VOLUME 4, ISSUE 3
The Aligning practice with policy to improve
Volume 4, Issue 3
THE OR CONNECTION
The Pink Glove
Dance Page 70
Positioning to Prevent Injury
Habits of Very Happy People
Brand New Fire Prevention Guidelines www.medline.com
Peggy Fleming Comes to Congress
OR Connection Aligning practice with policy to improve
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Content Key We've coded the articles and information in this magazine to indicate which patient care initiatives they pertain to. Throughout the publication, when you see these icons you'll know immediately that the subject matter on that page relates to one or more of the following national initiatives: • IHI's Improvement Map • Joint Commission 2009 National Patient Safety Goals • Surgical Care Improvement Project (SCIP) We've tried to include content that clarifies the initiatives or gives you ideas and tools for implementing their recommendations. For a summary of each of the initiatives, see pages 6 and 7.
PATIENT SAFETY Editor
Sue MacInnes, RD, LD Clinical Editor
Alecia Cooper, RN, BS, MBA, CNOR Senior Writer
Carla Esser Lake Creative Director Mike Gotti
6 8 9 11 12 20
Jayne Barkman, RN, BSN, CNOR Rhonda J. Frick, RN, CNOR Anita Gill, RN
Megan Shramm, RN, CNOR, RNFA
Kimberly Haines, RN, Certified OR Nurse Jeanne Jones, RNFA, LNC Carla Nitz, RN, BSN
Connie Sackett, RN, Nurse Consultant Claudia Sanders, RN, CFA
Angel Trichak, RN, BSN, CNOR
Sharon Danielewicz, MSN, BSN, RN, RNFA St. Lukeʼs The Woodlands, Texas
Tracy Diffenderfer, RN, MSN Vanderbilt University Medical Center, Tennessee Barb Fahey RN, CNOR Cleveland Clinic, Ohio
Susan Garrett, RN Hughston Hospital Inc., Georgia Zaida I. Jacoby, RN, MA, M.Ed NYU Medical Center, New York Jackie Kraft, RN, CNOR Huntsville Hospital, Alabama Tom McLaren Florida Hospital, Florida
Donna A. Pritchard, RN, BSN, MA, CNOR, NE-BC Kingsbrook Jewish Medical Center, New York Debbie Reeves, RN, CNOR, MS Hutcheson Medical Center, Georgia
Diane M. Strout, RN, BSN, CNOR Chesapeake Regional Medical Center, Virginia
Margery Woll, RN, MSN, CNOR North Shore Shore University Health System, Illinois
13 Revised Universal Protocol for 2010 33 Can a Rigid Container System Be Greener and Safer at the Same Time? 39 O.R. Fires: New Recommendations for Prevention 45 Scoring Fire Risk for Surgical Patients 48 Breaking Free From Our Cultural Chains
Perioperative Advisory Board Larry Creech, RN, MBA, CDT Carilion Clinic, Virginia
Three Important National Initiatives for Improving Patient Care New SCIP Measures for Normothermia, Urinary Catheters Delaware Hospitals Standardize Wristband Colors CDC to Fund State Infection Control Efforts State Reporting of Infections and Adverse Events Perioperative Positioning Injuries on the Rise: What to Do!
43 Mark Bruley Talks About New Surgical Fire Prevention Guidelines 56 Changing the Catheter Culture at Your Facility 69 Peggy Fleming to Speak at Medline’s AORN Breast Cancer Awareness Breakfast 70 Medline’s Pink Glove Dance: A YouTube Sensation
CARING FOR YOURSELF
65 9 Habits of Very Happy People 77 Healthy Eating: Cheesy Potatoes Recipe Page 56
FORMS & TOOLS
79 80 81 84 85 87 89
FAQs About Catheter-Associated Urinary Tract Infection Surgical Safety Team Communication Universal Protocol and Fire Risk Assessment Extinguishing a Surgical Fire Preventing Surgical Fires H1N1 Patient Handout: English H1N1 Patient Handout: Spanish
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.
Meeting the highest level of national and international quality standards, Medline is FDA QSR compliant and ISO 13485 registered. Medline serves on major industry quality committees to develop guidelines and standards for medical product use including the FDA Midwest Steering Committee, AAMI Sterilization and Packaging Committee and various ASTM committees. For more information on Medline, visit our Web site, www.medline.com.
©2010 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
THE OR CONNECTION I Letter from the Editor Dear Reader, 2010 is going to be a great year … for you and for us.
Check out this month’s cover. The photo was shot in
I believe this because we witnessed 2009 become
the O.R. from the “now famous” YouTube video, the
one of the busiest and most productive years in the
“Pink Glove Dance,” filmed at Providence St. Vincent’s
last two decades, and I am convinced that 2009 was
Hospital in Portland, Ore. (To view the video, visit
just setting the momentum for what is coming in
youtube.com and type “pink glove dance” in the
2010. As we move into the New Year and this excit-
search bar.) Who would have believed that an off-the-
ing time, I want to thank a number of you for your con-
cuff idea like this video would generate more than six
million hits to date … and still counting.
First, thank you to our advisory board, for the time you
For the past five years Medline has been an active and
spent with us deliberating over details, testing ideas
visible supporter of breast cancer awareness. Our first
and working with us to help make these ideas a
Breast Cancer Awareness Breakfast was held at the
reality. Your time is valuable, and we appreciate every
AORN Congress in Washington, DC. I remember hop-
minute you gave to us.
ing you would show up for that event … and you did! And every year since, many of you have joined us for
I’d also like to thank the Medline Grant Committee for
our annual Breast Cancer Awareness Breakfast at
the many hours you spent reviewing and scoring grant
Congress to support this important cause. The “Pink
applications. Because of your dedication, Medline
Glove Dance” video is just our latest effort to engage
was able to award $685,000 in grant funding for
you in this effort. Since the posting on YouTube,
healthcare research. Close to 25 percent of those
you’ve sent us hundreds of congratulatory e-mails and
grants were specifically OR-related. While I’m at it, I’d
letters. Thank you for your continued support.
like to thank all of you who are associated with perioperative activities in your facilities. You deserve a lot
Take care. I look forward to an action-packed year
of credit for all you do.
Thank you to the many, many healthcare workers who
Here’s to you!
have contributed suggestions that have led to our developing innovative product solutions, unique programs and state-of-the-art educational offerings. Here at Medline, we want to continue to lead the way in developing cost-effective and practical solutions that
Sue MacInnes, RD, LD Editor
will make your jobs easier. That wouldn’t be possible without your input.
On the cover: Shelley Galvin (left) and Alana Ellerbroek (right) from the Cardiac Surgery department at Providence St. Vincent Medical Center in Portland, Ore. during the filming of the “Pink Glove Dance” video. See page 70 for the full story.
The OR Connection
I am convinced that 2009 was just setting the momentum for what is coming in 2010.
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Three Important National Initiatives for Improving Patient Care Achieving better outcomes starts with an understanding of current patient-care initiatives. Hereâ€™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 70 processes grouped into three domains: leadership and management, patient care and processes to support care.
2 Origin: Purpose:
Joint Commission 2010 National Patient Safety Goals Developed by Joint Commission staff and the Patient Safety Advisory Group (formerly the Sentinel Event Advisory Group) To promote specific improvements in patient safety, particularly in problematic areas
Joint Commission-accredited organizations are evaluated for compliance with these goals. The Joint Commission offers guidance to help organizations meet goal requirements.
Over the next year, the current National Patient Safety Goals (NPSGs) will undergo an extensive review process. As a result, no new NPSGs will be developed for 2010; however, revisions to the NPSGs will be effective in 2010.
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: 70 Processes to Transform Hospital Care The IHI Improvement Map is an online tool that distills the best knowledge available on the key process improvements that lead to exceptional patient care.
Top 5 Key Processes Viewed by Improvement Map Users 1. Acute Myocardial Infarction (AMI) Core Processes 2. Set Direction: Aims 3. CA-UTI 4. Communication and Teamwork 5. Central Line Bundle
Top 5 Key Processes Shared by Improvement Map Users 1. Central Line Bundle 2. CA-UTI 3. Anti-Biotic Stewardship 4. Falls Prevention 5. Heart Failure Core Processes
To learn more about the IHI Improvement Map and the 70 processes to transform hospital care, go to www.ihi.org/imap/tool
Joint Commission 2010 National Patient Safety Goals • Improve the accuracy of patient identification. • Improve the effectiveness of communication among caregivers. • Improve the safety of using medications. • Reduce the risk of healthcare-associated infections. • Accurately and completely reconcile medications across the continuum of care. • Reduce the risk of patient harm resulting from falls. • Prevent healthcare-associated pressure ulcers (decubitus ulcers).
• The organization identifies safety risks inherent in its patient population. • Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery.™
No new NPSGs have been developed for 2010. Effective January 1, 2010, organizations are expected to have fully implemented the requirements related to healthcare-associated infections established in 2009.
To learn more about National Patient Safety Goals, go to www.jointcommission.org.
Surgical Care Improvement Project (SCIP): Target Areas
1. Surgical infections * Antibiotics, blood sugar control, hair removal, perioperative temperature management • Remove urinary catheter on POD 1 or 2 2. Perioperative cardiac events • Use of perioperative beta-blockers 3. Venous thromboembolism • Use of appropriate prophylaxis
By the numbers: • 3,740 hospitals are submitting data on SCIP measures, representing 75 percent of all U.S. hospitals • Currently, SCIP has more than 36 association and business partners
Aligning practice with policy to improve patient care 7
New SCIP Measures for Normothermia, Urinary Catheters
As reported in the last issue of The OR Connection, the Surgical Care Improvement Project (SCIP) introduced two new performance measures effective October 1, 2009, in the areas of normothermia and urinary catheters. To clarify, here are the key points to remember regarding each measure:
SCIP Infection Measure #9: Urinary catheter removed on Postoperative Day 1 (POD 1) or Postoperative Day 2 (POD 2) with day of surgery being day zero.
SCIP Infection Measure #10: Surgery patients for whom either active warming was used intraoperatively for the purpose of maintaining normothermia or who had at least one body temperature equal to or greater than 96.8 degrees F/36 degrees C recorded within the 30 minutes immediately prior to Anesthesia End Time or the 15 minutes immediately after Anesthesia End time.
Rationale: It is well-established that the risk of catheterassociated urinary tract infection (UTI) increases with increasing duration of indwelling urinary catheterization. Studies have shown the following: • Bacteriuria will develop in 26 percent of patients after two to 10 days of catheterization; 24 percent Rationale: Core temperatures outside the normal range pose a risk in all patients undergoing surgery. Studies of those patients will develop symptomatic have shown the following: urinary tract infection and bacteremia will • Impaired wound healing, adverse cardiac events, develop in 3.6 percent. altered drug metabolism and coagulopathies • Patients who had indwelling catheters for more are associated with unplanned perioperative than two days postoperatively were 21 percent hypothermia. more likely to develop a urinary tract infection; • Incidence of surgical site infections among those significantly less likely to be discharged to home with mild perioperative hypothermia was three and had a significant increase in mortality at times higher than with normothermic periopera30 days. tive patients. • Hypothermia is associated with a significant increase in adverse outcomes, an increased chance of blood products administration, Source: Specifications Manual for National Hospital Inpatient Quality myocardial infarction and mechanical ventilation. Measures. Available at http://www.qualitynet.org/dcs/ContentServer?c= • Adverse outcomes resulted in prolonged hospital Page&pagename=QnetPublic%2FPage%2FQnetTier4&cid=1228695698425. stays and increased healthcare expenditures.
The OR Connection
Delaware Hospitals Standardize Wristband Colors In September 2009 Delaware joined the growing list of states that have standardized the use of color-coded hospital patient wristbands. In coordination with the Delaware Healthcare Association, all acute care general hospitals in the state have voluntarily agreed to adopt the following colors and meanings to convey specific patient information to healthcare professionals.1 Red = patient allergies Yellow = fall risk Purple = do not resuscitate In addition to these three colors, some states use a pink wristband to identify a restricted extremity and green to symbolize a latex allergy.2
Movement toward a national standard of color-coded patient wristbands gained momentum in 2005 after a hospital patient in Pennsylvania nearly died because a nurse incorrectly used a yellow wristband, which she thought meant “restricted extremity,” as it did at another hospital where she worked. At this hospital, yellow meant “do not resuscitate,” and the patient was nearly not resuscitated.1 References 1 Improving Patient Safety: Delaware Hospitals Adopt Common Color Wrist Bands. Delaware Healthcare Association. Press Release. September 14, 2009. Available at: http://www.deha.org/news.htm. Accessed September 30, 2009. 2 State color-coded wristband standardization. Available at: http://www.patientidexpert.com/material/us_colorcode_implementation.pdf. Accessed September 30, 2009. 3 American Hospital Association. Hospitals in Pursuit of Excellence website. Available at http://www.hpoe.org/hpoe/wristband-colors.shtml.
WA VT MT
States with Standardized Wristband Colors3 HI
Aligning practice with policy to improve patient care 9
ARGLAES IN THE OR ANTIMICROBIAL SILVER TECHNOLOGY Use silver to fight bacteria. Medline Industries, Inc. first introduced Arglaes® silver dressings in 1997, and we’ve continued to be a leader in silver antimicrobial technology ever since. Arglaes technology utilizes ionic silver to create an environment that is hostile to bacteria and fungi yet completely non-cytotoxic. Arglaes’ sustained-activity ionic silver maintains full efficacy for up to seven days. The Arglaes family of products has something for every wound: Arglaes Film is ideal for managing bacterial penetration on post-op and line sites. Arglaes Island
features a calcium alginate pad for fluid management in addition to controlled-release silver. Arglaes Powder is perfect for difficult-to-dress wounds and can be easily combined with other dressings to create a system for antimicrobial protection. To schedule a FREE demonstration of Arglaes in your OR, contact your Medline representative, call 1-800-MEDLINE or visit www.medline.com.
©2009 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
CDC to Fund State Infection Control Efforts
The Centers for Disease Control and Prevention (CDC) is set to distribute $40 million in federal funds to state health departments to help reduce healthcare-associated infections. The CDC’s funding focuses on controlling bloodstream infections (BSI), surgical site infections (SSI) and catheterassociated urinary tract infections (CAUTI). Specifically, the agency wants state health departments to increase investments in the U.S. Department of Health and Human Services’ HAI Action Plan, which is designed to create widespread infection prevention practices by coordinating the efforts of local public and private partners. The $40 million investment, funded by the American Recovery and Reinvestment Act, marks the first time Congress has allocated money to curb healthcare infection rates at the state level. Part of the funding is earmarked to increase healthcare facilities’ use of the CDC’s National Healthcare Safety Network, a surveillance system that tracks, analyzes and compares HAI data. Funds also will go toward hiring and training local public health staff to implement and coordinate national infection prevention efforts. “We expect these programs to strengthen tracking and prevention of healthcare-associated infections, enhance facility accountability, provide data for informed policy, and ultimately save lives,” said CDC Director Thomas R. Frieden, MD, MPH. “Funding critical prevention efforts at state and local levels represents a significant investment toward elimination of HAIs and improved patient safety.” Outpatient Surgery Magazine. September 8, 2009. Available at: http://www.outpatientsurgery.net/newsletter/eweekly/2009/09/08.php
Aligning practice with policy to improve patient care 11
State Reporting of Infections and Adverse Events WA VT MT
NE NV CA
States with study laws FL
HAI Reporting Laws and Regulations Nearly 56 percent of states currently require public reporting of hospital-acquired infections.
Mandates public reporting of infection rates Voluntary
Copyright 2008 â€“ Association for Professionals in Infection Control and Epidemiology, Inc. Please contact email@example.com for reprint permission and update requests. Reprinted with permission.
SC MS TX
Hospital-specific public data FL
Statewide public data No public data
Voluntary reporting HI
No reporting System pending
State Reporting of Adverse Events With no national mandatory event reporting system in place, the United States is blanketed by a patchwork of state reporting systems collecting a variety of data in different ways. The amount of information available to the public also differs from state to state.
12 The OR Connection
Reprinted with permission from Hearst Newspapers. Hearst research by Olivia Andrzejczak. Graphic by Kyla Calvert. Template by Alberto Cuadra. Available at http://www.chron.com/deadbymistake/hospitals.
Joint Commission Update
Revised Universal Protocol for 2010: What This Means for the OR Manager by Connie Yuska, RN, MS
One of the most challenging management responsibilities in every operating room or procedure area is keeping patients safe. There are several ways to ensure this happens, but one way is to make sure practices are up-to-date and staff are fully aware of requirements established by accrediting and regulatory bodies. Recently, The Joint Commission revised the Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery. Revisions were made in four areas to ensure that safe care is provided to every patient having a surgical or nonsurgical invasive procedure. The changes apply to procedures performed in acute care and critical access hospitals, ambulatory care and office-based surgery programs. The intent of the changes is to continue to address important patient safety issues while giving organizations the flexibility needed to apply the requirements in their own particular setting and also to be able to incorporate the changes into their unique work processes. The purpose of this article is to summarize the changes so you can educate your staff and revise your practices to meet the revised elements of performance (EP).
The highlights of the changes are summarized below: Applicability: The Universal Protocol has been revised to apply to “all surgical and non-surgical invasive procedures.” In the past, the protocol applied to “all invasive procedures that put patients at more than minimal risk, regardless of the location within an organization.” Pre-procedure verification (UP.01.01.01): As a manager, you know patient safety in the OR begins with ensuring that the right procedure is performed on the right patient. The Universal Protocol has been revised to remove references to the location (pre-procedure area) and timing of the verification. In addition, the term checklist has been replaced by reference to a standardized list that can be used in the verification process. The changes recognize that the pre-procedure verification is an ongoing process of gathering and confirming information. The purpose of the pre-procedure verification is to ensure that all relevant documentation, information and equipment are available prior to the start of the procedure. Staff also must ensure that all documents are correctly identified, labeled and matched to the patient’s identifiers. Another important aspect of this process is making sure the patient understands what procedure will be performed and ensuring that all members of the operating or procedure area correctly identify the patient and the procedure to be performed.
Aligning practice with policy to improve patient care 13
Joint Commission Update
Site Marking (UP.01.02.01)
The changes recognize that the pre-procedure verification process may occur at more than one time and place before the procedure is performed. It is now up to the hospital to decide when this information is collected and who will collect it. Some possibilities for when and where to collect this information include: • When the procedure is scheduled • At the time of preadmission testing and assessment • At the time of admission or entry into the facility for a procedure • Before the patient leaves the pre-procedure area or enters the procedure room
What this means for you Now you have the opportunity to work with your colleagues who lead your pre-anesthesia and same-day surgery ambulatory areas to develop a staff protocol to ensure the preprocedure verification process is completed in the area that makes the most sense based on practices related to how patients come into your institution. Site Marking (UP.01.02.01): Surgery performed on the wrong site should never, never happen. One way to make sure that everyone in the operating room or procedure area knows the correct location of the surgery or other procedure is to clearly mark the site. Patient safety is enhanced when a consistent process is used throughout the hospital to mark the site. The revised Universal Protocol requires that the pro-
14 The OR Connection
cedure site be marked by “a licensed independent practitioner who is ultimately accountable for the procedure and will be present when the procedure is performed.” However, The Joint Commission recognized the complexity of work processes surrounding invasive procedures and changed the standard so that site marking can now be delegated to another individual in limited situations where the individual is familiar with the patient and involved in the procedure. They define those individuals as: • Individuals who are permitted through a residency program to participate in the procedure • A licensed individual who performs duties requiring collaborative or supervisory agreements with a licensed independent practitioner. These individuals include advanced practice nurses (APRNs) and physician assistants (PAs.)2 It is important to remember that the licensed independent practitioner remains fully accountable for all aspects of the procedure even when the marking of the site is delegated to another practitioner.
What this means for you Check the regulations in your state regarding the scope of practice for your advanced practice nurses and your physician assistants to make sure this activity is consistent with the state’s practice act. Discuss this change with the members of your healthcare team who are doing surgery or performing procedures. You’ll want to review your current Continued on page 16
Setting a new standard in patient safety.
Medline’s Gold Standard Safety Program—a complete tool kit for surgical safety. Designed to break down barriers to surgical safety compliance by offering easy-to-use tools to help you reach your safety goals, Medline’s Gold Standard Safety Program offers four levels of safety options: 1. The Gold Standard Safety Bundle: Includes six products to serve as visual safety reminders to reduce needle sticks and wrong site surgery. 2. Innovative safety products: Surgical Time Out Procedure (S.T.O.P.™) Drape and Dual Tip Marker remind OR staff to take time to verify key information before the first incision to reduce wrong site surgery. 3. Med-Pack™: Electronic pack audit and a review of safety components.
Visit www.medline.com/goldstandard for a quick video overview on how Medline’s Gold Standard Safety Program can help improve safety in your OR.
©2009 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
among all members of the procedure team. Time-outs have been found to be most effective when conducted consistently across the hospital, so the OR manager often can take a leadership role in helping to establish protocols for other ambulatory procedure areas. Keeping patients safe at all times when they are under our care is the goal of every healthcare provider. Your role in making your colleagues aware of these changes and inviting them to actively participate in updating procedures at your facility will ensure that you meet that goal. procedure and discuss situations in which exceptions to site marking may be allowed. Develop an alternative process if that meets your needs, but be sure to document the change and educate all personnel who will interact with the patient. Time-out (UP.01.03.01): The purpose of the time-out procedure is to conduct a final check that the correct patient, site and procedure are identified. This is the final safety check that all systems are go! In the revised version of in the Universal Protocol, all references to conducting the time-out before initiating anesthesia have been removed. The rationale states â€œa hospital may conduct the time-out before anesthesia or may add another time-out at that time.â€?2 The list of issues to be addressed during the time-out was shortened to enable healthcare team members to focus on the correct patient, procedure and site.
What this means for you You have the opportunity to meet with the surgeons and other members of your team to decide how you want to structure the time-out procedure. When is the best time for you to perform the time-out? Think about all the steps you take to keep your patient safe and ask yourself what the patient can contribute during the time-out. If you determine that the patient can contribute to the safety aspect of their care, then it would make sense to do the time-out prior to the start of anesthesia. Remember to designate a member of the team to initiate the time-out and include active communication
16 The OR Connection
References 1. Approved: revised Universal Protocol for 2010. The Joint Commission Perspectives. 2009;29(10):3. Available at: http://www.jointcommission.org/NR/rdonlyres/DFBF9FFDAF97-4CA1-A9C8-8102C2D77AE0/0/JCP1009.pdf. Accessed October 28, 2009. 2. The Joint Commission. 2010 National Patient Safety Goals (NPSGs). Pre-publication Version of the 2010 National Patient Safety Goals (NPSGs) outlines and chapters for all applicable programs. Available at: http://www.jointcommission.org/patientsafety/ nationalpatientsafetygoals/. Accessed November 24, 2009.
About the author
Connie Yuska, RN, MS began her career as a nurse in the specialty of otorhinolaryngology. Her clinical experience includes both inpatient and outpatient care of head and neck oncology patients, and she is certified in otorhinolaryngology and headneck nursing. She has held clinical manager and director of nursing positions in a large academic medical center and also has experience in the home care setting as the vice president of operations for a large academically affiliated home care agency in the Chicago area. Connie later joined the executive suite as the chief nursing officer of a large community hospital in Chicago, and she is currently a vice president of clinical services for Medline. In all of her leadership roles, she has been responsible for ensuring the delivery of high quality, safe and cost-effective nursing care. Connie is a 2003 graduate of the J&J/Wharton Nurse Executive Program. She is member of the Board of the Illinois Organization of Nurse Leaders and a member of the American Organization of Nurse Executives. In 2005, she was inducted into the 100 Wise Women Program sponsored by Deloitte & Touche. In addition, she has published several articles and chapters in oncology journals and textbooks.
Your hands will love you even more.
Sterillium® Rub’s high alcohol content delivers a devastating blow to microorganisms— not your skin. Sterillium® Rub’s balanced emollient blend leaves hands feeling soft and smooth, never greasy or sticky, and makes gloving a breeze. But that doesn’t mean that Sterillium® Rub makes any sacrifices in efficacy. In fact, it meets FDA requirements for efficacy specifications. It’s also CHG, latex and non-latex glove compatible. We know that comfort drives compliance. When you choose Sterillium® Rub, you have an ally that’s tough on bacteria but a real softie on your skin. To download a transcript of interviews with international hand hygiene experts Didier Pittet and Günter Kampf, go to www.medline.com/mediaroom and choose Featured Article 3. ©2009 Medline Industries, Inc. Medline® is a registered trademark of Medline Industries, Inc. Sterillium® is a registered trademark of BODE Chemie GmbH.
Increased efficacy. Incredible comfort. Improved compliance. Sterillium® Rub. Sterillium® Rub with touchless dispenser pictured.
BREAKING THROUGH HAND HYGIENE & SKIN CARE BARRIERS “Effect of Lotions and Creams on Irritant Hand Dermatitis in Health Care Workers” Featured in the American Journal of Infection Control Join us for this exclusive webcast highlighting the latest hand care research as Dr. Marty Visscher, PhD, discusses the conclusions of her recently published study showing that frequent use of lotions and creams may mitigate the damaging effects of repetitive hand hygiene. She also will discuss the need for intensive treatment of irritant contact dermatitis in healthcare workers to counteract skin compromise and minimize negative effects on infection control. About the Presenter Marty Visscher, PhD, is director at The Skin Sciences Institute, Cincinnati Children’s Hospital Medical Center. She pioneered the development and use of sensory techniques to measure the patient/consumer relevant skin effects of ingredients and products, and is an expert on the effects of environment and skin treatment products on the skin.
Shown on demand January 25-29, 2010, with one CE credit available through Medline University. For more information and to register, please visit www.medlineuniversity.com
©2009 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
PERIOPERATIVE PRESSURE ULCER EDUCATION More important than ever before Medline’s Pressure Ulcer Prevention Program now has a component designed specifically for perioperative services. The easy-to-use interactive CD addresses the following: • Hospital-acquired conditions • CMS reimbursement changes • Best practices for pressure ulcer prevention • Perioperative assessment tools • Critical patient and equipment risk factors
I have seen an increase in the number of legal issues linking facility-acquired pressure ulcers to post-surgical patients. A pressure ulcer program for the OR is more critical than ever.” Diane Krasner, PhD, RN, CWCN, CWS, BCLNC, FAAN
To learn more about Medline’s Pressure Ulcer Prevention Programs and FREE webinars for acute care and perioperative services, call your Medline representative or visit www.medline.com/pupp-webinar.
The AORN Seal of Recognition has been awarded to Pressure Ulcer Prevention for Perioperative Services in June 2009 and does not imply that AORN approves or endorses any product or service mentioned in any presentation, format or content. The AORN Recognition program is separate from the AORN, ANCC Accredited Provider Unit and therefore does not include any CE credit for programs. ©2009 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc. The AORN Seal of Recognition is a trademark of AORN, Inc., All rights reserved.
20 The OR Connection
Back to Basics
Eleventh in a Series
Perioperative Positioning Injuries on the Rise:
What to Do! by Alecia Cooper, RN, BS, MBA, CNOR
Author’s note: In 2007, I wrote a “Back to Basics” article on the principles of proper positioning and prevention of positioning injuries. I listed many types of injuries that can occur as a result of improper positioning before, during and after a surgical procedure. The content of that article still holds true, but when I went back to the topic recently in preparation for a live presentation, I was alarmed to learn that these injuries were not on the decline, but rather on the rise. And that’s what prompted me to write this article as a refresher on positioning for perioperative professionals.
Positioning for a surgical procedure depends on the surgeon’s preference, the anesthesia provider’s needs, the procedure being performed and the need for exposure of the surgical site. Overall, positioning is recognized as a balance between the position a patient can physically assume and what can be physiologically tolerated, based on the patient’s age, height, weight and overall health. A patient’s body must be positioned adequately on an OR bed, and proper body alignment must be maintained to lessen the potential for injuries.3
The importance of proper patient positioning must not be overlooked. More and more studies are attributing hospitalacquired pressure ulcers to lack of proper positioning in perioperative services. In fact, AORN’s 2009 Perioperative Standards and Recommended Practices states that the incidence of pressure ulcers occurring as a result of surgery may be as high as 66 percent.1 In addition, more and more lawsuits are being filed due to positioning injuries, not only because of avoidable pressure ulcers, but also physiologic compromises and nerve damage. The incidence of nerve injuries is unknown, however in the United States, nerve damage accounts for 15 percent of postoperative litigation claims.2
Assessment Proper patient positioning begins with an assessment before the patient ever arrives in the operating room. Elements to consider include the patient’s pre-existing conditions, the type and duration of the procedure and individual patient characteristics such as height, weight, age, skin condition, etc.1 Regardless of these factors, however, all surgical patients should be considered at risk for pressure ulcers because of the uncontrollable length of surgery and the effects of anesthesia on the patient’s hemodynamic state, along with the use of vasoactive medications during surgery.3
Aligning practice with policy to improve patient care 21
Risk factors identified during the assessment can determine the degree of pressure the patient can tolerate. The following factors affect the ability of the skin and supporting structures to respond to pressure:3 • Vasoactive medications and steroids • Comorbid diseases, such as cancer, cardiovascular and peripheral vascular deficiencies, diabetes and neurological or respiratory disease • Extracorporeal circulation • Impaired regulation in body temperature • Existing fractures • Low hemoglobin and hematocrit levels • Nutritional deficiencies • Obesity • Low serum protein (i.e., prealbumin or total albumin plus globulin) • Smoking • Low blood pressure
Special considerations for avoiding eye injuries1
Maintaining optimal physiological conditions lessens the risk for complications both intraoperatively and postoperatively. When a patient has inadequate arterial blood flow, improper positioning can cause complications with blood pressure, decrease tissue perfusion and venous return and cause blood clots.
The length of the procedure is another consideration. Often, the longer a patient is on the operating table, the greater the risk for pressure ulcers. One study reported that intraoperative pressure ulcers increased when the procedure time extended beyond three hours. Cardiac, general, thoracic, orthopedic and vascular procedures were reported to be the most common types of procedures associated with pressure ulcer formation.1
Pre-existing conditions are important to assess because certain patients are especially vulnerable to pressure ulcers and/or nerve damage. Patients with vascular disease may have existing tissue ischemia and often have additional risk factors such as age, nutritional deficits, obesity or diabetes.1 Interestingly, these are the same patients who often undergo cardiovascular surgery, which already puts patients at higher risk for injury simply because the procedures typically last four hours or longer. In addition, patients who smoke often experience vasoconstriction, which contributes to pressure ulcer formation.1 Patients with respiratory, circulatory, neurologic or immune conditions are also more vulnerable to injury, as are those with physical limitations such as back problems and prostheses or implants, such as an artificial hip or knee.
22 The OR Connection
Patients are at increased risk of developing post-operative vision loss if they: • Are undergoing procedures lasting 6.5 hours or more • Have substantial blood loss • Are in a prone position In general, direct pressure on the eye should be avoided to reduce the risk of central retinal artery occlusion and other ocular damage, including corneal abrasion. Assess eyes regularly, especially in long procedures and when the patient is in the prone position. The type of procedure dictates how the patient will be positioned on the operating table and the type of positioning equipment that will be required. The most common surgical positions are supine, prone, lateral and lithotomy. Each position carries its own risks and safety considerations, as shown in Table 1 on page 29.
Specific factors such as age, weight and skin condition, among others, are also important to assess prior to surgery.1 Patients who are 65 years of age or older experience the highest incidence of pressure ulcer development.3 These patients also have less flexibility and poorer peripheral circulation, making them more prone to skin- and nerve-related injury. The same holds true for obese patients.4 Of course, every individual is different, and your assessment will reflect this. A fit, healthy 82-yearold may be less vulnerable than an overweight 35-year-old with diabetes. Very young pediatric patients are also at greater risk for surgical injuries, as are frail, malnourished individuals. Continued on page 24
NO PRESSURE, JUST SUPPORT. Gel positioners ease pressure in the OR Recent studies have shown that pressure ulcers can start to form in as little as 20 minutes in the operating room.1 When every second counts, the surfaces used for positioning and transporting patients need to be chosen carefully. Medline’s gel positioners are designed to help reduce pressure while providing exceptional support during surgical procedures. They’re latex- and silicone-free, antimicrobial, antibacterial and radiolucent. They’re also reusable and can easily be cleaned and disinfected with standard hospital disinfectants. Available in a wide variety of shapes and sizes. Gel positioners are one of several products recommended as part of Medline's Pressure Ulcer Prevention Program. This proven, systematic approach combines education, best-in-class products and dedicated program management to reduce pressure ulcer incidence. To sign up for a FREE webinar on perioperative pressure ulcer prevention, go to www.medline.com/pupp-webinar. References 1 Pressure ulcers hit a sore spot in the operating room. Healthcare Purchasing News. Available at: http://www.hpnonline.com/inside/2007-08/0708-OR-pressure.html. Accessed November 17, 2008. ©2009 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
ment and support of joints when an older adult patient is positioned after undergoing sedation. If not contraindicated, the circulating nurse should also place a pillow under the patient’s knees to avoid postoperative stiffness that may limit early mobility. Heels are an often overlooked but vulnerable area than can benefit from additional padding as well.6
Be sure to assess the patient’s skin before surgery, looking for dryness, skin tears and existing wounds, including pressure ulcers, and document your findings in the medical record. This information will be critical for comparing the condition of the patient’s skin after surgery to determine any damage that may have occurred in the operating room. Many pressure ulcers that originate during surgery do not appear until one to four days after an operation, some are mislabeled as burns and some are unexplained because they appear and progress differently from the pressure ulcers seen in nonsurgical patients. OR-acquired pressure ulcers initially have a distinctive purple appearance.5 Shearing movement should be avoided when transferring patients onto the OR table, especially the elderly, whose fragile skin can tear more easily than the skin of younger patients. The overall goal of positioning elderly patients is to reduce stress and pressure on the spine and skin. The circulating nurse should be particularly vigilant about optimal body align-
24 The OR Connection
After assessment, the next step is planning. The nurse must anticipate the proper positioning equipment and supplies that will be needed based on the knowledge acquired during the assessment. The nurse should review the surgery schedule before the patient’s arrival – preferably before the day of surgery – to identify potential conflicts in the availability of positioning equipment.1 The nurse should also confirm that the room is set up appropriately for the planned procedure before the patient arrives. In addition, positioning and transporting equipment should be periodically inspected and maintained. Properly functioning equipment contributes to patient safety and assists in providing adequate exposure of the surgical site.1 Even when you have a plan, observe the patient right before surgery to ensure that your positioning recommendations are still correct. Also double check that all necessary positioning devices and padding materials are in the operating room prior to transporting the patient.
Tools for Proper Positioning The goal is to use equipment that is designed to redistribute pressure and decrease the risk for positioning injuries. An Continued on page 26
KEEP YOUR SURGICAL PATIENTS DESERT DRY. Medline’s Sahara® Super Absorbent OR table sheets are designed with your patients’ skin integrity in mind.
QuickSuite® OR Clean Up Kit
The Braden Scale tells us that moisture is one of the major risk factors for developing a pressure ulcer.1 We also know that as many as 66 percent of all hospital-acquired pressure ulcers come out of the operating room.2 That’s why we developed the Sahara Super Absorbent OR table sheet. The Sahara’s super-absorbent polymer technology rapidly wicks moisture from the skin and locks it away to help keep your patients dry. Sahara OR table sheets are available on their own or as a component in our QuickSuite® OR Clean Up Kits, which were designed to help you dramatically improve your OR turnover time and help reduce cross contamination risk through a combination of disposable products.
To sign up for a FREE webinar on perioperative pressure ulcer prevention, go to www.medline.com/pupp-webinar.
Braden Scale for Predicting Pressure Sore Risk. Available at: www.bradenscale.com/braden.PDF. Accessed November 6, 2008.
Recommended practices for positioning the patient in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2008.
©2009 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
inverse relationship may exist between the duration and intensity of pressure. Low-intensity pressure over a long period can initiate tissue breakdown, as can high-intensity pressure for a short period of time.3 During the positioning procedure, it is the nurse’s responsibility to:1 • Restrict access to the operating room • Close all doors • Limit traffic within the operating room • Minimize exposure • Provide auditory privacy • Prohibit prejudicial behavior Positioning devices. Safety is the primary concern when determining the adequate number of personnel and type of devices to safely transfer and position the patient. Transferring is accomplished with a lateral transfer device (e.g., slide boards, air-assisted transfer devices) that reduces friction and shear.3 One study involving the review of 16 perioperative incident reports showed that in 63 percent of the cases, patients were above the weight limit for the equipment. To avoid this situation in your practice, ensure in advance that you will be using a bed that is sufficiently sized for the patient, obtain pressure redistribution table pads and be sure that armboards are available.1 Use specific positioners for head and neck surgeries, extremities procedures and procedures performed on the torso. Support surfaces. Proper padding around the patient’s body helps prevent skin breakdown, especially on high-risk areas where soft tissue is compressed between a bony prominence and a hard surface, such as the OR table. Use of too many pads or blankets, however, can cause the capillary pressure to rise over 32 mmHg, which increases the risk for poor tissue perfusion, causing the patient to be at risk for developing pressure ulcers.3 Pressure redistribution devices should be used to promote reduction of interface tissue pressure for patients at high risk of developing pressure ulcers or nerve injuries. Several
26 The OR Connection
Special considerations for avoiding nerve injuries1 Surgery-related nerve injuries most often are attributed to careless positioning. The most common injury is to the ulnar nerve, followed by the brachial plexus. To minimize the risk of nerve injury, safety measures should include: • Padded arm boards attached at less than a 90-degree angle for the supine position • Placing the patient’s hands palms up with fingers extended • Keeping shoulder abduction and lateral rotation of the patient to a minimum • Preventing the patient’s extremities from dropping below the level of the procedure bed. • Placing the patient’s head in a neutral position, if not contraindicated by the surgical procedure or the patient’s physical limitations • Adequate padding for the saphenous, sciatic and peroneal nerves, especially for patients in the lithotomy or lateral position • Placing a well-padded perineal post against the perineum between the genitalia and the uninjured leg when a patient is positioned on a fracture table
types of pressure redistribution support surfaces are available. One type is an overlay, which is placed directly on the mattress or bed frame as a replacement for the standard foam OR mattress.3 Foam, static-air and gel are common types of overlays. Static-air overlays allow air to exchange through multiple chambers when a patient lies on the overlay. This type of overlay must be reinflated periodically. Gel overlays prevent shearing, support weight and prevent bottoming out. One study found that gel overlays helped prevent skin changes and pressure ulcers in older adults, including those with chronic health comorbidities or vascular disease and those experiencing extended surgical duration.3 Mackey reviewed three OR trials that indicated that the use of air and gel pressure overlays might be beneficial in reducing the incidence of pressure ulcers for high-risk surgical patients.3
According to research published by Reddy et al, mattress overlays on the OR bed may decrease the incidence of postoperative pressure ulcers, along with adequate nutrition, moistening the skin and repositioning.3 Note: Rolled sheets and towels should not be used beneath the procedure bed mattress or overlay because they may negate the pressure-reducing effect of the mattress or overlay.1
Documentation Here’s a question. Should nurses document specifically who does what when positioning a patient for a surgical procedure? According to legal experts, the nurse should document exactly who did what to make it easier to determine liability in case of a lawsuit. Remember that everyone in the OR is responsible for their own actions.7 If the anesthesia provider tucks the patient’s arm to the side, give that person the credit on the operative record. If the surgeon positions the patient’s legs in stirrups, document that fact. Of course the nurse must always check to make sure all pressure points are padded or that pedal pulses are intact after the legs are positioned. It may be time-consuming and cumbersome to chart all of the specifics of positioning; however, it is advisable for the nurse’s protection. To simplify the task, a checklist could be developed, and the nurse could simply write the initials of the responsible party next to each task performed.7
Position to protect and support1 • • • • • • • • • • • •
Pad bony prominences Protect arms from nerve damage Confirm finger locations Carefully apply safety restraints to avoid nerve damage Ensure no body parts touch metal equipment Elevate heels whenever possible Align head and upper body with the hips Keep legs parallel (do not cross ankles) Position head in neutral position on a headrest A pillow may be placed under the back of the patient’s knees to relieve pressure on the lower back If pregnant, insert a wedge under the right side Do not tuck arms at patient’s sides unless absolutely necessary
Documentation should include the following:1 • A written preoperative assessment, including a skin assessment on arrival and discharge • The type and location of positioning equipment • Names and titles of persons participating in positioning • Position patient is placed in and new position if repositioning occurs • Post-operative assessment for injury
Aligning practice with policy to improve patient care 27
Documentation Makes or Breaks the Case at Trial If it’s not recorded, it didn’t happen5 A 60-year-old patient with multiple medical problems underwent 12-hour vascular reconstruction of the right leg. Sacral pressure ulcers were noted soon after, and despite treatment, severe necrosis developed. The patient’s leg was amputated below the knee and the sacral ulcer required surgical debridement with grafting. The patient alleged negligence in positioning during surgery, which resulted in severe sacral pressure ulcers that required prolonged hospitalization and additional surgery. A review of the medical record revealed a lack of documentation by the surgeon, anesthesiologist and the OR nursing staff regarding the patient’s increased risk for skin breakdown. Although serious skin breakdown may not have been preventable, documentation of heightened awareness by staff, as well as preventive measures, and a description of the patient’s skin after surgery, may have made it easier for the hospital to defend the case. The OR nursing documentation lacked information on the condition of the patient’s skin, and the padding used to position the patient on the OR table. The patient received a $100,000 indemnity payment and later sought additional compensation.
References 1. Recommended practices for positioning the patient in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, Colo.:AORN, Inc. 2009. 2. Prevention of injuries in the anaesthetised patient. Available at: http://www.surgicaltutor.org.uk/core/preop1/perioperative_injuries.htm. Accessed October 23, 2009. 3. Walton-Geer PS. Prevention of pressure ulcers in the surgical patient. AORN Journal. 2009;89(3):538-548. 4. Meltzer B. A guide to patient positioning. Outpatient Surgery. 2001;2(4). Available at: http://www.outpatientsurgery.net/issues/2001/04/a=guide-to-patient-positioning. Accessed December 3, 2009. 5. ECRI Institute website. Executive summary. Pressure ulcers. HRC.2006;3(4). Available at: http://www.ecri.org/documents/patient_safety_center/pressureulcers.pdf. Accessed December 3, 2009.
28 The OR Connection
Thorough nursing documentation wins the case8 A patient sued her surgeon and the hospital over persistent numbness in her right hand, which she first noticed after a total right hip replacement. Her lawsuit alleged the numbness was an ulnar nerve injury from improper positioning or the surgeon pressing against her arm or hand during surgery. All defendants were exonerated from blame due to the effort made by the circulating nurse to document in precise detail how the patient had been positioned, stabilized and padded before surgery. Of special note was the nurse’s documentation of the steps taken to extend the patient’s arms out of harm’s way and to pad her arms and hands to avoid injury due to positioning or pressure. The court record reiterated the circulating nurse’s documentation word-for-word: “6 table with safety strap in place 2 in. above knees – supine with bean bag underneath patient post induction & catheter insertion into the left side, with right side up, per __MD & __MD, - auxiliary roll in place (1000 cc bag IV fluid wrapped in muslin cover) – held in place per surgeons until bean bag deflated with suction – pillow placed under right leg with left leg bent slightly – U drape in place per surgeons pre-prep – left arm extended on padded arm board - right arm placed on mayo tray that is padded”
6. Doerflinger DMC. Older adult surgical patients: presentation and challenges. AORN Journal. 2009;90(2):223-240. 7. For the nurse’s protection, it is advisable to document all specifics of positioning a patient for surgery. AORN Journal.1993;58(1):116. 8. Ulnar nerve injury alleged from surgery: hospital not liable – circulating nurse’s documentation of patient’s positioning carries the day. Legal Eagle Eye Newsletter for the Nursing Profession. 1997;5(1):3. Available at: http://www.nursinglaw.com/ ulnar.pdf. Accessed December 4, 2009.
Injury Risks and Safety Considerations When Positioning Patients1 Position Supine
Pressure points, including occiput, scapulae, thoracic vertebrae, olecranon process, sacrum/coccyx, calcaneae, and knees.
• Padding to heels, elbows, knees, spinal column, and occiput alignment with hips, legs parallel and uncrossed ankles.
• Maintain cervical neck alignment.
Neural injuries of extremities, including brachial plexus and ulna, and pudendal nerves.
• Padded headrest to provide airway access. • Chest rolls (ie, clavicle to iliac crest) to allow chest movement and decrease abdominal pressure.
Chest compression, iliac crests Breasts, male genitalia
• Breasts and male genitalia free from torsion. • Knees padded with pillow to feet.
Bony prominence and pressure points on dependent side Spinal alignment
• Arm boards at less than 90-degree angle and level with floor. • Head in neutral position. • Arm board pads level with table pads. • Protection for forehead, eyes, and chin.
• Padded footboard.
• Axillary role for dependent axilla. • Lower leg flexed at hip. • Upper leg straight with pillow between legs. • Maintain spinal alignment during turning. • Padded support to prevent lateral neck flexion. • Place stirrups at even height. • Elevate and lower legs slowly and simultaneously from stirrups.
Hip and knee joint injury Lumbar and sacral pressure Vascular congestion Neuropathy of obturator nerves, saphenous nerves, femoral nerves, common peroneal nerves, and ulnar nerves. Restricted diaphragmatic movement Pulmonary region
• Maintain minimal external rotation of hips. • Pad lateral or posterior knees and ankles to prevent pressure and contact with metal surface.
• Keep arms away from chest to facilitate respiration. • Arms on arm boards at less than 90-degree angle or over abdomen.
Aligning practice with policy to improve patient care 29
Back to Basics
Perioperative Positioning Injuries on the Rise: What to Do! True or False (circle one) 1. In the United States, nerve damage accounts for 15 percent of postoperative litigation claims. T F 2. Patients who are 45 years of age and older experience the highest incidence of pressure ulcer development. T F 3. Surgical documentation should include a written preoperative assessment, including a skin assessment on arrival and discharge. T F 4. Patients are at increased risk of developing post-operative vision loss if they are in a prone position. T F 5. OR-acquired pressure ulcers initially have a distinctive greenish appearance. T F Multiple Choice 6. The incidence of pressure ulcers occurring as a result of surgery may be as high as a. 10 percent b. 82 percent c. 66 percent d. 38 percent 7. Which of the following affects the ability of the skin and supporting structures to respond to pressure? a. Obesity b. History of sleep apnea c. Nutritional deficiencies d. Both a and c
Submit your answers at www.medlineuniversity.com and receive 1 FREE CE credit
30 The OR Connection
8. Which of the following is an often overlooked but vulnerable area that can benefit from additional padding? a. Calves b. Heels c. Nose d. None of the above 9. Use of too many pads or blankets can cause the capillary pressure to rise over a. 19 mmHg b. 32 mmHg c. 76 mmHg d. 94 mmHg 10. The most common perioperative nerve injury is to the a. Lingual nerve b. Ulnar nerve c. Brachial plexus d. Sciatic nerve
TAKE THE PRESSURE OFF YOUR SURGICAL PATIENTS It’s estimated that up to 66 percent of pressure ulcers occur as a result of surgery.1 What can you do to help prevent your patients from becoming statistics? Medline’s pressure redistribution OR table and stretcher pads can help redistribute the pressure that can occur before surgery while lying on stretchers, on the table during surgery and while being transported to the postoperative care unit. All of our OR table and stretcher pads are designed with state-of-the-art materials to offer an advanced level of pressure redistribution. Each pad offers a different level of pressure redistribution and can be custom-made to fit any OR table. Finally — product solutions to help you meet your pressure ulcer prevention goals! To sign up for a FREE webinar on perioperative pressure ulcer prevention, go to www.medline.com/pupp-webinar.
Reference 1 AORN. Recommended practices for positioning the patient in the perioperative practice setting. Perioperative Standards and Recommended Practices. 2008 Edition. Denver, Colo.: AORN Publications; 2008. ©2009 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
Completely conforms to the body
PROTECTION, PERFORMANCE & COMFORT.
WITHOUT COMPROMISE SensiCare® surgical gloves address a rising concern in the OR — latex allergies. The American Latex Allergy Association estimates that between 8 and 17 percent of all healthcare workers are sensitized to natural rubber latex.1 Studies have suggested that the costs of healthcare workers’ disability compensation due to latex allergies justifies or significantly offsets the cost of conversion to a latex-free environment.2 Medline’s Sensicare® latex-free polyisoprene surgical gloves are made from Isolex™ (synthetic polyisoprene) that has a molecular structure that is virtually identical to natural rubber latex.
In fact, it is softer, more elastic and more comfortable. So never compromise again. Choose the SensiCare® glove that best fits your needs. • SensiCare® with Aloe – standard thickness, smooth grip • SensiCare® LT with Aloe – standard thickness, textured grip • SensiCare® Green with Aloe – 10% thinner for enhanced tactile sensitivity • SensiCare® Ortho – 40% thicker for extra protection Get a FREE one-day supply of SensiCare surgical gloves to try for yourself. To learn more, contact your Medline representative, call 1-800-MEDLINE or e-mail firstname.lastname@example.org.
References: 1 American Latex Allergy Association. Latex Allergy Statistics. Available at: www.latexallergyresources.org/topics/LatexAllergyStatistics.cfm. Accessed November 5, 2008 2 Phillips VL, Goodrich MA, Sullivan TJ. Health care worker disability due to latex allergy and asthma: a cost analysis. American Journal of Public Health. 1999:89(7):1024-28. ©2009 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
Can a Rigid Container System Be Greener and Safer at the Same Time? Unique rigid container benefits healthcare “greening” efforts by Rose Seavey, RN, BS, MBA, CNOR, CRCST, CSPDT
Providing optimal safety for patients is a major responsibility of any healthcare provider. One of the highest priorities should be to promote patient safety by tackling problems and finding solutions to known issues. In today’s healthcare environment, infection prevention plays a huge role in national initiatives to reduce healthcare-acquired infections (HAIs). This is particularly important for perioperative professionals in regard to surgical site infections (SSI). One critical way to minimize risks to surgical patients is to present items that are sterile (free of contamination) at the time of use. It is imperative that sterilization packaging systems ensure the integrity of the sterilized contents until opened for use. The material or packaging device used for items to be sterilized should provide a microbial barrier, protect package integrity, provide adequate seal integrity, allow for aseptic presentation and reduce the chance of contamination of the contents once sterilized.1
Aligning practice with policy to improve patient care 33
Shelf life It has been proven that sterility does not change over time, but is compromised by events that harm the integrity of the package and/or the environmental conditions. We refer to the time that an item may remain on the shelf and still maintain sterility as shelf life.1,2,3 The integrity of sterile packaging can be compromised by many things, such as poor package quality, improper storage conditions and excessive and/or abusive handling.2
Sterile packages or trays must be handled several times when they are placed on and pulled off storage shelves, placed on and off case carts, and then again when in the procedure area or operating room. Due to the fast-paced environment of the operating room, packages are not always handled with the greatest of care and are sometimes inadvertently subject to abuse (i.e., dropping). Therefore, we must place an increased importance on the hygienic security of sterilization packaging.
Package choices Events that may lead to decreased package integrity and therefore loss of sterility include:2 • Multiple handling • Moisture penetration • Exposure to environmental contaminants • Uncontrolled/unclean storage conditions • Improper type or configuration of packaging materials used
There are many available choices for sterilization packaging on the market today. A popular choice for numerous reasons is reusable rigid sterilization containers. These containers serve as packaging for surgical instruments before, during and after sterilization. Sterilization container systems have been on the market for more than 25 years and vary in design, mechanics and construction materials. Reusable rigid sterilization containers require a barrier system (i.e., filters or valves) to maintain package integrity.4
Handling sterile supplies After surgical instruments are sterilized and cooled, it is extremely important that they are handled carefully to maintain sterility. “Care should be taken to avoid dragging, sliding, crushing, bending, compressing, or puncturing the packaging or otherwise compromising the sterility of the contents.”3
34 The OR Connection
Rigid container systems protect instruments, contain sets and help eliminate the chance of package compression, tears or holes that may be associated with other types of packaging, resulting in compromised package integrity. Reusable containers are an environmentally friendly alternative to disposable packaging. In the push for healthcare
1. Double Lid
Solid, double lid ensures maximum protection and complete hygienic security. Also allows safe transportation of soiled instruments after a procedure.
2. Reusable Valve
Patented, automatic valve eliminates the need for disposable filters. It assures reliable, cost-effective, maintenance-free sterilization.
Patented locking system eliminates the need for disposable, tamper-evident locks/arrows.
4. Condensate Drain
Temperature-activated drain removes excess condensation from container.
facilities to become more “green,” reusable containers offer an opportunity to reduce the carbon footprint. A unique rigid container on the market is the Steriset container system manufactured in Germany by Wagner and distributed by Medline®. Steriset does not require any disposable filters or locks, which is an added benefit for our healthcare greening efforts. According to the Sterilization Container Overview & Technical Data sheet, Steriset containers are composed of a completely closed double lid protection system that is exceptionally tamper proof and hygienically secure. The containers are designed with a permanent reusable stainless steel valve that opens and closes to allow steam to
enter and exit based on the steam pressure during the sterilization cycle. The containers are also equipped with reusable tamper-proof locks that are temperature-activated.5
Environmentally responsible With the national initiatives to reduce HAIs, healthcare professionals’ major concern is patient safety. Perioperative professionals must do everything they can to help decrease the chances of surgical site infections. Sterilization containers in themselves are much more environmentally friendly than sterilization wrap; however, eliminating the use of disposable filters or locks as well makes Steriset containers the “greenest” container of them all, thereby best meeting the need for both patient safety and environmental responsibility.
Aligning practice with policy to improve patient care 35
These environmentally friendly containers are a better alternative to those requiring disposable items, but do they offer any additional protection? The containerâ€™s double lid is designed to provide complete hygienic security, therefore adding an additional shield from any external contaminants once sterilized. Further, with its permanent filter and lock features, Steriset requires much less assembly time and significantly reduces the possibility of user error during packaging â€“ which can only benefit patient safety. Does this design really help protect the contents against external contaminants while in storage? To validate the complete hygienic security provided by Steriset against disposable filters, an independent lab study was conducted by Q Laboratories Inc. in Cincinnati, Ohio.
Study design and methodology
Study purpose The purpose of this study was to compare the Steriset container system with two other rigid container systems that use disposable filters and locks. The principle idea was to evaluate the ability of each container to protect the contents from environmental contaminants.6
Table 1. Test Results Steriset Container 1 Container 2 Container With disposable With disposable No filters filter filter Did the methylene blue strike through the filters? Trial No. 1 Yes Yes No Trial No. 2 Yes Yes No Trial No. 3 Yes Yes No Trial No. 4 Yes Yes No Trial No. 5 Yes Yes No Trial No. 6 Yes Yes No Trial No. 7 Yes Yes No Trial No. 8 Yes Yes No Trial No. 9 Yes Yes No Trial No. 10 Yes Yes No Total number of strike-throughs 10 10 0
A methylene blue strike-through test was employed to evaluate the rigid containers. In this analysis, tests were performed on empty containers. Two containers included the manufacturer-recommended filter material assembled in the perforated lids and bottoms of the containers. The Steriset containers do not contain any filters. A single sheet of wet facial tissue was placed over the bottom filters on the inside of the two containers. A wet facial tissue was placed on the bottom of the Steriset container. After the lids were closed and latched, one teaspoon of methylene blue dust was sprinkled on top of each of the three containers.7
Each container was dropped three times onto a hard table surface from a height of 10 cm (3.9 inches). Following the drop test, each container was placed into a closed cabinet, and the door was closed at normal force five times. Then the three types of container were again dropped three times onto a hard table surface from a height of 10 cm (3.9 inches). The lids were then carefully opened to observe for any strike-through of the methylene blue on the wet facial tissue inside of each container. In order to evaluate the degree of strike-through present, the lids and
36 The OR Connection
filters were sprayed with distilled water. To obtain a thorough set of qualitative data, this entire procedure was replicated 10 times on each container. After each test, photos of the filters and moistened facial tissue were taken for a visual comparison.7
Results of study The study results indicate that none of the Wagner Steriset containers had any methylene blue strike-through residue present. The other two rigid sterilization containers had strike-through residue present at the conclusion of all 10 trials tested. (See Table 1.)
Study conclusion Wagnerâ€™s Steriset container is superior at eliminating the possibility of external contaminants entering a closed container under storage and handling conditions. Steriset provides extra protection because it is a closed design container system with no pathway though the outer lid and inner valve, therefore bacteria cannot reach contents unless opened.
Summary As choices continue to expand, perioperative nurses, as well as sterile processing professionals, have an essential role in evaluating and selecting products that may affect the quality of care and safety of the surgical patient while being more ecologically responsible.8
Other safety issues Before being opened, sterile packages should be inspected for package integrity. If the packaging is a rigid sterilization container system, the external latch, filters, valves and tamper-evident devices should be inspected for integrity. The lid should be inspected for the integrity of the filter or valve and the gasket.3 For disposable filters, this means the circulator must remove filter retention plate(s) in order to do a complete inspection of the filter before the items are handled by the scrub person. As mentioned earlier, Wagner’s Steriset container design helps significantly reduce user errors that surround disposable filters and locks. Common errors include: • Forgetting to replace disposable filters before every use • Forgetting to inspect disposable filters for pinholes before every use • Incorrectly replacing a disposable (i.e., not positioning it correctly) • Forgetting to use disposable locks before sterilizing the set • Insufficiently securing disposable locks to ensure set it adequately sealed All of the above insecurities are eliminated by the Steriset container design. Event-related shelf life means dependence on the physical integrity of the sterile packaging. However, if dust is able to strike through disposable filters in rigid containers; will the particulates be visible to the naked eye?
When it comes to product selection, patient safety should be the principal concern. In an effort to do all we can to help decrease the chance of surgical site infections in our patients, additional safety margins that help protect sterile instruments from external contaminants are definitely worth considering. Steriset Sterilization Containers manufactured by Wagner are protected under United States Patent No: US 6,620,390.
Medline is a registered trademark of Medline Industries, Inc. Steriset is a registered trademark of Wagner GMBH Company References 1. Recommended practices for maintaining a sterile field. In: Standards, Recommended Practices, & Guidelines. Denver, CO: AORN, Inc.;2009. 2. Recommended practices for selection and use of packaging systems for sterilization. In: Standards, Recommended Practices, & Guidelines. Denver, CO:AORN, Inc.; 2009. 3. Comprehensive guide to steam sterilization and sterility assurance in health care facilities. ANSI/AAMI ST79:2006, A1:2008 and A1:2009. Arlington, VA: Association for the Advancement of Medical Instrumentation; 2009. 4. Containment devices for reusable medical device sterilization. ANSI/AAMI ST77:2006. Arlington, VA: Association for the Advancement of Medical Instrumentation; 2006. 5. Medline Industries. Sterilization Container Overview & Technical Data page. Available at: http://www.medline.com/products/centralsterile/steriset-sterilization-containers.asp. Accessed July 24, 2009. 6. Proposal for the evaluation of the methylene blue test for sterilization of containers. Q Laboratories, Inc., Cincinnati, OH. Aug. 14, 2008. 7. Crowley, E. Final report: an evaluation of sterilization containers using the methylene blue test. Q Laboratories, Inc. Cincinnati, OH. September 2008. 8. Recommended practices for product selection in perioperative practice settings. In: Standards, Recommended Practices, & Guidelines. Denver, CO: AORN, Inc.;2009.
About the author
Rose Seavey, RN, BS, MBA, CNOR, CRCST, CSPDT, is president/CEO of Seavey Healthcare Consulting Inc., and former director of the sterile processing department at The Children’s Hospital of Denver. Rose is an elected member of the 2008-2010 Association of periOperative Registered Nurses (AORN) Board of Directors. She was honored with AORN’s award for Outstanding Achievement in Clinical Nurse Education in 2001. She has authored many articles on various topics relating to perioperative services and sterile processing.
Aligning practice with policy to improve patient care 37
JOIN THE PROGRAM TO REDUCE PRESSURE ULCERS We’ve made pressure ulcer prevention easy. Systematic efforts at education, heightened awareness and specific interventions by interdisciplinary healthcare teams have demonstrated that a high incidence of pressure ulcers can be reduced.1 The main challenges to having an effective pressure ulcer prevention program are: lack of resources; lack of staff education; behavioral challenges; and lack of patient and family education.2 Medline’s comprehensive Pressure Ulcer Prevention Program offers solutions to these challenges. The Pressure Ulcer Prevention Program from Medline will help you in your efforts to reduce pressure ulcers in your facility. The program includes: • Education for RNs, LPNs, CNAs and MDs • Teaching materials for you to help train your staff • Practical tools to help reduce the incidence of pressure ulcers • Innovative products supported by evidence-based information that results in better patient care
This has been a great learning experience for our staff and for our facility as a whole. I am thankful Medline had this program and that we were able to access it. I can’t imagine recreating this wheel!” Katrina “Kitty” Strowbridge, RN Quality Improvement Coordinator St. Luke Community Healthcare Network Ronan, Montana
For more information on the Pressure Ulcer Prevention Program, contact your Medline representative, call 1-800-MEDLINE or visit www.medline.com/pupp-webinar to register for a free informational webinar.
References 1 Holmes A, Edelstein T. Envisioning a world without pressure ulcers. ECPN. 2007;122(8):24-29. 2 CMS Roundtable, Omni Hotel, Chicago, Ill. March 10, 2008. ©2009 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
O.R. FIRES Although surgical fires are relatively rare, their effects are almost always tragic. Healthcare professionals were reminded once again of this chilling fact when a 65-year-old woman died September 8, 2009, six days after being burned in a flash fire during surgery at a Marion, Ill. hospital. According to the medical examiner, the woman died from complications of thermal burns. Further details have not been released publicly.1 Virtually all operating room fires ignite on or in the patient, causing considerable injury or even death. The ECRI Institute, an independent not-for-profit organization that researches approaches to improving patient care, estimates that 550 to 650 surgical fires occur among the 65 million surgical cases performed in the United States each year. Of those fires, about 20 to 30 are serious, resulting in disfiguring or disabling injuries. One or two result in patient deaths.2 The good news is that similar to many other healthcare-related errors, surgical fires are 100 percent preventable.3
The ECRI Institute released new surgical fire safety guidelines in October 2009, which are based on their own research and investigations and collaboration with the Anesthesia Patient Safety Foundation (APSF) and the American Society of Anesthesiologists (ASA) surgical fire task force. The primary change in the new guidelines is the recommendation to discontinue the traditional practice of open delivery of 100 percent oxygen during surgery of the head, face, neck and upper chest. The purpose for this recommendation is to prevent the formation of oxygen-enriched atmospheres near the surgical site, reducing the likelihood of fires.2
The fire triangle4 Understanding the elements needed to create a fire is the first step toward learning how to prevent a fire. Three basic elements â€“ known as the fire triangle â€“ are necessary to ignite a fire and keep it burning. The elements are oxidizers, ignition sources and fuel. In the operating room, oxidizers include oxygen supplied for the patient, as well as nitrous
NEW RECOMMENDATIONS FOR PREVENTION Aligning practice with policy to improve patient care 39
The Surgical Fire Triangle
Oxidizers (Mainly controlled by anesthesia providers) - Air - Oxygen - Nitrous oxide
Ignition sources (Mainly controlled by surgeons) - Electrosurgical devices - Electrocautery devices - Lasers - Fiber optic light sources - Defibrillator paddle or pads
Fuel Fuel (Mainly controlled by nurses) - Prepping agents - Anesthesia components - Linens - Patientâ€™s hair - Dressings - Tracheal tubes - Ointments - Intestinal gases
oxide. Examples of ignition sources are electrosurgical and electrocautery devices, heated probes, defibrillators, lasers and fiberoptic light sources and cables. Fuel sources include certain prepping agents and ointments, linens, dressings, the patientâ€™s hair and anesthesia components. 2
How to prevent surgical fires
The most obvious and easiest method of fighting fires is to prevent them from starting, primarily by making sure the three elements of the fire triangle never combine in the operating room (OR). This task is achieved by controlling ignition sources, managing fuels and minimizing oxygen concentration. Similar to best practices for protecting patients from healthcareacquired injury in the OR, fire prevention must be a team effort. For the most part, anesthesia professionals control oxidizers, surgeons control ignition sources and nurses control fuel sources. Each team member should understand the fire hazards associated with each side of the fire triangle and do their best to keep those elements apart.
40 The OR Connection
Minimizing oxidizers. High oxygen concentration, including the oxygen contributed by nitrous oxide, enhances the ignitability of most fuels. Conversely, minimizing the percentage of oxygen flowing around the patient will reduce the fire risk. According to new guidelines, except for certain cases, the traditional practice of open delivery of 100 percent oxygen should be discontinued. In the majority of cases, room air or a low concentration of oxygen balanced by an inert gas (e.g., nitrogen, helium) may be adequate for ventilation and thus reduce the fuel-ignition risk. If supplemental oxygen is needed during surgery, the patientâ€™s airway should be sealed using a tracheal tube or laryngeal mask. Controlling ignition sources. Electrosurgical devices are the most common ignition source in surgical fires. These devices can produce a high-temperature electric arc or incandescence at the probe tip. Surgical fires also can start if electrosurgical electrode cables spark. This problem usually occurs with
The primary change in the new guidelines is the recommendation to discontinue the traditional practice of open delivery of 100 percent oxygen during surgery of the head, face, neck and upper chest.
reusable monopolar cables that connect to an active electrode, such as those used in laparoscopy. (Note: The ECRI Institute reports that to their knowledge, there has never been a report of a fire with bipolar electrosurgery; only monopolar.) Sparking typically results from cable failure at the active electrode connector or at its strain relief. The cable’s internal conductor strands become severed over time from use and handling during sterilization. A scheduled program of periodic cable replacement is one way to avoid this problem. Managing fuels. Allotting sufficient time after patient prepping and before draping allows vapors and gases to dissipate. Where volatile liquid exists, so does the risk of fire. Volatile fuels, such as alcohol, collodion and acetone, can take several minutes to fully vaporize, and a few minutes more to become diluted in room air. Care should be taken to avoid or minimize pooling of volatile liquids – particularly under the patient, where they may not be noticed. Taking the time to check that these volatile fuels have fully evaporated on and under the point of application will prevent them from being ignited when electrosurgery or other heat-producing devices are in use.
Developing a fire plan that includes fire drills Being prepared for a fire will minimize the cost in dollars, lost time, emotional shock and injury or death. Preparation involves a number of steps—the most important of which is practicing fire drills that teach all staff about their responsibilities during a fire. Having a predetermined method of fighting a surgical fire so that every team member knows what to do is critically important.2
Practice drills for fires on and in the patient are especially crucial to ensure OR staff knows how to: • keep minor fires from getting out of control • manage fires that do get out of control • locate and properly use fire-fighting tools; medical gas valves; heating, ventilation, and air-conditioning (HVAC) controls; and electrical supply switches • operate the fire alarm and communication system Although many facilities, in compliance with Joint Commission requirements, conduct drills for evacuating the OR in the event of a major fire, drills for the surgical team for fighting fires involving the patient are rare—and should not be. Operating Room Fire Equipment and Supplies to Keep Immediately Available5 • Several containers of sterile saline • A CO2 fire extinguisher • Replacement tracheal tubes, guides, face masks • Rigid laryngoscope blades; this may include a rigid fiberoptic laryngoscope • Replacement airway breathing circuits and lines • Replacement drapes, sponges Note: Your operating room may benefit from assembling a portable cart containing equipment and supplies to expedite immediate response to an operating room fire. The contents of this cart will vary depending on your procedures and resources.
What to do if the patient is on fire2 A 2008 Practice Advisory published by the American Society of Anesthesiologists notes that all team members should take a joint and active role in agreeing on how a fire will be prevented and managed. Each team member should be assigned a specific fire management task to perform in case of a fire. If a team member completes a pre-assigned task, he or she should help other team members perform their tasks.5
Most fires in the OR will be either on or in the patient. In either case, quick action will avert a disaster. Smoke, the smell of fire or a flash of heat or flame should prompt a fast response. In 30 seconds or so, a small fire can progress to a life-threatening large fire. During any fire, protecting the patient is the primary responsibility of the staff; self-protection is a secondary consideration.
Aligning practice with policy to improve patient care 41
All-new guidelines regarding open delivery of oxygen in the operating room2
To contain the flames, the fire triangle must be disrupted by diminishing or removing one or all of its sides. For example, a small area of burning drape or gown can be patted out effectively and safely by hand; larger areas can be smothered effectively with a fire blanket or towel. Fires inside the patient are typically small, but can be deadly. Practicing for an airway fire, such as from a burning tracheal tube, can develop the speed that will minimize injury in a real emergency.
Closing thoughts Stopping small fires before they become big fires – or preventing them altogether – requires a team effort. Good communication among the surgical team can ensure fire-safe practices. If a surgical fire occurs, the anesthesia provider should stop the flow of gas; the surgeon should remove the burning material and the nurses should extinguish the burning material. Once the fire has been extinguished, attention must be turned to the patient, resuming ventilation but using only air until it’s certain the fire is totally out, then resuming use of oxygen appropriate to the patient’s needs; controlling bleeding; evacuating the patient (if in danger from smoke or fire) and then examining the patient for injuries.
References 1 Suhr J. Woman catches fire during surgery. Associated Press. September 17, 2009. Available at: http://news.aol.com/article/woman-dies-after-catching-fire-during/675219? Accessed September 27, 2009. 2 New clinical guide to surgical fire prevention. Health Devices. 2009; 38(10):314-332. 3 AORN guidance statement: fire prevention in the operating room. In: Standards, Recommended Practices & Guidelines. Denver, Colo.: AORN, Inc.; 2009:171-179. 4 Mathias, JM. Scoring fire risk for surgical patients. OR Manager. 2006;22(1). 5 Practice advisory for the prevention and management of operating room fires. Anesthesiology. 2008; 108(5):786-801. Available at: http://journals.lww.com/anesthesiology/Fulltext/2008/05000/Practice_Advisory_for_the_Prevention_and.6.aspx. Accessed September 28, 2009.
42 The OR Connection
• Use only air (not oxygen) for open delivery to the face if the patient can maintain a safe blood oxygen saturation without supplemental oxygen. • If the patient cannot maintain a safe blood oxygen saturation without extra oxygen, secure the airway with a laryngeal mask airway or tracheal tube. Exceptions: The following recommendations are for surgery in which the patient’s verbal responses may be required – such as carotid artery surgery, neurosurgery and pacemaker insertion – and where open oxygen delivery is required to keep the patient safe. At all times, deliver the minimum oxygen concentration necessary for adequate oxygenation (as monitored with a pulse oximeter). • Begin with a 30 percent oxygen concentration and increase as necessary. • For unavoidable delivery above 30 percent, deliver five to 10 L/minute of air under drapes to wash out excess oxygen. • Stop supplemental oxygen at least one minute before and during use of electrosurgery, electrocautery or laser, if possible. Surgical team communication is essential for this recommendation. • Use an adherent incise drape, if possible, to help isolate head, face, neck and upper-chest incisions from oxygen-enriched atmospheres and from flammable vapors beneath the drapes. The incise drape can help prevent gas communication channels between the under-drape space and the surgical site. • Keep fenestration towel edges as far from the incision as possible to prevent their ignition from electrosurgical flames or sparks. • Arrange drapes to minimize oxygen buildup underneath (such as from an uncuffed tracheal tube or a laryngeal mask airway) and to direct gases away from the operative site. • Coat hair on head and face within the fenestration with water-soluble surgical lubricating jelly to make it non-flammable. • For coagulation, use bipolar electrosurgery, not monopolar electrosurgery.
Mark Bruley Talks About New Surgical Fire Prevention Guidelines
Vice President, Accident and Forensic Investigation, ECRI Institute
The OR Connection had the opportunity to interview surgical fire safety expert Mark Bruley in October 2009, shortly after publication of the new ECRI Institute surgical fire safety guidelines, which he authored. As a forensic investigator for the ECRI Institute for the past 30 years, Bruley has acquired a wealth of knowledge and data through numerous on-site surgical fire investigations and related research at the ECRI Institute laboratories. Bruley said that in terms of well-researched, evidence-based recommendations, the newly published surgical fire safety guidelines are “at the pinnacle of recommendations. These recommendations are supported by the physics of fire and the physics of anesthesia machinery.” The new ECRI Institute guidelines came about coincident with Bruley and his colleagues being approached by the Anesthesia Patient Safety Foundation (APSF) – an affiliate of the American Society of Anesthesiologists (ASA) – to create an updated surgical fire safety educational video. “As we began working on the video,” Bruley said, “we came upon pragmatic problems regarding the exceptional surgical cases that require open delivery of oxygen and the logistics of how to provide blended air and oxygen in the operating room.” Exceptional cases are those where a patient may need to speak during the surgery.
As a traditional course of practice, the majority of surgeries under monitored anesthesia care (MAC) of the head, face, neck and upper chest have involved open delivery of 100 percent oxygen, however, the ECRI Institute’s years of surgical fire investigations have shown a strong correlation between surgical fires and this practice. Therefore, they recommend avoiding the use of open delivery of oxygen whenever possible and delivering medical air instead. For patients who need extra oxygen, they recommend securing the airway with a tracheal tube or laryngeal mask airway. That recommendation is endorsed by APSF. For the exceptional cases when open delivery is necessary, the anesthesia provider should blend air and oxygen to provide a lower percentage of oxygen. But because open delivery of oxygen has been routine for so long, the prospect of changing this clinical practice led to considerable debate among anesthesia providers and surgical fire prevention specialists. In order to address these issues, the guidelines needed to explain how to provide a blended air and oxygen mixture in those exceptional cases when open delivery of oxygen was required. “The problem with open delivery of oxygen is that the oxygen will exhaust at the patient’s head and neck, which presents a flash fire hazard,” Bruley said. To minimize this effect, the ECRI
Aligning practice with policy to improve patient care 43
Flash fires will occur during surgery only when oyxgen levels are between approximately 40 and 100 percent
Institute’s new guidelines recommend a variety of techniques to use in those exceptional cases when the patient requires open delivery of oxygen, including:1 1. Delivery of the lowest percentage of oxygen possible to maintain patient safety 2. Beginning with 30 percent delivered oxygen concentration and increasing as necessary 3. Delivery of 5 to 10 L/min of air under drapes to wash out excess O2 4. Stopping supplemental oxygen at least one minute before and during use of an ignition source such as electrosurgery According to Bruley, with oxygen levels at 30 percent or below, there is no flash fire hazard. ECRI Institute recommends beginning with 30 percent oxygen, and titrating up only if necessary to maintain the patient at a healthy oxygen level. “Flash fires, which begin in an instant, will occur during surgery only when oxygen levels are between approximately 40 and 100 percent,” Bruley said. This new approach, however, of blending air and oxygen brings about a logistical dilemma. Not all anesthesia equipment is designed to deliver blended air and oxygen. So how can the blending be achieved? According to the ECRI Institute’s 2009 guidelines, three approaches are recommended for blending oxygen:1 • Use an oxygen-air blender. This is the preferred and most reliable approach because it is the simplest. • Use a three-gas (air, oxygen, N2O) anesthesia machine that has a common gas outlet (CGO) and take the blended gas from the CGO. • Use the breathing circuit wye on an anesthesia machine that does not have an available CGO. Close the APL valve on the absorber for faster changes in the delivered oxygen concentration. Regardless of how the oxygen-air mixture is obtained, monitoring of the delivered oxygen by the anesthesia provider is recommended to ensure that the gas mixture is as desired.
How to minimize risk when a surgical fire occurs2
In spite of taking precautions to prevent surgical fires, they can and do occur. If a fire or other serious incident ever takes place in your operating room, the ECRI Institute advises taking the following steps immediately in order to minimize risk and preserve evidence for later forensic investigation. • Take emergency measures to minimize and care for injury to, discomfort of, and threat to life of patients and staff. • Take appropriate action to minimize damage to equipment and the environment. • Notify the attending clinician who has legal responsibility for the patient. • Impound all equipment attached or contiguous to the injured party in the same room or areas. • Do not disconnect or change the relative physical positions of equipment or connecting cables, except as absolutely necessary to avoid further injury or damage. • Retain and preserve any disposable products that may have been involved (e.g., drapes, electrodes), as well as their packaging materials. Free educational posters on surgical fire prevention and extinguishment are available at ECRI Institute’s surgical fire website at www.ecri.org/surgical_fires. See also pages 84 – 85.
Locations of Surgical Fires1
In the airway
Elsewhere in the patient
Elsewhere on the patient
26% On the patient References 1 New clinical guide to surgical fire prevention. Health Devices. 2009;38(10):314-332. 2 Accidents happen – an immediate action plan. The ECRI Institute website. Available at: https://www.ecri.org/Products/PatientSafetyQualityRiskManagement/CustomizedServices/Pages/Immediate_Action_Plan.aspx. Accessed November 2, 2009.
44 The OR Connection
In the patient On the head, neck, or upper chest
FIRE RISK FOR SURGICAL PATIENTS
Fires in the operating room are a risk that requires prevention, vigilance, and quick action to prevent patient injury. To heighten awareness, the Christiana Care Health System (CCHS) in Newark, Del., added a Surgical Fire Risk Assessment Score to its Patient Identification and Surgical Site documentation form. Aligning practice with policy to improve patient care 45
“What brought this issue to our attention were two surgical fires. One occurred in the electrophysiology lab and the other in the OR with a patient having a carotid endarterectomy. Both cases involved a high concentration of oxygen, surgery above the xiphoid, and a heat source,” Judith Townsley, RN, MSN, CPAN, director of clinical operations for perioperative services, told OR Manager. The chairman of the anesthesiology department, Kenneth Silverstein, MD, developed the fire risk assessment score after the fires were investigated by ECRI Institute (www.ecri.org), a not-for-profit organization that researches health services and technology, and Russell Phillips & Associates (www.phillipsllc.com), consultants in fire, code compliance and emergency management.
The surgical team at Christiana Care Health Services in Newark, Del., follows a surgical safety checklist as they perform a pre-incision team briefing. The checklist is mounted on the opposite wall and includes the components of the surgical time out and the fire risk assessment score. Pictured, left to right: scrub nurse Judy Saunders, CST; anesthesia provider Ron Castaldo, CRNA; surgeon Mike Conway, MD; assistant Paul Aguilon (medical student) and circulator Kelly Saunders, RN.
Assigning a fire risk score The fire risk assessment is performed by the entire surgical team (anesthesia provider, surgeon and nurse) before the incision is made and is documented by the circulating nurse, noted Denise Dennison, RN, BSN, CNOR, staff development specialist. The assessment requires the surgical team to identify the three key elements that are necessary for a fire to start – the fire triangle: • Heat • Fuel • Oxygen In the OR, three key risks are: • Surgical site or incision above the xiphoid • Open oxygen source (i.e., patient receiving supplemental oxygen via face mask or nasal cannula) • Available ignition source (i.e., electrosurgery unit, laser or fiberoptic light source)
46 The OR Connection
Score 3 = High risk. All three components of the fire triangle are present. Score 2 = Low risk with potential to convert to high risk. This score is given when the procedure is in the thoracic cavity, the ignition source is remote from an open oxygen source, the ignition source is close to a closed oxygen source, or no supplemental oxygen is used. Score 1 = Low risk. Only supplemental oxygen is being used. Each risk score has a fire protocol assigned to maximize patient safety. The documentation form allows the circulating nurse to indicate that the high-risk protocol was initiated. It also allows for documentation that sufficient time was allowed for fumes to dissipate when an alcoholbased prep solution is used.
Fire Risk Protocols Score 3 = High risk The circulating nurse and anesthesia provider take these precautions.
The surgical site fire risk assessment guide (above) was developed by Kenneth Silverstein, MD, anesthesiologist and chair of the anesthesiology department at Christiana Care Health Services. He developed the guide to help prevent surgical fires at the hospital.
Communication heightens awareness Since adding the fire risk assessment to the OR documentation, communication among the surgical team members as well as identification of the fire risk triangle have vastly improved, noted Dennison. “The secret to success of this process is that this formal communication and documentation makes everyone involved aware of the potential risk of a fire,” Townsley said. “Enhancing communication between providers has strengthened our focus on providing clinical excellence for our patients.”
References Bruley ME. Surgical fires: Perioperative communication is essential to prevent this rare but devastating complication. Qual Saf Health Care. December 2004;13:467-471. Meltzer HS, Granville R, Aryan HE, et al. Gel-based surgical preparation resulting in an operating room fire during a neurosurgical procedure: Case report. Neurosurg. April 2005;102:347-349. Paugh DH, White KW. Fire in the operating room during tracheostomy: A case report. AANA J. April 2005;73:97-100.
Circulating nurse • Verifies fire triangle, including verbal confirmation of the oxygen percentage • Ensures appropriate draping techniques to minimize oxygen concentration under the drapes • Minimizes ESU setting • Assesses that enough time has been allowed for fumes of alcohol-based prep solutions to dissipate (minimum of 3 minutes) • Encourages use of wet sponges • Ensures a basin of sterile saline and bulb syringe are available for fire suppression Anesthesia provider • Ensures that a syringe full of saline is in reach for procedures conducted within the oral cavity • Documents oxygen concentrations and flows • Uses the MAC circuit for oxygen administration initially at FiO2 of .30 using fresh gas flows of at least 12 L/min. Score 2 = Low risk with potential to convert to high risk Standard fire safety precautions are followed with the potential to convert to high-risk precautions if necessary. Standard precautions are to: • Observe alcohol-based prep drying times (minimum of 3 minutes) • Protect heat sources (e.g., using the ESU pencil holster) • Use standard draping procedure Score 1 = Low risk Standard fire safety precautions are followed.
Reprinted with permission from OR Manager, copyright ©2006.
Aligning practice with policy to improve patient care 47
By Kathleen Bartholomew, RN, RC, MN
Human beings rarely, if ever, succeed at accurately perceiving their own culture. So deeply entrenched is culture that no one talks about it: the unspoken rules and behaviors (called norms) are never written down, and yet everyone knows them. We learn these norms the hard way through the process of assimilation into a culture. For example, when Shelli was a new scrub nurse with only six months’ experience, she failed to anticipate that the surgeon would need a particular scalpel. Immediately, her experienced preceptor deftly handed the correct blade to the impatient surgeon with a glare in Shelli’s direction. At that moment, Shelli learned that if she was not on top of the surgeon’s needs, she would end up feeling embarrassed and looking incompetent. Shelli did not find this information in her orientation manual.
Breaking Free From Our Cultural Chains
Culture also determines what we see – and what we don’t. Scrub nurses do not innately “know” which surgeon tolerates technical questions or joking and which ones do not, or what subjects are acceptable to talk about among their team. They figure this out. Humans quickly pick up on these subtle cues and then act accordingly. Like any group, operating teams learn norms by induction and trial and error because the need to belong is so strong. So without a conscious thought (whether scrub nurse, anesthesiologist, tech or surgeon),
48 The OR Connection
we mimic the behaviors of those around us in order to be accepted. After a while, no one even notices the subtle, unspoken rules. And why would they? Everyone exhibits the same behaviors. The norms are now downloaded into our subconscious mind. Culture even determines our perception of the scrub nurses’ work – much of which goes unnoticed. In a review of 13 papers looking at scrub nurse skills, there were no behaviors that could be classified as leadership or decisionmaking.1 The vast amount of problem-solving, anticipation and critical decision-making that scrub nurses demonstrate constantly during surgery is invisible. In addition to operating room norms, each subgroup has its own specific norms as well. For example, residents learn quickly that asking questions is a sign of vulnerability and weakness; and to protect each other no matter what.2 Scrub nurses learn to assess situations without interrupting, and they read surgeons’ demeanor to sense the appropriate time to ask a question. This is known as “prudent silence.”3 Some group norms have to do with errors, i.e., “Don’t ever speak about a sentinel event outside these walls.” And for those who break these unspoken rules, there are serious repercussions – the worst of which is being ostracized from the group. There is nothing more painful for any human being, no matter the role or education level.
When individuals merge and form a group there are always things they can do, things they must do and things they can never do. For example, healthcare workers do not typically share their feelings in high-tech, high-pressure environments because feelings are perceived by the general culture to be “soft stuff.” Ironically, this belief couldn’t be further from the truth. Feelings not only matter, but are conveyed unconsciously, because 93 percent of all communication is non-verbal. If you think someone doesn’t like you, they probably don’t. In a study of collaboration among residents, nurses and physicians, the single most important factor in producing positive collaborative outcomes turned out to be affect. Our bodies consistently express what we feel.4
Another overarching cultural imperative holds that in a dangerous environment, the group must stay together in order to stay safe. In one case, a surgeon accidentally began incising the wrong breast for a mastectomy procedure. The incision was only an inch long when the circulator screamed and the physician stopped, acknowledged the mistake, and sewed up the cut. After the operation, the surgeon called his team together in the room and said: “I need to know that you are with me on this one. There is absolutely nothing to be gained by telling this patient what happened. I’m asking for your support to tell her that the incision on her left breast was exploratory.” This misuse of power tells us more about the culture this physician is ‘leading’ than any statistic ever could; and his use of coercion raises the impetus to be safe to a higher status than even ethics. Continued on page 51
Aligning practice with policy to improve patient care 49
S.T.O.P.™ FOR SAFETY. It could be the difference between life and death. Wrong site surgery has recently moved into the number one position as the most frequently reported hospital error.1 This is despite a conscientious effort to eliminate this problem before it occurs. What is needed is another layer of safety...something that will improve our chances of correcting the mistake before it happens. Enter S.T.O.P. Surgical Drapes* from Medline. We just made a good idea even better. S.T.O.P. (Surgical Time Out Procedure) drapes are available in a variety of configurations, and include a “S.T.O.P.” strip across the fenestration. As a result, you can’t forget to take a time out to verify the correct patient, procedure, side and site. Then all that is left is to hand the sticker off to the circulating nurse to include in the medical record, documenting that the verification process was completed.
S.T.O.P.!!! Perform “TIME OUT” Verify correct: Person Procedure Site & Side Position
Date: ______ Time: ______ Initials: _________
S.T.O.P. strip and sticker
For a free sample of the S.T.O.P. Drape system to evaluate for yourself, ask your Medline representative, call 1-800-MEDLINE or visit www.medline.com.
References The Joint Commission. The Statistics page. Available at:http://www.jointcommission.org/NR/rdonlyres/D7836542-A3724F93-8BD7-DDD11D43E484/0/SE_Stats_12_07.pdf. Accessed March 13, 2008.
* Patent pending ©2009 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
In the operating room, each player has a specific role: surgeon, scrub nurse, circulator, perfusion specialist, etc. Each role also comes with a set of expectations for behavior. On top of this, every operating room has its own unique culture. For example, scrub nurses in the United Kingdom perceived their main responsibility was to not upset the surgeon and to keep the surgeon happy.1
Ignorance Squared Educators often state that the worst knowledge deficit is when “You don’t know what you don’t know.” So if we are so deeply entrenched that we can’t perceive our own culture, then how do we rationally and logically assess whether our operating room is, for example, a just culture or a blame culture? A collegial interactive team or just a group of people working in the same place at the same time? We learn about the culture by listening to their stories.
The Play of “Human Error” The drama in our worlds will tell us more about our culture than anything else because it is riddled with feelings: anger, shame, embarrassment, hurt and grief. These are powerful emotions felt at one time or another by every member of the team simply because we are human beings working in a complex, high-stress environment with the same people every day. When humans work that closely and frequently, their relationships become the dominant value. Dana Jack calls this “self silencing.”5 Healthcare workers silence themselves because they value the relationship with their coworkers more than anything (even the patient) and fear reprisal. On a very primal level we are keenly aware that our survival depends on the group’s survival. A deeply worrisome example of this comes from a new study where 80 percent of nurses demonstrated knowledge of best practice for oxytocin administration during delivery, yet only 22.5 percent would actually implement the appropriate clinical action if the physician asked them to increase the dose.6 There is nothing stronger than culture – not even education. Not upsetting the physician even trumps best practice.
Groups quickly learn not to speak up about certain issues. One OR team feared they would be diminished in the eyes of their peers when a sentinel event was made public, missing entirely the opportunity to use their experience for teaching, improving the system and building a healthy culture around mistakes. Unknowingly, our well-intentioned but predictable responses perpetuate the predominant culture. Humans under stress will consistently default to previously learned behaviors and responses.
The Behaviors We Can Expect • Human error - inadvertent action; inadvertently doing other than what should have been done; slip, lapse, mistake. CONSOLE • At-risk behavior – behavioral choice that increases risk where risk is not recognized, or is mistakenly believed to be justified. COACH • Reckless behavior - behavioral choice to consciously disregard a substantial and unjustifiable risk. PUNISH
Standing up to the predominant culture is a monumental task. This quest is better undertaken as a team because of the critical amount of support that is needed in any organization to produce adaptive change. For example, at Cincinnati Children’s Hospital, every employee computer when turned on displays an icon labeled “Patient Safety Tracker” in the upper right hand corner stating how long it has been since harm has come to a child in their care. If an event occurs, you can then click on another box for details of the event, which are general knowledge. The result: no one loses focus. This admirable demonstration of transparency takes phenomenal leadership and support from the bedside to the boardroom. In the healthcare culture, however, transparency and open dialogue are the exception rather than the rule. Instead of these healthy behaviors, several other survival behaviors have been observed. Sometimes leaders inadvertently
Aligning practice with policy to improve patient care 51
The single greatest impediment to error prevention in the medical industry is that we punish people for making mistakes.”
divert their group’s attention away from the real issue because it is too volatile, painful, or simply, unpredictable. In this way, the group is once again united – although dysfunctionally. In one emergency room, for example, staff were furious with the ICU and would complain incessantly about how poorly they were treated by this department. As Dr. Phil would say, “What’s this doing for you?” In this case, as in many others, having a common enemy united the group. Another behavior that fuels an unhealthy culture occurs when groups or individuals are at odds with each other. They never sit down at the same table face-to-face. If they did, then the rumors and gossip might end the saga that sustains them. The sad reality is that well-intentioned people are unaware of the strong emotional maneuvers designed at a very primal level to simply keep the group safe.
– Dr. Lucian Leape
In a healthy safety culture every surgeon, tech, scrub and circulator would know about an error or near-miss as soon as possible in order to produce a heightened sense of awareness and to decrease the chances of the same error occurring again. Clearly, these events are complicated, and it often takes time to gather information. But information is shared as it is gathered with the whole team. Unbelievable as it seems, this is just not happening at most healthcare facilities, and our well-respected leaders fail to see their own behavior. For example, one day a surgeon shared the details of a disturbing sentinel event that happened to him just a few days earlier. Yet his colleague sat next to him oblivious and uninterested in his dilemma because, after all, it didn’t happen to him – even though they worked in the same OR!
The Second Victim Emotions and the Blame Culture Emotional drama is more prevalent in a blame culture than a just culture because the ethos of a just culture re-focuses on the event as an opportunity to learn and share. When an event is submerged, defensive emotions will emerge larger than life every time. Another indication of a blame culture is secrecy. Members of the team being kept in the dark about a serious incident is another indication of a blame culture.
52 The OR Connection
In every sentinel event, there is more than one victim. The first is the patient – harm or vulnerability to harm is tangible, perceived and acknowledged. The victim’s emotional state is tended to very carefully. We invest a great deal of time and emotional energy in understanding the impact of the error on the individual and their family. Forms are filled out documenting the error and we work diligently through root cause analysis to change our system and processes so that the
What we know changes what we see. What we see changes what we know.” – Piaget
event never has the opportunity to occur again. But there are other victims as well whose pain is not so visible. In the healthcare culture, we seldom speak about the second victim – the scrub, tech or surgeon who assumes whether rightly or not, that they could have anticipated or prevented the event; who beat themselves up and privately grieve their role in the play of “Human Error.” The impact of mistakes on clinicians is devastating. Any healthcare worker will confirm the difficult process of forgiving themselves – especially if the event results in harm or death. Unfortunately, the current system frequently does not provide the consolation and solace they so desperately need.
Blame vs. Just Culture There is a movement in the healthcare industry to shift from a blame culture toward a just culture. This call to action is being heralded by concerned patient safety advocates. A blame culture is characterized by secrecy, overt or covert punishment for mistakes, ostracism and strong emotional responses such as blaming and shaming. Individuals are often targeted (named) and the focus is “who did what?” rather than on system issues. This is “the way we’ve always done it.” A just culture is characterized by open dialogue surrounding errors, inclusion of all involved, a clear understanding of whether the error was human error, at-risk or reckless behavior and appropriate management response7 as well as a focus on processes, learning and sharing. Research shows that the hospital culture in and of itself is a good indicator of whether a just or blame culture prevails. Some hospitals have a command and control-based
philosophy, whereas others are engaged in a commitmentdriven philosophy. A consistent pattern emerged from the research: a blame culture is more likely to occur in hierarchical organizations, and a just culture is more likely to occur in institutions that actively engage employees in the decision-making process.8 In other words, the greater the number of hoops you have to jump through to get what you need to do your job, the greater the hierarchy and the greater the tendency toward a blame culture. Successful patient safety programs are not top-down driven initiatives. They are a core value.
Conclusion In 1999 Dr. Lucian Leape, a professor at the Harvard School of Public Health, briefed a congressional sub-committee on the state of human error management in health care. Sadly, the statistics from a decade ago have not changed. An estimated one million people are injured by treatment errors at hospitals every year, resulting in an estimated 120,000 deaths. But because of the punitive healthcare culture, Leape revealed that only two to three percent of major errors are actually reported through incident reporting systems, mostly because “workers often report only what they cannot conceal.”9 Research specific to the operating room found that OR/PACU staff reported more frequent witnessing of unsafe patient care.10 Our stories tell us that in the healthcare culture we value the safety of our group more than the patient, ethics or even best practice. How can this change? A culture does not change overnight. Nor will any culture sharply change direction as a group. Imagine an army of 12
Aligning practice with policy to improve patient care 53
million healthcare workers marching shoulder-to-shoulder in one direction. It’s dangerous for a single individual to fall out of step. If we could only visualize the thousands of wounded and deceased in one place, then the entire army would immediately about-face. But we can’t. And we don’t. People die and are harmed from healthcare-related errors one-by-one; and they will only be saved one-by one as each individual’s awareness rises above the group, and we consciously and courageously decide to break the cultural chains that bind us to our old familiar ways.
References 1. Mitchell L, Flin, R. Non-technical skills of the operating theatre scrub nurse: literature review. Journal of Advanced Nursing. 2008;63(1):15-24. 2. Maxfield D, Grenny J, McMillan R, Patterson K., Switzler A. Silence kills: the seven crucial conversations for healthcare. VitalSmarts and the American Association of Critical-Care Nurses. 2005. 3. Riley RG & Manias E. Governance in operating room nursing: nurses’ knowledge of individual surgeons. Social Science and Medicine. 2006;62(6):1541-1551. 4. McGrail KA, Morse DS, Glessner T, Gardner K. What is found there: qualitative analysis of physician-nurse collaboration stories. Journal of General Internal Medicine. 2009;24(2):198-204. 5. Jack, D. Silencing the self: woman and depression. Harvard University Press. 1993. 6. Simpson KR & Lyndon A. Clinical disagreements during labor and birth: how does real life compare to best practice? The American Journal of Maternal/Child Nursing. 2009;34(1):31-39. 7. The North Carolina Just Culture Journey [videotape]. North Carolina Board of Nursing and North Carolina Hospital Association. Available at: http://www.justculture.org. Accessed November 1, 2009. 8. Khatri N, Brown GD. From a blame culture to a just culture in health care. Health Management and Informatics, University of Missouri School of Medicine, Columbia. 2009. 9. Marx D. Patient safety and the “just culture”: a primer for health care executives in support of Columbia University. Funded by a grant from the National Heart, Lung, and Blood Institute National Institutes of Health (Grant RO1 HL53772, Harold S. Kaplan, MD, Principal Investigator). 2001. 10. Kaafarani HM, Itani KM, Rosen AK, Zhao S, Hartmann CW, Gaba DM. How does patient safety culture in the operating room and the post-anesthesia care unit compare to the rest of the hospital? American Journal of Surgery.2009;98(1):70-75.
About the author
Kathleen Bartholomew, RN, RC, MN, has been a national speaker for the nursing profession for the past seven years. Her background in sociology laid the foundation for correctly identifying the norms particular to health care – specifically physician and nurse relationships. For her master’s thesis, she authored Speak Your Truth: Proven Stategies for Effective Nurse-Physician Communication, which is the only book to date that addresses physician-nurse communication. She also wrote Stressed Out About Communication, a book designed for new nurses. Save 20 percent by using source code MB84712A at www.HCMarketplace.com or call customer service at (800) 6506787. To increase performance with High Reliability Organization methods, Kathleen has now partnered with ConvergentHRS.
54 The OR Connection
ARE YOUR PHYSICIANS MAKING THE GRADE? A recent survey graded physicians’ abilities to recognize, assess and document Stage III and IV pressure ulcers at a “D” level. Medline’s new Pressure Ulcer Prevention Program MD Education CD contains everything physicians need to brush up on their skills and comply with the new CMS Inpatient Prospective Payment System (IPPS).
The new MD Education component of Medline’s Pressure Ulcer Prevention Program is critical for acute-care facilities to ensure that physicians understand their role in recognizing and accurately documenting POA pressure ulcers.” Michael Raymond, MD, Associate Chief Medical Quality Officer, NorthShore University HealthSystem, Skokie Hospital, Skokie, IL
To learn more about Medline’s Pressure Ulcer Prevention Programs and FREE webinars for acute care and perioperative services, call your Medline representative, or visit www.medline.com/pupp-webinar.
©2009 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
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©2009 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc. SmartSponge® is a registered trademark of ClearCount Medical Solutions.
e h t g n i e g r n u a t l h u C C r y e t i t l i e c h t a F a C r u o Y at
56 The OR Connection
Connie M. Yuska, RN, MS
Recently my husband was hospitalized following a 10-foot fall at work. We were thankful his injuries were not life-threatening, but he did have bilateral ankle and heel fractures. Given the immobility we knew was ahead, I was discussing the treatment plan with a good friend who is a nurse. One of her first questions was, “They are going to put in a catheter aren’t they?” My reply was, “I certainly hope not. I don’t want him to get a catheter-associated infection. That is the last thing we need with everything else that’s going on!” This conversation verified what I have experienced for the majority of my career both as a staff nurse and as a chief nursing officer. More likely than not if a patient was incontinent or having difficulty getting to the bathroom, one of the first requests would be an order for a urinary catheter. The nurses believed that their primary intervention of catheter insertion would maximize the patient’s comfort and avoid skin breakdown. Today we know that urinary tract infection is the most common healthcare-associated infection (HAI); 80 percent of these infections are attributable to an indwelling urethral catheter.1 One in four patients receives an indwelling urinary catheter at some point during their hospital stay and up to 50 percent of these catheters are placed unnecessarily.2,3 So, how do you change the culture at your facility if nurses still want to place a catheter? We all know that changing an organization’s culture can feel like turning a cruise ship around in a wild and stormy sea. The perception of nurses traditionally has been that putting a catheter in an incontinent patient is the best standard of care. We have to change that perception. As we begin to collect data, the evidence is showing that avoiding catheterization protects the patient from acquiring a catheter-associated urinary
tract infection. And we know that too many indwelling urinary catheters are inserted. We also know that indwelling urinary catheters stay in too long.4
Components of Successful Culture Change Successful culture change consists of many components. The following are some key strategies you can try at your facility, including use of the new Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009, education and training, engaging front-line staff, a reward program, and finally, being creative, having fun and tracking progress. The Centers for Disease Control and Prevention (CDC) Guideline The Healthcare Infection Control Practices Advisory Committee (HICPAC) of the CDC recently published the Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009. This is an excellent reference to review prior to initiating a catheter reduction program at your facility. The document contains recommendations on appropriate urinary catheter use and proper techniques for urinary catheter insertion and maintenance. In addition, the guideline outlines strategies for quality improvement and surveillance programs and summarizes recommendations for an administrative infrastructure to support a CAUTI prevention program.5 Education and training A logical place to start is by designing a comprehensive education and training program. Having a program that provides the supporting framework for education also helps to organize and publicize the initiative. Medline’s ERASE CAUTI program will give you all the tools you will need.
Continued on page 59
Aligning practice with policy to improve patient care 57
ALL NEW AND UPGRADED CONTENT. WWW.MEDLINEUNIVERSITY.COM Easier navigation to find what you need – faster. Interactive courses and competencies Continuing education courses are still available, and now you can earn all credits for FREE! In addition, we are adding online competencies. Courses and competencies are more interactive with more graphics, sound and animation to make learning more fun.
And for facilities participating in the Pressure Ulcer Prevention and Hand Hygiene programs, all materials, pre- and post-tests are now conveniently located online at www.medlineuniversity.com. Log on to www.medlineuniversity.com today and start earning CE credits —FREE.
Facility-specific features Now each facility has the option of creating a group account on Medline University. This will help you and your facility view and keep track of all completed courses.
©2009 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
The ERASE CAUTI Program for nurses (RNs and LPNs) is a two-part educational program. Part One is a step-by-step product training program on the ERASE CAUTI catheter tray and insertion methodology. Part Two includes the following four modules: Module 1: Indications and Alternatives to Catheterization Module 2: Aseptic Technique and Proper Insertion of a Foley Catheter Module 3: Care and Maintenance, Signs and Symptoms of CAUTI Module 4: Competency Validation In addition, current practice guidelines, sample policies and procedures and competency validation tools are included. You have the opportunity to initiate the training at orientation when a new employee joins your organization. This “sets the stage” for the catheter culture in your facility. You are setting the expectation that your staff will keep an incontinent patient clean and dry without exposure to the unnecessary risk of acquiring a catheter-related urinary tract infection. Then during your annual competency reviews for your staff, you can reinforce the training and the new “catheter culture.” This gives you a greater chance of hardwiring the change into your culture and ensuring that your staff’s new viewpoint on catheterization is sustained. Engaging front-line staff It is also important to identify staff nurse champions at the beginning of the program. Enlisting their help through a formalized assignment is one good way to generate enthusiasm and support for the new program. Staff nurses have very good ideas and usually know the best answer if we remember to include them! Getting them involved in the literature review and in planning the staff education roll-out will solidify their role as “champions.” They also can be the cheerleaders to encourage their peers to join the Race to ERASE CAUTI!
Join the RACE to ERASE CAUTI
Reward program In sustaining any long-term change, it is extremely important to recognize achievement. Staff work very hard, and
Aligning practice with policy to improve patient care 59
their efforts need to be recognized. Another part of the ERASE CAUTI Program is a reward component. Everyone who successfully completes the course and achieves at least an 80% on the post test receives one CE credit, a certificate of completion and a pin to display on their ID badge or uniform. The pin recognizes individual achievement and provides an opportunity for the staff to talk about the program with patients, families and other healthcare professionals, keeping the program top-of-mind. Being creative, having fun and tracking progress Since this is a Race to ERASE CAUTI, encourage your staff to post statistics regarding the decline in catheter- associated infections. Nursing units in hospitals or hospitals in systems can make this a fun, competitive event that results in better patient care. Finally, celebrate when an individual or the entire facility crosses the finish line of achieving zero catheter-associated urinary tract infections.
A Happy Ending Although my husband did not have any incontinence, he was non-weight bearing and thankfully, none of the nurses actually asked that a catheter be placed prior to surgery. He did have a catheter placed during surgery, but it was taken out within 24 hours! The hospital staff did follow the Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009, which states “for operative patients who have an indication for an indwelling catheter, remove the catheter as soon as possible postoperatively, preferably within 24 hours, unless there are appropriate indications for continued use.”5 I am happy to report that my husband was discharged from the hospital to a rehabilitation facility, and he was able to come home for Thanksgiving. This year I was very thankful that he was in a hospital with an up-to-date catheter culture, and he is on the road to recovery!
60 The OR Connection
References 1. Lo E, Nicolle L, Classen D, Arias A, Podgorny K, Anderson DJ, et al. SHEA/IDSA practice recommendations: strategies to prevent catheter-associated urinary tract infections in acute care hospitals. Infect Control Hosp Epidemiol. 2008;29:S41-S50. 2. Saint S, Kaufman SR, Thompson M, Rogers MA, Chenoweth CE. A reminder reduces urinary catheterization in hospitalized patients. Jt Comm J Qual Patient Saf. 2005;31(8):455-462. 3. Stokowski, LA. Preventing catheter-associated urinary tract infections. Medscape Nursing Perspectives. February 3, 2009. Available at: http://www.medscape.com/viewarticle/587464-4. Accessed July 6, 2009. 4. Sulzback-Hoke, Linda M. “Ask the Experts.” Critical Care Nurse. 2002,22:84-87. Available at: http.//ccn.accnjournals.org/cgi/content/full/22/3/84. Accessed July 24, 2009. 5. Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009, Healthcare Infection Control Practices Advisory Committee, Centers for Disease Control. Available at: http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/CAUTI_Guideline2009final.pdf.
About the author
Connie Yuska RN, MS began her career as a nurse in the specialty of otorhinolaryngology. Her clinical experience includes both inpatient and outpatient care of head and neck oncology patients, and she is certified in otorhinolaryngology and head-neck nursing. She has held clinical manager and director of nursing positions in a large academic medical center and also has experience in the home care setting as the vice president of operations for a large academically affiliated home care agency in the Chicago area. Connie later joined the executive suite as the chief nursing officer of a large community hospital in Chicago, and she is currently a vice president of clinical services for Medline. In all of her leadership roles, she has been responsible for ensuring the delivery of high quality, safe and cost-effective nursing care. Connie is a 2003 graduate of the J&J/ Wharton Nurse Executive Program. She is member of the Board of the Illinois Organization of Nurse Leaders and a member of the American Organization of Nurse Executives. In 2005, she was inducted into the 100 Wise Women Program sponsored by Deloitte & Touche. In addition, she has published several articles and chapters in oncology journals and textbooks.
MEDLINE’S HAND HYGIENE COMPLIANCE PROGRAM
FOR ALL THE LIVES YOU TOUCH. Now more than ever, hand hygiene compliance is crucial. As of October 1, 2008, the Centers for Medicare & Medicaid Services no longer reimburses hospitals for eight hospitalacquired conditions, including catheter-associated urinary tract infections, surgical site infections and bloodstream infections.1 We know that hand hygiene is the number one line of defense against hospital-acquired infections.2 There’s no such thing as “overeducating” when it comes to hand hygiene. Enhance your current strategy with Medline’s Hand Hygiene Compliance Program!
References 1 Centers for Medicare & Medicaid Services. Medicare program; changes to the hospital inpatient prospective payment systems and fiscal year 2007 rates. Available at: www.cms.hhs.gov/AcuteInpatientPPS/downloads/CMS-1533-FC.pdf. Accessed November 20, 2007. 2
The Hand Hygiene Compliance Program includes: • An instructor’s manual that takes the guesswork out of planning lessons • A customizable plug-and-play CD that contains presentations, posters and more • Forms and tools to serve as reminders and reinforcements • A cost calculator to help you determine the cost of prevention vs. the cost of an infection • A rewards program to recognize those who complete the course • Patient and family education materials • CE-credit courses for staff • A how-to guide on enhancing your presentation skills For an on-site presentation of the Hand Hygiene Compliance Program and our Healthy Hands Product Bundle, contact your Medline representative or visit www.medline.com/handhygiene.
Davis D, Sosovec D. The value of products that improve hand hygiene and skin. Healthcare Purchasing News. Available at: http://www.hpnonline.com/inside/2003-11/1103hygiene.htm. Accessed November 20, 2007.
©2009 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
We didn’t just design a new tray, we designed a way to make it hard for healthcare workers to do the wrong thing. The new ERASE CAUTI program combines design, education and awareness to tackle catheter-associated urinary tract infection – the number one hospital-acquired infection.1
Design The innovative one-layer tray design guides the clinician through the process of placing a catheter to ensure aseptic technique.
Education The acronym ERASE is easy to remember, reminding the clinician to:
Evaluate indications – Does the patient really require a catheter?
Read directions and tips – Follow evidence-based insertion techniques
Aseptic techniques – Key design solutions support aseptic technique
Open up the innovative one-layer catheter tray and see the intuitive design for yourself.
Secure catheter – A properly secured catheter will reduce movement and urethral traction
Educate the patient – Printed materials tell the patient how to reduce the likelihood of infection
Awareness Join the Race to ERASE CAUTI! The current state of health care demands that nurses play a leading role in identifying and implementing CAUTI risk reduction strategies. Help us reach our goal to introduce 100,000 nurses to the ERASE CAUTI system. To sign up for a FREE webinar, “Innovation in the Prevention of CAUTI,” go to www.medline.com/erase/webinar.asp.
©2009 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
Education Click here for details on nursing education materials that promote evidence-based practice.
Awareness Visit this section to join 100,000 nurses in the Race to ERASE CAUTI.
Reference 1. Catheter-related UTIs: a disconnect in preventive strategies. Physicians Weekly. 25(6), February 11, 2008.
64 The OR Connection
Caring for Yourself
Habits of Very Happy People By Wolf J. Rinke, PhD, RD, CSP
Economy sputtering; swine flu getting everyone upset; lots of changes at my facility, and you want me to be happy? You’re kidding, right? Actually not! Because no matter how bad things seem to be, it’s important to remind ourselves that Abraham Lincoln was absolutely right when he said, “Most people are about as happy as they make their minds up to be.” Happy people are not happy because they are endowed with the happiness gene—although researchers tell us that accounts for about half of one’s potential for happiness—happy people are happy because they realize that happiness is something they control by doing certain things every day. So here are nine things you can do that will make you happier:
1. Love what you do I find it ironic that many people deny themselves the joy of their work. Somehow they assume that work is a dirty four letter word and that they must escape it as soon and as fast as possible so that they can get home and plop down in front of the TV. (This by the way, is a great way to become more unhappy and depressed.) I suspect it is because they have not found what they love to do. The key word here is love—not like— because once you find what you love to do you will not ever have to “work” another day in your life. (By the way, it took me 36 years to find what I love to do, so don’t give up your search, because when you find your passion, the quality of your life will improve dramatically.) If you would like help with this, read my book Make It a Winning Life: Success Strategies for Life, Love and Business.
Aligning practice with policy to improve patient care 65
2. Chase your dreams Happiness is often a byproduct of something that we are going after—something that juices us. Think of children. When are they the happiest? About two weeks before the Christmas or Hanukkah holidays, or when they have ripped all the presents open? Once we have clearly-defined, specific, firein-the-belly goals, we get turned on, and we become happy. In other words, if your goal is to be happy—that’s what many people in my seminars tell me—you won’t necessarily be happy. You get happy from traveling the journey or reminding yourself that you are doing something that improves the quality of someone else’s life. Chasing your dreams cranks up your internal body chemistry to such an extent that it energizes you to achieve extraordinary results and may keep or may even make you healthy. Want proof? A good example is Lance Armstrong, who after being diagnosed in 1996 with an advanced form of testicular cancer that had metastasized to his brains and lungs, was given only about a 50 percent chance of survival. After receiving aggressive cancer therapy, including brain and testicular surgery and extensive chemotherapy, he went on to win the Tour de France—cycling’s most prestigious and grueling race—seven times in a row from 1999-2005. (The previous record was winning it five times.) And just when everyone thought he was down and out, he returned to competitive racing after four years of “retirement” to finish third in the 2009 Tour de France. Not bad for someone who at age 38 is considered old in the punishing sport of competitive cycling.
3. Nourish an attitude of gratitude A difficulty for many successful people is that they perpetually look up the mountain, never down. To feel a sense of gratitude you must have goals—look up the mountain—but also take the time to reflect on all that you have already achieved and accumulated—look down the mountain. If you need a bit of help with this, take advantage of the next holiday season. Instead of buying gifts for people who already have more than they will ever need, rally the whole family and serve a meal at a homeless shelter. Or visit a third world country. For example, when I used to speak in the Pacific Rim, my sense of gratitude was always renewed. Typically the client booked me in a five-star hotel, which makes any of our five star hotels pale in comparison. One of the hotels in Jakarta even had a marble driveway. Not concrete, not flagstones— marble. When I looked out of my 29th story window I saw many other super-modern high-rise buildings. I also saw a garbage dump several blocks away swarming with people – people who were living on the dump in cardboard “houses” and foraging for scraps. Stop right now, and be grateful for all the love and abundance that surrounds you.
66 The OR Connection
4. Love someone deeply Barbra Streisand was absolutely right, “people who love people are the luckiest people in the world.” Start by developing a strong bond and lifetime relationship with a significant other. Having been happily married to my “Superwoman” for 41 years, I can attest that she by far is my biggest source of joy and happiness. (She got that name because she is a one-in-a-million mate, mother, business partner and confidant.) If you don’t have such a relationship, make it one of your top three fire-in-the belly goals, because such a partner becomes increasingly more important as you enter the later passages of your life. Extend that same love to your family and your close friends. The greater your circle of loving relationships, the greater your happiness.
5. Treat your “bodymind” like a temple Neuroscientist and pharmacologist Dr. Candance Pert, who discovered the opiate receptor – the cellular binding site for endorphins in the brain – calls our body and mind the “body-mind” because her work has unequivocally demonstrated that the mind and the body are one. Her work also shows that thoughts are things – things that manifest themselves in the body and in your life. So if you think “bad” or negative thoughts, then that will have a negative impact on your body. And of course the reverse is true. Since the mind can have only one thought at a time, get in the habit of monitoring your thoughts and selftalk by asking, “Is what I’m thinking about right now negative?” (The worst is hate.) If it is, it will move you away from happiness and optimum health. On the other hand, positive thoughts, such as love, kindness and appreciation will move you in a positive direction. This is so powerful that we now have a whole science concerned with this phenomenon—
psychoneuroimmunology, or PNI for short. (Want to know more? Read Dr. Pert’s books: Molecules of Emotions: The Science Behind Mind-Body Medicine and Everything You Need to Know to Feel Go(o)d.)
6. Laugh more That’s right – go ahead and laugh right now. Can’t seem to get it going? Go to the bathroom, stick your tongue out, wiggle your nose and make the silliest face you can possibly come up with and get yourself to laugh. If you need more help, join a laughter yoga club, popularized in India, and now available all over the world including the United States (http://www.laughteryoga.org). Or consult with a “certified laughter leader.” (Hey, I’m not making this stuff up!) A good way to nurture this is to laugh more at yourself. It will cause you to take yourself less serious—which is a great start because you are not nearly as important as you think you are. (I’m including myself in that statement; so don’t get bent out of shape). Laughter has innumerable benefits. It turns on your endorphins and other internal “drugs” that are far more powerful than anything you can ingest—legal or illegal. In fact, it is so powerful that the late Norman Cousins used it as an “anesthetic” to combat pain associated with his incurable disease.
7. Give more of what you want A shortcut to happiness is making other people feel happy. Why? Because life is like a mirror—whatever you give—is what you get. Make people happy and you will be happier. Hate people and you will live in a hateful world. Love people the way they are, and you will experience more love. You catch my drift. Actually you already knew that. And that’s why you are much more anxious to give a gift than get one. Happiness certainly does not come from things. Otherwise the happiest people on
Aligning practice with policy to improve patient care 67
Be sure to never give up hope, no matter how bleak it gets. And even more important, be sure not to confuse inconveniences with problems. earth would be lottery winners. They are not. In fact lottery winners often become discouraged and depressed because they become so obsessed with “stuff” that most are broke three years after they have won the jackpot. “Superwoman” and I have come to the realization that less is more. That is to say, the more stuff we have, the more problems and stress we have. That’s why we evaluate every new opportunity by asking ourselves whether taking advantage of the new opportunity will add to the quality of our lives. If the answer is yes, we go for it. If the answer is no, we don’t.
8. Develop a Positive Explanatory Style Professor Marty Seligman, of the University of Pennsylvania, who has had a tremendous influence on getting psychologists to focus on the good—what he has dubbed “positive psychology”— wrote a number of powerful books addressing this topic (http://www.authentichappiness.sas.upenn.edu/seligman.aspx). His research has demonstrated that we can learn to be more optimistic by developing a “positive explanatory style” (PES). The way you do that is by focusing on the good stuff, especially when bad things happen to you. In other words you learn to fake it until you make it. Research has shown that people who have developed PES, as opposed to a Negative Explanatory Style (NES) are able to evaluate “reality” more clearly—just the opposite of what most people assume. Process “bad” news more effectively, and you are more likely to accept what can’t be changed and move on. In short, PES enables you to inoculate yourself against the negative attitude “virus” and his big cousin—depression.
68 The OR Connection
9. Keep Hope Alive Hope is an incredibly powerful emotion. Without it not only do you become unhappy—you die. No one has told that story more powerfully than Dr. Victor Frankl in his book Man’s Search for Meaning, in which he details the role of hope in surviving the German concentration camps. So be sure to never give up hope, no matter how bleak it gets. And even more important, be sure not to confuse inconveniences with problems. Because many of the “problems” that we get ourselves all worked up about are inconveniences, not tragedies. When you are in the middle of one of these, a great diagnostic is to ask yourself: “How will I feel about this five years from now?” And then act accordingly. To deal more effectively with the real tragedies—which will come—turn to the source of hope and inspiration that works for you. It may be religion, spirituality, meditation or listening to a great motivational speech. (Just had to sneak that in there.) It will help you keep hope alive and make you more optimistic and happier. © 2009 Wolf J. Rinke Dr. Wolf J. Rinke, PhD, RD, CSP is a keynote
speaker, seminar leader, management consultant, executive coach and editor of the free electronic newsletters Make It a Winning Life and The Winning Manager. To subscribe go to www.WolfRinke.com. He is the author of numerous books, CDs and DVDs including Make it a Winning Life: Success Strategies for Life, Love and Business; Winning Management: 6 Fail-Safe Strategies for Building High-Performance Organizations and Don’t Oil the Squeaky Wheel and 19 Other Contrarian Ways to Improve Your Leadership Effectiveness. All are available at www.WolfRinke.com. His company also produces a wide variety of quality, pre-approved continuing professional education (CPE) selfstudy courses including Beat the Blues: How to Manage Stress and Balance Your Life, on which this article is based, available at www.easyCPEcredits.com. Reach him at WolfRinke@aol.com.
Olympic Figure Skater
Peggy Fleming to Speak at Medline’s AORN Breast Cancer Awareness Breakfast For the fifth year in a row, Medline will be hosting a complimentary breast cancer awareness breakfast March 15, 2010, during the Association of periOperative Registered Nurses (AORN) Congress in Denver, Colo. Olympic gold medalist and breast cancer survivor Peggy Fleming will share stories about her personal experience with breast cancer. Each year since 2006, breakfast participants have been inspired by celebrities who have won the battle against breast cancer. In 2009 Medline was proud to host TV journalist Linda Ellerbee. Past speakers have included Dr. Marla Shapiro, Rue McClanahan and Ann Jillian. Save the Date! Medline’s Breast Cancer Awareness Breakfast
March 15, 2010 – 5:45 to 7:30 a.m Speaker Peggy Fleming presents “The Fight of a True Champion” AORN Congress
Hyatt Regency at Colorado Convention Center, Denver, Colo.
Attendance by invitation only. Contact your Medline sales representative for more information.
Aligning practice with policy to improve patient care 69
Thank You! Providence St. Vincent Medical Center F ro m t h e h i g h e s t l e v e l s o f y o u r o r ganization down through your entire staff, we could not have picked a better partner for the “Pink Glove Dance,” video project. Thank you for taking part in a cause that touches us all.
70 The OR Connection
Boosting Hearts, Minds and Support for Breast Cancer Awareness
One early November morning, when the OR staff of Providence St. Vincent Medical Center was approached by Medline to take part in a little breast cancer awareness video they were doing, little did they know what an impact their participation would soon make. A little more than a month later, over six million people across the globe have seen the “Pink Glove Dance” video. The YouTube video phenomenon has been featured on CNN, ABC World News with Charles Gibson, Fox & Friends - Fox News Network’s national morning show, and literally more than 100 local TV newscasts across the country. News stories about the video also span the Internet, from the Huffington Post to the AOL home page. People can’t stop talking about this video, which showcases more than 200 hospital workers from the medical center in Portland, OR. dancing in Medline’s pink gloves. Phone calls, cards and e-mails are flooding both the hospital and Medline. And more than 10,000 people have posted comments about the video on YouTube. It has entertained and inspired laughter and, for many, it has evoked memories of their own battle with breast cancer or battles faced by loved ones. One viewer wrote: “Wonderful! This brought tears to my eyes as I am a survivor 13 years out and it reminded me of the wonderful staff at Yale Oncology unit. Thank you to all in the medical field. Please be sure to share this with those who are going through treatments. I am sure this will be helpful.” – mamakawecki55 Another said: “Given the type of work that they do, it is good to see them having fun for a good cause. Remember they are the ones who care for those with cancer.” – seaglassfriends
Aligning practice with policy to improve patient care 71
Birth of an Idea Why would perfectly sane and incredibly busy hospital workers agree to dance in a YouTube video? The short answer is to get people talking about breast cancer. But there’s more to the story. It all began at Medline’s Corporate office when employees were brainstorming ideas to promote their new Generation Pink™ glove (launched in October). To further support Medline’s ongoing breast cancer awareness campaign (visit www.medline.com/breast-cancer-awareness for details), they had already implemented a promotion to donate $1 of every case purchased to the National Breast Cancer Foundation to fund mammograms for individuals who cannot afford them.
The next few days were a blur of action. The hospital sent out a call for employee volunteers to dance in the video. Back at Medline, the wheels were in motion. Jay Sean’s hit song “Down” was selected for the video and discussions took place to coordinate which areas of the hospital would be filmed, the number of staff participating in each shot and the overall plan of events.
But they needed a big idea to help spread the word. So, they asked, “What if we were to video healthcare workers dancing in pink gloves? Could we produce a viral video?” Little did they know. . . The first step was finding the right hospital to partner with Medline to create the video. The Providence Health System, a 26-hospital system in the northwest area of the country, proved to be the perfect choice. The health system suggested Medline work with Providence St. Vincent Medical Center in Portland, which not only was willing to give full access to each area of the facility for the video shoot, but also shared Medline’s passion for breast cancer awareness.
72 The OR Connection
The Making of the Video A week later, Medline product manager Emily Somers was at the hospital with a few boxes of pink gloves and the film crew. More than 200 employees of all ages, departments and skill levels answered the call to participate. “We had so many people who said, ‘You know, this disease has touched my life. I want to be a part of it,’” said
I am very honored that Medline and Providence St. Vincent Medical Center 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. – Jay Sean
Martie Moore, the chief nursing officer at Providence St. Vincent Medical Center. The filming took two days and Emily taught the volunteers basic dance moves to showcase the pink gloves. “In an environment filled with sickness and gloom, the caregivers brought incredible energy to the making of the video, expressing their great heart and spirit,” Emily said. From lab technicians and the kitchen help to surgical teams, they all let loose, dancing throughout the hospital.
Monte Crawford, “the mop man,” has become one of the more popular figures in the “Pink Glove Dance” video.
Touching People Around the World Thousands of people across the globe have posted inspiring comments about the video — even singer Jay Sean responded by posting a link to the video on his website. On his Facebook page he wrote, "The vid is awesome … medicine will always be close to my heart and this is such a worthy and important cause. So maybe I could have been a doctor and a singer at the same time after all then? Just brilliant."
17,000 Screaming Pink-Gloved Fans
Emily Somers, Medline product manager – and the choreographer of the “Pink Glove Dance” – teaches the lab staff of Providence St. Vincent some dance moves during the shooting of the video.
74 The OR Connection
To further spread the “Pink Glove Dance” message, more than 17,000 passionate fans recently wore Medline’s pink gloves at a live concert held in Chicago. With 34,000 pink gloved hands swaying back and forth to a live performance by Jay Sean singing his hit song “Down,” the arena took on a surreal appearance of a dense forest of pink trees waving in the wind. It was an unbelievable sight that brought tears to the eyes of many in the audience.
A world without breast cancer is in our hands. Medline’s Generation Pink latex-free, third-generation vinyl exam gloves have the comfort, barrier protection and price you love. Even better, when you choose Generation Pink gloves, you’re helping Medline support the National Breast Cancer Foundation.
Other ways to show your support: Become a Facebook fan at: facebook.com/ medlinebreastcancerawareness
Watch the “Pink Glove Dance” video at: YouTube.com/watch?v=OEdvfyt-mLw
For more information on Medline’s exam gloves, please contact your Medline representative, call 1-800-MEDLINE or visit www.medline.com.
©2009 Medline Industries, Inc. The cross-fingered pink glove hand image is a trademark of Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
“ • National news – ABC, CNN, FOX, MSNBC • 17,000 fans donning pink gloves during a live performance of Jay Sean’s hit song, “Down”
Pink Glove Dance Video Goes Viral!
” • Over 6 million views on YouTube • Over 10,000 comments on YouTube • More than 120 TV news stories across the country
Support The Cause. Help fund free mammograms! When you choose Generation Pink Gloves, a portion of the proceeds will be donated to the National Breast Cancer Foundation to fund free mammograms for women who cannot afford them.
76 The OR Connection
Depending on who you are (an individual or a facility), there are two sites to choose from when ordering gloves. • Individuals visit www.scrubs123.com • Healthcare facilities visit www.medline.com/breast-cancer-awareness • If you wish to donate directly to the National Breast Cancer Foundation, visit the NBCF website www.nationalbreastcancer.org.
Cheesy Potatoes (12 servings) • 16 oz. bag frozen hash brown potatoes (cubed or shredded) • 16 oz. container sour cream • 1 can cream of chicken soup • ½ c. chopped onion • 8 oz. bag shredded cheddar cheese
Topping: • 2 c. corn flakes • ¾ stick melted butter or margarine
Nutrition Information Servings: 12 Calories: 296 Fat: 12.7 g Sodium: 407.7 mg Fiber: 1.2 g
Directions: Mix together all ingredients and place in a baking dish. Top with crushed corn flakes mixed with the melted butter. Cover with foil and bake at 350 degrees F for 30 minutes. Remove the foil and bake an additional 20-30 minutes.
The Shannons regularly host parties at their home, where they have a fully outfitted game and entertainment room in the basement. Dennis said his cheesy potatoes dish is a big favorite with guests. “It’s easy and inexpensive to make, and people really like it.”
Hint: To cut down on salt and fat, use low-sodium soup and reduced fat cheese and sour cream.
With football season in full swing, the Shannons have been doing their usual entertaining, and Dennis offered another quick, easy and inexpensive recipe: Spread a thin layer of chive-flavored cream cheese onto a flour tortilla and then layer it with a slice of turkey breast lunch meat, a piece of red leaf lettuce and pimentos. Roll it up and cut into slices for an attractive and delicious snack.
Shipping employee Dennis Shannon has worked at Medline’s Allentown, Penn. warehouse for 10 years. In his spare time, he enjoys cooking and entertaining. He said at his house, “I do the cooking and my wife does the baking, so it works out well.”
Aligning practice with policy to improve patient care 77
Forms & Tools
The following pages contain practical tools for implementing patient-focused care practices at your facility. CAUTI FAQs about Catheter-Associated Urinary Tract Infection . . . . . . .79 Surgical Fire Safety Surgical Safety Team Communication . . . . . . . . . . . . . . . . . . . . .80 Universal Protocol and Fire Risk Assessment . . . . . . . . . .81 Extinguishing a Surgical Fire . . . . . . . . . . . . . . . . . . . . . . . . . . . . .84 Preventing Surgical Fires . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .85 H1N1 (Swine Flu) H1N1 Patient Handout (English) . . . . . . . . . . . . . . . . . . . . . . . . . .87 H1N1 Patient Handout (Spanish) . . . . . . . . . . . . . . . . . . . . . . . . .89
78 The OR Connection
Forms & Tools
system, which includes the bladder (which stores the urine) and the kidneys (which filter the blood to make urine). Germs (for example, bacteria or yeasts) do not normally live in these areas; but if germs are introduced, If you have a urinary catheter, germs can travel along the catheter and ca What is a urinary catheter? A urinary catheter is a thin tube placed in the bladder to drain urine. Urine drains through the tube into a bag that collects the urine. A urinary catheter may be used: • If you are not able to urinate on your own • To measure the amount of urine that you make, for example, during intensive care • • During some tests of the kidneys and bladder
o Catheters are put in only when necessary and they are removed as soon as possible. o Only properly trained persons insert catheters using sterile (“clean”) technique. o The skin in the area where the catheter will be inserted is cleaned be • External catheters in men (these look like condoms and are placed over the penis rather than into the penis) • aw Catheter care o Healthcare providers clean their hands by washing them with soap and wa touching your catheter.
If you do not see your providers clean their hands, please ask them to do so. -
o The catheter is secured to the leg to prevent pulling on the catheter. germs tha
there. Germs can enter the urinary tract when the catheter is being put in or while the catheter remains in the bladder.
• Burning or pain in the lower abdomen (that is, below the stomach) • Fever • problems • So
emoval or change of the catheter. Your doctor will deterWhat are some of the things that hospitals are doing to prevent catheter-
o Keep the bag lower than the bladder to prevent urine from backflowing to the bladder. o Empty the bag regularly. The drainage spout should not touch anything while emptying the bag. if I have a catheter? • • Always keep your urine bag below the level of your bladder. • Do not tug or pull on the tubing. • Do not twist or kink the catheter tubing. • What do I need to do when I go home from the hospital? • If you will be going home with a catheter, your doctor or nurse should explain everything you need to know about taking care of the catheter. Make sure you understand how to care for it before you leave the hospital. • as burning or pain in the lower abdomen, fever, or an increase in the • Before you go home, make sure you know who to contact if you have ques
80 The OR Connection
Team members are encouraged to speak up when any problems are noted.
Monitors applied and functioning Anesthesia equipment and medical check complete Special airway equipment Antibiotic prophylaxis ordered/ initiated (60min)
Team verbally agrees or corrects discrepancies
OR staff reviews • Sterility/equipment/irrigation solutions • Fire Risk Assessment score
given or N/A • IV access/fluids/blood products • Specific patient concerns
Surgeon confirms with OR team: Patient name, procedure • Operative side & site/mark visible • Correct positioning (patient/table) • Relevant images available/labelled? • Implants available? • Specimen collection • Length of case/critical steps
Based on the WHO Surgical Safety Checklist, http://www.who.int/patientsafety/safesurgery/en © World Health Organization 2008 All rights reserved.
Info from circulator/OR staff.
Info from surgeon.
Info from anesthesia provider.
Anesthesia reviews Transfer to ____/oxygen needed
Counts complete (instrument, sponge, needle)
Nurse confirms with OR team: Procedure name? • Specimen(s)/labelling? • Estimated blood loss? • Any equipment/pick list issues? • Postop concerns? • Wound packing/dressing? •
Circulator confirms items with surgeon / OR team before patient leaves OR.
Forms & Tools
Introductions: All team members Please state name and role
Surgeon arrives: Team introductions begin followed by confirmation of items and anticipated critical steps.
Anesthesia: We are going to go over a checklist to provide the safest possible care.
BEFORE PATIENT LEAVES ROOM
Patient/staff has confirmed: Identification (name/DOB) • Procedure • Side/site • Allergies Consent verifies procedure? Consent for blood or blood refusal? Site/side is initialed? OR equipment available/working? Surgeon present in facility?
BEFORE SKIN INCISION
BEFORE INDUCTION OF ANESTHESIA
Surgical Safety Team Communication
JBK_OR12.3.qxp:Layout 1 Page 80
Surgical Safety Team Communication
Prep & Holding
Aligning practice with policy to improve patient care 81
Unit Doing Procedure
Time:________O#4 FIRE RISK ASSESSMENT
FIRE RISK ASSESSMENT
Time Out: Time:_________
(see side 2 for specifics)
SCORE 1 or 2: Initiate Routine Protocol SCORE 3: Initiate High Risk Fire Protocol
Procedure site or incision above the xiphoid Open oxygen source (face mask/ nasal cannula) Ignition source (cautery, laser, fiberoptic light source)
2 Time Out: Time:_________
1st Time Out: Time:_________
0 (NO) 0 (NO)
1 (Yes) 1 (Yes)
OR – Universal Protocol
The entire procedure team has performed a Time Out and all members have verbally agreed. 2nd 3rd Time out included the verification of: 1st Correct patient identity Agreement on procedure to be done Correct site and side Diagnostic study confirmation of site and side Availability of implants Availability of special equipment
Universal Protocol and Fire Risk Assessment
Side marked by: Patient Family member (Relationship):____________ Healthcare Provider
C After verification has been completed, the patient if able, will write “Yes” with a permanent marker on or as near the site as possible: RIGHT ____________________ LEFT ___________________
COMPONENT # 2 SITE MARKING (If required)
Name and date of birth confirmed ** Patient/Decision maker verbalizes planned procedure Schedule confirms planned procedure Consent confirms planned procedure ** History and Physical confirms planned procedure Diagnostic Study confirms planned procedure Progress Record/Consult confirms planned procedure Site marking required (go to Component 2) Site marking not required Date/Time: Initial:
COMPONENT # 3 TIME OUT
Mark all that apply ** indicates required field
COMPONENT # 1 VERIFICATION PROCESS
Date of Procedure
Planned Procedure: ___________________________________________________
UNIVERSAL PROTOCOL AND FIRE RISK ASSESSMENT
JBK_OR12.3.qxp:Layout 1 Page 81
Forms & Tools
The caregiver (RN/LPN, anesthesia provider, surgeon, resident, PA) beginning the verification process will initiate the form. When care of the patient is transferred to a new care area, the new care giver will complete the appropriate columns and initial. Mark (¥) only the boxes that indicate the method reviewed to confirm the planned procedure. Resolve discrepancies identified through the verification process prior to moving the patient to the procedure area or prior to the initiation of the bedside procedure/anesthesia regional block.
82 The OR Connection
Time out is completed prior to the start of the procedure and a designated person (circulating RN, assisting RN or tech) will complete the section and initial. Mark (¥) only the boxes that indicate the components confirmed. An additional Time Out is documented for a second procedure. In the event that the physician performing the procedure leaves the patient or repositions the patient after the Time Out process has occurred, the Time Out process is repeated and documented.
FIRE RISK ASSESSMENT x Routine Protocol 1. FUEL: A. When an alcohol based solution is used, use minimal amount of solution and allow sufficient time for fumes to dissipate before draping. Observe drying time (minimum 3 minutes). Do not drape patient until flammable prep is fully dry. B. Do not allow pooling of any prep solution (including under the patient). C. Remove bowls of volatile solution from sterile filed as soon as possible after use. D. Utilize standard draping procedure 2. IGNITION SOURCE: A. Protect all heat sources when not in use. (cautery pencil holster, laser in stand by mode etc.) B. Activate heat source only when active tip is in line of sight. C. De-activate heat sources before tip leaves surgical site. D. Check all electrical equipment before use. x High Risk Protocol (includes all of routine protocol) A. Use appropriate draping techniques to minimize O2 concentration (i.e., tenting, incise drape). B. Electrical Surgical Unit (ESU) setting should be minimized C. Encourage use of wet sponges. D. Basin of sterile saline and bulb syringe available for suppression purposes only. E. Anesthesia Care Provider considerations: x A syringe full of saline will be available, in reach of the anesthesia care provider, for procedures within the oral cavity. x Documentation of oxygen concentration/flows. Use of “MAC Circuit” for oxygen administration.
A. B. C. D.
COMPONENT #3 TIMEOUT Purpose: To conduct a final verification of the correct patient, procedure, site and implants, if applicable.
Document site marking for patients having surgical/invasive procedures involving laterality or digits. (Patients having surgical/invasive procedures involving level(s) (i.e. spine or ribs) will have level(s) marked by the Licensed Independent Practitioner (LIP) performing the procedure or identified by the LIP using radiographic techniques during the procedure.)
Forms & Tools
COMPONENT #2 SITE MARKING Purpose: To clearly identify the intended site of incision or insertion.
A. B. C. D.
Side 2 COMPONENT # 1 VERIFICATION PROCESS Purpose: To outline the process for identifying the correct person, correct procedure, and correct site for surgical and invasive procedures with involvement of the patient or decision maker when possible.
UNIVERSAL PROTOCOL AND FIRE RISK ASSESSMENT (For Operating Room and Non-Operating Room Settings)
JBK_OR12.3.qxp:Layout 1 Page 82
Universal Protocol and Fire Risk Assessment
THE CHOICE IS YOURS. Medline’s comprehensive line of facemasks was designed to meet a variety of needs and preferences, but all of our masks are united by a common trait — quality. Every mask we manufacture — from our fluid-resistant masks to our spearmint-scented masks — is backed by Medline’s quality guarantee and designed to exceed expectations for comfort and protection. • Fluid resistant • Fog-free • Spearmint-scented • Chamber style • Isolation • Procedure • Face shield • Protective eyewear
©2009 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
Forms & Tools
Extinguishing a Surgical Fire
EXTINGUISHING A SURGICAL FIRE Fighting Fires ON the Surgical Patient Review before every surgical procedure.
In the Event of Fire on the Patient: 1. Stop the flow of all airway gases to the patient. 2. Immediately remove the burning materials and have another team member extinguish them. If needed, use a CO2 fire extinguisher to put out a fire on the patient. 3. Care for the patient: —Resume patient ventilation. —Control bleeding. —Evacuate the patient if the room is dangerous from smoke or fire. —Examine the patient for injuries and treat accordingly. 4. If the fire is not quickly controlled: —Notify other operating room staff and the fire department that a fire has occurred. —Isolate the room to contain smoke and fire. Save involved materials and devices for later investigation.
Extinguishing Airway Fires
Review before every surgical intubation.
At the First Sign of an Airway or Breathing Circuit Fire, Immediately and Rapidly: 1. Remove the tracheal tube, and have another team member extinguish it. Remove cuff-protective devices and any segments of burned tube that may remain smoldering in the airway. 2. Stop the flow of all gases to the airway. 3. Pour saline or water into the airway. 4. Care for the patient: —Reestablish the airway, and resume ventilating with air until you are certain that nothing is left burning in the airway, then switch to 100% oxygen. —Examine the airway to determine the extent of damage, and treat the patient accordingly. Save involved materials and devices for later investigation.
Source: New Clinical Guide to Surgical Fire Prevention. Health Devices 2009 Oct;38(10):330. ©2009 ECRI Institute More information on surgical fire prevention is available at: www.ecri.org/surgical_fires
84 The OR Connection
Preventing Surgical Fires
Forms & Tools
ONLY YOU CAN PREVENT SURGICAL FIRES Surgical Team Communication Is Essential
The applicability of these recommendations must be considered individually for each patient.
At the Start of Each Surgery: X
Enriched O2 and N2O atmospheres can vastly increase flammability of drapes, plastics, and hair. Be aware of possible O2 enrichment under the drapes near the surgical site and in the fenestration, especially during head/face/neck/upper-chest surgery.
Do not apply drapes until all flammable preps have fully dried; soak up spilled or pooled agent.
Fiberoptic light sources can start fires: Complete all cable connections before activating the source. Place the source in standby mode when disconnecting cables.
Moisten sponges to make them ignition resistant in oropharyngeal and pulmonary surgery.
During Head, Face, Neck, and Upper-Chest Surgery: X
Use only air for open delivery to the face if the patient can maintain a safe blood O2 saturation without supplemental O2.
If the patient cannot maintain a safe blood O2 saturation without extra O2, secure the airway with a laryngeal mask airway or tracheal tube. Exceptions: Where patient verbal responses may be required during surgery (e.g., carotid artery surgery, neurosurgery, pacemaker insertion) and where open O2 delivery is required to keep the patient safe: — At all times, deliver the minimum O2 concentration necessary for adequate oxygenation. — Begin with a 30% delivered O2 concentration and increase as necessary. — For unavoidable open O2 delivery above 30%, deliver 5 to 10 L/min of air under drapes to wash out excess O2. — Stop supplemental O2 at least one minute before and during use of electrosurgery, electrocautery, or laser, if possible. Surgical team communication is essential for this recommendation. — Use an adherent incise drape, if possible, to help isolate the incision from possible O2-enriched atmospheres beneath the drapes. — Keep fenestration towel edges as far from the incision as possible. — Arrange drapes to minimize O2 buildup underneath. — Coat head hair and facial hair (e.g., eyebrows, beard, moustache) within the fenestration with water-soluble surgical lubricating jelly to make it nonflammable. — For coagulation, use bipolar electrosurgery, not monopolar electrosurgery.
During Oropharyngeal Surgery (e.g., tonsillectomy): X X
Scavenge deep within the oropharynx with a metal suction cannula to catch leaking O2 and N2O. Moisten gauze or sponges and keep them moist, including those used with uncuffed tracheal tubes.
During Tracheostomy: X
Do not use electrosurgery to cut into the trachea.
During Bronchoscopic Surgery: X
If the patient requires supplemental O2, keep the delivered O2 below 30%. Use inhalation/exhalation gas monitoring (e.g., with an O2 analyzer) to confirm the proper concentration.
When Using Electrosurgery, Electrocautery, or Laser: X
The surgeon should be made aware of open O2 use. Surgical team discussion about preventive measures before use of electrosurgery, electrocautery, and laser is indicated.
Activate the unit only when the active tip is in view (especially if looking through a microscope or endoscope).
Deactivate the unit before the tip leaves the surgical site.
Place electrosurgical electrodes in a holster or another location off the patient when not in active use (i.e., when not needed within the next few moments).
Place lasers in standby mode when not in active use.
Do not place rubber catheter sleeves over electrosurgical electrodes.
Developed in collaboration with the Anesthesia Patient Safety Foundation.
Source: New Clinical Guide to Surgical Fire Prevention. Health Devices 2009 Oct;38(10):319. ©2009 ECRI Institute More information on surgical fire prevention, including a downloadable copy of this poster, is available at www.ecri.org/surgical_fires
Aligning practice with policy to improve patient care 85
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Forms & Tools
H1N1 Patient Handout
H1N1 (Swine Flu) What is H1N1 flu? H1N1 influenza, or swine flu, is a respiratory illness caused by type A influenza viruses. This virus was originally referred to as “swine flu” because it was thought to be very similar to flu viruses that normally occur in pigs (swine) in North America. H1N1 flu was first detected in people in the United States in April 2009. How does H1N1 flu spread? H1N1 flu is contagious and is spreading between people. This virus may be transmitted in similar ways that other flu viruses spread, through coughing or sneezing. A person may be able to infect another person one day before symptoms develop and for seven or more days (longer for children) after becoming sick. It is possible that someone may become infected by touching something with the virus on it and then touching his mouth or nose. Eating pork does not cause swine influenza.
What are the symptoms of H1N1 flu? The symptoms of H1N1 flu include fever, cough, sore throat, runny or stuffy nose, body aches, headache, chills and fatigue. Diarrhea and vomiting may also be associated with H1N1 flu. Most people with the virus have recovered without needing treatment, but hospitalizations and deaths have occurred.
H1N1 Symptoms • Headache • Fever • Fatigue
What should I do if I think I have H1N1 flu? If you have flu symptoms, stay home and avoid contact with other people to avoid spreading your illness. It is recommended that you stay home for at least 24 hours after your fever is gone, or if possible, until your cough is gone. If you have severe illness or you are at high risk for flu complications, contact your health care provider. He or she will determine whether testing or treatment is needed.
Seek emergency medical care for any of the following warning signs:
• Body aches
• Runny or stuffy nose • Sore throat • Cough
• • • • • •
• Difficulty breathing or shortness of breath • Pain or pressure in the chest or abdomen • Sudden dizziness • Confusion • Severe or persistent vomiting • Flu-like symptoms improve but then return with fever and worse cough
Fast breathing or trouble breathing Bluish skin color Not drinking enough fluids Not waking up or not interacting Being so irritable that the child does not want to be held Flu-like symptoms improve but then return with fever and worse cough • Severe or persistent vomiting
Text courtesy of NursingCenter.com. Images courtesy of Anatomical Chart Company. Lippincott Williams & Wilkins | Wolters Kluwer Health Businesses.
Aligning practice with policy to improve patient care 87
Forms & Tools
H1N1 Patient Handout
How is H1N1 flu treated? The CDC recommends the use of oseltamivir (brand name Tamiflu) or zanamivir (brand name Relenza) to treat and/or prevent swine influenza. These antiviral medications may also prevent serious complications. For treatment, antiviral drugs work best if started within 2 days of symptoms.
What can I do to prevent H1N1 flu? You can reduce your risk of contracting and spreading swine influenza and other influenza viruses by: • Coughing or sneezing into your arm; avoiding close contact with people who have respiratory symptoms such as coughing or sneezing
• Not touching your eyes, nose, or mouth because this is how germs get into your body
• Staying home when you're sick and getting as much rest as possible
• Keeping surfaces and objects (especially tables, counters, doorknobs, toys) that can be exposed to the virus clean
• Washing your hands often with soap and water for 15-20 seconds; using alcohol-based hand cleansers is also acceptable
• Practicing other good health habits, including getting plenty of sleep, staying active, drinking plenty of fluids, and eating healthy foods
Lisa Morris Bonsall, MSN, RN, CRNP
Text courtesy of NursingCenter.com. Images courtesy of Anatomical Chart Company. Lippincott Williams & Wilkins | Wolters Kluwer Health Businesses.
88 The OR Connection
Check with your healthcare provider to see if the H1N1 vaccine is right for you.
Forms & Tools
H1N1 Español por los Pacientes
Virus de la influenza A subtipo H1N1 (anteriormente llamado de la «gripe porcina») ¿Qué es la gripe por H1N1? La gripe por H1N1, originalmente llamada «gripe porcina», es la enfermedad respiratoria que causa la infección por el virus de la influenza A subtipo H1N1. A este virus originalmente se le llamó virus de la «gripe porcina» puesto que se pensó que era muy similar a los virus que causan gripe en los cerdos (porcinos) en Norteamérica. El virus de la influenza A subtipo H1N1 fue detectado por primera vez en humanos en los Estados Unidos de Norteamérica en abril del 2009. ¿Cómo se propaga la gripe por H1N1? La gripe por H1N1 es contagiosa y se propaga de persona a persona. El virus puede propagarse de manera similar a otros virus de la gripe; a través de la tos o de los estornudos. Una persona puede infectar a otra un día antes de presentar síntomas y durante siete o más días (más tiempo en los niños) después de haber enfermado. Existe la posibilidad de que una persona se infecte al tocar una superficie contaminada con el virus si esta persona luego se pone las manos sobre la boca o nariz. Comer carne de cerdo no causa gripe por H1N1.
¿Cuáles son los síntomas de la gripe por H1N1? Los síntomas de la gripe por H1N1 incluyen fiebre, tos, dolor de garganta, nariz con mucosidad o tupida; dolor en el cuerpo, dolor de cabeza, escalofríos y fatiga. La mayoría de las personas que han tenido el virus se han recuperado sin necesitar tratamiento, pero ha habido otras que han necesitado hospitalización, y también otras que han muerto.
Síntomas de A(H1N1) • Dolor de cabeza • Fiebre • Fatiga
¿Qué debo hacer si pienso que tengo gripe por H1N1? Si usted piensa que tiene síntomas de gripe quédese en casa y evite entrar en contacto con otras personas para no propagar la enfermedad. Es recomendable quedarse en casa por lo menos durante 24 horas después de que le haya pasado la fiebre, o si es posible, después de que le haya pasado la tos. Si está gravemente enfermo, o si pertenece a un grupo de alto riesgo para desarrollar complicaciones, entre en contacto con su proveedor de atención médica. Él determinará si es necesario que le hagan análisis o que tome tratamiento.
• Escalofríos • Nariz con mucosidad o tupida • Dolor de garganta • Tos • Dolores corporales
Busque atención médica de urgencias si presenta cualquiera de los siguientes signos (señas) de alarma:
• • • • • •
• Dificultad para respirar o sensación de «falta de aire» • Dolor o sensación de presión en el pecho o en el abdomen • Mareo súbito • Confusión • Vómito intenso o persistente • Los síntomas como de gripe mejoran pero luego reaparecen con fiebre y tos más fuerte.
Respiración acelerada o dificultad para respirar Tonalidad morada en la piel No está tomando suficientes líquidos No se despierta o no responde a las acciones Está tan irritable que no quiere que lo alcen Los síntomas como de gripe mejoran pero luego reaparecen con fiebre y tos más fuerte. • Vómito intenso o persistente
Texto por cortesía del centro NursingCenter.com. Imágenes por cortesía de Anatomical Chart Company. Lippincott Williams & Wilkins | Wolters Kluwer Health Businesses.
Aligning practice with policy to improve patient care 89
Forms & Tools
H1N1 Español por los Pacientes
¿Cómo es el tratamiento para la gripe por A(H1N1)? Los Centros para el Control y la Prevención de Enfermedades de los EE. UU. (CDC) recomiendan el uso de oseltamivir (nombre de marca Tamiflu) o de zanamivir (nombre de marca Relenza) para el tratamiento y la infección, o solamente para prevenir la infección por el virus de la influenza A(H1N1). Estos medicamentos antivíricos también pueden prevenir complicaciones graves. Para el tratamiento, los medicamentos antivíricos funcionan mejor si se comienzan a usar en un lapso de dos días después de que comienzan los síntomas.
¿Qué puedo hacer para prevenir la gripe por A(H1N1)? Usted puede disminuir su riesgo de contraer gripe por A(H1N1) y de propagar otros virus de la influenza de la siguiente manera:
• Tosiendo o estornudando sobre su brazo y evitando el contacto cercano con personas que presentan síntomas respiratorios tales como tos o estornudos.
• No tocándose los ojos, nariz o boca, pues ésta es la manera como los gérmenes llegan hasta nuestro cuerpo.
• Quedándose en casa cuando está enfermo y descansando el mayor tiempo que pueda.
• Manteniendo limpias las superficies y objetos (especialmente mesas, mesones, cerraduras de puertas) que puedan estar expuestos al virus.
• Lavándose las manos con frecuencia con agua y jabón durante 15 a 20 segundos o usando un limpiador para las manos con base en alcohol.
• Practicando otros hábitos saludables; incluso dormir bastante, mantenerse activo, tomar líquidos en cantidad y comer alimentos saludables.
Escrito por Lisa Morris Bonsall, MSN, RN, CRNP Traducido por Marcela D. Pinilla, M.H.E., M.T. (ASCP)
Texto por cortesía del centro NursingCenter.com. Imágenes por cortesía de Anatomical Chart Company. Lippincott Williams & Wilkins | Wolters Kluwer Health Businesses.
90 The OR Connection
Verifique con su proveedor de atención médica para determinar si la vacuna contra el virus de la influenza A(H1N1) es adecuada para usted.
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