance as much as possible. Medline corporate headquarters hosted a Pink Glove Day this year on

the launch date of the competition, when Medline employees enthusiastically donned their best pink clothes, sipped pink lemonade and tweeted pink to get the word out. How did last year’s winner do it? Wilson reflected, “Lexington Medical Center believes that one of the elements that made our video a winner was the fact that it showcased hundreds of our employees, emphasizing the commitment of a large number of people to battling breast cancer. Importantly, the video also used the lyrics from the Katy Perry song Firework to help tell a story.” The Pink Glove Dance reflects Medline’s commitment to saving lives through raising awareness and funds for early detection of breast cancer. Medline has donated more than $1 million to date to the National Breast Cancer Foundation to fund free mammograms from the proceeds of pink gloves and other Generation Pink™ products.

Update your family and friends on your project. Your loved ones will love supporting you! Contact local media (newspaper, tv and radio) and ask for help promoting the campaign. Create an account on one or more social media sites such as Facebook® or Twitter®. Be sure to “like” Medline Breast Cancer Awareness on Facebook and “follow” @pinkglovedance on Twitter. Connect with your friends and remind them to vote. Email everyone you know with a description of how to vote, and a link to Get creative to spread the word—our favorite videos featured people dancing their heart out. Host a bake sale, make flyers, paint your nails pink. Anything and everything you do makes a difference, and we thank you in advance for your participation!

Aligning practice with policy to improve patient care 87

Yes, They’re Genuine. Only Medline’s Pink Pearl™ gloves combine aloe, nitrile and breast cancer awareness.


©2012 Medline Industries, Inc. Medline is a registered trademark and Pink Pearl is a trademark of Medline Industries, Inc.


Pink C O O K I N G

The foods you choose every day are one of the most important

factors in protecting you against cancer. Most Americans eat a diet that is far too high in meat and calories. Even more

important is what the average diet lacks: a variety of vegetables, fruits, beans and other plant-based foods.

Plant-based foods give your body not only the nutrients it needs for good health, but an arsenal of compounds (phytochemicals) that help protect against naturally-occurring cancer risks you face every day.

Healthy Pink Foods

3 Beets 3 Raspberries 3 Cranberries 3 Salmon

3 Cherries 3 Red peppers 3 Watermelon 3 Shrimp

3 Strawberries 3 Pink grapefruit 3 Red potatoes 3 Red beans

Aligning practice with policy to improve patient care 89


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Whatâ&#x20AC;&#x2122;s in it for you?

with cano p mufďŹ n tin

Blueberries are high in soluble ďŹ ber. They are an excellent source of vitamins C and Kâ&#x20AC;&#x201D;all for about 80 calories per cup. In addition, blueberries contain a family of plant compounds called anthocyanides, which are among the most potent antioxidants and may play a role in reducing risk of chronic diseases such as cancer.

90 The OR Connection


!"#  $%  &' %  ( Delicious food. Healthy food. Theyâ&#x20AC;&#x2122;re one in the sameâ&#x20AC;&#x201D;especially when the recipes are developed by the American Institute for Cancer Research (AICR) cookbook team. AICR is proud to announce the publication of its treasure-trove of 200 recipes, which ravish the palate while helping you manage your weight and reduce the risk of disease. Available at amazon. com and Barnes & Noble.

Source: American Institute for Cancer Research

Strawberries provide a hearty dose of vitamin C, and their vibrant color is a sign that they are rich in cancerďŹ ghting phytochemicals. In addition, strawberries are a source of ellagic acid, which has shown promising anticancer properties in laboratory studies.

Aligning practice with policy to improve patient care 91

Myth #1 Men do not get breast cancer.

Fact Quite the contrary. Each year it is estimated that approximately 1,700 men will be diagnosed with breast cancer and 450 will die. While this percentage is still small, men should also give themselves regular breast self-exams and note any changes to their physicians.

Myth #2 A mammogram can cause breast cancer to spread.


BREAST CANCER Myths Donâ&#x20AC;&#x2122;t let yourself be a victim of misinformation and myths generated by fear.

92 The OR Connection

Quite the contrary. Each year it is estimated that approximately 1,700 men will be diagnosed with breast cancer and 450 will die. While this percentage is still small, men should also give themselves regular breast self-exams and note any changes to their physicians.

Myth #3 Having a family history of breast cancer means you will get it.

Fact While women who have a family history of breast cancer are in a higher risk group, most women who have breast cancer have no family history. If you have a mother, daughter, sister, or grandmother who had breast cancer, you should have a mammogram ďŹ ve years before the age of their diagnosis, or starting at age 35.

Myth #4 Finding a lump in your breast means you have breast cancer.

Fact If you discover a persistent lump in your breast or any changes in breast tissue, it is very important that you see a physician immediately. However, 8 out of 10 breast lumps are benign, or not cancerous. Sometimes women stay away from medical care because they fear what they might find. Take charge of your health by performing routine breast self-exams, establishing ongoing communication with your doctor, and scheduling regular mammograms.

Myth #7 Knowing you have changes in the BRCA1 or BRCA2 gene can help you prevent breast cancer.

Myth #5 Breast cancer is contagious.

Fact You cannot catch breast cancer or transfer it to someone else’s body. Breast cancer is the result of uncontrolled cell growth in your own body. However, you can protect yourself by being aware of the risk factors and following an early detection plan.

Fact While alterations in these genes in men and women can predispose an individual to an increased risk of breast cancer, only five to 10 percent of patients actually have this mutation. This is not an absolute correlation. Like your age or having a family history of breast cancer, it’s a factor you just can’t control. But you can let your physician know, perform regular breast self-exams, and focus on the fact your chances of not having this disease are greater than 90 percent.

Myth #6 Antiperspirants and deodorants cause breast cancer.

Fact Researchers at the National Cancer Institute (NCI) are not aware of any conclusive evidence linking the use of underarm antiperspirants or deodorants and the subsequent development of breast cancer. For more information, visit factsheet/Risk/AP-Deo.

Source: National Breast Cancer Foundation. Arm yourself with knowledge. About-Breast-Cancer/Myths.aspx.


Get your mammogram.


Pink merchandise from Medline helps support the National Breast Cancer Foundation.

Continued from page 54


Results showed an 82% hand hygiene failure rate among a range of anesthesia providers

A high rate of HH failure was observed among anesthesia providers. The operating room environment is an epicenter of infectious disease organisms where a large number of patients have active infectious disease and many who are immunocompromised. Patients and providers have the opportunity to come into contact with one another with multiple, ongoing opportunities for both vertical and horizontal transmission of organisms in such an environment. The insular nature of anesthesia care is such that a provider works without much observation from others because of their generally being at the patientâ&#x20AC;&#x2122;s head with surgical drapes obscuring view of them. This is unlike the surgeon, technicians, and nurses, who are within view of each other and who subscribe to an intense level of institutional and peer pressure, as well as tradition in achieving a powerful culture of asepsis. Furthermore, providing surgical anesthesia care can be very challenging because of the high intensity of psychomotor task density that must be accomplished, often in a very compressed period of time. The current study revealed a high rate of HH opportunities that averaged 34 to 41 times per hour over the phase of care and, in some cases, approached 54 opportunities per hour. Audits performed in the intensive care unit have found that HH is indicated at an average rate of about 20 times per hour.12 Performing adequate HH in such a setting can prove daunting if not impossible given the intensity and nature of the provider-to-patient interactions. Although health care providers are often primarily concerned about the transmission of microbes from one patient to another, or from patient to provider, it is important to recognize that patients must be protected both from their own ďŹ&#x201A;ora as well as ďŹ&#x201A;ora from their providers. To illustrate this, consider that Staphylococcus aureus is the most common cause of a surgical site infection.13 Now consider that one-ďŹ fth of health care providers are persistent carriers of S. aureus in our nares, and fully 30% of us are intermittent carriers.14 BioďŹ lms are ubiquitous throughout the hospital; are within and on our bodies; and, because of the constant shedding of organisms from bioďŹ lms, we are constantly inoculating everything we come into contact with, inclusive of our patients.15,16 HH is vital to breaking the vector chain.

The intent of the current study was not to seek relationship between anesthesia provider HH behavior and subsequent patient outcome as has been done in 2 previous studies, although both employed methodology where any noted â&#x20AC;&#x153;causal linkâ&#x20AC;? could be readily challenged.9,10 Rather, the goals were (1) quantify the HH behaviors of a range of anesthesia providers during the realtime care of patients and (2) determine the rate of indicated HH for these providers over the continuum of perioperative care. With respect to the ďŹ rst goal, a very low rate of HH success was observed with an aggregate failure rate of 82%. With respect to the second goal, there was a very high rate of HH opportunities that averaged 34 to 41 times per hour. The resultant taxonomy of failures (Table 1) may provide organizations with the ability to strategically target educational, facility, and technologic interventions that are designed to improve HH in the setting of the anesthesia work station and operating room. The culture of the anesthesia workstation needs a wake-up call, having been largely, until recently, outside the intense scrutiny experienced by other domains in the hospital setting. A recent editorial17 in a prominent international anesthesia journal ends with the asking of relevant questions, including the following: t 4IPVMETUPQDPDLTJO*7MJOFTCFFMJNJOBUFECFDBVTFPG complexities in keeping them germ free? t 4IPVMEQSPWJEFSTXJUILOPXO4BVSFVT BOEPUIFS  pathogens wear special masks? t 4IPVMEQSPWJEFSTXJUIBDUJWFEFSNBUPMPHJDJOGFDUJPVTCF permitted to render care? t 4IPVMECFUUFSEJTJOGFDUJPOQSPUPDPMTCFVTFEGPSPVS equipment including computer keyboards? t 4IPVMEXFOPUBMMPXQFSTPOBMJUFNT DFMMQIPOFT CBHT  iPods, and others) to enter the workstation? It may be that, given the intense culture of asepsis by the OR team (surgeon, scrub, circulators, and others) yet the persistence of a disturbing rate of surgical site infections of at least 5% despite nearly mandated use of preincisional antibiotics,18 then perhaps our focused attention should be directed at patient and anesthesia provider factors. Even the ubiquitous use of stop-

Aligning practice with policy to improve patient care 95


Given the intense culture of asepsis by the OR team (surgeon, scrub, circulators, and others) yet the persistence of a disturbing rate of surgical site infections of at least 5% ... then perhaps our focused attention should be directed at patient and anesthesia provider factors.

cocks in facilitating the IV administration of perioperative drugs is hampered by difficulties in maintaining good aseptic technique because of their cumbersome design (Fig 1). Stopcock contamination is extraordinarily common with any associated poor HH providing direct IV entry of pathogenic material into the patient.9,10,17 Overall, the HH and aseptic practices of anesthesia providers, revealed in this study, were poor. Whereas criticism might be directed that this study holds anesthesia providers to an impossibly high standard, it might also be viewed as a further opportunity to generate a much needed dialogue on the issue and to promote novel educational and interventional strategies to improve practice. Given the demands of anesthesia care and the high rate of HH opportunities, aggressive strategies for achieving improved rates of HH should be pursued.

References 1.

Trampuz A, Widmer AF. Hand hygiene: a frequently missed lifesaving oppor¬tunity during patient care. Mayo Clin Proc 2004;79:109-16.


Stone PW, Larson E, Kawar LN. A systematic audit of economic evidence lining nosocomial infections and infection control interventions: 1900-2000. Am J Infect Control 2002;30:145-52.


Lee C. Studies: hospitals could do more to avoid infections. The Washington Post. November 21, 2006. Section 1; p. A-3.


Jarvis W. The United States approach to strategies in the battle against healthcare-associated infections, 2006: transitioning from benchmarking to zero tolerance and clinician accountability. J Hosp Infect 2006;65:3-9.


Cantrell D, Shamriz O, Cohen MJ, Stern Z, Block C, Brezis M, et al. Hand hygiene compliance by physicians: Marked heterogeneity due to local culture? Am J Infect Control 2009;27:301-5.


Wachter RM, Pronovost PJ. Balancing “no blame” with accountability in patient safety. N Engl J Med 2009;361:1401-6.


Muller MP, Detsky AS. Public reporting of hospital hand hygiene compliance: helpful or harmful? JAMA 2010;304:1116-7.


Klevens RM, Edwards JR, Richards CL Jr, Horan T, Gaynes R, Pollock D, et al. Estimating health care associated infections and deaths in US hospitals, 2002. Public Health Rep 2007;122:160-6.

In his day, Dr Ignaz Semmelweis was scorned and literally driven from practice for his zealotry in urging health care providers to engage in HH. Semmelweis would likely be greatly disturbed at the current state of affairs of HH in the US health care institutions.


Loftus RW, Koff MD, Burchman CC, Schwartzman J, Thorum V, Read M, et al. Transmission of pathogenic bacterial organisms in the anesthesia work area. Anesthesiology 2008;109:399-407.

10. Koff MD, Loftus RW, Burchman CC, Schwartzman J, Thorum V, Henry E, et al. Reductin in intraoperative bacterial contamination of peripheral intravenous tubing through the use of a novel device. Anesthesiology 2009;110:978-85. 11. Biddle C. Semmelweiss revisited: hand hygiene and nosocomial disease transmission

The current study’s findings further fuel this view. Signage, immediate availability of gloves, access to HH foam/gel dispensers, aggressive education of providers at grand rounds, journal clubs, and staff meetings have been instituted in an effort to improve HH among anesthesia providers. A follow-up study is planned in this calendar year, using a similar methodology to determine the efficacy of our multidimensional interventional program in improving HH among anesthesia providers.

in the anesthesia workstation. AANA J 2009;77:229-37. 12. Boyce JM, Pitter D. Guideline for hand hygiene in healthcare settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HIPAC/SHEA/ APIC/IDSA Hand Hygiene Task Force. Am J Infect Control 2002;30:S1-46. 13. Kaye KS, Anderson DJ, Sloane R, Chen L, Choi Y, Link K, et al. The effect of surgical site infection on older operative patients. J Am Geriatr Soc 2009;57: 46-54. 14. van Belkum A, Melles DC, Nouwen J, van Leewen W, van Wamel W, Vos M, et al. Co-evolutinary aspects of human colonization and infection by Staphylococcus aureus. Infect Genet Evol 2009;9:32-47. 15. Sheretz RJ, Bassetti S, Bassetti-Wyss B. “Cloud” health care workers. Emerg Infect Dis 2001;7:241-4. 16. Edmiston CE, Seabrook GR, Cambria RA, Brown K, Lewis B, Sommers J, et al. Molecular epidemiology of microbial contamination in the operating room: is there a risk for infection. Surgery 2005;138:573-82.

Address correspondence to Chuck Biddle, CRNA, PhD, Box 980226, Virginia Commonwealth University Medical Center, Richmond, VA 23298-0226. E-mail address: (C. Biddle).

17. Roy RC, Brull SJ, Eichhorn JH. Surgical site infections and the anesthesia professionals’ microbiome: We’ve all been slimed! Now what are we going to do about it. Anesth Analg 2011;112:4-7. 18. Neumayer L, Hosokawa P, Itani K, El-Tamer M, Henderson WG, Khuri SF. Multivariable predictors of postoperative surgical site infection after general and vascular surgery: results from the patient safety in surgery study. J Am Coll Surg 2007;204:1178-87. American Journal of Infection Control. Published online 13 February 2012. Copyright ©2012 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. Reprinted with permission.

96 The OR Connection


MEDLINE GOLD STANDARD SAFETY COMPONENTS Medline’s Gold Standard safety products stand out against the sea of blue in the OR to alert the surgical team to focus on safety. Promote Correct-Site Surgery Our Surgical Time Out Procedure (S.T.O.P.™) safety products alert the surgical team to perform a time-out verification and help reduce the risk of wrong-site surgery. Support Sharps Safety Practices Transfer trays, scalpel holders and needle counters with blade guards promote sharps safety and help make you OSHA compliant.1 Improve Fluid Disposal Safety The Safety-Splash™ fluid management system converts biohazardous fluids into a solid, minimizing the risk of exposure.

LEARN MORE ABOUT MEDLINE’S GOLD STANDARD SAFETY PRODUCTS 1 Download a QR Code Reader app 2 Launch the QR app 3 Scan this QR Code or visit http://

References: 1. Occupational Safety and Health Standards, Toxic and Hazardous Substances, Bloodborne pathogens. Regulations (Standards - 29 CFR). Available at: http:// id=10051#1910.1030(d)(2)(i). Accessed October 13, 2010. ©201 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc. Safety-Splash and S.T.O.P are trademarks of Medline Industries, Inc.

Aligning practice with policy to improve patient care 97

Healthy Eating Nutrition Information Servings: 6 Calories: 391 Fat: 35.8 Sodium: 156mg Fiber: 3.2g

Lillian Stafford’s Oriental Broccoli Broccoli is a nutrition star. Its resumé of vitamins and minerals includes beta carotene, vitamin C, calcium, fiber, and phytochemicals, specifically indoles and aromatic isothiocynates. Some suggest broccoli other cruciferous vegetables may be responsible for boosting certain enzymes that help to detoxify the body, even helping to prevent cancer, diabetes, heart disease, osteoporosis and high blood pressure. Ready-to-use broccoli slaw is available in most grocery stores’ packaged salad aisle. It’s long shreds of broccoli stems (and sometimes some other veggies, too) that you can substitute for the shredded cabbage in traditional cole slaw, or as the main ingredient in this delicious salad. Ingredients 1 pkg broccoli cole slaw 1 6-oz pkg slivered almonds 1 7.25-oz jar sunflower seeds 4 green onions, thinly sliced 1 pkg chicken-flavored ramen noodles, crushed Crush the uncooked ramen noodles and toss all the ingredients together. Add dressing and toss immediately before serving for a great crunchy texture. The next day it’s still very good, but the ramen will have lost its crunch.

98 The OR Connection

Dressing ½ C canola oil (light virgin olive oil works, too) 3 T vinegar 1 T soy sauce 3 T sugar 1 chicken flavor packet (from the ramen noodles) Whisk or shake to thoroughly mix the ingredients together. Set aside until ready to serve the salad. Diane Seminary is a 15-year Medline veteran who works closely with the manufacturing team in Medcrest. Born here, her family is originally from Quebec, which she still visits every summer. The salad’s namesake is the daughter of Bill Stafford from Medline warehouse B02, who introduced it to Diane’s family. “This salad is light and carries well for any picnic adventure.” Enjoy.

The Medline employee cookbook is $10. To purchase your own copy, please e-mail Judy at


Forms & Tools

Sharps Safety

Now You See It, Now You Donâ&#x20AC;&#x2122;t. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 Sharps Safety Begins with You . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 Malignant Hyperthermia

Emergency Therapy for Malignant Hyperthermia . . . . . . . . . . . . . . . . . 102 Malignant Hyperthermia Drill . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 Hand Hygiene

Your 5 Moments for Hand Hygiene . . . . . . . . . . . . . . . . . . . . . . . . . . . 104 Preventing SSIs

Caring for Your Surgical Incision at Home . . . . . . . . . . . . . . . . . . . . . . 105

Aligning practice with policy to improve patient care 99

Medline natural OR towels


A LOT OF DIFFERENCE The greensmartâ&#x201E;˘ collection of OR products helps reduce your impact on the environment. t/BUVSBM03UPXFMTBSFEZFGSFFBOECMFBDIGSFF5IFZQSPEVDFMFTTMJOUBOE are more absorbent than traditional blue towels. t"O03TVJUFXJUISPPNTUIBUTXJUDIFTGSPNCMVF03UPXFMTUPOBUVSBM03 towels could save up to one half ton of dye, bleach and other chemicals from polluting the environment every year. tCJPEFHSBEBCMFUSBZTBSFNBEFPGDPNQSFTTFEQBQFSXJUIBO eco-friendly, water-resistant coating. t5IFSFWPMVUJPOBSZ&DP%SBQFTM has all the features and protection you expect. It breaks down in landďŹ lls in two to ďŹ ve months.


greensmartâ&#x201E;˘ is not a third-party certiďŹ cation. The use of the greensmartâ&#x201E;˘ trademark is determined by Medline Industries, Inc. through an internal review process of environmental claims.

Š2011 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc. greensmart and EcoDrape are trademarks of Medline Industries, Inc.

Sharps Safety


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NOW YOU DONâ&#x20AC;&#x2122;T.

PROTECT YOURSELF AND OTHERSUSE SHARPS WITH SAFETY FEATURES BE PREPARED. Anticipate injury risks and prepare the patient and work area with prevention in mind. Use a sharps device with safety features whenever it is available.

BE AWARE. Learn how to use the safety features on sharps devices.

Support for printing this poster came from an unrestricted educational grant provided by Safety Institute, Premier, Inc.

DISPOSE WITH CARE. Engage safety features immediately after use and dispose in sharps safety containers.

DISCLAIMER: Mention or depiction of any company or product does not constitute endorsement by CDC.

Aligning practice with policy to improve patient care 101

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1-800-644-9737 Outside the US: 1-315-464-7079

Effective May 2008




Sudden/Unexpected Cardiac Arrest in Young Patients:

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MH Hotline

Malignant Hyperthermia


1 GET HELP. GET DANTROLENE â&#x20AC;&#x201C; Notify Surgeon J7A1=<B7<C3D=:/B7:3/53<BA/<2AC117<G:16=:7<3  J!G>3@D3<B7:/B3E7B6

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D =::=EC@7<3;G=5:=07</<27<AB7BCB3B63@/>GB=>@3D3<B;G=5:=07<>@317>7B/B7=<7<@3</:BC0C:3A/<2B63 AC0A3?C3<B23D3:=>;3<B=41CB3)3</:/7:C@3 #:3D3:A/0=D3 

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

Non-Emergency Information MHAUS ('=F  /AB*B/B3*B@33B *63@0C@<3&.   Phone 


Email 7<4=;6/CA =@5 Website EEE ;6/CA =@5

This protocol may not apply to all patients; alter for specific needs.

Produced by the Malignant Hyperthermia Association of the United States (MHAUS). MHAUS is a non-profit organization under IRS-Code 501(c)3. It operates solely on contributed funds. All contributions are tax deductible. For more information, go to

The OR Connection

Hyperthermia Drill

Forms & Tools



5JNF%SJMM&OEFE@@@@@@@@ Not Met


Staff member was able to call MH drill appropriately ( called operator from location and indicated Malignant Hyperthermia alert and location Hospital Operator appropriately called MH event overhead

All members of MH team presented to Drill t&%$IBSHF t/VSTJOH4VQFSWJTPS t&%1SPWJEFS t"OFTUIFTJB JG"QQMJDBCMF


Emergency Department @@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@ Observers

Aligning practice with policy to improve patient care 103

Forms & Tools

Hand Hygiene





for Hand Hygiene 4 Y E







5 1 2 3 4 5




Clean your hands before touching a patient when approaching him/her.


To protect the patient against harmful germs carried on your hands.



Clean your hands immediately before performing a clean/aseptic procedure.


To protect the patient against harmful germs, including the patient's own, from entering his/her body.



Clean your hands immediately after an exposure risk to body fluids (and after glove removal).


To protect yourself and the health-care environment from harmful patient germs.



Clean your hands after touching a patient and her/his immediate surroundings, when leaving the patient’s side.


To protect yourself and the health-care environment from harmful patient germs.



Clean your hands after touching any object or furniture in the patient’s immediate surroundings, when leaving – even if the patient has not been touched.


To protect yourself and the health-care environment from harmful patient germs.

All reasonable precautions have been taken by the World Health Organization to verify the information contained in this document. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. WHO acknowledges the Hôpitaux Universitaires de Genève (HUG), in particular the members of the Infection Control Programme, for their active participation in developing this material.


The OR Connection

11:13 PM 8/8/03 SharpsSafety_posterFINAL.qxd

This fun group of perioperative nurses from the University Medical Center of Princeton at Plainsboro, in Plainsboro, NJ, took first place in Medline’s Pink Glove Dance Photo Contest at the 2012 AORN Conference in March. From left to right, Lori Mozenter, BSN, CNOR, RNFA, Staff Nurse; Mary Zegarski, RN, CNOR, Staff Nurse and Vice President of AORN Chapter 3109; Fe Moreo BSN,CNOR, Staff Nurse and Patricia Lum, RN, BSHA, CNOR, CMLSO, Perioperative Educator/Interim OR Manager.

Page 1


Be responsible for

the sharps you use. Activate safety


beds and waste receptacles.

inspect for unprotected sharps in trays,

Keep exposed sharps in view

and under your control. Visually


Your name Facility and position Mailing address E-mail address


We also welcome any suggestions you might have on how we can continue to improve The OR Connection! Love the content? Want to see something new? Just let us know!

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Sharps Safety

Aligning practice with policy to improve patient care 107

Patient Handout

Caring for Your Surgical

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Incision at Home

The following are general guidelines. Consult your surgical team for more speciďŹ c instructions. Bathing and Showering Most incisions should be kept dry for several days after surgery, except for incisions closed with surgical glue. It is usually safe to allow glued incisions to get wet while showering or bathing. It is important, however, to dry the area around the incision carefully after washing. Physical Activity and Exercise Avoid any activity that pulls on the edges of the incision or puts pressure on it. Walking and other light activities are encouraged to restore normal energy levels and digestive functions. Do not, however, participate in sports, engage in sexual activity or lift heavy objects until after your postoperative checkup. Aspirin Avoid aspirin or over-the-counter medications containing aspirin for a week to 10 days after surgery. Aspirin interferes with blood clotting and makes it easier for bruises to form near the incision. Sun Exposure As an incision heals, the new skin that forms over the cut is very sensitive to sunlight and will burn more easily than normal skin and lead to worse scarring. Keep the incision area covered from direct sun exposure for three to nine months in order to prevent burning and severe scarring. General Hygiene Infection is the most common complication of surgical procedures. It is important, therefore, to minimize the risk of an infection when caring for your incision at home. Observe the following precautions:  t 8BTIZPVSIBOETDBSFGVMMZBGUFSVTJOHUIFUPJMFUBOEBGUFSUPVDIJOHPSIBOEMJOHUSBTI   QFUTBOEQFUFRVJQNFOUEJSUZMBVOESZBOEBOZUIJOHFMTFUIBUJTEJSUZPSIBTCFFOVTFEPVUEPPST  t "TLGBNJMZNFNCFST DMPTFGSJFOET BOEPUIFSTUPXBTIUIFJSIBOETCFGPSFDPOUBDU with you  t "WPJEDPOUBDUXJUIGBNJMZNFNCFSTBOEPUIFSTXIPBSFTJDLPSSFDPWFSJOHGSPNB contagious illness  t 4UPQTNPLJOH TNPLJOHTMPXTEPXOUIFIFBMJOHQSPDFTT 

Adapted from

Aligning practice with policy to improve patient care 105




OR Connection Volume 7 Issue 2  

Medline's OR Connection Magazine, Volume 7, Issue 1 - FREE CE: In the Heat of the Moment: Malignant Hyperthermia Calls for Action

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