VOLUME 7, ISSUE 2
The Aligning practice with policy to improve
Volume 7, Issue 2
Special Breast Cancer Awareness Issue!
Ways to Improve Surgical Outcomes
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Malignant Hyperthermia ARE YOU PREPARED?
Get into the Groove!
PerforMAX scrubs THE OR CONNECTION
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 Scrubs123.com 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
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?
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?
"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
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
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
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.
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 www.ihi.org/imap/tool
Joint Commission 2012-2013 National Patient Safety Goals Effective January 1, 2012: t *NQSPWFUIFBDDVSBDZPGQBUJFOUJEFOUJmDBUJPO t *NQSPWFUIFFGGFDUJWFOFTTPGDPNNVOJDBUJPO among caregivers t *NQSPWFUIFTBGFUZPGVTJOHNFEJDBUJPOT t 3FEVDFUIFSJTLPGIFBMUIDBSFBTTPDJBUFEJOGFDUJPOT t 3FEVDFUIFSJTLPGQBUJFOUIBSNSFTVMUJOHGSPNGBMMT t 1SFWFOUIFBMUIDBSFBTTPDJBUFEQSFTTVSFVMDFST (decubitus ulcers) t *EFOUJGZTBGFUZSJTLTJOIFSFOUJOUIFQBUJFOUQPQVMBUJPO
t 6OJWFSTBM1SPUPDPMGPS1SFWFOUJOH8SPOH4JUF Wrong Procedure, and Wrong Person Surgery.â„˘ - 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 www.jointcommission.org.
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 www.qualitynet.org
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 www.easyCPEcredits.com. 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 WolfRinke@aol.com.
The OR Connection
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: http://www.outpatientsurgery.net/newsletter/ 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:// www.hopkinsmedicine.org/news/media/releases/surgical_site_infections_more_likely_ 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
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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: www.outpatientsurgery.net/article-archive. 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. nih.gov/pubmed/22801787. 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: http://www.hopkinsmedicine.org/news/media/ 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: http://www.who.int/ 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: www.outpatientsurgery.net/article-archive <http://www.outpatientsurgery.net/article-archive> . 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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Martie Moore (far right) and colleagues, Providence St. Vincent Medical Center, Portland, OR
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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.
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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
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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.
Woodland Healthcare MH Cart Contents
-( $OSE #HART ,AMINATED s #URRENT -( 0OLICY s -( $OCUMENTATION &ORMS -( 1UICK 2EFERENCE -IX 3HEET s -( $RUG 3TICKERS s $ISPENSING 0INS WITH ,EUR ,OCK 3AFESITE VALVES s -INI 3PIKE $ISPENSING 0INS s 5RINE COLLECTION CONTAINERS FOR MYOGLOBIN LEVEL s !"'