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The Aligning practice with policy to improve


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Volume 5, Issue 4

Tips for

Tackling Introducing ...


THE NEW REMEDY WEBSITE Now you and your family can enjoy professional quality Remedy skin care products at home.



Principles for achieving inner peace

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Checklists Work


OR Connection Aligning practice with policy to improve

Patient Handout

Forms & Tools

patient care

Caring for Your Surgical Incision at Home The following are general guidelines. Consult your surgical team for more specific instructions.

Bathing and Showering Most incisions should be kept dry for several days after surgery, except for incisions closed with surgical glue. It is usually safe to allow glued incisions to get wet while showering or bathing. It is important, however, to dry the area around the incision carefully after washing. Physical Activity and Exercise Avoid any activity that pulls on the edges of the incision or puts pressure on it. Walking and other light activities are encouraged to restore normal energy levels and digestive functions. Do not, however, participate in sports, engage in sexual activity or lift heavy objects until after your postoperative checkup.

Never miss an issue of The OR Connection! Subscriptions are free and signing up is a snap! Subscribing to The OR Connection guarantees that you’ll continue to receive this info-packed magazine and won’t miss out on our industry updates and articles addressing on-thejob issues and tips on caring for yourself!

To subscribe, simply go to You will need to provide: Your name Facility and position Mailing address E-mail address

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

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 10 and 11.

Aspirin Avoid aspirin or over-the-counter medications containing aspirin for a week to 10 days after surgery. Aspirin interferes with blood clotting and makes it easier for bruises to form near the incision. Sun Exposure As an incision heals, the new skin that forms over the cut is very sensitive to sunlight and will burn more easily than normal skin and lead to worse scarring. Keep the incision area covered from direct sun exposure for three to nine months in order to prevent burning and severe scarring. General Hygiene Infection is the most common complication of surgical procedures. It is important, therefore, to minimize the risk of an infection when caring for your incision at home. Observe the following precautions: • Wash your hands carefully after using the toilet and after touching or handling trash; pets and pet equipment; dirty laundry and anything else that is dirty or has been used outdoors • Ask family members, close friends, and others to wash their hands before contact with you • Avoid contact with family members and others who are sick or recovering from a contagious illness • Stop smoking (smoking slows down the healing process)

Adapted from

Aligning practice with policy to improve patient care 111

Editor Sue MacInnes, RD, LD Clinical Editor Alecia Cooper, BS, MBA, RN, CNOR Senior Writer Carla Esser Lake Creative Director Mike Gotti Clinical Team Jayne Barkman, BSN, RN, CNOR Margaret Falconio-West, BSN, RN, APN/CNS, CWOCN, DAPWCA


10 12 20 24 39 42 46 74

Three Important Initiatives for Improving Patient Care Patient Safety News Conversation with Dr. Peter J. Pronovost Checking it Twice: Yes! Checklists Do Save Lives Why the Universal Protocol Hasn’t Eradicated Patient Harm A New Guidebook for Patient Safety in the OR They’re Lurking in the Operating Room and Beyond 5-Step Approach for Avoiding VAP

Page 24

Rhonda J. Frick, RN, CNOR


Anita Gill, RN Kimberly Haines, RN, Certified OR Nurse Carla Nitz, BSN, RN Claudia Sanders, RN, CFA Megan Shramm, RN, CNOR, RNFA

36 Preventing Sharps Injury in the OR 55 Medline Joins Greening the Operating Room Initiative 60 Stuck Like Surgical Glue

Angel Trichak, RN, BSN, CNOR

Page 60


Perioperative Advisory Board Larry Creech, RN, MBA, CDT Carilion Clinic, Virginia Sharon Danielewicz, MSN, RN, RNFA St. Luke’s The Woodlands, Texas Tracy Diffenderfer, MSN, RN Vanderbilt University Medical Center, Tennessee Barb Fahey RN, CNOR Cleveland Clinic, Ohio Susan Garrett, RN

7 14 30 56

Pink Glove Survey Comments Third Annual Prevention Above All Conference Highlights Patient, Heal Thyself 3 Checklists on the Cleaning and Disinfection of Endoscopic Equipment 69 Product Spotlight: Medline Bioguard Barrier Dressings 92 Pink Glove Dance: The Sequel

Page 74

Hughston Hospital Inc., Georgia


Zaida I. Jacoby, MA, MEd, RN NYU Medical Center, New York Jackie Kraft, RN, CNOR Huntsville Hospital, Alabama

78 Get Set for Winter Illness Season 84 8 Principles for Achieving Inner Peace 96 Healthy Eating: Crock Pot Chili

Tom McLaren Florida Hospital, Florida Susan Phillips, RN, MSH, CNOR University of North Carolina Hospitals Donna A. Pritchard, BSN, MA, RN, CNOR, NE-BC Kingsbrook Jewish Medical Center, New York Debbie Reeves, MS, RN, CNOR Hutcheson Medical Center, Georgia Diane M. Strout, BSN, RN, CNOR St. Joseph Medical Center, Washington


99 100 101 103 105 109 111

AORN Surgical Time Out SCOAP Surgical Safety Checklist – Ambulatory Surgery SCOAP Surgical Safety Checklist Wrong-Site Surgery Prevention Tool Medicare & the New Healthcare Law Tips for Safer Surgery Caring for Your Surgical Incision at Home

Page 84

Page 92 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,

©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 Letter from the Editor

Another New Year is here! It’s a great time to reminisce, to make our New Year’s resolutions and set our goals for 2011. Do you ever just stop and think about what was happening this time last year or even five years ago? Do you think about what you were doing then? Have you changed responsibilities, or maybe even careers? Did you get married, have a child, become a grandparent, move, have to deal with a tragic situation … And when you think back, do you ever say, “I can’t believe I’ve come this far.” Because if you haven’t, you should! You should recognize and celebrate your achievements. Those milestones are what will continue to inspire you and push you to be your very best. And, when you are at your best and do your best, everyone wins…especially the patients you are caring for. So, for 2011, I hope you will take care of yourself. You are so important to your patients. Sometimes it takes being a patient or the family member of a patient to really appreciate all that you do. I’ve been there, and so have many, many of the people I work with. We all thank you. To set the tone for 2011, you might want to start reading on page 84, “8 Principles for Achieving Inner Peace.” There is nothing better than an inspirational article like this one to get those New Year’s resolutions and goals flowing. Highlight the article, take notes, think about the message…and then figure out what YOU are going to do to make 2011 the best ever!! Once you’ve put your plan together, look again at the pictures of the pink glove dancers. Take note of the hospitals involved, look at the people’s faces, feel their joy. Breathe in all those positive vibes. Then set the magazine aside and do something for yourself, something that makes you feel good. Surprise a co-worker with a smile, ask them about their holiday, get them a cup of coffee. Or, listen to your child or your spouse talk about their day. Be there, in the moment, and forget everything else that is distracting you and taking time away from living.


The OR Connection

I know, I know, at some point you have to get back to work and deal with reality and everyday pressures. But it is easier to do when you make time for yourself and your family. I realize it’s hard to do everything, know everything, remember everything…that is why in this issue of The OR Connection, you are going to learn more than you probably ever wanted to know about checklists. On the cover isn’t just another handsome face. It is Dr. Peter Pronovost, a well-known advocate of patient safety, quality and the infamous checklist. On page 20, he tells his own personal story about his father and how it has inspired him to champion a culture of safety. Whether your checklist is healthcare-related or a checklist for travel or a social event, it is easy to forget the simplest things when our minds are buzzing. We should embrace and adopt checklists and encourage others to do likewise. If one life is saved or one error is avoided, it’s worth it, don’t you think? This edition is packed full of stories and ideas you can use in your profession as well as in your personal life. You are the face of health care. Thank you for making a difference in so many people’s lives. And don’t forget. Step one is making sure you take care of YOU.

Sue MacInnes, RD, LD Editor

And the winning pink glove ad is… Yes, They’re Genuine. Only Medline’s Pink Pearl™ gloves combine aloe, nitrile and breast cancer awareness.

Precious. And Pink.

only wear Pink Pearls.

Soft and shimmery. Layered with organic aloe. Fashioned from nitrile. The Pink Pearl.™ Medline’s newest Generation Pink glove. Supporting the National Breast Cancer Foundation.

Only Medline’s Pink Pearl™ gloves combine aloe, nitrile and breast cancer awareness. ©2010 Medline Industries, Inc. Medline is a registered trademark and Pink Pearl is a trademark of Medline Industries, Inc.

©2010 Medline Industries, Inc. Medline is a registered trademark and Pink Pearl is a trademark of Medline Industries, Inc.

©2010 Medline Industries, Inc. Medline is a registered trademark and Pink Pearl is a trademark of Medline Industries, Inc.

The results are in! We’ve tallied your votes and compiled your thoughts about Medline’s pink gloves and the Pink Glove Dance. Thank you for your heartfelt comments and participation in last issue’s survey. Turn the page to find the winner!

54% Voted for Pearls! Yes, They’re Genuine. Only Medline’s Pink Pearl™ gloves combine aloe, nitrile and breast cancer awareness.

©2010 Medline Industries, Inc. Medline is a registered trademark and Pink Pearl is a trademark of Medline Industries, Inc.


The OR Connection


pink glove survey

What our readers said:


It means unity, joy, excitement, a cause “on the go” for all involved. Shannon Sessoms, RN, BSN, CNOR Southeast Missouri Hospital Cape Girardeau, MO

Awareness! Hope! While in the OR I told co-workers and the patient about this. It raised our spirits. Big company that CARES. Deb Cimino, RN, BSN, CPSN, CNOR Yardley Plastic & Reconstructive Surgery Yardley, PA

Celebrating the lives of two of our nurses who died—and the two who are still with us.

What does the Pink Glove Dance mean to you?

MJ Balun Naples Day Surgery Naples, FL

It is a fun but touching video that shows the true concern healthcare workers have for people with breast cancer. Holly Creel, RN The Kirklin Clinic Warrior, AL

Aligning practice with policy to improve patient care 7

What does the Pink Glove Dance mean to you?

Left to right: Tina Hollis, Patrick Montgomery and Cindy Gibson. Co-workers in the surgery department at Northeast Alabama Regional Medical Center in Herflin, AL.

My mother had breast cancer, so it means everything. Tina Hollis Northeast Alabama Regional Medical Center Herflin, AL

Hope for patients with breast cancer. Beautiful women, strength, good fun.

Kathleen Ingraham FirstHealth Moore Regional Hospital Pinehurst, NC

Shows how much healthcare workers want to make a difference toward recognition, education and care of breast cancer. Susan Karns, CST, CFA Kettering Medical Center - Sycamore Franklin, OH

Patricia Nieszel, RN Algonquin Surgery Center Crystal Lake, IL

People from all different walks of life coming together for a common cause – fighting breast cancer.

It shows how caring healthcare workers

Sue Montgomery, RN Foothill Presbyterian Hospital Glendora, CA

of ALL types are towards supporting the cause! Helen Aylward, RN, BSN, L.Ac. Maine Medical Center Portland, ME

Wonderful healthcare providers, not professional dancers, working hard to spread the word about breast cancer awareness.

It made me cry to see the teamwork that went into making it. I’m a breast cancer survivor.

Mary Valley, RN, CNOR Frisbie Memorial Hospital Rochester, NH

Carolyn Meyer, RN, BSN, CNOR St. John Medical Center Bartlesville, OK

Joy for cancer survivors and hope for more.

As a breast cancer survivor it means so much to know that many people care and want to show it - keep it up! Ellen Whitehead, RN, CNOR Georgia Surgical Acworth, GA


Those with cancer are not alone. We are out there standing beside them and showing our support.

The OR Connection

Carol Athey, RN, MSN, CNOR Woodland Heights Medical Center Lufkin, TX

It makes me smile. Debra Ann Caise, RN, BSN Provena St. Mary’s Hospital St. Anne, IL

The dance demonstrates the joy of living while increasing awareness about breast cancer. Paula Bishop, RN, MSN, CNOR Aultman Hospital Canal Fulton, OH

The closer we get to a cure! I lost a sister and have a sister who is a survivor going on 10 years now! Very close to my heart. Lynetta Baldwin Advanced Surgical Care Creve Coeur, MO

A hospital works as a unified unit to complete its mission. Colleen Witt, RN BSN Roswell Park Cancer Institute Buffalo, NY

A way to show support for breast cancer survivors. John Ratliff, BS, CST, FAST York Technical College Rock Hill, SC

People getting involved to bring awareness to breast cancer. Darlene McCraney, RN South Central Regional Medical Center Laurel, MS

As a breast cancer survivor, every time I see the videos I cry with gratitude that so many people care and did something so fun and positive as a response. Thank you to everyone who participated. And thank you to so-hip Portland for getting the ball rolling. And as a lifetime rock and roller, dancer and silly person, every time I see these folks dance and carry on, I laugh and I am infused with love of life and humanity. Boy do they get their groove on! I was diagnosed with breast cancer in mid-2004. I had two lumpectomies and two months of radiation, and have been free and clear ever since (as of October 2010). I had very good care in Marin County, CA. I made some wonderful friends in my support group and became closer to many of the friends I already had. Besides my support group, I have about ten women friends who have had breast cancer. I would never wish it on anyone as a life experience (I don’t believe that things like this happen to teach us a lesson, but rather that we use what happens to us in a way that teaches us something), but I used it to recommit myself to the best health and the best appreciation of life and friendships that I can muster, which is pretty dang good. Every single day counts, as does every single person. In the pink, Francine Falk-Allen San Rafael, CA

It energizes you and makes you want to move, especially when you see everyone working toward the same goals. Jerlene McClain, RN, BSN, MHR, CNOR Reynolds Army Community Hospital - Fort Sill Lawton, OK

Aligning practice with policy to improve patient care 9

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


IHI Improvement Map

Origin: Purpose:

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

Hospitals sign up through IHI and can choose to implement some or all of the recommended interventions. IHI provides how-to guides and tools for all participating hospitals.

The IHI Improvement Map covers the entire landscape of outstanding hospital care to help hospitals make sense of countless requirements and focus on high-leverage changes to transform care. There are 70 processes grouped into three domains: leadership and management, patient care and processes to support care.




Joint Commission 2011 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 2011; however, revisions to the NPSGs will be effective in 2011.


Origin: Purpose: Goal:

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

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

10 The OR Connection

Patient Safety

IHI Improvement Map: 73 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.

3 New Key Processes as of June 2010 1. Anticoagulation Management 2. Essential Care for Frail Older Patients 3. Glycemic Control in Non-Critically Ill Patients

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 73 processes to transform hospital care, go to

Joint Commission 2011 National Patient Safety Goals Effective January 1, 2011: • 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.

• The organization identifies safety risks inherent in its patient population. • Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery.™

To learn more about National Patient Safety Goals, go to

Surgical Care Improvement Project (SCIP): Target Areas

1. Surgical infections • Antibiotics, blood sugar control, hair removal, perioperative temperature management • Remove urinary catheter on Post Operative Day (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 measure #9, 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 11

PATIENT SAFETY NEWS APIC, CDC, Other Infection Control Organizations Pledge to Eliminate HAIs1

Death Rate Six Times Higher for Hospital Patients with HAIs3

Action steps published in AJIC A number of professional healthcare organizations, i n cluding the Association for Professionals in Infection Control and Epidemiology (APIC), the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), the Centers for Disease Control and Prevention (CDC) and others have joined together to move toward the elimination of healthcare-associated infections (HAIs). They announced their plan in a white paper, “Moving Toward Elimination of Healthcare-Associated Infections: A Call to Action,” published in the November 2010 issue of the American Journal of Infection Control (AJIC).

Adults who developed health care-associated infections (HAIs) due to medical or surgical care while in the hospital in 2007 had a death rate six times higher than patients without an HAI, according to the latest News and Numbers published by the Agency for Healthcare Research and Quality (AHRQ).

The group proposes to eliminate healthcare-associated infections through a series of action steps, as outlined in the paper: • Adherence to evidence-based practices • Aligning financial incentives • Innovation and research • Gathering data for action

New Hampshire Hospital Initiative Aims to Eliminate Harm to Patients by 20152 In a new effort to promote better and safer patient care, the New Hampshire Hospital Association and Foundation for Healthy Communities recently began a new initiative to eliminate harm to patients by 2015. The definition of “harm,” according the New Hampshire initiative, refers to an injury associated with medical care that requires or prolongs hospitalization and/or results in permanent disability or death. A statewide steering committee will spearhead the New Hampshire Eliminate Harm Initiative and identify which aspects of harm hospitals will target for elimination.

12 The OR Connection

Patients with HAIs also had to stay in the hospital an average of 19 days longer. On average, the cost of a hospital stay of an adult patient who developed an HAI was about $43,000 more expensive than the stay of a patient without an HAI. AHRQ also discovered that: • In 2007, about 45 percent of patients with HAIs were 65 or older, 33 percent were 45 to 64 and 22 percent were 18 to 44. • Patients in the 45 to 64 age group had the highest rate of HAIs. • The top three diagnoses in hospitalized adult patients who developed HAIs were septicemia (12 percent), adult respiratory failure (6 percent) and complications from surgical procedures or medical treatment (4 percent).

References 1. Cardo D, Dennehy PH, Halverson P, Fishman N, Kohn M, Murphy CL, et al. Moving toward elimination of healthcare-associated infections: a call to action. American Journal of Infection Control. 2010;31(11):1101-1105. Available at: Accessed October 25, 2010. 2. New Hampshire’s hospitals commit to eliminate harm [news release]. Concord, NH: New Hampshire Hospital Association; September 27, 2010. Accessed October 25, 2010. 3. Health care-associated infections greatly increase the length and cost of hospital stays. Agency for Healthcare Research and Quality website. October 2010 feature story. Available at: Accessed October 25, 2010.

Medline Partners with The Joint Commission to Help Solve Healthcare Quality and Safety Issues Medline Industries, Inc. has signed an agreement with the Joint Commission Center for Transforming Healthcare to contribute financially to the Center’s Endowment Fund. The Center for Transforming Healthcare was developed to help solve healthcare’s most critical safety and quality problems. In this effort, Medline is joining other leading healthcare organizations in their commitment to eliminate preventable complications and transform healthcare.

“Medline is proud to support and share in the mission of solving healthcare’s most critical safety and quality problems,” said Andy Mills, president of Medline. “Medline’s approach is to ‘Make it hard for the healthcare worker to do the wrong thing.’ The Center is studying some of the most pressing issues facing providers, bringing together teams of experts to design and test practical solutions to healthcare’s everyday challenges.” Issues the Center is working on include Hand Hygiene, Surgical Site Infections, Wrong Site Surgery and Hand-off Communication.

Ways to improve hand-off communication

Hospitals and Healthcare Systems Participating

Healthcare organizations have long struggled with errors and issues associated with passing along critical patient information from one caregiver to the next, also known as hand-off communication.

in the Hand-Off Communication Project • Exempla Lutheran Medical Center, Wheat Ridge, Colorado • Fairview Health Services, Minneapolis, Minnesota

The Center and participating hospitals set out to solve these problems and recently released some new solutions using the acronym SHARE.

• Intermountain Healthcare LDS Hospital,

Standardize critical content by providing details of the patient’s history to the healthcare worker who will be taking over the patient’s care, emphasizing key information about the patient.

• Kaiser Permanente Sunnyside Medical Center,

Hardwire within your system, which includes developing standardized forms, tools and methods, such as checklists to assist in making the hand-off successful. Allow opportunity to ask questions and use critical thinking skills when discussing a patient’s case as well as sharing and receiving information as an interdisciplinary team. Reinforce quality and measurement, which includes holding staff accountable, monitoring compliance with use of standardized forms, and using data to determine a systematic approach for improvement.

Salt Lake City, Utah • The Johns Hopkins Hospital, Baltimore, Maryland Clackamas, Oregon • Mayo Clinic Saint Marys Hospital, Rochester, Minnesota • New York-Presbyterian Hospital, New York • North Shore-LIJ Health System Steven and Alexandra Cohen Children’s Medical Center, New Hyde Park, New York • Partners HealthCare, Massachusetts General Hospital, Boston • Stanford Hospital & Clinics, Palo Alto, California

Educate and coach, which includes organizations teaching staff what constitutes a successful hand-off and making successful hand-offs an organizational priority.

Aligning practice with policy to improve patient care 13

Third Annual Prevention Above All Conference

Strategies for Thriving in the New Era of Healthcare Reform The heat is on in health care like never before. Error prevention, efficiency and cost containment have been top priorities for a very long time, but now, with the introduction of healthcare reform, they are absolutely critical for survival, according to Joint Commission President Mark Chassin, MD, MPP, MPH. What to expect from healthcare reform Dr. Chassin delivered the keynote address at Medline’s 3rd Annual Prevention Above All Conference devoted to sharing new strategies for delivering cost-effective, high-quality, evidence-based health care. An audience of more than 100 hospital CEOs, chief nursing officers and other executives attended the meeting August 16 and 17, 2010, in New York City. “Today’s message is clear,” Dr. Chassin said. “Solve safety and quality problems. Don’t say you’re trying; just solve them. Take care of 30-plus million more people in your organizations. Become or participate in an accountable care organization. Figure out bundled payments. Adopt electronic medical records quickly. And one more thing. You can’t have any more money.” Overall, Dr. Chassin explained, healthcare reform increases coverage while experimenting with some new payment and care delivery ideas. Reform will increase federal costs, and

14 The OR Connection

there is only one vehicle for cost containment: limiting payment to providers. Dr. Chassin cautioned, “You will never be paid better than you are being paid now. This was true six months ago, it’s true now, and it will be true tomorrow and next week.” So how do healthcare providers control costs and avoid major payment cuts and benefit reductions while also maintaining quality? Dr. Chassin outlined several keys to survival in today’s era of healthcare reform. Employ a quality-driven strategy to eliminate overuse of health services. Examples include discontinuing wasteful practices such as prescribing antibiotics for colds and inducing labor earlier than 39 weeks. “This is one part of health policy that has not received any attention,” Dr. Chassin explained. “It’s been overlooked for decades in the research community. We must come together to do this.” Two more keys to survival are eliminating the waste inherent in needlessly complex care delivery processes and putting an end to preventable complications.

Special Feature

Deborah Adler, Trent Haywood, Mark Chassin and Mikel Gray answer questions from the audience at the Third Annual Prevention Above All Conference held at the Hudson Theatre in New York City.

Aligning practice with policy to improve patient care 15

A look into the future Speaking from his experience as CEO of New York City’s Mount Sinai Hospital, one of the nation’s largest and busiest hospitals, Wayne Keathley provided a firsthand look at what he predicts will be the norm for the average U.S. hospital amidst the new era of healthcare reform—having to do a lot more with a lot less at average capacity levels of 95 percent.

Left: Keynote speaker Joint Commission President Mark Chassin, MD, MPP, MPH.

“A fair number of you probably don’t recognize the kind of congestion, overcrowding and difficulties with flow that I’m about to describe,” Keathley said. “I would ask you to indulge in a little suspension of disbelief and assume for a minute that as health reform evolves, possibly because of a whole new group of patients who will come to you for care … and more likely because the economics will require you to rethink capacity and the way you manage it — that the situation I’m going to describe for us, in fact has some meaning for you.” Mount Sinai is operating at 95 percent capacity, and they are currently working with GE Healthcare to implement new systems to accommodate this level of activity. Keathley advocates improvement through fixing systems, not by adding more resources. For example, whereas hospitals often rely on intuition and personal judgment when managing patient flow and locating empty beds, Keathley suggests that studying capacity patterns and related data leads to more efficient use of resources. He also encourages collaboration among departments, viewing the hospital as a whole rather than operating as individual silos. “If money were no object, we would add more beds, add more operating rooms, hire more nurses, and we could drive occupancy back down to the ideal 85 percent,” Keathley said. “But I am telling you, that fantasy doesn’t exist.” Prevention Above All Another solution to meeting the challenges of healthcare reform lies in preventing costly medical errors and infections that are indeed preventable. Sue MacInnes, Medline’s Chief Marketing Officer and host of the Prevention Above All Conference, reviewed Medline’s growing offering of preventive strategies for healthcare providers: The Gold Standard Surgical Safety Program to help prevent operating room errors, the Hand Hygiene Compliance Program, the Pressure Ulcer Prevention Program, Educational Packaging, the ClearCount Surgical System to help prevent sponges from being left behind and the Catheter-Associated

16 The OR Connection

Above (left to right): Medline President Andy Mills, Deborah Adler, Medline Chief Marketing Officer, Sue MacInnes, RD, LD, Atul Gawande, MD, MPH, Medline COO Jim Abrams.

Right: The Third Annual Prevention Above All Conference took place at the historic Hudson Theatre in New York City.

Urinary Tract Infection (CAUTI) Foley Catheter Management System to help prevent CAUTIs. These six strategies are targeted, focused and achievable evidence-based solutions that are also practical. They fit with everyday processes and systems currently in place at most healthcare facilities. MacInnes emphasized, “Sometimes the simplest solutions make the biggest difference.”

What the Experts Are Saying ...



Caroline Fife, MD and Kevin W. Yankowsky, JD Lawsuits, Technology and Wound Care: How Electronic Health Records Change Your Legal Risks “Any time a lawsuit is filed, you and your facility and your practitioners lose. The only question is the question of degree ... I would suggest and recommend that you take a moment to focus on how, in addition to improving your clinical care, you can take steps to absolutely minimize your risk of ever being involved in the legal system; of ever being sued in the first place.” - Kevin W. Yankowsky Trent T. Haywood, MD, JD Social Practice: Observation for Understanding and Improving “One of the key things people have taught us in anything that has to do with practice improvement is not really what you don’t know; it’s what you think you know that ain’t so.”



Dale Bratzler, DO, MPH Healthcare-Associated Infections and Public Accountability “Clearly, if there is a single practice that we can do better that will dramatically reduce healthcare-associated infections, it would be hand hygiene.” Mikel Gray, PhD, FNP, CUNP, CCCN, FAANP, FAAN Evolution of Evidence: New Models for Demonstrating Effectiveness “Insufficient evidence remains the primary challenge of evidence-based practice; demystification of the research process is urgently needed.”



For video clips of the speakers’ presentations from the 3rd Annual Prevention Above All Conference, visit Or contact your Medline representative for a free set of DVDs.

Atul Gawande, MD, MPH Author, The Checklist Manifesto “What we have today, though, is a volume and complexity of medical discovery that has now exceeded our ability as individual specialized artisans to be able to deliver that care to the right person, the right way, at the right time without waste of resources.”

Continued on page 19

Aligning practice with policy to improve patient care 17

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on a patient prep, remember this: AORN, CDC & NQF don’t. There are a good reasons to inventory tory more than one surgical al patient skin prep. Surgical cal site, patient variables and procedure types pes demand different performance rmance features. Both ChloraPrep raPrep ® Patient Preoperative P Skin Preparation (2% Chlorhexidine Gluconate [CHG] & 70% Isopropyl Alcohol) hol) and 33M M™ D DuraPrep uraPrep™ Su Surgical rgical SSolution olution ((Iodine Iodine PPovacrylex ovacrylex [0.7% [0.7% available available iodine] iodine] and and Isopropyl Isopropyl Alcohol, Alcohol, 74% w/w w/w) w) Patient Preoperative Skin Pre Preparation eparation rreceived eceived N NDA DA aapproval pproval bbased ased oonn AASTM STM ttesting esting ffor or eefficacy fficacy sset et fforth orth bbyy the the FDA. FDA. Which Which may may be be why why both both are are recommended recommended ffor or tthe he rreduction eduction ooff SSSI SI bbyy AAORN, ORN, C CDC DC aand nd N NQF. QF. TToo learn more ore about the surprising differences es between surgical patient preps, ps, visit us at raprep. 33M M Infection Infection Prevention Prevention Solutions Solutions

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AORN: Spreading knowledge, preventing complications

Practicing Advanced Medicine Within Outdated Systems Atul Gawande, MD, a Harvard professor and author of several books, including his most recent, The Checklist Manifesto, addressed the challenges of delivering highly advanced medical care within outdated systems. He pointed out that we’ve entered a complex medical world in which we have 13,600 different diagnoses, 6,000 prescription medications and more than 4,000 medical and surgical procedures. Compounding matters, we’ve inherited a structure from 50 years ago that didn’t have nearly so many diagnoses, drugs and procedures. At that time, the doctor was considered an artisan, and all you really needed was the physician’s brain, along with an operating room, a few simple tools and some skills behind that. “What we have today, though, is a volume and complexity of medical discovery that has now exceeded our ability as individual specialized artisans to be able to deliver that care to the right person, the right way, at the right time without waste of resources,” Dr. Gawande said. The Checklist Manifesto: How to Get Things Right Atul Gawande, MD, MPH We live in a world of great and increasing complexity, where even the most expert professionals struggle to master the tasks they face. Longer training, ever more advanced technologies — neither seems to prevent grievous errors. But in a hopeful turn, acclaimed surgeon and writer Atul Gawande finds a remedy in the humblest and simplest of techniques: the checklist.

AORN Executive Director Linda K. Groah, RN, MSN, CNOR, NEA-BC, FAAN, began her presentation with these statistics: the average department of surgery is responsible for 40 to 60 percent of expenses, 70 percent of revenue and 50 percent of errors. To help reduce surgical errors, the Association of periOperative Nurses (AORN) promotes safe surgical practices and optimal patient outcomes by educating perioperative nurses and partnering with other professional and governmental healthcare organizations. AORN collaborates on patient safety initiatives with a number of major healthcare organizations, including the Centers for Medicare & Medicaid Services (CMS), the Surgical Care Improvement Project (SCIP), the World Health Organization (WHO), the Joint Commission, IPPS, Blue Cross and others. In fact, AORN worked closely with the WHO and Dr. Atul Gawande to ensure the perioperative nurse’s role was incorporated into the Surgical Safety Checklist. As a leader in the perioperative arena, AORN has also developed a number of its own initiatives for practical application in the OR. Some of these include Perioperative Standards and Recommended Practices, a complete perioperative curriculum and various toolkits. “The Perioperative Standards really are the core of AORN,” Groah said. “They represent the intellectual property of AORN.” Groah also emphasized that hundreds of hospitals and surgery centers across the country look to the Perioperative Standards as the go-to guide for evidence-based surgical practices. New and revised standards go through up to three rounds of revisions based on input from surgical professionals and the general public. To learn more about AORN, including group and individual membership, visit

Aligning practice with policy to improve patient care 19

Patient Safety

Conversation with Dr. Peter J. Pronovost

Doctor Leads Quest for Safer Ways to Care for Patients by Claudia Dreifus

What got you started on your crusade for hospital safety? My father died at age 50 of cancer. He had lymphoma. But he was diagnosed with leukemia. When I was a first-year medical student here at Johns Hopkins, I took him to one of our experts for a second opinion. The specialist said, “If you would have come earlier, you would have been eligible for a bone marrow transplant, but the cancer is too advanced now.” The word “error” was never spoken. But it was crystal clear. I was devastated. I was angry at the clinicians and myself. I kept thinking, “Medicine has to do better than this.”

Dr. Peter J. Pronovost, 45, is medical director of the Quality and Safety Research Group at Johns Hopkins Hospital in Baltimore, which means he leads that institution’s quest for safer ways to care for its patients. He also travels the country, advising hospitals on innovative safety measures. The Hudson Street Press has just released his book, “Safe Patients, Smart Hospitals: How One Doctor’s Checklist Can Help Us Change Health Care from the Inside Out,” written with Eric Vohr. An edited version of a two-hour conversation follows.

20 The OR Connection

A few years later, when I was a physician and after I’d done an additional Ph.D. on hospital safety, I met Sorrel King, whose 18-month-old daughter, Josie, had died at Hopkins from infection and dehydration after a catheter insertion. The mother and the nurses had recognized that the little girl was in trouble. But some of the doctors charged with her care wouldn’t listen. So you had a child die of dehydration, a third world disease, at one of the best hospitals in the world. Many people here were quite anguished about it. And the soul-searching that followed made it possible for me to do new safety research and push for changes.

What exactly was wrong here? As at many hospitals, we had dysfunctional teamwork because of an exceedingly hierarchal culture. When confrontations occurred, the problem was rarely framed in terms of what was best for the patient. It was: “I’m right. I’m more senior than you. Don’t tell me what to do.” With the thing that Josie King died from — an infection after a catheter insertion, our rates were sky high: about 11 per 1,000, which, at the time, put us in the worst 10 percent in the country. Catheters are inserted into the veins near the heart before major surgery, in the I.C.U., for chemotherapy and for dialysis. The C.D.C. estimates that 31,000 people a year die from bloodstream infections contracted at hospitals this way. So I thought, “This can be stopped. Hospital infections aren’t like a disease there’s no cure for.” I thought, “Let’s try a checklist that standardizes what clinicians do before catheterization.” It seemed to me that if you looked for the most important safety measures and found some way to make them routine, it could change the picture. The checklist we developed was simple: wash your hands, clean your skin with chlorhexidine, try to avoid placing catheters in the groin, if you can, cover the patient and yourself while inserting the catheter, keep a sterile field, and ask yourself every day if the benefits of catheterization exceed the risks. Wash your hands? Don’t doctors automatically do that? National estimates are that we wash our hands 30 to 40 percent of the time. Hospitals working on improving their safety records are up to 70 percent. Still, that means that 30 percent of the time, people are not doing it.

At Hopkins, we tested the checklist idea in the surgical intensive care unit. It helped, though you still needed to do more to lower the infection rate. You needed to make sure that supplies — disinfectant, drapery, catheters — were near and handy. We observed that these items were stored in eight different places within the hospital, and that was why, in emergencies, people often skipped steps. So we gathered all the necessary materials and placed them together on an accessible cart. We assigned someone to be in charge of the cart and to always make sure it was stocked. We also instituted independent safeguards to make certain that the checklist was followed. We said: “Doctors, we know you’re busy and sometimes forget to wash your hands. So nurses, you are to make sure the doctors do it. And if they don’t, you are empowered to stop takeoff on a procedure.” How did that fly? You would have thought I started World War III! The nurses said it wasn’t their job to monitor doctors; the doctors said no nurse was going to stop takeoff. I said: “Doctors, we know we’re not perfect, and we can forget important safety measures. And nurses, how could you permit a doctor to start if they haven’t washed their hands?” I told the nurses they could page me day or night, and I’d support them. Well, in four years’ time, we’ve gotten infection rates down to almost zero in the I.C.U. We then took this to 100 intensive care units at 70 hospitals in Michigan. We measured their infection rates, implemented the checklist, worked to get a more cooperative culture so that nurses could speak up. And again, we got it down to a near zero. We’ve been encouraging hospitals around the country to set up similar checklist systems.

Aligning practice with policy to improve patient care 21

In your book, you maintain that hospitals can reduce their error rates by empowering their nurses. Why? Because in every hospital in America, patients die because of hierarchy. The way doctors are trained, the experiential domain is seen as threatening and unimportant. Yet, a nurse or a family member may be with a patient for 12 hours in a day, while a doctor might only pop in for five minutes. When I began working on this, I looked at the liability claims of events that could have killed a patient or that did, at several hospitals — including Hopkins. I asked, “In how many of these sentinel events did someone know something was wrong and didn’t speak up, or spoke up and wasn’t heard?” Even I, a doctor, I’ve experienced this. Once, during a surgery, I was administering anesthesia and I could see the patient was developing the classic signs of a life threatening allergic reaction. I said to the surgeon, “I think this is a latex allergy, please go change your gloves.” “It’s not!” he insisted, refusing. So I said, “Help me understand how you’re seeing this. If I’m wrong, all I am is wrong. But if you’re wrong, you’ll kill the patient.” All communication broke down. I couldn’t let the patient die because the surgeon and I weren’t connecting.

22 The OR Connection

So I asked the scrub nurse to phone the dean of the medical school, who I knew would back me up. As she was about to call, the surgeon cursed me and finally pulled off the latex gloves. What can consumers do to protect themselves against hospital errors? I’d say that a patient should ask, “What is the hospital’s infection rate?” And if that number is high or the hospital says they don’t know it, you should run. In any case, you should also ask if they use a checklist system. Once you’re an in-patient, ask: “Do I really need this catheter? Am I getting enough benefit to exceed the risk?” With anyone who touches you, ask, “Did you wash your hands?” It sounds silly. But you have to be your own advocate.

From The New York Times, © March 8, 2010 The New York Times. All rights reserved. Used by permission and protected by the Copyright Laws of the United States. The printing, copying, redistribution, or retransmission of the Material without express written permission is prohibited.


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Patient Safety

Checking it Twice Yes! Checklists

do save lives

It’s been more than a decade since the Institute of Medicine (IOM) issued its groundbreaking report, To Err is Human, outlining the poor state of patient safety in the United States. And yet, progress toward reducing healthcare errors over the past ten years has been “frustratingly slow,” say the authors of the report.1 Patients continue to die at a rate of 99,000 per year due to hospital-acquired infections alone, according to the latest estimate from the Centers for Disease Control and Prevention.1

Needless to say, healthcare professionals have a long way to go toward improving patient safety. There are, however, glimmers of hope, one of which comes in the form of a checklist.

Dr. Pronovost introduced the checklist at Johns Hopkins Hospital, asking staff to run through it each time they inserted a line. The central line infection rate soon decreased from 11 percent to zero.4

A checklist for the ICU

Next, Dr. Pronovost implemented the ICU checklist and other related safety interventions at 103 hospitals across Michigan, resulting in a 66 percent reduction in CRBSIs.6 In the first 15 months of the study, known as the Keystone Initiative, the checklist is estimated to have saved 1,500 lives and $175 million in costs.4

Buried on page 171 of the thick To Err is Human report is one sentence recommending that healthcare organizations use checklists as a way to prevent errors by avoiding reliance on memory.2 But it was not until 2006, with the published results of a study headed by now renowned patient safety advocate Peter Pronovost, MD, PhD, that the healthcare checklist came to the forefront as a proven way to prevent errors and save lives.3 Dr. Pronovost, a practicing anesthesiologist and critical care physician at Johns Hopkins in Baltimore, crafted his first checklist by listing on paper the steps necessary to avoid catheter-related bloodstream infections (CRBSIs).4 The steps were nothing new; just things that clinicians may not remember to do every time they place a new central line. He and fellow researchers then refined the list, making sure the steps corresponded with items from the CDC guidelines for preventing CR-BSIs.5

The ICU checklist is simple; as experts recommend healthcare checklists should be. It requires clinicians to employ the following evidence-based practices when placing central venous catheters: hand washing, using full-barrier precautions during the insertion of the catheter, cleaning the patient’s skin with chlorhexidine, avoiding the femoral site, if possible, and removing unnecessary catheters.6 To download a sample copy of Dr. Pronovost’s ICU checklist, go to Continued on page 27

24 The OR Connection

Aligning practice with policy to improve patient care 25

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Despite SCIP Measure #9 recommending removal of urinary catheters in surgical patients by postoperative day one or two,1 and CDC guidelines advising prompt removal of catheters,2 74 percent of hospitals do not keep track of how long patients have catheters in place.3 Medline’s Foley InserTag is a sticker to be placed on each catheter bag as part of the insertion procedure. It has space to write when the catheter was placed in order to minimize duration and encourage timely removal. The InserTag is included with each Medline ERASE CAUTI tray. Medline’s Foley InserTag. The one little sticker that can make all the difference.

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

Checklists for safer surgery Not long after the Keystone Initiative study came out, the World Health Organization (WHO) Surgical Safety Checklist gained recognition in 2009 with a study published in the New England Journal of Medicine describing how use of the checklist helped reduce patient morbidity and complications.7 The WHO Surgical Safety Checklist was used at hospitals around the world, resulting in a reduction in complication rates from 11 percent to 7 percent. Death rates dropped from 1.5 percent to 0.8 percent.7 For a copy of the WHO Surgical Safety Checklist and tips on how to use it, visit

Four Es

for implementing a healthcare checklist5 Patient safety advocate Peter Pronovost, MD PhD, offers the following four steps to remember when implementing a safety checklist at your own facility:

1. Engage staff and physicians with stories and baseline performance.

2. Educate staff and physicians explicitly on what needs to be done to carry out the checklist; walk through the checklist a few times to identify any glitches

Another study, just published in October 2010 in the Journal of the American Medical Association (JAMA), showed an 18 percent reduction in surgery deaths over three years at 74 Veterans Affairs hospitals that used a surgery checklist.8,9

3. Execute the checklist, making sure everyone is

The Surgical Care and Outcomes Assessment Program (SCOAP), has developed a surgical safety checklist as well, which is being used by most hospitals and some freestanding surgery centers in the state of Washington. SCOAP links hospitals and surgeons with clinicians from across Washington to increase the use of best practices in surgical care. The organization’s goal is to provide the kind of surveillance of procedures and response to negative outcomes that exists in the world of aviation.10

He also recommends determining in advance the products and equipment needed to carry out the items on the checklist, making sure all supplies are close at hand when clinicians go to implement the checklist.

To access a copy of the SCOAP Surgical Checklist, including a version specifically for ambulatory surgery centers, go to Copies of the SCOAP Surgical Checklists are also included in the Forms & Tools section of this issue.

committed to following it.

4. Evaluate how it’s working by analyzing collected data.

For more tips, read Safe Patients, Smart Hospitals: How One Doctor’s Checklist Can Help Us Change Health Care from the Inside Out by Peter Pronovost and Eric Vohr.

Checklist success requires teamwork Both Dr. Pronovost and Atul Gawande, MD, who co-authored the paper on the WHO Surgical Safety Checklist, agree that in order to work, checklists must be studied carefully in advance, and then implemented wisely.11 And, although checklists are helpful, they are only one part of the equation for improving patient safety. Before a checklist can be useful, healthcare teams must improve communication and change the way they work together.12

Dr. Pronovost wrote, “Until a junior nurse can correct a senior physician who forgot to use the checklist, until that conversation goes well, we will continue to harm patients. In most U.S. hospitals, that conversation does not go well.”12 In fact, in the OR, the lowest perceptions of teamwork are reported by nurses with surgeons.13 Have a serious discussion with physicians and nurses, Dr. Pronovost recommends. Instruct nurses to speak up

Aligning practice with policy to improve patient care 27

Seven Steps + 1 if a doctor misses a step on the checklist. Explain to the doctor that it is not about hierarchy or second guessing. It’s about the obligation to make sure every patient all the time receives evidence-based interventions.5 Dr. Pronovost also remarked that if any link in the chain of accountability is not intact, the checklist will not be effective. He said it is the hospital’s senior leadership that is ultimately responsible for getting and keeping staff on board.14 According to Dr. Pronovost, “To reach our ultimate goal – making patients safer – we must engage teams to embrace the concepts behind checklists and become full partners in developing and improving this lifesaving tool. And, we must measure our results to make sure that every patient always gets the care they deserve.”12

References 1. O’Reilly KB. Patient safety improving slightly, 10 years after IOM report on errors. American Medical Association. December 28, 2009. Available at Accessed November 1, 2010. 2. Linda T. Kohn, Janet M. Corrigan, and Molla S. Donaldson, Eds. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000. Available at: Accessed October 29, 2010. 3. Wachter RM. Patient safety at ten: unmistakable progress, troubling gaps. Health Affairs. 2010;29(1). Available at: Accessed November 1, 2010. 4. Laurance J. Peter Pronovost: champion of checklists in critical care. The Lancet. 2009;374(9688). 5. Pronovost P. On Call: How a Simple Checklist Can Dramatically Reduce Medical Errors [audio]. Institute for Healthcare Improvement (IHI) website. Recorded November 3, 2008. Available at: Accessed November 2, 2010. 6. Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. The New England Journal of Medicine. 2006;355(26):2725-2732. Available at: Accessed November 1, 2010. 7. Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AS, Delliner EP, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. The New England Journal of Medicine. 2009;360(5):491-499. 8. Tanner L. Big U.S. study shows surgery checklist saves lives. ABC-2 News Baltimore website. Posted October 21, 2010. Available at: Accessed November 3, 2010. 9. Neily J, Mills PD, Young-Xu Y, Carney BT, West P, Berger DH, et al. Association between implementation of a medical team training program and surgical mortality. Journal of the American Medical Association. 2010;304(15). 10. SCOAP Surgical Checklist Initiative. Surgical Care and Outcomes Assessment Program website. Available at Accessed October 22, 2010. 11. Szalavitz M. Study: a simple surgery checklist saves lives. Time. January 14, 2009. Available at:,8599,1871759,00.html. Accessed October 22, 2010. 12. Pronovost P. Checklists alone won’t change health care: the full story. Huffington Post. February 23, 2010. Available at: Accessed November 1, 2010.

28 The OR Connection

to Patient Safety for Hospital Executives

1. Assess your organization’s safety culture. A widely used survey developed by the Agency for Health care Research and Quality (AHRQ) is available at 2. Understand the science of improvement and reliability. Strive to be a high reliability organization. 3. Foster transparency. 4. Create a formal, written leadership promise that outlines the steps you personally will take to attain and maintain patient safety at your facility. 5. Engage physicians in your organization’s safety efforts. 6. Develop hiring and credentialing processes grounded in selecting candidates with a desire to serve, good communication skills, an eagerness to work in teams, a commitment to excellence and an appreciation for feedback. 7. Involve board members in the safety journey. + 1 Another helpful tool for fostering a safety culture at your organization is the Comprehensive Unit-Based Safety Program (CUSP) developed at Johns Hopkins Hospital by Dr. Pronovost and his team. For details, visit Adapted from Rupp W, Bonacum D, Frush K, Balik B, Haraden C. The role of leadership. In: Frankel A, Leonard M, Simmonds T, Haraden C, Vega KB, eds. The Essential Guide for Patient Safety Officers. Oakbrook Terrace, IL: Joint Commission Resources; 2009:1-10.

13. Carney BT, West P, Neily J, Mills PD, Bagian JP. Differences in nurse and surgeon perceptions of teamwork: implications for use of a briefing checklist in the OR. AORN Journal. 2010;91(6):722-729. 14. Aizenman NC. Hospital infection deaths caused by ignorance and neglect, survey finds. The Washington Post. July 13, 2010. Available at: Accessed October 21, 2010.


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Special Feature

Patient, Heal Thyself After shorter hospital stays, doctors raise demands and time for recovery

By Laura Landro 30 The OR Connection

For Michael Noonan, knee surgery in April was practically a breeze — an outpatient procedure that had the 41-year-old investment banker hobbling home on crutches in a matter of hours after surgeon David Altchek replaced his anterior cruciate ligament using small incisions. But recovery was another matter. He needed the crutches for three weeks, had 12 weeks of physical therapy three times a week, then six weeks of exercises at home. He rented a strap-on ice compression device to reduce swelling, and wore a brace for about five weeks. Though fully healed now, being responsible for so much of his own rehabilitation, he says, “was like taking a new baby home for the first time—you don’t really feel like you’re licensed to do it.” Surgery is easier and faster than ever before: Nearly 65% of all surgeries don’t require an overnight hospital stay, compared to 16% in 1980. Hospitals that once kept patients for three weeks after some major operations now discharge them within a matter of days. But the body still heals at its own pace, and reduced time in hospital care means patients are assuming more responsibility for their own recovery—and more risks. Patients not only have to perform rehabilitation regimens at home, but they are more often caring for their own incision wounds and dressings and having to watch for signs of infections and blood clots. They also may be managing drains, implanted IV ports and pumps, all of which can be difficult and stressful.

The mean charge for outpatient surgery was $6,100 versus $39,000 for inpatient surgery in 2007, according to the most recent report on surgical costs from the federal government. Insurance companies are also less likely to pay for stays at rehabilitation centers, places where surgical patients were often sent after hospital discharge to recuperate. With patients going home so quickly, more are having to grapple with complications on their own. Of all the complications that occur in the 30 days after surgery, such as infection and blood clots, almost half will surface after a patient leaves the hospital, according to data from one million patients in a surgical quality improvement program sponsored by the American College of Surgeons. “The onus is really on patients to recognize if something is a problem,” says Clifford Ko, a colorectal surgeon at the University of California, Los Angeles, and director of research and optimal patient care for the American College of Surgeons. “The recovery period is often as important as the procedure itself, and patients who don’t follow their discharge instructions could have longer recovery times, greater risk of a complication, and potentially more pain.”

The move to speedier surgeries is largely the result of new minimally invasive techniques, improvements in anesthesia and cost-cutting by insurance companies and hospitals. Surgical procedures now often use smaller incisions, cut less muscle, and result in less blood loss. Newer anesthetics allow patients to regain consciousness quickly or not go to sleep at all. Pain medications are more effective. At the same time, concern about rising health care costs has led to changes in Medicare and insurance plans that have encouraged the development of outpatient surgical centers and created financial incentives for hospitals to shift less complex surgery to their own outpatient facilities. So, many types of surgeries previously performed in hospitals with overnight stays are now being done on an outpatient basis: The number of freestanding surgery centers grew from about 240 in 1983 to more than 5,000 now.

The Long Road to Recovery While most surgeries now require much shorter hospital stays than in years past, patients often face weeks or months of recovery on their own. The picture for some common procedures: Knee surgery patients, for example, are counseled to maintain their weight after surgery. But a recent study shows that most patients gain weight, which can jeopardize the health of the other knee. Depression,

Continued on page 33

Aligning practice with policy to improve patient care 31


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84,000 patients who developed a surgical site infection found that more than half occurred after discharge another common after-surgery occurrence, also can inhibit healing, if patients don’t seek treatment. Efforts are underway to improve follow-up for patients, particularly those who have surgery in doctor’s offices, which don’t have the same regulation as outpatient surgery centers. The Institute for Safety in Office-Based Surgery has developed a checklist that includes assuring that discharge instructions are provided and a plan for follow-up care is clear. “Patients need to be asked things like if there is redness at the incision site, do you know what to do?” says Fred Shapiro, a Harvard anesthesiologist and president of the group. (Redness at an incision site can be a sign of infection.) Infections that can occur after any surgery can lead to a severe bloodstream infection that can be fatal. A study published in July in the Journal of Hospital Infection of 84,000 patients who developed a surgical site infection found that more than half occurred after discharge, increasing the risks of an emergency room visit, readmission to the hospital, and another surgery. For months after a procedure, surgical patients are also at high risk of developing blood clots which can travel to the lung and cause death from a pulmonary embolism. After joint replacement, for example, though the risk is greatest within two to five days, a second peak development period occurs about 10 days after surgery when most patients have been discharged from the hospital. In knee surgery patients, a clot can form in the calf if the patient fails to

elevate the leg and perform specific movement exercises. Blood clots and subsequent pulmonary embolisms remain the most common cause for emergency readmission and death following joint replacement, according to the American Academy of Orthopaedic Surgeons. The American Academy of Orthopaedic Surgeons sponsors workshops to teach its members better communications skills to help patients understand procedures and to stress the importance of follow-up care, such as providing clear written instructions and monitoring patients after surgery. “We can have a perfect total knee replacement but then have a poor outcome if we don’t convince surgeons that explaining the post-operative care is in everyone’s best interest,” says John Tongue, a Portland, Ore.-area orthopedic surgeon and clinical associate professor at Oregon Health & Science University who teaches the workshops. Insurers have become stricter about paying for inpatient rehabilitation programs where surgical patients were once transferred to recover. The move has been spurred partly by studies that show that cheaper at-home visits from therapists are effective. But Nina Reznick, a 63-year old patient who had both hips replaced last July, says the home therapist her insurance paid for did not have the equipment or time to really help, so she did extra exercises on her own. She believes that effort enabled her to walk a week after surgery. “You are really on your own, and you have to be very motivated,” she says.

Aligning practice with policy to improve patient care 33

Blood clots and subsequent pulmonary embolisms remain the most common cause for emergency readmission and death following joint replacement.

Some doctors say that the changing demographics of their patients also can contribute to bumpy recoveries. Dr. Altchek, who performs knee and rotator cuff surgery at the Hospital for Special Surgery in New York, says that more younger patients are opting to replace troublesome knees and hips so they can resume athletic activities such as tennis and skiing; close to 42% of all knee replacements in 2008 were for patients aged 45 to 65, compared to less than 35% in 2002, and studies show that waiting too long once a joint starts to deteriorate before having surgery can make recovery more difficult.

Andrew Minko, a 41-year-old patient of Dr. Altchek’s who plays tennis and surfs, has had two surgeries to repair joints on his left shoulder and now needs surgery on his right shoulder. Though he healed well, he admits he was somewhat lax about doing his exercises at home and may have rushed into some activities too quickly after the previous procedures. For the upcoming surgery, he says, “I will be more diligent about the recovery.” Write to Laura Landro at

But younger patients may also be impatient and assume they are healed, and then quit rehabilitation too early, Dr. Altchek says.

Reprinted by permission of The Wall Street Journal, Copyright © 2010 Dow Jones & Company, Inc. All Rights Reserved Worldwide. License number 2537291131129

To download a new guide to help patients take care of themselves at home, visit “Taking Care of Myself: A Guide for When I Leave the Hospital” is published by the Agency for Healthcare Research and Quality (AHRQ).

34 The OR Connection

DASH® in use gently retracting the small intestine while absorbing fluid

THE NEW SHAPE OF SURGERY The DASHTM absorbent retractor bends into just the shape you need The DASH retractor is 12 times more absorbent than a standard lap sponge. Its smooth stainless steel core gives the DASH device strength and malleability. Shape it into almost any form to gently retract tissues from the surgical field—without the pinch-point trauma traditional retractors can cause. Once you see the DASH in action you’ll never want to go back to old, bulky metal retractors.

To find out how to get your free DASH Retractor sample, go to

©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

Preventing by Mary Ann Alexander-Magalee, MSN, RN, CNOR-BC

Nearly 30% of the estimated 385,000 needle sticks and other sharps-related injuries that occur each year happen in the OR.1 The CDC’s recommended work practices that can help ensure safety can be simplified into three points: Be prepared, be aware, and dispose with care.1 This article describes what you can do to protect yourself from sharps injury. Studies indicate that 6% to 16% of all percutaneous injuries for scrubbed personnel are self-inflicted during hand-to-hand passing of suture needles, with the nondominant hand being the most injured body part.2 This often occurs during the loading or repositioning of suture needles, loading or removing scalpel blades, suturing, tying sutures with the needle attached, and immediately before or after the sharp has been used and remains unattended on the operative field.2 For nonscrubbed personnel, the greatest risk of injury is during hand-off of used sharps or disposal of sharps. Healthcare organizations and their employees are responsible for actively participating in strategies to reduce percutaneous injuries. Wear personal protective equipment when indicated. Use needless systems or sharps with

36 The OR Connection

injury protection devices, and use a one-handed recapping technique, if no other alternatives exist. The Occupational Safety and Health Administration requires healthcare organizations to protect their workers and have a written exposure control plan.3 Facilities must also observe local, state, and federal regulations on injury prevention. Common strategies for sharps injury prevention during a procedure include: • Double gloving and monitoring gloves for punctures.2 • Encouraging neutral or hands-free technique for passing sharp items.2 • Giving verbal notification when passing a sharp item. • Loading suture needles using the suture packet to help mount the needle in the needle holder. • Using the appropriate instrument to help adjust or unload the needle. • Removing the needle before tying the suture, or using control-release sutures. • Activating the safety feature of a safety-engineered device immediately after use.2 • Using another available instrument or a magnet to pick up a sharp item that’s fallen on the floor. Discard the sharp immediately.

OR Issues

sharps injury in the OR


Points of Sharps Safety

Be prepared.

Be aware.

Dispose with care.

Aligning practice with policy to improve patient care 37 About the author After the procedure, follow these strategies: Mary Ann Alexander-Magalee, MSN, RN, CNOR-BC, is a • Transport sharps in a closed, secure container professor of nursing at Valencia Community College in Orlando, and place them in an approved, puncture-resistant Fla., and a board-certified nurse informatist. container large enough to accommodate the entire device. References • Don’t put your hands or fingers into the container 1. CDC Workbook for Designing, Implementing, and Evaluating a Sharps Injury Prevention Program. 2008. to dispose of a device.1 2. AORN. Guidance statement: Sharps injury prevention in the perioperative • Keep your hands behind the sharp tip when setting. Perioperative Standards and Recommended Practices. Denver, CO: AORN; 2010:697-702. disposing of the device. In addition to common strategies, using safety scalpels is recommended, as scalpels are the second most frequent mechanism of percutaneous injuries (suture needles are first).2

3. OSHA. Regulations (Standards-29 CFR) Bloodborne pathogens 1910.1030. http://wwwloshalgov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=10051. 4. Taylor DL. Bloodborne pathogen exposure in the OR—what research has taught us and where we need to go. AORN J. 2006;83(4):834-848. Printed with permission. Mary Alexander-Magalee, Preventing sharps injury in the OR, OR Nurse 2010, September 2010, p. 56.

If you experience a needle-stick injury, follow your facility’s policy for postexposure management and report the injury immediately. Maintaining a sharps-injury log is another intervention that identifies the number of employees injured as well as the products and circumstances of the injury.4

Aligning practice with policy to improve patient care 37

Just what I was looking for.

Introducing CE Courses for Surgical Techs! For the first time ever, Medline University introduces surgical technologist courses at Visit today to earn free CE credits with the following courses: • #2 on the Joint Commission List - Retained Foreign Objects • 9 on the Line to Improve Patient Safety • Applying Evidence-Based Information to Improve Hand-off Communication in Perioperative Services • Breaking Through Hand Hygiene & Skin Care Barriers • Legal Implications of Pressure Ulcers • Safe Medication Practices in the Perioperative Practice Setting • Tell Me Again Why This Patient Needs a Catheter? • Why is Pressure Ulcer Assessment So Important? Access courses on your computer, iPhone or iPad. Join us on Twitter Be the first to know when we add new courses and content. ©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

* Courses are approved for continuing education credit by the Association of Surgical Technologists.

Patient Safety

By Steve Harden


According to a recent report in the Archives of Surgery, patients undergoing surgery still risk being victims of stunning medical mistakes including procedures done on the wrong surgical site and undergoing surgery intended for another patient. To try to curb the rate of surgical errors, the Joint Commission in 2004 introduced a Universal Protocol for all hospitals, ambulatory care facilities, and office-based surgical facilities to follow. However, even though these steps have largely been adopted, errors continue to happen. The study’s author, Dr. Philip F. Stahel, a visiting associate professor at the University of Colorado School of Medicine in Denver, had this to say about the research: “What is shocking about the data is that each and every one of those wrong-site, wrong-patient errors is really an event that should never happen. These happen much more frequently than we think.” “This is just the tip of the iceberg,” he said, “introducing the Universal Protocol has not reduced the frequency of these events.” During the research done in Colorado, doctors reported 27,370 adverse events that happened between January 2002 and June 2008. Among these, the researchers identified 25 wrong-patient and 107 wrong-site operations. The report cites the reasons for these mistakes.

Aligning practice with policy to improve patient care 39

Not surprisingly, 100 percent had poor communication as a root cause. And 72 percent were due to not performing a “Time Out” as required by the Universal Protocol. At LifeWings, we’ve helped almost 100 organizations create and implement a successful Time Out process that really does eliminate patient harm. From that experience, here are three things you can do to fix these problems with your Universal Protocol. 1. Make sure your physicians lead the Time Out. In aviation, the captain of the aircraft always “calls” for the checklist at the appropriate time. The captain has the responsibility to start the checklist and to make sure that it is accomplished correctly and in its entirety. Once the checklist is started, he can delegate portions of the checklist to others, but the captain has the ultimate and final responsibility to lead the checklist process. 2. To cure communication failures during the Universal Protocol, give as many folks as possible a “speaking part” in your Time Out process. Knowing that they have a speaking part and will have to verbally respond to a checklist item creates mindfulness, focus on the process and participation. No one wants to be the person not prepared and gumming up the works. 3. Make sure your Time Out is a true “challenge and response” checklist, requiring a real cross check with two or more sets of eyeballs confirming critical items—and not just a “tick sheet” where one staff member independently puts a check in the box when they think an item has been completed. A “tick sheet” mentality is the number one reason we see for failing to complete the Time Out as required.

40 The OR Connection

As Dr. Stahel, the author of the report notes, “... Now we hide behind a safety system that should cover the problem. The Time Out is performed, but people are not mentally involved—the system alone cannot protect you from wrong-site surgery.” Dr. Stahel is absolutely spot on. The Universal Protocol is not going to protect your patients if your teams are not going to use the safety system correctly. About the author

Steve Harden is Chairman of the Board and CEO of LifeWings Partners LLC and co-founder of Crew Training International, Inc. (CTI). He has helped over 80 healthcare organizations in 28 states implement the best safety practices from aviation and other high reliability industries. He is the author of Never Go to the Hospital Alone, published by BPS Books, and co-author of CRM: The Flight Plan for Lasting Change in Patient Safety, the definitive how-to text on implementing aviation-based safety tools in health care, published by HCPro. LifeWings Partners is the industry leader in using aviation safety, leadership, team building and human factors tools to reduce patient-harming medical errors and improve safety and quality.


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A New Guidebook for Patient Safety in the OR by Connie Yuska, RN, MS, CORLN

42 The OR Connection

Patient Safety

More than 50 million surgical procedures are performed in the United States each year.1 And while the number of procedures is rising, so are the risks. The risk of death from a surgical procedure is 10-100 times greater than the risk of having a baby.1 Surgical

Over the last decade, many organizations have focused on principles of surgical safety, such as ensuring accurate sponge counts, adhering to hand hygiene standards and labeling medications on the surgical field. These practices, however, have been applied inconsistently across the country.1

errors are second only to medication errors as the most frequent cause of error-related death.1

Building a culture of safety continues to be a priority for hospital administrators since the publication of the Institute of Medicineâ&#x20AC;&#x2122;s groundbreaking report, To Err is Human in 1999. Awareness of patient safety has been heightened, but the progress has been slow. Improvements in safety have grown by only one percent annually between 2000 and 2009.1 Over the past decade, standards that specifically address safety have been added to the work done by regulatory and accrediting bodies. For example, The Joint Commission added National Patient Safety Goals with the purpose of promoting specific improvements in patient safety. There are many rules and regulations that address safety and guide healthcare practitioners, but unless a culture of safety is strong and supported by senior leaders in the organization, significant progress will continue to be slow, and patients will continue to be harmed. The Safe Surgery Guide, released in November 2010 by The Joint Commission, is specifically designed to provide

organizations with direction on how to improve safety in the surgical suite. The book focuses not only on improving safety in procedural and operative areas, but also addresses the patientâ&#x20AC;&#x2122;s surgical experience across the continuum of care. The book begins with a foreword by patient safety expert Peter Pronovost, MD, PhD, in which he emphasizes the need to remove barriers to complying with patient safety practices and measure performance. He also recognizes that overcoming the hurdles to patient safety requires culture change. And so, Chapter 1 discusses effective communication techniques, emphasizing the importance of senior leadership support in establishing those techniques. Chapter 2 focuses on hand hygiene, a practice that often remains difficult for organizations to consistently practice and enforce. The chapter offers suggestions for improving hand hygiene compliance in the surgical suite and throughout the organization. Chapter 3 outlines all of the preparation that occurs before the patient enters the surgical suite. These activities include managing the operating room schedule, cleaning the room, preparation of the sterile field, ensuring the proper instruments are available, ensuring proper air quality and ventilation and controlling traffic in the room and surrounding areas. Chapter 4 contains information for a review of everything that must be ready for the procedure when the patient arrives in the surgical suite. Information focuses on assessing the patient for risk, documentation of medications the patient is currently taking and preparation of the surgical site.

Aligning practice with policy to improve patient care 43

Key points to ensure the readiness of the surgical team are outlined in Chapter 5. The discussion not only includes obvious preparation, such as appropriate surgical attire, but also addresses the attitudes and behaviors of the personnel involved, a key component to ensuring safety in a high stress environment such as an OR suite.

Now available from Joint Commission Resources!

Chapter 6 discusses the Joint Commission’s ongoing efforts to reduce the incidence of surgical errors through its Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery. The chapter also describes the World Health Organization’s Surgical Safety Checklist. Monitoring the patient through all aspects of the surgical procedure is critical to ensuring safety. Chapter 7 describes the activities of monitoring anesthesia and sedation levels, medications, body temperature, blood glucose levels and blood administration. Chapter 8 discusses some of the problems that can occur during the surgical procedure and offers suggestions for handling those issues. Some of the problems discussed include objects that are inadvertently left in the patient’s body, fire breaking out and distractions during the procedure that may divert the staff’s attention away from the patient. Chapter 9 reviews all of the activities that occur after the procedure, including disposal of medical waste, transportation of contaminated materials such as sheets and instruments, and clean-up of the operating suite. Chapter 10 outlines the care the patient receives following the procedure, including assessment of the patient’s physiological and mental status, medications ordered postoperatively and care of the surgical site, including measures to prevent postoperative infection. Finally, Chapter 11 is a review of the activities that promote the patient’s discharge and appropriate care after the patient leaves the organization. Attaining a successful, safe surgical outcome is the result of a TEAM of healthcare professionals who are committed

44 The OR Connection

Safe Surgery Guide Price: $75 (PDF version); $85 (hard copy) ISBN: 978-1-59940-638-1 198 pages

To order Call 877-223-6866 (M-F, 8 am to 8 pm Eastern time), or visit e-books/EBSSW10/2177

to the same goal of providing safe surgical care. The team must be fiercely dedicated to supporting each other in their individual roles and keenly aware of all steps needed to ensure the procedure goes safely from beginning to end. There are many resources available to assist with establishing a culture of safety in your hospital. Reading the Safe Surgery Guide is an excellent place to start. Reference 1. Schuldt LM, ed. Safe Surgery Guide, Oakbrook Terrace, IL: Joint Commission Resources; 2010. Available at: http:// Accessed November 12, 2010.

About the author

Connie Yuska, RN, MS, CORLN, began her nursing career in the specialty of otolaryngology. Her clinical experience includes both inpatient and outpatient care of head and neck oncology patients, and she is certified in otolaryngology and head and 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 vice president of operations for a large 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.


MEDLINE GOLD STANDARD SAFETY COMPONENTS Medline’s Gold Standard safety products stand out against the sea of blue in the OR to alert the surgical team to focus on safety. Promote Correct-Site Surgery Our Surgical Time Out Procedure (S.T.O.P.™) safety products alert the surgical team to perform a time-out verification and help reduce the risk of wrong-site surgery. Support Sharps Safety Practices Transfer trays, scalpel holders and needle counters with blade guards promote sharps safety and help make you OSHA compliant.1 Improve Fluid Disposal Safety The Safety-Splash™ fluid management system converts biohazardous fluids into a solid, minimizing the risk of exposure. References: 1. Occupational Safety and Health Standards, Toxic and Hazardous Substances, Bloodborne pathogens. Regulations (Standards - 29 CFR). Available at: http:// id=10051#1910.1030(d)(2)(i). Accessed October 13, 2010. ©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc. Safety-Splash and S.T.O.P are trademarks of Medline Industries, Inc.

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46 The OR Connection

Patient Safety

by Cynthia A. Fleck, RN, BSN, MBA, ET/WOCN, CWS, DWC, CFCN

Remember the old riddle, “Where do most pressure ulcers occur?” The answer is — in the ambulance! Well, the truth is pressure ulcers do occur in the ambulance — and lots of other places you might not even think about, including the operating room (OR). In fact, the pressure ulcer incidence rate as a result of surgery may be as high as 66 percent1 and 42 percent of all hospital-acquired pressure ulcers are occurring in surgical patients.2

Here are some more daunting facts: • 37 percent of patients undergoing head or neck surgery develop sacral ulcers3 • Cardiac, general vascular and open heart surgeries have a high incidence of occiput and heel ulcers • 72 percent of perioperative pressure ulcers occur on heels4

The following types of surgical patients are at greater risk for pressure ulcers: • • • • • •

Neonates Elderly Malnourished Morbidly obese Patients with chronic diseases Patients with existing pressure ulcers

Aligning practice with policy to improve patient care 47

Perioperative risk factors for pressure ulcer development Certain conditions specific to the surgical experience can also contribute to the risk of pressure ulcers. Some of these conditions include blood volume loss, temperature, time and moisture. Blood volume loss. Blood volume loss and shunting can increase the hazard of pressure ulcers and lack of blood flow to the lower extremities.5,6 Temperature. Another consideration is the cold OR environment. The body will likely shunt blood away from the skin into the trunk of the body to protect the vital organs, which can be dangerous to the skin. The use of warming blankets tends to occur in lengthy procedures. These can be helpful to prevent cooling of the body, which can contribute to pressure ulcers, however, the blanket should be covered with a sheet. In addition, the thermostat on the unit should be set at a maximum temperature of 42 degrees Celsius. Time. Increased time in the OR is associated with increased pressure ulcer development as well.7 Surgeries lasting between three and four hours had pressure ulcer incidence rates of 5.8 percent; seven or more hours had incident rates of 13.3 percent,8 and there is a significant increase in pressure ulcer incidence for operations lasting longer than eight hours.9 Moisture. We all know moisture can wreak havoc on the skin and predispose individuals to pressure ulcers, so it is recommended that pooling of any fluid or blood be monitored intraoperatively. It is suggested that the OR surface have minimal linens or layering. There are also novel OR products available (modern-day “chux” that are super absorbent) that can actually absorb large volumes of fluid and remain dry to the touch, thus protecting the patient’s skin.

48 The OR Connection

Perioperative tips for avoiding pressure ulcers • Assure that the OR table or surface is of sufficient size to support the patient – especially important for obese patients whose bodies may be larger than the average size OR surface • Lift – do not drag – the patient from surface to surface. • Monitor pressure points when possible during “time outs”

Post-operative considerations for avoiding pressure ulcers • Be aware of a possible delay in visualization due to bandages and other monitoring equipment • Prolonged immobility or confinement to a bed or chair increases pressure ulcer risk10

Evaluating surgical surfaces Always remember that no matter where a patient’s body resides, pressure ulcers can develop rapidly. OR surfaces should be evaluated before each case, and the Association of Perioperative Registered Nurses (AORN) guidelines recommend using pressure redistribution surfaces for surgeries lasting longer than two-and-a-half hours. In fact, I recently had foot surgery, and my surgeon originally thought it would last only a couple of hours. Lo and behold, it lasted three hours and 45 minutes, and although I am a fairly young, well-nourished and healthy individual, I succumbed to a Stage II perioperative pressure ulcer. The lesson to be learned: because there is no guarantee how Continued on page 50

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Relieve Pressure on Vulnerable Heels HEELMEDIXâ&#x201E;˘ Heel Protector Pressure relief and skin protection all in one The heels are the most common site for facility-acquired pressure ulcers in long-term care, and the second most common site overall.1 According to clinical experts, the most effective aspect of pressure ulcer prevention for heels is pressure relief, also known as offloading.1,2 Offloading is achieved with the use of pillows or heel protection devices that relieve pressure by elevating the heel. The HEELMEDIX Heel Protector is designed to help eliminate pressure, friction and shear on the skin by elevating the heel. Made of soft, suede-like material on the inside and easy-to-clean nylon on the outside. Adjustable straps are soft against vulnerable skin. Includes a mesh laundry bag with patient ID label to simplify washing and sorting.

1 Fowler E, Scott-Williams S, McGuire JB. Practice recommendations for preventing heel pressure ulcers. Ostomy Wound Management. 2008;54(10):42:48. 2 Langemo D, Thompson P, Hunter S, Hanson D, Anderson J. Heel pressure ulcers: stand guard. Advances in Skin & Wound Care. 2008;21(6):282-292.

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AORN guidelines recommend using pressure redistribution surfaces for surgeries lasting longer than 2 1/2 hours.

Figure 1

long a surgery will take, a pressure redistribution surface should be available in every operating room. There are high-quality surfaces that self-adjust (Figure 1), provide a stable environment for the surgeon and OR staff to work and conform to the patient’s body. Some of these surfaces contain the same type of visco or viscoelastic memory foam many of us sleep on in our own bedrooms. When evaluating various surfaces, ask the vendor about the warranty, weight limits, cleaning instructions and comparative data such as pressure mapping. This will help you make an educated decision regarding your purchase.

Important steps to take after surgery At the hand-off to the post-anesthesia care unit (PACU) it is advisable to: • Clean and dry the patient’s skin • Conduct a post-op skin assessment, noting: - Skin irritation - Discoloration - Bruising - Swelling • Provide a thorough report including: - Results of pre-surgery risk factors and potential new risks that developed during surgery - Results of threats and skin assessment performed before, during and after surgery - How long the surgery lasted (e.g., my own surgery was scheduled for two hours and lasted almost double that time)

50 The OR Connection

Pressure ulcer risk in ancillary services There is also high risk for pressure ulcers in ancillary services: • Radiology • Renal dialysis • Cardiac and vascular procedure laboratories such as cath labs The problem is that until awareness is increased, we will continue doing what we always did, and patients will continue to develop pressure ulcers. Patients undergoing lengthy radiology procedures have a 53.8 percent incidence of pressure ulcers. Emergency departments are another area of risk, with 40 percent of patients admitted through the emergency department at risk for pressure ulcer development.11 The average emergency department patient waits six to eight hours lying on a stretcher that usually consists of two to three inches of open-celled foam and an uncomfortable non-conformable cover that can contribute to the development of pressure ulcers. This is especially important now that acute care facilities are financially responsible for acquired pressure ulcers – which can be quite costly. Many hospitals have instituted a comprehensive program to prevent pressure ulcers across the continuum, including the OR, ED and ancillary areas. Introducing a tool kit on average can reduce a facility’s Continued on page 52

Benefits Of A Great Work Environment By Greg Smith

Businesses can improve retention and make their organization the good place to work by following the five-step PRIDE model:


– – – – –

Provide a positive working environment Recognize, reinforce, and reward individual efforts Involve and engage everyone Develop the potential of your workforce Evaluate and hold managers accountable


Medline Named One of Becker’s

100 Best Places to Work in Healthcare Becker’s recognizes company for “Excellence in Promoting Teamwork, Professional Development” Medline Industries, Inc. has been named one of the “100 Best Places to Work in Healthcare” for 2010 by Becker's ASC Review and Becker's Hospital Review, well respected industry publications. According to Becker’s, the list was developed “through nominations, recommendations and research, and the organizations were selected for their demonstrated excellence in creating a work environment promoting teamwork, professional development and quality patient care.”

1 Contact Hour


Join us for this webcast presentation as two industry experts bring you critical information on how the utilization of the nursing process and proper documentation are vital components in maintaining the standard of care and avoiding litigation. Presented by attorney Kevin W. Yankowsky, JD, a partner in the health law litigation group of Fulbright & Jaworski, LLP, Houston, Texas, and physician Caroline Fife, MD, the Chief Medical Officer of Intellicure, Inc. and an associate professor at the University Texas Medical School at Houston.

To view this webcast, visit

Courses approved for continuing education by the Florida Board of Nursing and the California Board of Reigistered Nursing.

pressure ulcers by 70 percent while substantially increasing the knowledge of licensed staff and nurse assistants.12

Take your knowledge and pass it on Consider sharing this article with the emergency department, ancillary areas such as the cath lab, dialysis and other high-risk area personnel, and of course with the ambulance companies where your patients could be at risk. If you are on a skin care committee, get the other members involved, as these care areas present jeopardy that can be easily mitigated. When we ask ourselves the age-old question of where all the pressure ulcers are occurring, now we have more ammunition to fight the battle. And yes, the ambulance, with its tiny vinyl-covered two-inch, foam mattress may be part of the problem. The good news is that we have answers and products that can make positive change happen.

About the author

Cynthia Ann Fleck, RN, BSN, MBA, CWS, DNC, CFCN is a certified wound specialist, dermatology advanced practice nurse, certified foot and nail care nurse, writer, speaker, a past president and chairman of the board for the American Academy of Wound Management (AAWM), past director for the Association for the Advancement of Wound Care (AAWC), and Vice President, Clinical Marketing for Medline Industries, Inc. Cynthia can be reached at

52 The OR Connection

References 1. Recommended practices for positioning the patient in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010. 2. Beckrich K, Aronovitch SA. Hospital-acquired pressure ulcers: a comparison of costs in medical vs. surgical patients. Nursing Economics. 1999; 17(5):263-271 3. Recommended practices for positioning the patient in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010. 4. Recommended practices for positioning the patient in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010. 5. Keller C. The obese patient as a surgical risk. Seminars in Perioperative Nursing. 1999; 8(3):109-117. 6. McEwen DR. Intraoperative positioning of surgical patients. AORN Journal. 1996; 63(6):1058-1063, 1066-1075, 1077-1082. 7. Papantonio C, Wallop J, Koldner K. Sacral ulcers following cardiac surgery: incidence and risks. Adv in Wound Care. 1994;7(2):24-36. 8. Aronovitch S. Intraoperatively acquired pressure ulcer prevalence: a national study. J Wound Ostomy Continence Nursing. 1999;26(3):130-136. 9. Ratliff C, Rodeheaver G. Prospective study of the incidence of OR-induced pressure ulcers in elderly patients undergoing lengthy surgical procedures. Adv Skin Wound Care. 1998;11(suppl 3):10. 10. Allman RM, Goode PS, Burst N, Bartolluci AA, Thomas DR. Pressure ulcer hospital complications and disease severity: impact on hospital costs and length of stay. Advances in Skin & Wound Care, 1999;12(1):22-30. 11. Tarpey A, Gould D, Fox C, Davies P, Cocking M. Evaluating support surfaces for patients in transit through the accident and emergency department. J Clin Nurs. 2000;9(2):189-198. 12. Armstrong DG, Ayello EA, Capitulo KL, Fowler E, Krasner DL, Levine JM, et al. New opportunities to improve pressure ulcer prevention and treatment: implications of the CMS inpatient hospital care present on admission (POA) indicators/hospital-acquired conditions policy. J Wound Ostomy Continence Nurs. 2008. 35(5):485-492.

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

References 1

Braden Scale for Predicting Pressure Sore Risk. Available at: 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.

©2010 Medline Industries, Inc. Medline, QuickSuite and Sahara are registered trademarks of Medline Industries, Inc.

The OR Goes Green – the only TRULY eco-friendly surgical drape Medline’s new patent-pending EcoDrape is the only eco-friendly surgical drape available today. Made of more than 96% wood pulp, EcoDrape will biodegrade in only two to five months in a landfill – polypropylene drapes take hundreds of years to break down. EcoDrape has all the same great features as other Medline drapes, including hook-and-loop line holders, large reinforcement zones, and premium tape and incise film flush to the fenestration.

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©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc. EcoDrape and greensmart are trademarks of Medline Industries, Inc.

OR Issues

Medline Joins Greening the Operating Room Initiative Medline has joined a group of corporate sponsors to support Practice Greenhealth’s Greening the Operating Room (GOR) initiative. This initiative to green the nation’s operating rooms was launched earlier in 2010 to reduce the environmental footprint of operating rooms in U.S. hospitals. Hospital operating rooms contribute between 20 and 30 percent of the hospital’s total waste.1

• • • • •

Medline will join the collaborative effort of hospitals, manufacturers and related stakeholders to develop guidance documents for helping reduce the environmental impact of the nation’s operating rooms and potentially reduce cost, increase quality and improve worker or patient safety. The following are the GOR areas for “green” interventions in the operating room: • Single-Use Device (SUD) Reprocessing • Reusables v. Disposables: Gowns, Surgical Drapes, Basins and Other Reusables

• • •

OR Kit Formulation Waste Anesthetic Gas Scavenging Systems Fluid Waste Management Systems Energy Use/Lighting & Thermal Comfort Regulated Medical Waste (RMW) Minimization/Segregation Substitution of Reusable Hard Cases for Blue Sterile Wrap Recycling of Medical Plastics Laser Safety/Smoke Evacuation Green Cleaning/Proper Disinfection in a Surgical Setting Medical Equipment and Supplies Donation

To learn more about Practice Greenhealth’s Greening the OR initiative visit

Reference 1. Esaki RK & Macario A. Wastage of supplies and drugs in the operating room. Medscape Anesthesiology. Posted October 21, 2009. Available at. Accessed October 22, 2010.

3 Checklists on the Cleaning & Disinfection of

Endoscopic Equipment by Lorri A. Downs RN, BSN, MS, CIC

According to the Association for Professionals in Infection Control (APIC), many factors contribute to endoscopy-associated infection, including numerous reports of outbreaks associated with equipment cleaning and disinfection. Infection prevention related to the use of endoscopy equipment begins with educating and training practitioners and strict adherence to reprocessing protocols.1 We know that in busy healthcare environments, checklists can help reduce errors and improve adherence to critical steps. Below you will find three checklists to help

56 The OR Connection

staff quickly and efficiently adhere to infection control guidelines for reprocessing endoscopic equipment in the central sterile processing department, same-day surgery arena and freestanding endoscopy clinics. The following checklists for the cleaning and disinfection of endoscopes were adapted from the Society of Gastroenterology Nurses and Associates (SGNA) Standards of Infection Control in Reprocessing of Flexible Gastrointestinal Endoscopes.2 To see the guidelines in their entirety, go to

Special Feature


Checklist 1: Cleaning the Endoscope Immediately After the Endoscopy Procedure

Reprocessing of soiled endoscopy equipment begins at the patient’s bedside immediately upon removal of the endoscope from the patient and prior to disconnecting the endoscope from the power source. Have the following equipment available immediately after the procedure: • Personal protective equipment: gloves, eye protection, impervious gown, face shield or surgical mask that will not trap vapors. • Container with detergent solution • A sponge and a soft, lint-free cloth • Air and water channel cleaning adapters per manufacturer’s instructions • Protective video caps if using video endoscopes

Use the following checklist after you have gathered the supplies listed above and put on your personal protective equipment. ❏ Immediately wipe the insertion tube with a wet cloth or sponge soaked in freshly prepared detergent solution. (Note: Do not reuse cloths or sponges between cases.) ❏ Place distal end of the endoscope in the detergent solution and suction the solution through the channel. Alternate suctioning, detergent solution and air several times until the solution is visibly clean. Finish with suctioning air. ❏ Flush or blow out air and water channels in accordance with the endoscope manufacturer’s instructions. ❏ Flush the auxiliary water channel. ❏ Detach the endoscope from the light source and suction pump. ❏ Attach the protective video cap if using a video endoscope. ❏ Transport the endoscope to the reprocessing area in an enclosed container.

Aligning practice with policy to improve patient care 57


Checklist 2: Cleaning the Endoscope in the Reprocessing Area

Have the following equipment available in the reprocessing area: • Personal protective equipment: gloves, eye protection, impervious gown, face shield or surgical mask that will not trap vapors • Leak-testing equipment • Channel cleaning adapters (per manufacturer’s instructions) • Large basin of endoscope detergent prepared per manufacturer’s instructions • Channel cleaning brushes • Sponge and lint-free cloth Use the following checklist after you have gathered the supplies listed above and put on your personal protective equipment. ❏ Leak test the endoscope either manually or via computer testing following the manufacturer’s instructions. If a leak is detected, follow the manufacturer’s instructions. ❏ Fill the sink or a basin with a freshly prepared solution (for each endoscope) of water and a medical grade, low-foaming, neutral pH detergent formulated for endoscopes that may or may not contain enzymes. ❏ Immerse the endoscope. ❏ Wash all debris from the exterior of the endoscope by brushing and wiping the instrument while submerged in the detergent solution. ❏ Keep the scope submerged to prevent splashing of contaminated fluid and aerosolization of bioburden. ❏ Use a small soft brush to clean all removable parts, including inside and under the suction valve, air/water valve, and biopsy port cover and openings. Brush all accessible channels, the scope body, insertion tube and the umbilicus of the endoscope. ❏ After each passage of the brush, rinse the brush in the detergent solution, removing any visible debris before retracting and reinserting it. Continue brushing until there is no visible debris on the brush. ❏ Clean and high-level disinfect reusable brushes between cases. ❏ Attach manufacturer’s cleaning adapters for special endoscopic channels. Flush all channels with detergent solution to remove debris. (Note: Automated pumps are available for flushing endoscopes. Refer to the manufacturer’s instructions.) ❏ Soak the endoscope and its internal channels for the period of time specified on the label of the detergent. ❏ Thoroughly rinse the endoscope and all removable parts with clean water to remove residual debris and detergent. ❏ Purge water from all channels using forced air and dry the exterior of the scope with a soft, lint-free cloth.

58 The OR Connection


Checklist 3: High Level Disinfection/Sterilization for Endoscopes in the Reprocessing Area

• Once the endoscope has been cleaned, it is ready for disinfectants and sterilants. • Be sure to follow the manufacturer’s instructions for proper use of these chemicals. • Test the chemical for the minimum effective concentration (MEC) according to the label on the test strip container. • Never use the MEC value to extend the “reuse” life claim on the product and never use beyond the date specified on activation. • Use product-specific test strips to check for the MEC and keep a log of the test results.

❏ Completely immerse the endoscope and all removable parts in a basin of high level disinfectant/sterilant. ❏ Inject disinfectant into all channels of the endoscope until it can be seen exiting the opposite end of each channel. Make sure no air pockets remain within the channels ❏ Do not coil the scope tightly and cover the basin to contain chemical vapors. ❏ Soak the endoscope in the high-level disinfectant/sterilant for the appropriate time and temperature. ❏ Required to achieve high-level disinfection. Use a timer to verify soaking time. ❏ Purge all channels completely with air before removing the endoscope from the highlevel disinfectant/sterilant. ❏ Thoroughly rinse all surfaces and removable parts and flush all channels of the endoscope and its removable parts with clean water and disinfectant per the manufacturer’s recommendations. ❏ Purge all channels with air until dry and follow with 70% isopropyl alcohol (even if sterile water is used to flush) to assist in drying the interior channel surfaces. ❏ Thoroughly rinse and dry all removable parts and do not store removable parts attached to the endoscope when not in use. ❏ Dry the exterior of the endoscope with a soft, lint-free cloth. ❏ Thoroughly rinse the endoscope and all removable parts with clean water to remove residual debris and detergent. ❏ Hang the endoscope vertically with the distal tip hanging freely in a clean, well-vented, dust-free area.

References 1. Stricof RL. Endoscopy. In: Carrico R, ed. APIC Text of Infection Control and Epidemiology. 3rd ed. Washington, DC: Association for Professionals in Infection Control and Epidemiology, Inc.; 2009. 2. Society of Gastroenterology Nurses and Associates, Inc. The Standards of Infection Control in Reprocessing of Flexible Gastrointestinal Endoscopes. 10-19. Available at: Accessed November 10, 2010.

About the author

Lorri Downs, RN, BSN, MS, CIC is a board-certified infection preventionist and vice president of infection prevention for Medline Industries, Inc. She has a diverse portfolio of more than 25 years in the nursing professions. Her expertise focuses on infection prevention surveillance at large acute care organizations, plus ambulatory and public health settings. Lorri has developed hospital infection control programs and local emergency preparedness plans, and she ahs lectured on various infection prevention topics.

Aligning practice with policy to improve patient care 59

60 The OR Connection

OR Issues

Continuing Education Article


By Alecia Cooper, RN, BS, MBA, CNOR and Debashish Chakravarthy, PhD

Are your surgeons increasingly requesting surgical glue? If they aren’t asking for it yet, all indications are that surgical glue will be a mainstay in operating rooms in the near future. Let’s explore why use of surgical glue is becoming so prominent among surgeons.

Current Market Snapshot Current research on the success of surgical sealants and glues in clinical practice was published in October 2010 by MedMarket Diligence, a provider of data and insight on advanced medical technologies. The report states that the advancements in surgical sealants and glue technology are enabling these products to increasingly penetrate the existing markets for sutures and staples, in addition to capturing a caseload of new applications.1 A wide array of wound closure products is now in use by both general surgeons and surgeons specializing in gynecologic, orthopedic, gastrointestinal, neurology, cosmetic, vascular and nearly all other surgical areas. Many aspects of prevailing surgical methods (from as recently as 10 years ago) have undergone major changes. The increased use of surgical sealants and glue is one such change and is primarily attributable to both new technological

advancements and the expanding caseloads for which these technologies apply. While traditional wound closure products, including sutures and staples, still command a sizable portion of the overall market, their rate of use compared to alternative products is relatively flat, and in some cases declining, in certain geographic regions. In contrast, the use of surgical sealants and glues is growing at an estimated 10 to 15 percent per year.1 In August 2010, Outpatient Surgery conducted a poll asking readers about their use of surgical glue and the results were as follows: OUTPATIENT SURGERY MAGAZINE READER POLL2

“In which types of cases do you use surgical glue instead of sutures?” ARTHROSCOPY . . . . . . . . . . . . . . . . . . .28% ENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1% GENERAL SURGERY . . . . . . . . . . .34% GYNECOLOGY . . . . . . . . . . . .11% PLASTICS . . . . . . . . . . . . .26%

Aligning practice with policy to improve patient care 61

Importance of Surgical Glue Knowledge

Focusing on Cyanoacrylates

Whereas surgeons select and evaluate the effectiveness of closure devices, including surgical glues, it is the responsibility of nurses, physician assistants, residents, interns and students to routinely assist or close the procedure under the surgeon’s direction. Therefore, it is imperative to have thorough knowledge of these materials and their appropriate application and use in order to achieve the best performance and results.

Cyanoacrylates were first used in 1949 after being discovered accidentally while researchers were studying refracting indexes of coatings on glass.3 Cyanoacrylates became popular during the Vietnam War as a hemostat for soldiers wounded in field combat. These compounds entered the clinical market during the 1980s and 1990s in dental products, bandages and wound closure adhesives. Today, several cyanoacrylates have been cleared and/or approved as medical devices by the FDA. Continued on page 64

TYPES OF SURGICAL TISSUE ADHESIVES Surgical glues, also referred to as surgical tissue adhesives or sealants, are used after a surgery or traumatic injury to bind together both deep as well as superficial tissue. These glues provide a chemical bond to hold tissue together for healing and serve as a barrier to stop the flow of bodily fluids. Certain physicians use surgical glues in conjunction with, or as and alternative to, sutures and staples. Including surgical closure glues, there are several main types of surgical glues approved for various surgical applications:


Fibrin sealants. Fibrin sealants are a type of surgical adhesive derived from both human and animal blood products. Ingredients in the fibrin sealant interact during application to form a clot. Fibrin sealants are effective for use in cardiovascular surgery, lung surgery, the closure of dura, and to seal spleen and liver lacerations. Fibrin sealants are not suitable for external or topical use.


Glutaraldehyde-based glues. Glutaraldehyde glues are protein-based compounds that are crosslinked by glutaraldehyde, in situ, to make a strong and bioabsorbable internal seal. These glues are not suitable for external or topical use.

62 The OR Connection


Collagen-based products. Collagen-based adhesives may be combined with other hemostatic proteins such as thrombin to make an effective internal adhesive.


Hydrogels. Hydrogels are synthetic polyethylene glycol (PEG) polymers commonly used in lung and thoracic surgery for their ability to seal air leaks. Due to their physical properties, they are unsuitable as an incision site closure or glue.


Cyanoacrylates. Cyanoacrylates are compounds ideally suited—because of their physical properties when “set up”—to close topical incisions, minor lacerations or an incision site. The subcutaneous tissue is closed with sutures and the glue is used only to close the dermal and epidermal incisional defects. These compounds are very commonly used on laparoscopic incisions and are much stronger than all the internal glues discussed above. Cyanoacrylates are also able to withstand the external environment while the incision heals naturally underneath the glue line. In general, cyanoacrylates are waterproof, flexible and require no secondary dressing. Cyanoacrylates are not bioabsorbable and must be restricted to external and temporary applications.

Stick with OctylSeal™ Flexible wound closure that’s easy on your budget Introducing Medline’s OctylSeal high viscosity tissue adhesive for closure of simple wounds • Flexible structure moves with the skin, minimizing the chance of cracking • Acts as a barrier to microbial penetration as long as the adhesive film remains intact • 40 percent more glue per container than most other tissue adhesives (0.7 grams versus 0.5 grams) • Easy, versatile application – interchangeable tips (swab and nozzle) included in every package; violet color for easier identification on skin • Metal tube instead of glass ampule means no risk of broken glass entering the wound

Indications for use

Topical application only to hold closed easily approximated edges of wounds from surgical incisions, including punctures from minimally invasive surgery and simple, thoroughly cleansed trauma-induced lacerations. OctylSeal may be used in conjunction with, but not in place of deep dermal sutures. Available by prescription only.

To learn more about OctylSeal, call 847-643-4526.

©2010 Medline Industries, Inc. Medline is a registered trademark and OctylSeal is a trademark of Medline Industries, Inc.

Table 1. Octyl versus butyl cyanoacrylates Octyl


No need to refrigerate Cures or polymerizes as a smooth surface and an even film Sets up with a flexible “glue” line at the application site.

Needs refrigeration Cures or polymerizes as a rough surface Sets up with a brittle “glue” line at the application site.

Two main types: octyls and butyls. There are, in essence, two main types of cyanoacrylates approved as medical tissue adhesives. One type is N-butyl-2-cyanoacrylate (simply called butyl in most cases) and the second type is 2-octylcyanoacrylate (Simply called octyl).4 The difference between the two types is in the nature of the chemical chains present in the ester groups of the molecules. The molecules are sometimes referred to as monomers. In contrast, the adhesive that is “set up” on skin post application is the polymer. A butyl cyanoacrylate contains a short chain (4 carbon length) portion in its structure. An octyl cyanoacrylate contains a longer chain (8 carbon length) portion. The polymer film resulting from the use of a butyl glue is considered to be more rigid than the film resulting from the set up of an octyl glue on skin, and far less flexible. Thus, butyls are more prone to cracking and splitting under tension and flexure of the skin, limbs and joints during normal movement. In summary, a butyl film provides only strength, but very little flexibility, while the octyl film seems to balance both tensile strength and flexibility without fissures or cracks appearing in the film. Since both types of cyanoacrylate adhesives have FDA approval,4 how does a surgeon select the preferred product? Many factors can play into the surgeon’s decision, though topping the list seem to be the features and benefits of each type of adhesive that appeals to the surgeon, the product type the surgeon trained on, and the product brand that the hospital stocks. Table 1 compares octyl and butyl cyanoacrylates and shows the factors that may play into the clinicians preference in product choice.

64 The OR Connection

Potential benefits of surgical wound closure with cyanoacrylates6 1. Quicker wound closure 2. Comparable/better scar cosmesis than sutures or staples 3. Occlusive microbial barrier 4. Non-invasive – less tissue trauma and reduced inflammatory reaction 5. No secondary dressings required 6. Easy-to-use/quick learning curve 7. Ease of wound visualization 8. Reduced risk of needle-stick injury associated with suturing 9. Cost-effective

Determining How to Close the Wound In determining the appropriate type of product to close any surgical procedure, surgeons take into account many factors based upon the desired goals. 1. Reason for the surgery 2. Location of where and how the injury occurred (if applicable) 3. Location of the wound 4. Length of the surgical procedure Surgical wound closure using a cyanoacylate is best suited for wounds that are not subject to significant stress or flexion. Many surgeons follow this rule of thumb: if the skin requires more than simple pulling together with forceps or fingers to

Most surgeons find that surgical glues offer a fast, simple and effective means of surgical wound closure achieve approximation of the wound, then deeper sutures and/or subcutaneous sutures should be used before the glue is applied.5 Octyl cyanoacylates appear to work better on areas of flexion as compared to butyl cyanoacylates, because they set up with a flexible “glue line” and maintain their microbial barrier. The best results are obtained when the wound incision is clean and dry with total hemostasis prior to the application of the skin adhesive. Cyanoacrylate adhesives close the skin by forming a polymerized layer across the top of the skin, creating a a bridge between the skin edges. Therefore, it is important for best results to obtain edge-to-edge apposition while the glue sets over the wound. If the procedure is a routine, elective surgery and not caused by a trauma, surgical glue should be considered. If an injury took place outdoors or on a playground, for example, where there are potential contaminants, it is best not to consider surgical glue. The duration of surgery may affect the potential for infection, and surgical glue should be used with caution.

Benefits of Using Surgical Tissue Adhesives Many surgeons prefer coverage of the suture line with a cyanoacrylate surgical glue as opposed to a dressing because the glue allows the incision line to be easily visible.6 Once comfortable with the technique, most surgeons find that surgical glues offer a fast, simple and effective means of surgical wound closure, particularly for smaller surgical incisions. In addition, cosmetic results are superior. Patients are pleased with the waterproof and microbial barrier nature of glue, especially octyl glues, which are resistant to cracking and allow patients to shower soon after the procedure. Additional benefits of using a surgical glue are the lack of visible dressings or sutures and the absence of procedures to remove sutures or staples.5


SKIN GLUE – TOP TIPS6 • Make sure the wound is clean and dry • Stop bleeding prior to application • Apply glue over tightly and correctly approximated wound edges • Hold until glue/tissue adhesive is dry • No further dressings required, although secondary dressing will not harm incision site and may provide additional microbial barrier protection • Ensure patient/post-op staff know glue was used and know wound site care • Provide patient information/instructions at discharge

Microbes and Surgical Tissue Adhesives Recent in vitro studies have shown that 2-octyl-cyanoacrylate is an effective microbial barrier for the first 72 hours after application.3 A key aspect of using surgical glues is that the skin formed with 2-octyl-cyanoacrylate is effective against gram-positive

Aligning practice with policy to improve patient care 65

and gram-negative bacteria including Staphylococcus epidermis, S. aureus, Escherichia coli, Pseudomonas aeruginosa, and Enterococcus faecium. The adhesive creates a protective layer for the wound and keeps the area moist, resulting in faster epithelialization. In this way, the system of closure and protection of the wound using surgical glue can result in reduced costs and better management in the postoperative phase.3 Cyanoacrylate skin adhesives may potentially reduce the risk of surgical site infections (SSIs) by:7 1. Forming an occlusive, impermeable, waterproof barrier 2. Prevention of translocation of local skin flora 3. Reducing post-operative wound dressing changes 4. Improving hygiene by allowing patients to shower

Wound Site Care To allow proper care and management of the incision site closed with surgical glue, it is imperative to communicate effectively regarding glue use at handoff in the immediate post-operative period. Incisions closed with glue typically do not produce drainage because in general, the use of glue is restricted to non-draining wounds. If the incision appears to be opening, the edges should be pushed together, and then butterfly-type bandages may be applied to hold the edges together. The surgeon may apply additional surgical glue to the wound as needed prior to discharge from the hospital. Surgical glues will slough off naturally as normal skin grows to heal the incision site. Best practice requires providing education and training on surgical wound care to the patient and family prior to discharge so that proper care is extended at home. Postoperative evaluation has shown good patient satisfaction when using surgical glues.3 Perioperative personnel need to know how to care for incisions closed with glue and should be able to communicate to patients and their families the methods to properly care for and maintain the incision site at home.

New Uses and Improved Outcomes The key to the successful use of surgical glue is that surgeons should precisely apply the products to the appropriate surgical wounds. Both surgeons and other clinicians will need to perfect their technique for applying and using surgical glues.

66 The OR Connection


Proper application of surgical glue can be learned quickly and easily; the method is not particularly challenging. As the process for the surgical glue to â&#x20AC;?set upâ&#x20AC;? and protect the incision site happens in about a minute, the use of surgical glue can save valuable time and improve both patient outcomes and patient satisfaction. Patients report more postoperative comfort, appreciate the ability to see the incision and like being able to bathe immediately following the procedure. Surgical glues are relatively inexpensive, comprising only a small fraction of the overall costs associated with most surgeries. There is no need for a secondary dressing or dressing changes, which adds to costs of treatment. Use of glue also may eliminate follow-up visits related to post op care and suture removal. Based upon these myriad factors, the use of surgical glues is likely to continue growing, and new innovations in the technology will continue to emerge.

References 1. Surgical Sealant and Glue New Uses and Penetration of Traditional Wound Closure, Hemostasis. MedMarket Diligence, LLC. October 11, 2010. Available at: Accessed November 8, 2010. 2. InstaPoll. In which types of cases do you use surgical glue instead of sutures? Outpatient Surgery E-Weekly, August 17, 2010. Available at: Accessed November 9, 2010. 3. Silvestri A, Brandi C, Grimaldi L, Nisi G, Brafa A, Calabro M, et. al. Octyl-2-cyanoacrylate adhesive for skin closure and prevention of infection in plastic surgery. Aesthetic Plastic Surgery. 2006;30(6):695-699. 4. Petrie EM. High strength surgical adhesives. Available at: Accessed November 18, 2010. 5. Liversedge NH. Get stuck in! Hands on experiences with surgical skin glue. Obs & Gynae News. 2007;14(1):24-28. 6. Malangoni MA, Cheadle WG, Dodson TF, Dohmen PM, Jones D, Kushagra K, et al. Roundtable discussion. New opportunities for reducing risk of surgical site infections. Surgical Infections. 2006;7 Suppl 1:S23-39. 7. Non-invasive closure of laparoscopic surgical incisions. Available at: Accessed November 18, 2010.

CE Test Questions

Stuck Like Surgical Glue: NEW USES AND IMPROVED OUTCOMES CE Test True/False 1. The use of surgical sealants and glues is growing at a rate of 10 to 15 percent per year. T F 2. Recent in vitro studies have shown that 2-octyl-cyanoacrylate is an effective microbial barrier for the first 72 hours after application. T F 3. Butyl cyanoacrylates cure or polymerize as a smooth surface. T F 4. Octyl cyanoacrylates require refrigeration. T F 5. Cyanoacrylate adhesives first entered the clinical market in the 1960s. T F Multiple Choice 6. Which of the following is one of the factors surgeons take into account when determining the appropriate type of product to close a surgical incision? a. Patientâ&#x20AC;&#x2122;s age b. Skin temperature c. Ability to approximate wound edges d. None of the above

8. Patients tend to prefer surgical glue over sutures or staples because __________________. a. It allows them to lightly wash or shower right after surgery b. There is no need for required follow up for removal c. They provide more postoperative comfort d. All of the above 9. Glutaraldehyde glues are used in the repair of _________________. a. Simple skin lacerations b. Aortic dissections c. Massive head wounds d. Laparoscopic surgical incisions 10. Surgical adhesives derived from both human and animal blood products are called _____________________. a. Fibrin sealants b. Collagen-based compounds c. Cyanoacrylates d. None of the above

7. Which type of surgical glue is commonly used in lung and thoracic surgery? a. Cyanoacrylates b. Glutaraldehyde glues c. Hydrogels d. Fibrin sealants

Submit your answers at and receive 1 FREE CE credit

Courses approved for continuing education by the Florida Board of Nursing and the California Board of Reigistered Nursing.

Aligning practice with policy to improve patient care 67


Medline BIOGUARD® Barrier Dressings A new product for your infection control program Medline BIOGUARD® barrier dressings are specifically designed to help protect wounds from more than 12 types of bacteria, including methicillin-resistant Staphylococcus aureus (MRSA). The active component is a cationic polymer called Poly (diallyl dimethyl ammonium chloride) (pDADMAC). No leaching Unlike similar cationic biocides (such as PHMB – the active component in the competitor’s dressings), pDADMAC is permanently bound to the barrier dressing. It keeps working at the same rate for the life of the dressing – without leaching. No resistance Lack of leaching helps prevent the potential for resistant strain formation.

No toxicity Medline BIOGUARD® barrier dressings are non-toxic, allowing them to be used safely on all wounds. Medline BIOGUARD® barrier products act as a physical barrier to outside contaminants and do not act on the surface or the interior of the wound nor do they contain antimicrobial agents that act on the body. These dressings are not intended as a treatment for clinical infection. If signs of clinical infection are present, consult a physician. Available by prescription only.

To request a sample of BIOGUARD® contact your Medline sales representative or e-mail

©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc. BIOGUARD is a registered trademark of Derma Sciences, Inc. US Patent No. 7,045,673 and 7,709,694 and 7,790,217 and foreign counterparts. NIMBUS technology is licensed by Quick-Med Technologies, Inc. NIMBUS is a registered trademark of Quick-Med Technologies, Inc. Covidien is a registered trademark of Covidien.

Special Feature

product spotlight INTRODUCING MEDLINE BIOGUARDÂŽ BARRIER DRESSINGS Proven 99.999% bacterial reduction for your infection control program Medline BIOGUARD is a new line of gauze-based dressings with a >5-log (99.999%) average reduction of more than 12 common pathogens, including MRSA, vancomycin-resistant Enterococcus faecium and Pseudomonas aeruginosa. The active component is a non-toxic, high molecular weight cationic polymer called Poly (diallyl dimethyl ammonium chloride) or p-DADMAC contained within the dressings. Unlike PHMB, the active ingredient in the competitorâ&#x20AC;&#x2122;s barrier dressing, p-DADMAC is permanently bound to the dressing. So it keeps working at the same rate for the life of the dressing. Lack of leaching helps prevent bacteria from growing and spreading in the dressing, reducing the potential for resistant strain formation. Time magazine Innovation Leader Dr. Greg Schultz developed the patented technique for bonding p-DADMAC to the gauze dressings.1 A biochemist with an interest in wound care, Dr. Schultz serves on the board of direc-

Aligning practice with policy to improve patient care 69

product spotlight tors for the National Pressure Ulcer Advisory Panel (NPUAP)2 and on the editorial boards of several journals in the areas of ocular and skin wound healing.3 Medline BIOGUARD® dressings are intended for use with: • Exuding wounds • First and second degree burns • Surgical wounds • Securing and preventing movement of a primary dressing • Wound packing

Reference 1. S Morrissey. Epidemiology: forging the future: microbe-busting bandages. Time. 2006; 167(12). Posted March 12, 2006. Available at:,9171,1172215,00.html. Accessed November 9, 2010. 2. National Pressure Ulcer Advisory Panel Board of Directors 2010. Available at: Accessed November 9, 2010. 3. University of Florida website. Biochemistry and Molecular Biology. Gregory Schultz, PhD. Available at: Accessed November 9, 2010. 4. Data on file. Bioguard is a registered trademark of Derma Sciences, Inc.

The dressings are available in many sizes and types, including rolls, sponges, packing strips, non-adherent pads and conforming bandages. Contact your Medline representative for further details. Medline BIOGUARD barrier products act as a physical barrier to outside contaminants and do not act on the surface or the interior of the wound nor do they contain antimicrobial agents that act on the body. These dressings are not intended as a treatment for clinical infection. If signs of clinical infection are present, consult a physician. Available by prescription only. Medline BIOGUARD Comparative Efficacy Study Laboratory testing4 comparing the effectiveness of Medline BIOGUARD dressing versus Covidien AMD dressing showed the same log reduction against MRSA, Pseudomonas aeruginosa (PA) and VRE. The efficacy remains the same at 24 and even after 48 hours. All results indicate >5-log reduction of broad spectrum microbes.

Antibacterial Activity (Log Reduction)

Efficacy of Medline BIOGUARD® and Covidien AMD After 24 and 48 Hours* 6 5 4 3 2 1 0

Methicillin-resistant Staphyloccus aureus (MRSA)

Pseudomonas aeruginosa (PA)

Medline Bulkee II BIOGUARD® Gauze Bandage Roll

Vancomycin-resistant Enterococcus faecium (VRE)

Covidien® Kerlix AMD™ Antimicrobial Large Roll *Tested at an Independent third party laboratory

70 The OR Connection

BioCon™- 500 Bladder Scanner Safely Measures Bladder Volume Minimize unnecessary catheterization Research has shown that 80 percent of urinary tract infections acquired at healthcare facilities are associated with an indwelling urethral catheter.1 This type of infection is known as CAUTI, or catheter-associated urinary tract infection. What’s more, Medicare no longer reimburses for treatment of CAUTI if it happens while a patient is hospitalized, giving hospitals a major incentive to prevent it. But how? Avoiding unnecessary catheter use is a primary strategy for preventing CAUTI, and clinical guidelines recommend the consideration of alternatives to catheterization.2 Bladder scanners can be used in place of a urinary catheter to assess bladder volumes, and many catheterizations can be avoided.3

To learn more about CAUTI prevention and the BioCon-500, visit or contact your Medline sales representative.

1. Lo E, Nicolle L, Classen D, Arias A, Podgorny K, Anderson DJ, et al. SHEA/IDSA practice recommendation: strategies to prevent catheter-associated urinary tract infections in acute care hospitals. Infect Control Hosp Epidemiol. 2008;29:S41-S50. 2. Stokowski, LA. Preventing catheter-associated urinary tract infections. Medscape Nursing Perspectives. February 3, 2009. 3. Stevens E. Bladder ultrasound: avoiding unnecessary catheterizations. Med/Surg Nursing. 2005; 14(4):249-253.

©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc. BioCon-500 is a trademark of Mcube Technology Co., Ltd.

What did we do after designing a revolutionary new catheter tray system?

We found THREE more ways to make it even better. Weâ&#x20AC;&#x2122;re obsessed with engineering new and better technology for healthcare workers. So after we revolutionized the outdated Foley catheter tray with a unique, one-layer system design, we immediately turned our attention to addressing how we could make it even easier to use. We studied how the tray was being used in the field. The result was three more great improvements.

Combined with the previous innovative tray redesign and comprehensive ERASE education, these three new features help to improve patient safety and quality, while reducing avoidable costs associated with waste and urinary tract infections. To learn about the ERASE CAUTI system, as well as other strategies for minimizing the risk of CAUTI, sign up for a free Innovation in the Prevention of CAUTI webinar at

Š2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.


Real photography on the outside – so you know exactly what’s inside A photo on the package helps identify the contents of the kit, serves as an educational tool for the clinician and can be used to discuss the procedure with the patient. Also, the label opens up to a booklet with step-by-step instructions and helpful tipsfor the clinician.


A revised checklist for the medical record The reformatted checklist is smaller, making it easier to place in the paper chart or attach to the electronic medical record.


Education you’ll want to present to your patient There’s nothing like the new Patient Education Care Card. Designed to look and feel like a “Get Well Soon” card, it tells patients about catheterization so they know you are providing them the best care possible.

Ventilator-associated pneumonia (VAP) is a hospital-acquired infection that occurs in up to 27 percent of all mechanically ventilated patients. 1 It is specifically defined as an airway infection that develops more than 48 hours after a patient is intubated.2

Five Step Approach for Avoiding

VAP 74 The OR Connection

Among ICU patients, nearly 90 percent of episodes of hospital-acquired pneumonia occur during mechanical ventilation.1 Because half of all episodes of VAP occur within the first four days of mechanical ventilation, it is especially critical to prevent the condition all together.1 Reducing mortality due to ventilator-associated pneumonia requires an organized process that guarantees early recognition of pneumonia and consistent application of evidence-based practices.2 The Institute for Healthcare Improvement (IHI) advocates use of a bundle approach to help fight VAP. The ventilator bundle is a series of interventions related to ventilator care that, when implemented together, achieves significantly better outcomes.2 The five components of the (IHI) Ventilator Bundle are:2 1. Elevating the head of the bed 30 degrees 2. Daily â&#x20AC;&#x153;sedation vacationsâ&#x20AC;? and assessment of readiness to extubate 3. Peptic ulcer disease prophylaxis 4. Deep vein thrombosis prophylaxis 5. Daily oral care with chlorhexidine

References 1. Kollef MH. What is ventilator-associated pneumonia and why is it important? Respiratory Care. 2005;50(6):714-724. Available at: Accessed November 4, 2010. 2. Implement the Ventilator Bundle. Institute for Healthcare Improvement (IHI) website. Available at: Accessed November 4, 2010.

Patient Safety

Tips 1. Elevating the Head of the Bed 30 Degrees

for Complying with the VAP Prevention Bundle

3. Peptic Ulcer Disease Prophylaxis

• Implement a mechanism to ensure head-of-the-bed elevation, such as including this intervention on nursing flow sheets and as a topic at multidisciplinary rounds. • Create an environment where respiratory therapists work collaboratively with nursing to maintain head-of-the-bed elevation. • Involve families in the process by educating them about the importance of head-of-the-bed elevation and encourage them to notify clinical personnel when the bed does not appear to be in the proper position. • Use visual cues to easily identify when the bed is in the proper position. • Include this intervention on order sets for initiation and weaning of mechanical ventilation, delivery of tube feedings, and provision of oral care.

2. Daily “Sedation Vacations” and Assessment of Readiness to Extubate • Implement a protocol to lighten sedation daily at an appropriate time to assess for neurological readiness to extubate. Include precautions to prevent self-extubation such as increased monitoring and vigilance during the trial. • Include a “sedation vacation” strategy in your overall plan to wean the patient from the ventilator; if you have a weaning protocol, add “sedation vacation” to that strategy. • Assess that compliance daily during multidisciplinary rounds. • Consider implementation of a sedation scale (e.g., the Riker Scale) to avoid oversedation.

• Include peptic ulcer disease prophylaxis as part of your ICU order admission set and ventilator order set. Make application of prophylaxis the default value on the form. • Include peptic ulcer disease prophylaxis as an item for discussion on daily multidisciplinary rounds. • Empower pharmacy to review orders for ICU patients to ensure that some form of peptic ulcer disease prophylaxis is in place at all times.

4. Deep Venous Thrombosis Prophylaxis • Include deep venous prophylaxis as part of your ICU order admission set and ventilator order set. Make application of prophylaxis the default value on the form. • Include deep venous prophylaxis as an item for discussion on daily multidisciplinary rounds. • Empower pharmacy to review orders for ICU patients to ensure that some form of deep venous prophylaxis is in place at all times.

5. Daily Oral Care with Chlorhexidine • Educate registered nurses (RNs) about the rationale supporting good oral hygiene and its potential benefit in reducing ventilator-associated pneumonia. • Develop a comprehensive oral care process that includes the use of 0.12% chlorhexidine oral rinse. • Schedule chlorhexidine as a medication, which then provides a reminder for the RN and triggers oral care process delivery. Source:

Aligning practice with policy to improve patient care 75

VAPREVENT SYSTEM: Making it easier to avoid Ventilator-Associated Pneumonia Evidence-based innovation in oral care Easy to identify which mouthwash the kit contains

Strong built-in IV pole hanger

IHI Checklist of activities to help reduce VAP

Compliance at a glance â&#x20AC;&#x201C; clearly labeled and sequenced in the order they should be used

Thumb grip for easy dispensing

VAPrevent is a comprehensive oral care system modeled after the guidelines of the Institute for Healthcare Improvement (IHI) Ventilator Bundle. It’s designed to address ventilator-associated pneumonia (VAP)—the second most common healthcare-associated infection1, affecting up to 40 percent of ventilator patients.2 The VAPrevent System brings you the three Ps to better oral care: the right products combined with a comprehensive educational program at a value-added price.

Product Only Medline features these three options for oral care: IHI-recommended chlorhexidine gluconate (CHG), the alcohol-free moisturizing of Biotene®, or the proven antisepsis of hydrogen peroxide. Color-coded packaging allows for quick identification, thorough caregiver education and simple compliance. The system is designed to dispense each kit one-at-a-time in the right order at the right time.

Record start time, date and patient information

Easy identification of oral care frequency

Suction Toothbrush & Catheter Kit

Program Clear visual identification of kit components

Products are only as beneficial as knowing how to use them appropriately. That’s why we also developed the Medline VAP Program, which helps build your staff’s knowledge and clinical skills with educational modules for novice and experienced clinicians, as well as an online interactive competency for oral care. We help you implement the program, and then provide you with 90day reports to help you track your incidence of VAP.

Price All this – and a lower price! The cost of the VAPrevent System is five to 10 percent lower than competitors, who offer less comprehensive systems.

To schedule your evaluation of the VAPrevent System, contact your Medline representative or call 1-800-MEDLINE (633-5463).

References 1 Bingham M, Ashley J, De Jong M, Swift C. Implementing a unit-level intervention to reduce the probability of ventilator-associated pneumonia. Nursing Research. 2010; 59(1): S40-S47. 2 Trouillet J, Chastre J, Vuagnat A, Joly-Guillou M, Combaux D, Dombret M, et al. Ventilator-associated pneumonia cased by potentially drug-resistant bacteria. Am J Respir Crit Care Med. 1998. 157(2):531-539. ©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

Caring for Yourself

Get Set for


SEASON In much of the Northern Hemisphere, this is prime time for colds, influenza (flu), and other respiratory illnesses. While contagious viruses are active year-round, fall and winter are when weâ&#x20AC;&#x2122;re all most vulnerable to them. This is due in large part to people spending more time indoors with others when the weather gets cold. The Food and Drug Administration (FDA) regulates medicines and vaccines that help fight winter illnesses.

Colds are usually distinguished by a stuffy or runny nose and sneezing. Other symptoms include coughing, a scratchy throat, and watery eyes. No vaccine against colds exists because they can be caused by many types of viruses. Often spread through contact with mucus, colds come on gradually. Flu comes on suddenly, is more serious, and lasts longer than colds. The good news is that yearly vaccination can help protect you from getting the flu. Flu season in the United States generally runs from November to April.

Colds and Flu Most respiratory bugs come and go within a few days, with no lasting effects. However, some cause serious health problems. Although symptoms of colds and flu can be similar, the two are different.

78 The OR Connection

Flu symptoms include fever, headache, chills, dry cough, body aches, fatigue, and general misery. Like colds, flu can cause a stuffy or runny nose, sneezing, and watery eyes. Young children may also experience nausea and vomiting with flu.

Prevention Tips Get vaccinated against flu. According to the Centers for Disease Control and Prevention (CDC): • More than 200,000 people in the United States are hospitalized from flu-related complications each year, including 20,000 children younger than age 5. • Flu-associated deaths number in the thousands each year. Between 1976 and 2006, the estimated number of flu-related deaths every year ranged from about 3,000 to about 49,000.

Tips for Avoiding Flu vaccine, available as a shot or a nasal spray, remains the best way to prevent and control influenza. The best time to get a flu vaccination is from October through November, although getting it in December and January is not too late. A new flu shot is needed every year because the predominant flu viruses change every year.

WINTER BUGS: • Get vaccinated against flu • Wash your hands often • Limit exposure to infected people

All people 6 months of age and older should be vaccinated. However, you should talk to your health care professional before getting vaccinated if you • have certain allergies, especially to eggs • have an illness, such as pneumonia • have a high fever • are pregnant Flu vaccination for health care workers is urged because unvaccinated workers can be a primary cause of outbreaks in health care settings. Certain people are more at risk for developing complications from flu; they should be immunized as soon as vaccine is available. These groups include: • people 65 and older • residents of nursing homes or other places that house people with chronic medical conditions such as diabetes, asthma, and heart disease • adults and children with heart or lung disorders, including asthma • adults and children who have required regular medical follow-up or hospitalization during the preceding year because of chronic metabolic diseases (including diabetes), kidney dysfunction, a weakened immune system, or disorders caused by abnormalities of hemoglobin (a protein in red blood cells that carries oxygen) • young people ages 6 months to 18 years receiving long-term aspirin therapy, and who as a result might be at risk for developing Reye’s syndrome after being infected with influenza (See aspirin information in the section “Taking OTC Products.”) Note that only one vaccine is needed for the 2010-2011 influenza season.

• Keep stress in check • Eat right • Sleep right • Exercise During last flu season, two different vaccines were needed; one to prevent seasonal influenza and another to protect against the 2009 H1N1 flu virus. This year’s seasonal flu vaccine protects against three strains of influenza, including the 2009 H1N1 flu virus. Also, a vaccine specifically for people 65 years and older is available this year. Called Fluzone High-Dose, this vaccine induces a stronger immune response and is intended to better protect the elderly against seasonal influenza. This vaccine—which was approved by FDA in 2009—was developed because the immune system typically becomes weaker with age, leaving people at increased risk of seasonal flu-related complications which may lead to hospitalization and death. Wash your hands often. Teach children to do the same. Both colds and flu can be passed through coughing, sneezing, and contaminated surfaces, including the hands. CDC recommends regular washing of your hands with warm, soapy water for about 15 seconds.

Aligning practice with policy to improve patient care 79

3 Things You Can Do:

1. Wash your hands often with soap and warm water.

2. Get vaccinated against the flu.

FDA says that while soap and water are undoubtedly the first choice for hand hygiene, alcohol-based hand rubs may be used if soap and water are not available. However, the agency cautions against using the alcohol-based rubs when hands are visibly dirty. This is because organic material such as dirt or blood can inactivate the alcohol, rendering it unable to kill bacteria. Try to limit exposure to infected people. Keep infants away from crowds for the first few months of life. This is especially important for premature babies who may have underlying abnormalities such as lung or heart disease. Practice healthy habits. • Eat a balanced diet. • Get enough sleep. • Exercise. It can help the immune system better fight off the germs that cause illness. • Do your best to keep stress in check. Also, people who use tobacco or who are exposed to secondhand smoke are more prone to respiratory illnesses and more severe complications than nonsmokers.

Already Sick? Usually, colds and flu simply have to be allowed to run their course. You can try to relieve symptoms without taking medicine. Gargling with salt water may relieve a sore throat. And a cool-mist humidifier may help relieve stuffy noses.

3. Choose over-the-counter medicines that treat only your specific symptoms.

Here are other steps to consider: • First, call your doctor. This will ensure that the best course of treatment can be started early. • If you are sick, try not to make others sick too. Limit your exposure to other people. Also, cover your mouth with a tissue when you cough or sneeze, and throw used tissues into the trash immediately. • Stay hydrated and rested. Fluids can help loosen mucus and make you feel better, especially if you have a fever. Avoid alcohol and caffeinated products. These may dehydrate you. • Know your medicine options. If you choose to use medicine, there are over-the-counter (OTC) options that can help relieve the symptoms of colds and flu. If you want to unclog a stuffy nose, then nasal decongestants may help. Cough suppressants quiet coughs; expectorants loosen mucus so you can cough it up; antihistamines help stop a runny nose and sneezing; and pain relievers can ease fever, headaches, and minor aches. In addition, there are prescription antiviral medications approved by FDA that are indicated for treating the flu. Talk to your health care professional to find out what will work best for you.

Taking OTC Products Be wary of unproven treatments. It’s best to use treatments that have been approved by FDA. Many people believe that products with certain ingredients—vitamin C or Echinacea, for example—can treat winter illnesses.

Continued on page 82

80 The OR Connection

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Unless FDA has approved a product for treatment of specific symptoms, you cannot assume that the product will treat those symptoms. Tell your health care professionals about any supplements or herbal remedies you use. Read medicine labels carefully and follow directions. People with certain health conditions, such as high blood pressure, should check with a health care professional before taking a cough and cold medicine. Some medicines can worsen underlying health problems. Choose appropriate OTC medicines. Choose OTC medicines specifically for your symptoms. If all you have is a runny nose, only use a medicine that treats a runny nose. This can keep you from unnecessarily doubling up on ingredients, a practice that can prove harmful. Check the medicine’s side effects. Certain medications such as antihistamines can cause drowsiness. Medications can interact with food, alcohol, dietary supplements, and each other. The safest strategy is to make sure your health care professional knows about every product you are taking, including nonprescription drugs and any dietary supplements such as vitamins, minerals, and herbals. Check with a doctor before giving medicine to children. Get medical advice before treating children suffering from cold and flu symptoms. Do not give children medication that is labeled only for adults. Don’t give aspirin or aspirin-containing medicines to children and teenagers. Children and teenagers suffering from flu-like symptoms, chickenpox, and other viral illnesses shouldn’t take aspirin. Reye’s syndrome, a rare and potentially fatal disease found mainly in children, has been associated with using aspirin to treat flu or chickenpox in kids. Reye’s syndrome can affect the blood, liver, and brain.

82 The OR Connection

Some medicine labels may refer to aspirin as salicylate or salicylic acid. Be sure to educate teenagers, who may take OTC medicines without their parents’ knowledge.

When to See a Doctor See a health care professional if you aren’t getting any better or if your symptoms worsen. Mucus buildup from a viral infection can lead to a bacterial infection. With children, be alert for high fevers and for abnormal behavior such as unusual drowsiness, refusal to eat, crying a lot, holding the ears or stomach, and wheezing. Signs of trouble for all people can include • a cough that disrupts sleep • a fever that won’t go down • increased shortness of breath • face pain caused by a sinus infection • worsening of symptoms, high fever, chest pain, or a difference in the mucus you’re producing, all after feeling better for a short time Cold and flu complications may include bacterial infections (e.g., bronchitis, sinusitis, ear infections, and pneumonia) that could require antibiotics. Remember: While antibiotics are effective against bacterial infections, they don’t help against viral infections such as the cold or flu.

Find this and other Consumer Updates at Sign up for free e-mail subscriptions at Article courtesy of the Food and Drug Administration (FDA).

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84 The OR Connection

Caring for Yourself

8 Principles For Achieving Inner Peace by Wolf J. Rinke, PhD, RD, CSP Travel alerts, seemingly never ending natural and manmade disasters, cranky patients bugging you…stress accelerating at logarithmic speed! We certainly live in a very unsettling and stressful time. A time where achieving inner piece seems totally out of reach. And yet I have found that you can attain it by relentlessly practicing the eight principles that follow.

1. Be honest BP, politicians, clergy … do I need to say more? But before you get too smug, better look at the face in the mirror. Study after study has shown that most people lie. We inflate our resumes, fudge our accomplishments and exaggerate even inconsequential events. And when we lie there is no trust, and without trust you can’t have solid relationships, without relationships there is no love, and without love you won’t have inner peace. Call me old-fashioned; I believe there is no excuse for lying … none. There is not even a good reason for exaggerating. Because if you do, you will have to talk from the head, always checking your memory to make sure you are consistent. And who can keep track of that, when most of us have trouble remembering where we put our car keys. Only by getting in the habit of always telling the truth—especially if it is at your own expense—will you be able to talk form the heart and that will set you free. This in turn will enhance your leadership skills because people follow people they can trust. And it will put you on the fast track in any endeavor. It will also enrich your personal relationships and, most importantly, will get you to like and respect yourself—the foundation for achieving inner peace.

2. Think empowering thoughts As a man thinkest, so he becomes, says the Bible. And yet most of the time we are totally inattentive to our thoughts. It’s almost like they run amok—totally out of control—doing their own thing. To achieve inner peace requires us to first become aware of our thoughts—instead of just letting them ruminate at the subconscious level. Second we must ask ourselves: is this a thought that empowers me and makes me stronger, or does it make me feel mad, bad or sad? And third we must become aware that at any one nanosecond our minds can hold only one thought. It can be a positive thought that gives us inner peace and improves our quality of life, or it can be a negative thought that does just the opposite. It’s so simple, yet difficult, to develop this powerful new awareness and transform it into a habit.

3. Take advantage of the abundance all around you When we are struggling and having trouble making ends meet, it is really difficult to see the abundance. What we see instead—almost oppressively—is scarcity. I know firsthand. Having been born right after World War II in Germany, with my parents losing all their earthly possessions—yes, everything—we had less than scarcity, we had desperation. Finding enough food and shelter to keep us alive is what consumed my parents. Then some 17 years later—when I immigrated to the United States—scarcity, although not as extreme, reared its ugly head again. Basi-

Aligning practice with policy to improve patient care 85

8 Principles For Achieving Inner Peace

cally I only spoke a few words of English, had $20 in my pocket and the proverbial shirt on my back. And I certainly had trouble finding all “the milk and honey” that supposedly was just waiting for me. However, it was all around me, and over time I learned to find it by internalizing a powerful concept that I learned from several different mentors: If you want more of something, you have to give it first. I know it sounds counterintuitive. (By the way, lots of things are…otherwise men would ride sidesaddle. If that didn’t at least make you smile, you’re taking this much too seriously.) Here is how it works: If you want more love in your life, give more love. If you want to be happier, make others happy. If you want people to trust you, give unconditional trust. Of course the only way you can take advantage of this principle is to internalize the next one.

4. Take really great care of #1 first Gotcha! Especially if you are a cynic. Those who are cynics immediately translate this into selfishness, conceit and greed. Nothing; however, could be further from the truth. (Why do you suppose that in an emergency, you are told to put your oxygen mask on first, before you help anyone else, even your own child?) It’s also important to remember that you can’t give away what you don’t own. Going back to the previous paragraph. If you want to love someone you must first love yourself, if you want to be happier you must choose to be happy. It you want to trust someone…I’m sure by now you’re catching on. Achieving inner peace requires you to begin to love who you are, not who you ought to be…by someone else’s standard, whether that’s your parents, spouse or friend. The unvarnished fact is that at this very nanosecond you are who you are. And no wishing, hoping or praying is going to change that one iota. Now, who you will become in the future will be determined by your thoughts (see Principle #2), which in turn will drive the actions you take.

86 The OR Connection

So begin right now to become your own best friend, because if it is not you, who is it going to be? In addition to taking really great care of your thoughts, also take extraordinary care of your body. And if you want to avoid psychosomatic illnesses—which, as you probably know, account for the majority of illnesses in this country—then you must eat right—which means you learn to stop when it tastes the best. Get adequate rest—seven to eight hours of sleep is a great start—and do 25-30 minutes of aerobic exercise three times per week, alternating with strength training for the other three days. (Go ahead and take Sunday off.) It also means that you don’t put stuff into your body that does not belong there—read drugs and nicotine. (Please don’t yawn. This is important. You only will be given one body—a the one you’ve got is it. So treat it accordingly.)

5. Become your own creator Movie directors, such as James Cameron of Avatar, are geniuses at creating exciting “realities.” You can be your own “creator” once you realize that there is no reality. There is only perception. (No, I haven’t lost it.) Let me explain with a wonderful story: A young man was interviewing for his dream job. He had done his homework. He spent hours on the Internet learning all he could about the hospital of his choice and the people he was going to be interviewing with. He had read the last three annual reports and knew the hospital’s mission, vision and core values by heart. In short he was ready to ace this interview. On the big day, he entered the impressive lobby of the hospital and had to check in with the security guard to get his visitor badge. Wanting to leave no stone unturned he said to the elderly gentleman behind the desk, “Sir, I’m interviewing for my dream job today. Tell me about the people at this hospital. What are they like?” The elderly man replied with a question. “Tell me young man, what were the people like at the last hospital you worked for?” “Oh, they were deceitful, unsupportive and mean. There simply was no vestige of teamwork or joy. In fact that’s why I left.” “Well,” the security guard answered, “I believe you will find the same kind of people here.” Continued on page 88

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Just about an hour later the scene repeated itself all over again. Except this time it was a young lady who was also interviewing for the same job. She, too, had done her homework and wanted to make a great impression. She also asked the security guard, “What are the people like around here?” In turn, he asked, “What were they like where you came from?” The vivacious young lady answered, “Oh, I just loved the people at my former hospital. They were kind, supportive and hardworking. Everyone worked together as a team. We cared so much for each other that I developed some of the best friendships. It’s really a shame that my husband is relocating to this area. I just hate to leave all those wonderful people behind.” “Well,” the wise elderly man answered, “I believe you will find the same kind of people here.”

6. Let go of the past It’s amazing how much we mental energy we spend in a place over which we have absolutely no control—the past. It was Dr. Wayne Dyer who likened our past to a bag of manure that we carry around with us. We keep putting more and more manure into the bag. Once in a while we put the bag down, reach in and smear manure all over

88 The OR Connection

us. And then, we wonder why our life stinks. Part of what we carry around in our bag is resentment, hate and blame. All of these emotions will attack our souls and diminish the quality of our spirit and our physiology. Instead, go ahead pay tribute to your past. Visit it. And then toss it in the trash. You can make that happen by taking ownership of all that is going on in your life. Your life is not a function of what other people have done to you; it is today what it is because of the choices you have made in the past. And if your feelings of resentment, hate and blame are attributed to the actions of others, then you have to wait for those people to change—which may never happen. And don’t even try to change them! Think about how many of us have difficulty changing ourselves, let alone others. Instead live by the axiom: If it is to be it is up to me. Once you’ve done that, you are ready to take it to the next level by substituting the emotions of love, empathy and kindness for resentment, hate and blame, which will put you on the fast track to inner peace. And while you are at it, force yourself to get off your case, quit living in the past, and become future-oriented by learning from every action. If an action gives you the results you desired, keep doing it. If the action did not accomplish the intended result,

review what happened; make a commitment to do it differently in the future, then quit doing it and let it go. No wait, I mean really let it go. Get on with your life by refocusing your thoughts on the only moment you and I have any control over, the now. 7. Kill your ego Ego, right along with greed and envy, is one of the most powerful destroyers of inner peace. A look at history confirms that these emotions are responsible for more evil. Think Napoleon, Stalin and Hitler—and more corporate catastrophes. Think Toyota’s and even venerable Johnson & Johnson’s recent recalls—as well as relationship killers. And yet we can get rid of our ego with just five powerful phrases expressed liberally and from the heart: • You are right about that. Any time you get into a conflict, use this phrase and you will have no more conflict— guaranteed! • I’ve made a mistake. This phrase helps you get off your high horse gracefully. All human beings make mistakes— and since you are a…I think you get it. There is only one omnipotent force in the universe—and it is not you. So quit defining unrealistic expectations for yourself. • I changed my mind. You are an evolving human being, one who is like red wine and gets better all the time. That means you have to let go of your past beliefs. (Remember that the only person who can change his/her mind is the one who has one.) • I don’t know. Admit it. You don’t know everything. It lets other people know that you have high levels of self-esteem. (Only people who are OK inside of their own skin can admit they don’t know everything.) • Let’s agree to disagree. The phrase to use if all else fails. By the way, do try all five of these at home; the positive results will astound you.

8. Never give up on your dreams The purpose of life is not to make it safely to the grave. Pursue your dreams no matter how late or how “weird.” Let me share an example. Doris Haddock had a passion. She felt that Congress needed to get off their duff and change the campaign finance laws! Unlike most of us; however, Doris did not sit around and complain and whine. Instead, Doris started to walk from Pasadena, Calif.; walking 10 miles a day, every day. Fourteen months and 3,200 miles later she arrived in Washington, DC. Now, here comes the startling part of the story. Doris, better known as Granny D, had a severe case of arthritis, wore a brace and turned 90 years “young” while on the trail. And for an added measure, she was arrested twice demonstrating for her beliefs. Why? Because she had a dream and a passion. So whatever you do, don’t ever give up on your dreams, it’ll make you cranky. Instead, get off your butt and act on your dreams today, and you, too, will be on the road to achieving the most coveted of all possessions—inner peace. © 2010 Wolf J. Rinke

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

Aligning practice with policy to improve patient care 89

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Special Feature


Pink Glove Dance: The Sequel From Halifax, Novia Scotia to San Francisco, California, Medline traveled across North America in 2010 showcasing the spirit of breast cancer survivors and caregivers who performed in the Pink Glove Dance: The Sequel. To see videos of Pink Glove Dancers in action visit Thank you, Pink Glove Dancers, for welcoming us to your city! • New York, NY • La Jolla, CA • Chicago, IL • Portland, OR • San Francisco, CA • New Orleans, LA • Indianapolis, IN • Denver, CO • Minneapolis, MN • Halifax, Novia Scotia • Richmond, VA • Plano, TX • Tallahassee, FL • Baltimore, MD • Newark, NJ

92 The OR Connection

Pink Gloves for a Cause Our goal is to create a Pink Glove Nation – that is, get as many people as possible talking about breast cancer and to raise awareness for early detection. To that end, partial proceeds from our pink gloves and other pink ribbon products are donated to the National Breast Cancer Foundation (NBCF) to help fund mammograms for women who cannot afford them. Medline presents a donation check to the NBCF each year during the Breast Cancer Awareness Breakfast at the Association of periOperative Nurses (AORN) Congress.

SAVE THE DATE! Medlineâ&#x20AC;&#x2122;s Breast Cancer Awareness Breakfast AORN Congress March 19 - 24, 2011 Philadelphia, PA

Providence St. Vincent Medical Center. Portland, OR

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Aligning practice with policy to improve patient care 93

Pink Glove Dance: The Sequel

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Providence St. Vincent Medical Center. Portland, OR

University of Minnesota Medical Center, Fairview. Minneapolis, MN

94 The OR Connection

HCA Johnston â&#x20AC;&#x201C; Willis Hospital. Richmond, VA

Tallahassee Memorial Healthcare, Inc. Tallahassee, FL

Indiana University Melvin and Bren Simon Cancer Center. Indianapolis, IN

Aligning practice with policy to improve patient care 95

Healthy Eating

Nutrition Information Servings: 6 Calories: 749 Fat: 19.5 g Sodium: 1427 mg Fiber: 21.8 g

Crock Pot Chili 1 lb. lean ground beef 1 lb. lean ground turkey 4 teaspoons chili powder 1 teaspoon ground cumin 1 large onion, chopped 2 jalapeno peppers, chopped

1 green pepper, chopped 4 teaspoons minced garlic 1 16-ounce can tomato sauce 1 16-ounce can diced tomatoes 1 15-ounce can chili with beans 1 6-ounce can tomato paste

Directions: Place ground beef and ground turkey in a large skillet, along with 1 teaspoon chili powder and 1 tsp. ground cumin. Cook until crumbled and brown. Drain and place in crock pot. Spray empty skillet with cooking spray. Saute onion, garlic, jalapenos and green pepper until tender. Place in crock pot. Add tomato sauce, diced tomatoes, beer, chili with beans and tomato paste. Simmer 20 minutes on high setting. Add kidney beans, chili beans, 3 teaspoons chili powder, pepper and hot sauce and simmer at least 30 minutes.

1 15-ounce can kidney beans 1 15-ounce can spicy chili beans 1 bottle beer 1 teaspoon black pepper (or to taste) Hot sauce to taste

recipe in Medline’s 2010 Chili Cookoff. She offers product expertise for Medline customers, sales representatives and customer service reps in the areas of diabetic testing, diagnostics, sharps containers, over-the-counter medications, enterals, oral care, ReadyBath and wet wipes. Jennifer originally found her chili recipe in one of her husband’s fitness magazines, and they have tweaked it a little over the years to get it just right. “It’s a healthier chili recipe, made with lean meat,” she said. You’ll also notice that the onions and peppers are sautéed with cooking spray rather than oil.

“I find the longer it simmers, the better the taste, so after the last round of ingredients are added, I let it simmer on low for 6 to 8 hours,” Jennifer said.

Jennifer has always enjoyed cooking, having learned by watching her mother from the age of six. Her favorite meals include seafood with lots of butter and garlic.

Senior Product Specialist Jennifer Sutschek, who has worked Medline’s corporate headquarters in Mundelein, Ill. since 1998, won second place for this

In addition to cooking, Jennifer, who lives on Illinois’ Chain O’Lakes with her husband and two children, enjoys water sports, such as boating, and in the winter months, she enjoys snowmobiling and skiing.

96 The OR Connection

Forms & Tools

The following pages contain practical tools for implementing patient-focused care practices at your facility.

Surgical Safety AORN Surgical Time Out . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .99 SCOAP Surgical Safety Checklist - Ambulatory Surgery . . . . . . .100 SCOAP Surgical Safety Checklist . . . . . . . . . . . . . . . . . . . . . . . .101 Wrong-Site Surgery Prevention Tool . . . . . . . . . . . . . . . . . . . . . .103 Patient Education Medicare & the New Healthcare Law . . . . . . . . . . . . . . . . . . . . .105 Tips for Safer Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .109 Caring for Your Surgical Incision at Home . . . . . . . . . . . . . . . . . .111

Aligning practice with policy to improve patient care 97

The benefits of counting and detection in one advanced system.

The SmartSponge® System takes the worry out of finding and counting surgical sponges There’s no greater relief than getting an accurate surgical sponge count. The SmartSponge System counts, locates and recounts each sponge up to 80,000 times during a single surgery. And because it is the only FDA-approved system that uses radio-frequency identification, it uniquely identifies each sponge , so you can use the SmartWand-DTX™ to find missing sponges below, beside or inside a patient

A quick demonstration of how the ClearCount SmartSponge System can make your time in the O.R. a little less stressful. Call your Medline representative for details.

©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc. SmartSponge is a registered trademark and SmartWand-DTX is a trademark of ClearCount Medical Sloutions.

Surgical Time Out

Forms & Tools



NAME: _______________________________________ DATE: ________________________________________ The use of Time Out is recommended by the Association of periOperative Registered Nurses (AORN), the Joint Commission Universal Protocol, and the World Health Organization (WHO). For more information on Time Out and how it can save patient lives, visit

Aligning practice with policy to improve patient care 99

Forms & Tools

Surgical Checklist

Ambulatory A mbulatory Surgery Surgery V Version ersion 1.1 1.1

Step 1: P Step Prior rior to to Incision Incision ALL A LL TEAM TEAM MEMBERS MEMBERS STOP STOP A ACTIVITY CTIVITY AND AND BEGIN BEGIN CHECKLIST CHECKLIST ‰ Team Team Members Members introduce introduce themselves themselves (w (when hen personnel personnel h have ave c changed) hanged) patient, verify procedure ‰ Introduce Introduce p atient, v erify consent, consent, p rocedure ‰ Confirm marked single orr multiple operative Confirm site site m arked and and iiff there there iis sas ingle o multiple o perative ffield ield

Anesthesia A nesthesia T Team eam Reviews Reviews ‰ Airway Airway iissues ssues o orr other other p patient-specific atient-specific co concerns ncerns ((special special m meds, eds, health health conditions conditions affecting affecting rrecovery, aff ecovery, etc.) etc.) ‰ Patient Patient a llergies reviewed reviewed allergies

‰ N/A N/A

‰ Antibiotics Antibiotics given given within within 60 60 mins mins before before incision incision

‰ N/A N/A

Surgeon S urgeon R Reviews eviews ‰ Brief Brief d description escription of of p procedure rocedure and and a anticipated nticipated d difficulties ifficulties needed, supplies ‰ Describe Describe iimplants mplants n eeded, unusual unusual iinstruments nstruments OR s upplies

‰ N/A N/A

‰ Confirm Confirm that that essential essential imaging imaging is is displayed displayed and and correctly correctly oriented oriented

‰ N/A N/A

Nursing N ursing T Team eam R Reviews eviews ‰ Confirm Confirm th that at supplies supplies a and nd iimplants mplants a are re av available ailable

‰ N/ N/A A

‰ If expiration If using using an an iimplant, mplant, confirm confirm e xpiration dates dates

‰ N/A N/A

Step 2: P Process rocess C Control ontrol IF PR PROCEDURE OCEDURE IS IS EXPECTED EXPECTED TO TO B BE E LONGER LONGER T THAN HAN ONE ONE HO HOUR: UR: ‰ Active Active warming warming iin n place place

‰ N/A N/A

‰ Glucose Glucose checked checked for for diabetic diabetic patients patients

‰ N/A N/A

‰ VTE VTE p prophylaxis rophylaxis

‰ N/A N/A

Step 3 3:: Debriefing—At Debriefing—At Com Completion pletion of Case Case ‰ (Surgeon (Surgeon and and Nursing) Nursing) Before Before closure: closure: Confirm Confirm that that instrument, instrument, sponge, sponge, a and nd n needle eedle c counts ounts c correct orrect ‰ If If counts counts incorrect, incorrect, confirm confirm x x-ray -ray n negative egative ‰ (S (Surgeon urgeon a and nd N Nursing) ursing) Confirm Confirm s specimen, pecimen, llabel abel & instructions instructions to p pathologist athologist

‰ N/A N/A

‰ ((All) All) C onfirm n ame o rocedure Confirm name off p procedure ‰ ((All) All) E Equipment quipment issues issues to be be addressed? addressed? ‰ No ‰ Yes, Yes, a and nd response response p plan lan formulated formulated (Who/When) (Who/When) ‰ ((All) All) W What hat could could h have ave b been een b better? etter? ‰ Nothing Nothing

‰So Something, mething, with with plan plan to address address (Who/ (Who/ W When) hen)

‰ (Surgeon (Surgeon and and Anesthesia) Anesthesia) Key K ey c concerns oncerns fo forr rrecovery ecovery (e (e.g., .g., p plan lan for for p pain ain management, management, nausea/vomiting) n ausea/vomiting) Š Adapted Adapted from from tthe he WHO WHO ""Safe Safe S Surgery urgery Saves Saves Li Lives" ves" campaign campaign an and d the the W WASCA/Proliance ASCA/Proliance Surgeons Surgeons S Surgical urgical Checklist Checklist Š SCOAP iiss a program program of the the Foundation Foundation for for H ealth Care Care Quality Quality SCOAP Health w rrev ev 1/ 1/19/2010 19/2010


The OR Connection

Surgical Checklist

Forms & Tools

SCOAP SCOAP Surgical Surgical Checklist Checklist

Version Version 3.7 3. 7 (July (July 2010) 2010 )

Before Before Skin Skin Incision: I n c is io n : Briefing Briefing All A lll Te Al T eam M Me e m bers b er e rs r Team Mem A tt t te tending S u r g e on o n Leads) L e a ds ds): Surgeon ((Attending (A E ach p erson introduces introduces self self Each person by name by n ame and and role ro le Surgeon, A nesthesia team team and and Surgeon, Anesthesia N u rs e c onfirm patient patient (at (at least le a s t 2 Nurse confirm identifiers), site, site, procedure p ro c e d u re identifiers), Personnel exchanges: exchanges: timing, timing, Personnel plan ffor or announcing announcing changes change s plan Description of of procedure procedure and and Description anticipated anticipated difficulties d iffic u ltie s Expected duration duration o p ro c e d u re Expected off procedure Expected blood blood loss loss & blood blood availability availability Expected Need ffor or instruments/supplies/IV in s tru m e n ts /s u p p lie s / IV Need access beyond access b eyond tthose hose normally n o rm a lly used procedure u sed for o the he p ocedu e Ques ons ssues from om any any Questions/issues team and eam member m em be a nd Invitation nv a on to o speak speak up up a any any time me in n the he procedure p ocedu e at

N u r s i ng Nu n g/ g / T e ch c h reviews: r e v ie w s : Nursing/Tech

A n e s th An t h es e s i a reviews: r e v ie w s : Anesthesia

Equipment issues issues (instruments (in s tru m e n ts Equipment ready, ready, trained trained on, on, requested re q u e s te d implants implants available, available, gas gas tanks tanks full) full) Sharps management management plan plan Sharps Other patient patient concerns c o n c e rn s Other

Air irw way or or other other concerns concerns Airway Special meds m eds Special ((beta beta blockers, blockers, etc.) e tc .) Allergies Allergies Conditions affecting affecting recovery re c o v e ry Conditions

Process Control Control Process A cases: cases All

case expected expec ed to o be be If case

S ur u rg r g e o n reviews ev ews (as as applicable): app cab e Surgeon

S u r g eo Su e o n reviews: ev ew s Surgeon

Essen a imaging mag ng displayed; d sp a y e d Essential gh and and left e confirmed con m ed right An b o c prophylaxis p ophy ax s given g ven in n Antibiotic as 60 60 m nu es last minutes Ac ve w a m ng in n place p a ce Active warming Spec a instruments ns umen s and/or and o implants m p an s Special

ou add: add 1h hour,

G ucose checked checked for o diabetics d abe cs Glucose nsu n protocol p o oco initiated n a ed if needed neede d Insulin DVT PE chemoprophylaxis chemop ophy ax s and/or and o mechanical m echan ca DVT/PE p ophy ax s plan p an in n place p ace prophylaxis pa en on on beta be a blocker, b ocke post-op pos o p If patient p an formulated o m u a ed plan Re dos ng plan p an for o antibiotics an b o cs Re-dosing Spec a y spec c checklist check s Specialty-specific

Just Before Before C lo s u re o p e ra tiv e F ie ld Just Closure off O Operative Field No Retained Retained O bjects No Objects A ttt en At e nd d ng n g Su S u r g e on o : Attending Surgeon

Nu u rs ur s ng Te T e ch ch: Nursing/Tech

Pe o m m e hod ca visual v sua and and physical p h y s ca Perform methodical sweep of the s w eep o he wound w ound

A music, mus c conversation, conve sa on and and distractions d s ac ons halted ha ed All Pe o m preliminary p e m na y count coun of o Perform needles/sponges/instruments need es sponges ns um en s Show Surgeon Su geon and and Anesthesia Anes hes a all a sponges sponges and and Show laps aps in n holders ho de s (“Show Show Me Me Ten”) Ten

A fte r S kin Closure C lo su re C omplete: e: After Skin Complete: No Retained Retained Objects, Objects, Debriefing, Debriefing, C are Transition Transition No Care A Te T e a m Me M e m bers b er e rs r s ((Attending A t te t e nd ng n g Su S u r g e on o n Leads) L e a ds d s) s : All Team Mem Surgeon Con m final na needles/sponges/ need es sponges instruments ns umen s count coun correct co ec Confirm Nu s ng Tech show show Surgeon Su geon and and Anesthesia Anes hes a all a sponges sponges and and laps aps in n Nursing/Tech holders h o de s (“Show Show Me Me Ten”) Ten C on m n ame of o procedure p ocedu e Confirm name pec m en c on m label abe and and instructions ns uc ons (e.g., e g orientation o en a on of o If s specimen, confirm specimen, 12 s pec m en 1 2 lymph ymph nodes nodes for o colon co on CA) CA Equ pmen issues ssues to o be be addressed? a d d e sse d ? Equipment Response planned p anned (who/when) w h o w hen Response W ha c ou d have have been been better? be e ? What could Improvement planned m p ov em en p anned (who/when) w h o w hen

Su urgeon a ur nd Anesthesia A n es e st s t h es es a: Surgeon and Key concerns conce ns for o patient pa en recovery e co v e y Key Wha is s the he plan p an for o pain pa n management? m anage m en ? What Wha is s the he plan p an for o prevention p even on of o PONV? P O NV ? What Does patient pa en need need special spec a monitoring mon o ng (time me Does in n RR, RR ICU, CU tele?) e e? pa en has has elevated e eva ed blood b ood glucose, g ucose plan p an for o If patient insulin nsu n drip d p formulated o m u a ed pa en on on beta be a blocker, b ocke post-op pos op continuation con nua on If patient plan p an formulated o m u a ed

A gn ng pract ce w th po cy to mprove pat ent care 101

ARGLAES® IN THE OR ANTIMICROBIAL SILVER TECHNOLOGY Use silver to fight bacteria and surgical site infections Arglaes provides: • • • • •

Antimicrobial protection for up to 7 days Moist wound healing Fewer dressing changes Non-attaining assay Transparency for wound monitoring

The Arglaes family of products has something for every incision: • Arglaes Film is ideal for managing bacterial penetration on post-op incision and line sites. • Arglaes Island features a calcium alginate pad for fluid management in addition to controlled-release silver.

To schedule a FREE demonstration of Arglaes in your OR, contact your Medline representative, call 1-800-MEDLINE or visit

©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc. Arglaes is a registered trademark of Giltech Limited Corporation.

Aligning practice with policy to improve patient care 103 CASE #2
























CASE #10

CASE #10

CASE #10

Page 1





2010 Pennsylvania Patient Safety Authority

Site marking was confirmed by intraoperative imaging, if for vertebrae, ribs, or ureters

Site marking was visible after patient was positioned, prepped, and draped

Site marking included discussion with patient

Site marking occurred before administration of sedative and/or anesthesia

Site marking occurred after reconciliation of all documents (schedule, consent, H&P)

OR staff member marking the site used his or her initials

Duration for the surgeon to complete the verification process and marking process

Site Marking

Verification included patient's understanding of the procedure

Verification included history and physical (H&P)

Verification included consent

Verification included OR schedule

Verification and documentation were completed independently by at least two providers

Preoperative Verification (a standardized checklist is suggested)

Consent was completed (including exact procedure, all required signatures, dates)

Exact description of procedure was on consent (including site, level, side, digit)

Exact description of procedure was on OR schedule (including site, level, side, digit)

Scheduling/Consent (a standardized form is suggested)

Perform 10 unannounced observations of operating room (OR) cases, preferably orthopedic with laterality, spinal, eye, and other procedures on extremities. Exclude cardiac and upper abdominal surgeries. For each blank box, indicate: Yes if element/action was completed as described, No if element/action was not completed as described, or N/A if not applicable. Document time in minutes where indicated.

Wrong-Site Surgery Prevention Observational Monitoring Tool


Facility name:

Wrong-Site Surgery Forms & Tools


Time-Out (a standardized tool is suggested)

Revised August 2010









CASE #10





2010 Pennsylvania Patient Safety Authority






Page 2

CASE #10



Adapted with permission from the Health Care Improvement Foundation

All patient information and specimens were removed from the OR before the next patient arrived

OR Turnover

Surgeon encouraged the entire surgical team to speak up if there were any concerns

Nurses were engaged during time-out—all work stopped and verbal acknowledgement occurred

Anesthesia provider was engaged during time-out—all work except ventilation stopped and verbal acknowledgement occurred

Surgeon was engaged during time-out—all work stopped and verbal acknowledgement occurred

Diagnostic, radiology, and pathology results were verified during time-out

All documents (schedule, consent, H&P) were verified during time-out

The final time-out was conducted after patient was positioned, prepped, and draped

A separate time-out was conducted prior to regional or local anesthesia, if applicable

Duration to complete the time-out

The OR Connection


Forms & Tools Wrong-Site Surgery

Patient Handout - Medicare




Forms & Tools


MAY 2010

Medicare and the New Health Care Law — What it Means for You A Message from Kathleen Sebelius, Secretary of Health & Human Services The Affordable Care Act passed by Congress and signed by President Obama this year will provide you and your family greater savings and increased quality health care. It will also ensure accountability throughout the health care system so that you, your family, and your doctor—not insurance companies—have greater control over your care. These are needed improvements that will keep Medicare strong and solvent. Your guaranteed Medicare benefits won’t change—whether you get them through Original Medicare or a Medicare Advantage plan. Instead, you will see new benefits and cost savings, and an increased focus on quality to ensure that you get the care you need. This brochure provides you with accurate information about the new services and benefits to help you and your family now and in the future. The Centers for Medicare & Medicaid Services (the federal agency that runs the Medicare, Medicaid, and Children’s Health Insurance Program) will continue to provide you with up-to-date information about these new benefits and will ensure that your personal information is safe. Remember—rely on your trusted sources of information when it comes to accurate information about Medicare, and don’t hesitate to call 1-800-MEDICARE or go on-line at if you have questions or concerns. Don’t give your personal Medicare information to anyone who isn’t a trusted source.

Aligning practice with policy to improve patient care 105

Forms & Tools

Patient Handout - Medicare


2 What Stays the Same The guaranteed Medicare benefits you currently receive will remain the same. During open enrollment this fall, you will continue to have a choice between Original Medicare and a Medicare Advantage plan. Medicare will continue to cover your health costs the way it always has, and there are no changes in eligibility. But, there are some important benefits that you and your family can take advantage of starting this year. Look for more details in your Medicare and You Handbook coming this fall.

Improvements in Medicare You Will See Right Away More Affordable Prescription Drugs • If you enter the Part D “donut hole” this year, you will receive a one-time, $250 rebate check if you are not already receiving Medicare Extra Help. These checks will begin mailing in mid-June, and will continue monthly throughout the year as beneficiaries enter the coverage gap. • Next year, if you reach the coverage gap, you will receive a 50% discount when buying Part D-covered brand-name prescription drugs. • Over the next ten years, you will receive additional savings until the coverage gap is closed in 2020.

Important New Benefits to Help you Stay Healthy • Next year you can get free preventive care services like colorectal cancer screening and mammograms. You can also get a free annual physical to develop and update your personal prevention plan based on current health needs.

Improvements to Medicare Advantage • Today, Medicare pays Medicare Advantage insurance companies over $1,000 more per person on average than Original Medicare. These additional payments are paid for in part by increased premiums by all Medicare beneficiaries—including the 77% of seniors not enrolled in a Medicare Advantage plan. • The new law levels the playing field by gradually eliminating Medicare Advantage overpayments to insurance companies. • If you are in a Medicare Advantage plan, you will still receive guaranteed Medicare benefits. • Beginning in 2014, the new law protects Medicare Advantage members by taking strong steps to ensure that at least 85% of every dollar these plans receive is spent on health care, rather than administrative costs and insurance company profits. 106

The OR Connection

Aligning practice with policy to improve patient care 106

Patient Handout - Medicare

Forms & Tools


3 Improvements in Medicare You Will See Soon Better Access to Care • Your choice of doctor will be preserved. • The law increases the number of primary care doctors, nurses, and physician assistants to provide better access to care through expanded training opportunities, student loan forgiveness, and bonus payments. • Support for community health centers will increase, allowing them to serve some 20 million new patients.

Better Chronic Care • Community health teams will provide patient-centered care so you won’t have to see multiple doctors who don’t work together. • If you’re hospitalized, the new law also helps you return home successfully—and avoid going back—by helping to coordinate your care and connecting you to services and supports in your community.

Improvements Beyond Medicare That You and Your Family Can Count On Improves Long-Term Care Choices • New tools and resources in the Elder Justice Act, which was included in the new law, will help prevent and combat elder abuse and neglect, and improve nursing home quality. • The new law creates a new voluntary insurance program called CLASS to help pay for long-term care and support at home. • Individuals on Medicaid will receive improved home- and communitybased care options, and spouses of people receiving home- and communitybased services through Medicaid will no longer be forced into poverty.

Helps Early Retirees • To help offset the cost of employer-based retiree health plans, the new law creates a program to preserve those plans and help people who retire before age 65 get the affordable care they need.

Helps People with Pre-existing Conditions • The new law provides affordable health insurance through a transitional high-risk pool program for people without insurance due to a pre-existing condition. • Insurance companies will be prohibited from denying coverage due to a pre-existing condition for children starting in September, and for adults in 2014. • Insurance companies will be banned from establishing lifetime limits on your coverage, and use of annual limits will be limited starting in September.

Expands Health Coverage for Young People • Young people up to age 26 can remain on their parents’ health insurance policy starting in September.

Aligning practice with policy to improve patient care 107

Patient Handout - Medicare

Forms & Tools


4 The New Law Preserves and Strengthens Medicare New Tools to Fight Fraud and Protect Your Medicare Benefits • The new law contains important new tools to help crack down on criminals seeking to scam seniors and steal taxpayer dollars. • It reduces payment errors, waste, fraud, and abuse to make Medicare more efficient and return savings to the Trust Fund to strengthen Medicare for years to come. • You are an important resource in the fight against fraud. Be vigilant and rely only on your trusted sources of information about your Medicare benefits. • Call 1-800-MEDICARE if you have any questions or want to report something that seems like fraud.

Keeps Medicare Strong and Solvent • Over the next 20 years, Medicare spending will continue to grow, but at a slightly slower rate as a result of reductions in waste, fraud, and abuse. This will extend the life of the Medicare Trust Fund by 12 years and provide cost savings to those on Medicare. • In 2018, seniors can expect to save on average almost $200 per year in premiums and over $200 per year in co-insurance compared to what they would have paid without the new law. • Upper-income beneficiaries ($85,000 of annual income for individuals or $170,000 for married couples filing jointly) will pay higher premiums. This will impact about 2% of Medicare beneficiaries.

For More Information For more information about the new health care law now, visit If you have any questions, call 1-800-MEDICARE (1-800-633-4227) or your State Health Insurance Assistance Program (SHIP). Visit or call 1-800-MEDICARE to get their telephone number. TTY users should call 1-877-486-2048. If you need help in a language other than English or Spanish, say “Agent” at any time to talk to a customer service representative. Visit the Eldercare Locator at to find out how to access home- and communitybased services and benefits counseling, transportation, meals, home care, and caregiver support services. You can also call 1-800-677-1116. The Eldercare Locator, a public service of the U.S. Administration on Aging, is your first step for finding local agencies in every U.S. community.

CMS Product No. 11467


The OR Connection

Patient Handout

Forms & Tools







Aligning practice with policy to improve patient care 109

Forms & Tools

Patient Handout



"CPVU4$*1 " CPVU4$*1




The OR Connection



OR Connection Aligning practice with policy to improve

patient care

Patient Handout

Forms & Tools

Caring for Your Surgical Incision at Home The following are general guidelines. Consult your surgical team for more specific instructions.

Bathing and Showering Most incisions should be kept dry for several days after surgery, except for incisions closed with surgical glue. It is usually safe to allow glued incisions to get wet while showering or bathing. It is important, however, to dry the area around the incision carefully after washing. Physical Activity and Exercise Avoid any activity that pulls on the edges of the incision or puts pressure on it. Walking and other light activities are encouraged to restore normal energy levels and digestive functions. Do not, however, participate in sports, engage in sexual activity or lift heavy objects until after your postoperative checkup.

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

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 10 and 11.

Aspirin Avoid aspirin or over-the-counter medications containing aspirin for a week to 10 days after surgery. Aspirin interferes with blood clotting and makes it easier for bruises to form near the incision. Sun Exposure As an incision heals, the new skin that forms over the cut is very sensitive to sunlight and will burn more easily than normal skin and lead to worse scarring. Keep the incision area covered from direct sun exposure for three to nine months in order to prevent burning and severe scarring. General Hygiene Infection is the most common complication of surgical procedures. It is important, therefore, to minimize the risk of an infection when caring for your incision at home. Observe the following precautions: • Wash your hands carefully after using the toilet and after touching or handling trash; pets and pet equipment; dirty laundry and anything else that is dirty or has been used outdoors • Ask family members, close friends, and others to wash their hands before contact with you • Avoid contact with family members and others who are sick or recovering from a contagious illness • Stop smoking (smoking slows down the healing process)

Adapted from

Aligning practice with policy to improve patient care 111


The Aligning practice with policy to improve


patient care

Volume 5, Issue 4

Tips for

Tackling Introducing ...


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©2010 Medline Industries, Inc. Medline and Remedy are registered trademarks of Medline Industries, Inc.


Checklists Work

OR Connection Volume 5 Issue 4  

Medline's OR Connection Magazine, Volume 5, Issue 4 - FREE CE: Stuck Like Surgical Glue: New Uses And Improved Outcomes

OR Connection Volume 5 Issue 4  

Medline's OR Connection Magazine, Volume 5, Issue 4 - FREE CE: Stuck Like Surgical Glue: New Uses And Improved Outcomes