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The Aligning practice with policy to improve

patient care

Volume 6, Issue 1

FREE CE!

Special

AORN Issue! Breast Cancer Awareness Section Page 84 Turn up the heat on

HYPOTHERMIA Nurse Leaders Rate Patient Experience

#1

Man on a Mission: Hand Hygiene Expert Professor Didier Pittet


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Content Key We've coded the articles and information in this magazine to indicate which patient care initiatives they pertain to. Throughout the publication, when you see these icons you'll know immediately that the subject matter on that page relates to one or more of the following national initiatives: • IHI's Improvement Map • Joint Commission 2009 National Patient Safety Goals • Surgical Care Improvement Project (SCIP) We've tried to include content that clarifies the initiatives or gives you ideas and tools for implementing their recommendations. For a summary of each of the initiatives, see pages 8 and 9.


PATIENT SAFETY Editor Sue MacInnes, RD, LD Clinical Editor Alecia Cooper, BS, MBA, RN, CNOR Senior Writer Carla Esser Lake

6 8 10 11 14

Creative Director Mike Gotti

30

Clinical Team Jayne Barkman, BSN, RN, CNOR Lorri Downs, RN, BSN, MS, CIC Margaret Falconio-West, BSN, RN, APN/CNS,

34 47

CWOCN, DAPWCA Rhonda J. Frick, RN, CNOR

61

Mission: Improving Hand Hygiene Three Important Initiatives for Improving Patient Care Patient Safety News Provider Preventable Conditions Turn Up the Heat: Avoiding Surgical Complications with Adequate Patient Warming ClearCount Clearly Makes a Difference in Patient Safety at Hunt Regional Hospital VAP: What is the Perioperative Nurse’s Role in Prevention? The Quest to Improve Staff and Patient Safety: How One Health District Converted to Latex-Free Surgical Gloves Unity Hospital: Utilizing Medline’s ERASE CAUTI Program

Page 14

Anita Gill, RN Kimberly Haines, RN, Certified OR Nurse Rebecca McPherson RN, MSN Carla Nitz, BSN, RN Claudia Sanders, RN, CFA Megan Shramm, RN, CNOR, RNFA Angel Trichak, RN, BSN, CNOR Perioperative Advisory Board

OR ISSUES

40 79 84 101

The Ins and Outs of Hernias and Ways to Repair Them Upcoming Green Events & Green Facts Study of Breast Biopsies Finds Surgery Used Too Extensively Less Invasive Surgery Just as Effective for Some Breast Cancer Patients

Page 68

Larry Creech, RN, MBA, CDT Carilion Clinic, Virginia Sharon Danielewicz, MSN, RN, RNFA Cedar Park Regional Medical Center, Texas Tracy Diffenderfer, MSN, RN Vanderbilt University Medical Center, Tennessee Barb Fahey RN, CNOR Cleveland Clinic, Ohio Susan Garrett, RN Hughston Hospital Inc., Georgia Zaida I. Jacoby, MA, MEd, RN NYU Medical Center, New York Jackie Kraft, RN, CNOR Huntsville Hospital, Alabama Tom McLaren

SPECIAL FEATURES

5 International Hand Hygiene Expert Urges U.S. to Use “Five Moments” to Reduce Infection 56 Nurse Leaders Survey Results: Patient Experience Is #1 68 12 Ways to Reduce Hospital Readmissions 77 Medline Joins Greening the Operating Room Initiative 78 Medline Launches Sustainability Program 88 Celebrating Six Years of Spreading Breast Cancer Awareness 92 Straight from the Heart: Quotes About the Pink Glove Dance 95 Beyond a Reasonable Doubt: Open Communication Helps Jill Eikenberry Raise the Bar for Breast Cancer Awareness

Page 77

Page 92

Florida Hospital, Florida Susan Phillips, RN, MSH, CNOR University of North Carolina Hospitals Donna A. Pritchard, BSN, MA, RN, CNOR, NE-BC

CARING FOR YOURSELF

102 How to Energize Your Team 110 Recipe: Aunt Judy’s Tortilla Roll-Ups

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

FORMS & TOOLS

113 Highlights of AORN’s Revised Recommended Practices for Surgical Attire 120 CDC Hand Hygiene Poster 121 How Well Do You Know Pressure Points?

Page 102

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. ©2011 Medline Industries, Inc. The OR Connection is published by Medline Industries, Inc. One Medline Place, Mundelein, IL 60060. 1-800-MEDLINE.


The OR Connection Letter from the Editor

Last night I had the opportunity to have dinner with Professor Didier Pittet (one of the foremost authorities on hand hygiene). He spoke with great energy and passion about a number of pertinent topics, including The World Health Organization’s Hand Hygiene Campaign, the “Five Moments of Hand Hygiene,” and the hand hygiene compliance rates of most facilities in the United States as compared to other countries. What a fascinating man he is. One of his achievements is being appointed Commander of the British Empire (or CBE, an international honor that includes knighthood). This honor was awarded by Queen Elizabeth II in 2007 for his services in the prevention of healthcare-associated infection in the United Kingdom. He told the story, with great charm and humility, of what is was like to be “knighted” by the Queen of England for his contributions to safety and health care. He said that while it was a great honor, it was also quite stressful, as he was allowed to bring only two people with him to the actual ceremony … he chose his two daughters. You can probably imagine their pride as they got to watch their dad become only the second person from Switzerland ever to be so honored. I was enthralled, sitting across the table from this icon of healthcare safety and listening to his stories of knighthood, his early training and his current projects, which include recording the English narration for the “Hand Hygiene Dance Video,” originally performed and filmed at the University of Geneva. (Our cover photo for this edition is from the recording session.) Watch for an online link to the final production to be printed in an upcoming issue of The OR Connection! Dr. Pittet’s visit was just one of the amazing experiences I’ve had in the last few weeks. Barely a week ago I met with Dr. Haywood, Senior Vice President and Chief Medical Officer of VHA, and his team to discuss research pertaining to

HCAHPS, the patient experience survey that is on the minds of many nurse executives. I think it is so important to be aware of the concerns and priorities of hospital administration, so I’ve included on page 56 very recent survey results on what’s most important to nursing leaders today. Prior to Dr. Haywood’s visit, I had met with Kaiser Permanente on the West Coast to talk about healthcare innovations that can be explored and tested. I don’t mean innovations that are made up in a lab or in some corporate office, but real-life examples of how healthcare professionals, thought leaders and industry can work together to make your jobs simpler and to make the chaos of everyday practice easier to navigate. We’ve all been accustomed to how things have always been done. But this is a new era of change designed to support the healthcare worker while improving care. And you are a very important part of this model. This edition of The OR Connection is being launched at the AORN 58th Congress, March 18-24, 2011, in Philadelphia, Pennsylvania – my hometown. For those attending the Congress, Medline has included a list of items on page 66 that we will be featuring at our Booth #3408. If you don’t get a chance to attend, but you would still like information on any of our programs or products, please give me a call at 847-643-4093. Although we would love to tell you more about our products and programs, we are just as interested in your ideas for innovation, so my line is open to you. This is our biggest issue yet. There are so many things going on in our industry, I’m sure within these pages there is something that will be of interest you. Sincerely,

Sue MacInnes

VISIT MEDLINE BOOTH #3408 AT AORN CONGRESS

4

The OR Connection


Special Feature

Coming to America:

International Hand Hygiene Expert Urges U.S. to Use ‘Five Moments’ to Reduce Infection International hand hygiene expert Professor Didier Pittet, MD, MS traveled from Geneva, Switzerland to Chicago this spring to partner with U.S. healthcare workers to improve hand hygiene compliance. Dr. Pittet emphasized that despite hand hygiene’s proven benefits in reducing infection, “It’s very frightening first to realize that the compliance is so low,” he said. “On average it’s around 40%, at the best, and it’s not rare that when you come in a unit or a ward the average compliance will be around 20%.” Dr. Pittet began his visit to Chicago at a recording studio where he recorded English narration for a short film that promotes the World Health Organization’s (WHO) “Five Moments for Hand Hygiene.” The film is called “O Les Mains!” – translated in English it means “Raise your Hands.” Dr. Pittet currently uses the film, which features professional dancers, to encourage and teach proper hand hygiene techniques at his hospital in Geneva. With Medline’s help, Dr. Pittet hopes to get the video to go “viral” to inspire healthcare workers in the U.S. and around the world to learn proper hand hygiene.

“Five Moments for Hand Hygiene” defines the key times for hand hygiene, presents a unified vision on proper hand hygiene technique and promotes a strong sense of ownership. While in Chicago, Dr. Pittet, along with Mark Chassin, president of The Joint Commission, also addressed more than 200 senior clinicians and infection preventionists at Loyola University Medical Center in Chicago. Their unified message was clear – a highly compliant and successful hand hygiene program starts at the top of an organization with its leadership. The event, called “Safe Care Town Hall Forum” was co-hosted by Medline and Loyola, and is the first in a series of patient safety forums to be held around the country. Dr. Pittet also spoke before medical and nursing students at Loyola’s Stritch School of Medicine. Dr. Pittet believes teaching healthcare professionals about proper hand hygiene techniques early in their careers will instill good habits that will stay with them long term.

Aligning practice with policy to improve patient care 5


Mission: Improving hand hygiene Joint Commission Center for Transforming Healthcare Targeted Solutions Tool for Hand Hygiene

“I encourage hospital leaders to use these tools to identify very specific ways to improve their hand hygiene programs,” said Mark R. Chassin, MD, MPP, MPH, president of the Joint

Medline Industries, Inc. is a proud sponsor of the Center for Transforming Healthcare Endowment Fund.

Mea sur e p erf orm anc e

Commission. “Consistent excellence in hand hygiene is vital to our larger aim of eliminating preventable health care-associated infections. The Targeted Solutions Tool provides hospitals with powerful new knowledge and methods they can use right away to make substantial advances toward this goal.” fy nti Ide

Joint Commission-accredited hospitals now have access to an interactive tool that simplifies processes for solving healthcare quality and safety. The Targeted Solutions Tool™ (TST) encapsulates the work of the Joint Commission Center for Transforming Healthcare and provides step-by-step processes to measure performance, identify barriers to excellent performance, and implement proven solutions.

6

The OR Connection

rs rie Bar

Data validates effectiveness of hand hygiene tool At the start of the project in April 2009, the parThe first set of targeted solutions focuses on ticipating hospitals were surprised to learn that improving hand hygiene. It was created by their rate of hand hygiene compliance avereight of the country’s leading hospitals and aged 48 percent. By June 2010 they had healthcare systems working with the reached an average rate of 82 percent that Center. The TST provides accredited had been sustained for eight months. hospitals the foundation and Nineteen small, medium and large hosImplement Proven Solutions framework of an improvement pitals across the country also collabomethod that, if implemented well, will improve hand hygiene rated with the Center to test the work of the original eight compliance and contribute substantially to reducing health hospitals and provide guidance on the development of the solutions that are now available through the TST. These care-associated infections. hospitals are experiencing similar gains as the original eight. The complimentary data-driven tool provides validated and customized solutions to address particular barriers to excel- For a free electronic copy of the Targeted Solutions Tool for lent performance. Self-paced and confidential, the TST offers hand hygiene, “Hand Hygiene Factors and Solutions,” go to http://www.centerfortransforminghealthcare.org/tst.aspx. instantaneous data analysis.


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For a FREE Sterillium® Rub Waterless Surgical Scrub trial, contact Lynsey Wolfe at 847-643-4329 (lwolfe@medline.com).

1. Topical Antimicrobial Drug Products for Over-the-Counter Human Use; Tentative Final Monograph for Health Care Antiseptic Drug Products, 59 FR 31042 (1994) (to be codified at 21 CFR 333) 2. Data on file

©2011 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc. Sterillium is a registered trademark of Bode Chemie GmbH


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.

1

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.

2 Origin: Purpose:

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.

3 Origin:

Purpose: Goal:

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

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

8

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. 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

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

To learn more about the IHI Improvement Map and the 73 processes to transform hospital care, go to www.ihi.org/imap/tool

Joint Commission 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 www.jointcommission.org.

Surgical Care Improvement Project (SCIP): Target Areas 1. Surgical infections • Antibiotics, blood sugar control, hair removal, perioperative temperature management • Remove urinary catheter on 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

Visit www.qualitynet.org

Aligning practice with policy to improve patient care 9


PATIENT SAFETY NEWS 134,000 Medicare patients per month hurt at hospitals1 The Department of Health and Human Services recently released its findings that about 134,000 Medicare patients experienced adverse events in hospitals during a single month in 2008. About 44 percent of the events were considered to be preventable. The cost to treat the affected patients was estimated at $324 million. The Centers for Medicare and Medicaid Services (CMS) responded that it will aggressively pursue efforts to expand adverse event reporting and the types of events that are considered reportable. Only six states currently require public reporting of medical errors.

New suggestions for blood glucose management during outpatient surgery The Society for Ambulatory Anesthesia (SAMBA) issued a consensus statement at the end of 2010 outlining glucose management suggestions for anesthesia providers. The significant practice changes include:2 • Preoperative advice to the patient regarding the use of their anti-diabetic drug on the day of surgery • The use of rapid-acting insulin rather than regular insulin during surgery • Use of the 1500/1800 formula for determining the dose of insulin • Avoiding the temptation to normalize blood glucose levels in patients with inadequately controlled levels

References 1. Hospitals hurt 134,000 Medicare patients a month. Outpatient Surgery Magazine. November 30, 2010. 2. SAMBA issues suggestions for blood glucose management in diabetic patients. Outpatient Surgery Magazine. December 2010.

10 The OR Connection

National Patient Safety Foundation launches new membership organization for healthcare professionals The American Society of Professionals in Patient Safety (ASPPS) is a new membership organization launched by the National Patient Safety Foundation (NPSF). It is seeking members from across the spectrum of healthcare disciplines to help extend the group’s agenda of accelerating the delivery of safe patient care and establishing consistency in safety practices and tools. The organization plans to implement a certification program to validate competencies and practices that are proven to reduce medical errors. Information on membership and the May 2011 Patient Safety Congress can be found at www.npsf.org/hp/ASPPS.php.


Patient Safety

Provider Preventable Conditions:

Expanding Never Event/No-Pay Regulations

Since the summer of 2008, the Centers for Medicare and Medicaid Services (CMS) has encouraged states to model their Medicaid payment rules after the federal Medicare program. Now, the Affordable Care Act (ACA) has mandated that the Medicare rules for withholding payment for “never events” now be extended to state-run Medicaid programs. The Affordable Care Act (ACA) requires the new rules extension be effective July 1, 2011. The eleven CMS-recognized preventable conditions are: • Retained items after surgery • Air embolism • ABO blood incompatibility • Catheter-associated urinary tract infection (CAUTI) • Pressure ulcers • Central line-associated bloodstream infection (CLABSI) • Surgical site infection (SSI)/mediastinitis • Falls and certain other traumas • SSI after certain elective procedures • Poor glycemic control manifestations • Deep vein thrombosis (DVT)/pulmonary embolism (PE) This list is exhaustive for Medicare, but for Medicaid CMS has intentionally granted states the flexibility for including other conditions beyond the eleven that CMS has already identified. The different nature of Medicaid and the services it pays for has created a new set of terminology to learn. HAC, hospitalacquired condition is now passé, as is HCAC, the more generic healthcare-acquired condition. The preferred new term is provider preventable condition, or PPC. The definition of a PPC is “a condition that could have reasonably been prevented

Aligning practice with policy to improve patient care 11


CMS “no pay for never events” policy used to be Medicare only. In July it’s set to be part of all 50 state Medicaid plans.

What does all this mean? Like any significant policy change such as this one, there will be both expected results and unexpected consequences. The original Medicare claims denials for HACs are running at approximately $20 million per year. Over the next five years, the Medicaid claims denials for PPCs are expected to total $35 million, or an average of an additional $7 million per year. The Medicaid savings are divided approximately 60/40 between Federal and state savings.

through the application of evidence-based guidelines.” PPCs would encompass the same healthcare-acquired conditions as defined for Medicare purposes, plus other PPCs defined by states and approved by CMS. Perhaps more significant than the “what” of a PPC is the “where” it may occur. CMS proposes using PPC as an umbrella term for both hospital and non-hospital conditions identified by a state for nonpayment. PPCs would encompass hospitalacquired conditions, as defined for Medicare purposes, and other PPCs applicable to service settings beyond the inpatient hospital setting. CMS notes that preventable conditions can occur in an outpatient hospital, nursing facility and ambulatory care settings. The denial of claims for PPCs happening in any of these environments is a significant expansion of the existing regulations.

12 The OR Connection

There will be costs associated with this new rule, too. CMS estimates that both states’ and providers’ regulatory and reporting compliance will be relatively small. Providers, however, will incur additional costs to reduce PPCs. These costs may be from hiring more nurses and infection control professionals as well as training staff on best practices for PPC prevention. Equipping staff with evidence-based products and programs that help deliver better outcomes may be seen as an additional, but very necessary cost as well. Most hospitals have taken these PPC prevention steps to comply with Medicare rules. However, most non-hospital health care settings will now find it necessary to make expenditures to address the PPCs that occur in their environment. While the explicit purpose of the regulation is cost containment through administrative action, the implicit purpose is the public benefit of an overall reduction in PPCs and a corresponding increase in healthy years of life. CMS is quick to point out, however, that the regulation itself is not responsible for the better health of the population, but rather the responses made to it by hospitals and other care providers. For more information, visit: https://www.federalregister.gov/ articles/2011/02/17/2011-3548/medicaid-program-paymentadjustment-for-provider-preventable-conditions-including-health


SAFETY DESERVES ATTENTION

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:// www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_ 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.

For a FREE sample bundle, email goldstandard@medline.com.


CE Article

Avoiding Surgical Complications with Adequate Patient Warming 14 The OR Connection


SCIP-Inf-101 “Measure: Surgical patients should be actively warmed during surgery or have at least one recorded body temperature equal to or greater than 96.8 degrees Fahrenheit within 30 minutes prior to the end of anesthesia to 15 minutes after anesthesia ends. (Patients with intentional hypothermia are excluded from this measure.)” In 2003, the Joint Commission and the Centers for Medicare and Medicaid Services (CMS) teamed up to align their common measures. In the process, they decided to add a set of measures for Surgical Infection Prevention (SIP), which was quickly added as a core measure set.2 In July, 2006, SIP was renamed the Surgical Care Improvement Project (SCIP). Members of the SCIP Steering Committee include the Association of periOperative Nurses (AORN), the Joint Commission, the Centers for Medicare and Medicaid Services (CMS), Agency for Healthcare Research and Quality (AHRQ), American College of Surgeons (ACS), American Hospital Association (AHA), American Society of Anesthesiologists (ASA), Centers for Disease Control and Prevention (CDC), Department of Veterans Affairs, and the Institute for Healthcare Improvement (IHI).3 This national partnership of organizations works together to improve the quality of surgical care. To date, SCIP has introduced 10 measures, plus three others specifically addressing cardiac patients and venous thromboembolism. All measures are to be followed in order to reduce surgicalsite infections and other complications of surgery. (For the complete list of all SCIP Measures, turn to the back of this article.) SCIP-Infection (Inf.)-10, also known as SCIP Measure 10 – “Surgery Patients with Perioperative Temperature Management,” went into effect October 1, 2009.4 When the measure was first adopted, the best available temperature management evidence was on patients having colectomies while under general anesthesia. Consequently, the measure initially focused on this population. Currently, SCIP-Inf.10 applies to patients of any age undergoing surgical or therapeutic procedures while under general or neuraxial anesthesia for one hour or more. It does not include patients undergoing cardiopulmonary bypass.5 Continued on Page 17


Innovation in Patient Warming

Underbody Warming for All Patients and Procedures For protection from unintentional hypothermia in patients undergoing surgery, PerfecTemp is an excellent alternative to forced-air warming systems. While other systems use disposable blankets to force warm air on top of patients, PerfecTemp’s unique surgical table pads offer. • Efficient underbody warming as effective as forced-air systems for preventing unintentional hypothermia.1 • More accurate patient monitoring • Complete patient access • Silent operation • Reduced staff time • No blowing air • Energy conservation

Flexible and durable carbon heating element for uniform heating.

PerfecTemp™ OR Patient Warming System

References 1. Egan C, Bernstein E, Reddy D, et al. A Randomized Comparison of Intraoperative Warming With the LMA PerfecTemp and Forced Air During Open Abdominal Surgery. ©2011 Medline Industries, Inc. Medline and PerfecTemp are registered trademarks of Medline Industries, Inc.


CE Article

Under SCIP-Inf-10 clinicians must either actively warm patients during surgery or record a body temperature of 36 degrees C (96.8 degrees Fahrenheit) or higher within 30 minutes before or 15 minutes immediately after the end of anesthesia. Clinicians must provide clear documentation of the temperature during active warming or in relation to the end of anesthesia.

What causes perioperative hypothermia? As warm-blooded creatures, human beings’ organ systems are designed to operate within a narrow temperature range. Hypothermia occurs when a person’s body loses more heat than it can produce, leading to a core body temperature drop. In nature, we know what makes us cold and we can respond. Exposure to cold air encourages us to get out of the cold or bundle up. Being damp causes us to seek drier conditions. We put on jackets or seek shelter to get out of the wind. In the OR, perioperative hypothermia is common, resulting from the effects of anesthesia on the body’s thermoregulatory control system.6

Intraoperative core temperatures about two degrees Celsius below normal increase the incidence of wound infection threefold and prolong hospitalization by about 20 percent.5

Many factors can contribute to unplanned perioperative hypothermia, including cool air temperature in the OR, length of surgery (the longer the surgery, the greater the likelihood of hypothermia occurring), blood and fluid loss, and effects from anesthesia, which alters the patient’s ability to regulate body temperature. A patient’s body type can also affect heat loss. Very thin, malnourished patients as well as those who are very young or elderly are more susceptible to perioperative hypothermia.7 Elderly patients are more susceptible to hypothermia for a number of reasons. The body's ability to regulate temperature and to sense cold may lessen with age. Comorbidities that affect temperature regulation are more likely in older adults, including conditions such as hypothyroidism, stroke, severe arthritis, Parkinson’s disease, and neuropathies including diabetic neuropathy. They are also frequently more dehydrated and malnourished than the general population. Finally, medications including some antipsychotics and sedatives (both of which are used more frequently in long-term care settings) can impair the body’s ability to regulate its temperature. Core body temperature changes occur in three stages, beginning with the onset of general anesthesia. During the first hour, redistribution is the main cause of potential perioperative hypothermia.

Aligning practice with policy to improve patient care 17


CE Article

During this stage, warmer blood from the core is allowed to mix with cooler blood from the rest of the body. The blood cools as it circulates, and the cooled blood that returns to the heart can cause a decrease in body temperature8 of up to one degree Celsius.7 Redistribution is followed by the second phase, which occurs during the second and third hours of anesthesia, during which heat loss exceeds the body’s ability to produce heat. During this phase, warming the patient can effectively limit further heat loss. Finally, after about three to five hours of anesthesia, the patient’s temperature reaches a plateau, which usually remains constant for the remainder of the surgery, regardless of how long the rest of the procedure takes.

UNINTENDED HYPOTHERMIA Typical Pattern of Hyp 0

Preciptious drop in patient temperature within the first hour of anesthesia induction

6CORE TEMP ($C)

-1

-2

-3

0

2

4

ELAPSED TIME

After inducing anesthesia, a patient’s core body temperature drops rapidly.9

6

Did you know? Some patients report that shivering and being cold are worse than surgical pain. Hypothermia can cause a vigorous shivering response, which increases carbon dioxide production and increases oxygen consumption 400 to 500 percent.10

Complications associated with perioperative hypothermia Hypothermia, which is defined as having a core body temperature of less than or equal to 36 degrees Celsius or 96.8 degrees Fahrenheit, is associated with several complications and an increased risk of death. Perioperative hypothermia can result in: 11 • three times the incidence of surgical site infection • increased bleeding and increased need for blood transfusions • three times the risk for cardiac complications • a higher risk for developing pressure ulcers • prolonged recovery after surgery Surgical site infection. Hypothermia causes the blood vessels to constrict, decreases blood flow to tissues and decreases oxygenation of surgical wounds, allowing a more favorable environment for bacterial growth. In 1996 Andrea Kurz, MD, and colleagues published a study involving 200 colorectal surgery patients; 100 were randomly assigned to undergo surgery with warming and the other 100 without warming. For those who did not receive warming, the final mean intraoperative core temperature was 34.7 degrees Celsius. The final mean temperature for those who were warmed was 36.6 degrees Celsius. Surgical wound infections were found in 19 percent of the hypothermic group and in six percent of the normothermic group. The authors concluded that intraoperative core temperatures about two degrees Celsius below normal increase the incidence of wound infection threefold and prolong hospitalization by about 20 percent.12 Melling et al. also conducted a study of wound infection rates following surgery. The random controlled trial included 421 patients and resulted in a four percent infection rate among patients who received local warming and 15 percent among those who were not warmed.8 Continued on Page 20

18 The OR Connection


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

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Published evidence shows high rates of complications among hypothermic surgical patients, making it important for perioperative professionals to keep patients warm.

One suspected cause of surgical site infections has been understood to be a lack of oxygen, in particular bactericidal oxide radicals. As a drop in core temperature leads to vasoconstriction to preserve heat in the body, less oxygenated blood flows to a wound site on the skin. That reduction in available oxygen at the wound site makes it more conducive to bacterial growth. One study found that dissolved oxygen (pO2) is a strong predictor of infection. Measuring levels of subcutaneous oxygen in post-surgical patients, he found that none with an oxygen tension greater than 90 mmHg developed a SSI whereas 43 percent of patients with an oxygen tension between 40 and 50 mmHg did develop a SSI. Increased blood loss. A meta-analysis published in 2008 by Daniel Sessler, MD, professor and chair of the Department of Outcomes Research at Cleveland Clinic, and colleagues found that less than one degree of hypothermia is enough to increase blood loss by about 16 percent and increase the need for intraoperative transfusion by about 22 percent. Normothermia, however, was associated with a reduced chance of blood loss and a reduced need for transfusion.13 Similarly, an earlier study by Schmied and colleagues in 1996 also found that mild hypothermia can increase blood loss and the need for transfusion during surgery.14

20 The ORâ&#x20AC;&#x2C6;Connection

Cardiac complications. A 1993 study by Johns Hopkins anesthesiologist S.M. Frank, MD, and colleagues revealed that a greater number of hypothermic patients (36 percent) experienced myocardial ischemia compared with normothermic patients (13 percent). The incidence of angina postoperatively was also greater among the hypothermic group (18 percent) compared with the normothermic group (1.5 percent).15 All 100 subjects in the study underwent a vascular reconstruction procedure. It is important to recognize the difference between unintended hypothermia that leads to cardiac conditions, and the growing practice of therapeutic, induced hypothermia in cardiac patients. Unintentional hypothermia (perioperatively or otherwise) can lead to an unusually slow or irregular heart rate, which manifests as a weak or slow pulse or other arrythmias.16 Therapeutic hypothermia is an evidence-based intervention that attempts to lower core temperatures to around 33 degrees Celsius for 24 hours after a cardiac event for the purpose of improving neurological outcomes. Perioperative pressure ulcers. Because of circulatory and metabolic changes that occur during surgery, the etiology of perioperative pressure ulcers is more complex than those that


CE Article

occur in medical patients. 17 In a 2001 study researchers hypothesized that patientsâ&#x20AC;&#x2122; capacity to withstand mattress pressures during surgery would increase if hypothermia were prevented. They performed a randomized control trial to explore the relationship between tissue viability and patient core temperatures during surgery and to test the hypothesis that patient warming would reduce the incidence of pressure ulcers. Their trial involving 324 surgical patients resulted in an eight percent pressure ulcer incidence among patients who were warmed with a forced air over-blanket, versus a 65.4 percent incidence among patients who were not warmed.18 Prolonged recovery. Rainer Lenhardt, MD, clinical director of the Neuroscience-Anesthesia Intensive Care at the University of Louisville School of Medicine, and colleagues hypothesized that intraoperative hypothermia may prolong immediate surgical recovery by increasing the potency of the anesthetic, delaying drug metabolism or depressing cognitive function. They followed 150 patients undergoing elective major abdominal surgery and discovered that hypothermic patients required about 40 minutes longer than normothermic patients to reach fitness for discharge.19 Length of stay in the post-anesthesia care unit (PACU) is an important issue for health care managers. PACU nurses care for a small number of patients because of the high level of attention and care needed by a person recovering from anesthesia. Some have calculated that the personnel cost for two-hours in the PACU stay is similar to the personnel cost for a full day on a general care unit in a hospital.20 In an era of cost control, decreasing recovery time is economically desirable for the institution.

Warming methods As summarized above, published evidence shows high rates of complications among hypothermic surgical patients, making it important to maintain normothermia. There are several kinds of surgical warming devices available. Types of warming devices include forced air over or under the body; circulating warm-water devices; or conductive, active warming devices, which include under-the-body warming mattresses or over-the-body warming blankets. In addition to requiring perioperative professionals to maintain normothermia in patients, SCIP-Inf.-10 also requires clear documentation regarding the use of active warming devices.11

Aligning practice with policy to improve patient care 21


How to prevent perioperative hypothermia Although SCIP recommends keeping patients warm during surgery, it does not recommend how to keep them warm.21 Nursing organizations, including the Association of periOperative Registered Nurses (AORN) and the American Society of Perianesthesia Nursing have developed standards for preventing hypothermia during surgery. The following are highlights from AORN’s “Recommended Practices for Prevention of Unplanned Perioperative Hypothermia.”22 Recommendation I The perioperative registered nurse should assess the patient for risk of unplanned perioperative hypothermia. Recommendation II The perioperative registered nurse should develop a plan of care to minimize the risk of unplanned perioperative hypothermia in patients identified at risk. Recommendation III Equipment to monitor core temperature should be selected based upon reliability and access to the route. III.a.1 There are four reliable sites for measurement of core temperature: • Tympanic membrane. The tympanic membrane temperature, measured by a thermocouple, is the preferred method in many perioperative and postoperative areas. This method is noninvasive, and the monitoring site receives blood supply from the carotid artery, which supplies the thermoregulatory center of the hypothalamus. • Distal esophagus. The distal esophagus is considered a desirable site to measure temperature, particularly in the operating room, and is less prone to artifact than most others. It is an alternative to the pulmonary artery and is widely used intraoperatively. Placement of the probe in the lower fourth of the esophagus prevents artifactual cooling of the probe by respiratory gases. • Nasopharynx. The nasopharynx is another reliable monitoring site for intraoperative measurement because it approximates core temperature. A thermistor probe is inserted through the nares to the nasopharynx. Measurements may be influenced by the temperature of inspired gases and often are 0.5 degrees Celsius lower than pulmonary artery temperatures.

22 The OR Connection

• Pulmonary artery. The most accurate measurement of the core body temperature is through the pulmonary artery, which is bathed in blood from the core. This invasive form of monitoring, however, is not justified solely for temperature assessment. Recommendation IV The core temperature of patients at risk for unplanned hypothermia should be monitored pre-operatively, intraoperatively and postoperatively. Recommendation V Interventions should be implemented to prevent unplanned hypothermia. Recommendation VI Warming devices should be used in a manner that minimizes the potential for patient injuries. Recommendation VII Competency Personnel should receive initial education and competency validation and updates on the prevention of unplanned hypothermia and the use of warming equipment. Recommendation VIII Documentation Patient assessments, the plan of care, interventions implemented, and evaluation of care to prevent unplanned perioperative hypothermia should be documented. Recommendation IX Policies and Procedures Policies and procedures for prevention of unplanned hypothermia should be developed in collaboration with anesthesia care providers, reviewed periodically, revised as necessary, and readily available in the practice setting. Recommendation X Quality A quality improvement/management program should be in place to evaluate the structure, process, and outcomes of interventions used to protect patients from unplanned perioperative hypothermia.


Methods of Patient Warming Warm IV Fluids Conductive Warming Devices Warming Blankets Forced Air Circulating Water Garments Increased Operating Room Temperature

In an interview with OR Manager, perioperative hypothermia expert Dr. Sessler stated that it doesn’t matter which warming method is used as long as the patient’s temperature is approximately normal at the end of the surgery.21 Dr. Sessler is a leading researcher in surgical warming and has co-written many studies on how hypothermia affects surgical patients and the effectiveness of warming devices. Warm IV fluids. Warming IV fluids is another way to increase body temperature, but only under certain circumstances. AORN’s “Recommended Practices for Prevention of Unplanned Perioperative Hypothermia” states:22 “Warming intravenous (IV) fluids should be considered only if large volumes (i.e., more than two liters/hour for adults) are being administered. Warming IV fluids to near 37 degrees Celsius (98.6 degrees Fahrenheit) prevents heat loss from the administration of cold IV fluids and should be considered as an adjunct to skin surface warming. When less than two liters of volume is given, fluid warming is of limited value because fluidinduced cooling is minimal.” Conductive warming devices. One type of patient warming pad on the market is an electrical resistive/conductive device that warms underneath the patient’s body. It takes the place of an existing OR table mattress pad. The device incorporates dual fiber optic interface temperature sensors under the pad cover

near the patient’s skin to continuously monitor and control the heat generation of the pad. Warming can begin as soon as the patient is positioned on the OR table. The anesthesiologist can select one of five preset temperatures of 37, 38, 39, 40, or 40.5 degrees Celsius. The heating element is placed below one inch of viscoelastic memory foam to provide pressure redistribution for the patient. The entire pad is encased in a fluid proof cover and all seams are sealed to prevent penetration by spilled fluids, meaning the mattress can be cleaned and reused, eliminating unnecessary environmental waste. In addition, because the patient is warming from underneath, blankets need not be placed on top of the patient, allowing for greater surgical access. The device also operates with no noise. Warming blankets. Warming blankets are one option that is portable, easy-to-use and effective. The downside, however, is that nurses must make multiple trips to and from the blanket warming cabinet to ensure the patient always has a warm blanket. This can reduce efficiency and increase laundry costs.23 Also, adding too many layers of warmed cotton blankets is ineffective in raising the patient’s body temperature. The first blanket can reduce heat loss by 33 percent, however, adding another blanket only adds another 18 percent reduction in heat loss. Adding three or more blankets adds no further warming.8 Forced air warming. Another widely used option is forced air warming. The system consists of a warming unit and a remov-

Aligning practice with policy to improve patient care 23


able disposable blanket. The warming unit, which resembles an industrial vacuum cleaner, draws in air from the room and warms it to a specified temperature. The warm air is then pumped through a hose into a disposable blanket that covers the patient. According to Dr. Sessler, operating rooms tend to use forced-air warming covers because they are effective, safe and inexpensive. The blowers are often provided, and the blankets are inexpensive.21 One difficulty with forced air warming is that it cannot always sufficiently warm a large enough surface to maintain normothermia during very large procedures when the patient is not in the supine position. For example, it can be difficult to maintain normothermia in a patient undergoing a colectomy in the lithotomy position. So much skin is exposed that there is not enough surface area to warm. In cases like this, a combination of patient warming devices and an ambient operating room may be the solution for maintaining normothermia.21 Some surgical staff reject the use of forced air warming because it can contribute to field contamination and the unit itself can be a source of pathogens. Another criticism of forced-air warming is that it can create too warm an environment for the surgeon.8 The blowing can also create a considerable amount of noise in the OR. Circulating water garments. These devices circulate water through a segmented garment that is wrapped around the anterior and posterior sides of the patient. This is in contrast to circulating water mattresses, which the patient lies on in a supine position, thereby warming the posterior side of the body. Research conducted by Dr. Sessler has shown that circulating water garments and energy transfer pads warm patients about 50 percent better than forced air because they warm both over and under the body. These systems tend to be more costly, however, experts argue the cost is justified by better patient outcomes when compared with other warming methods. The following is an excerpt from a study by Taguchi et al., which compares the efficacy of circulating water garments versus forced air to maintain perioperative normothermia.6 To read the study in its entirety, go to www.ncbi.nlm.nih.gov/pmc/articles/PMC1409744/?tool=pubmed. Akiko Taguchi, MD, is an instructor in the Department of Anesthesiology at Washington University in St. Louis, MO.

24 The OR Connection

“Differences in perioperative patient warming systems result largely from what tissues are in contact with what heating element and the available surface area. Heat transfer also depends on physical characteristics of the heater-skin interface. For example, the surface area of the lung is enormous, but airway heaters and humidifiers transfer trivial amounts of heat because the thermal capacity of air is small. With any cutaneous warming system, heat transfer into the thermal core depends on skin temperature, tissue insulation, and circulatory convection of heat within the body. Device efficacy thus depends on which surface area is heated because the core is relatively isolated from distal skin surfaces. But most importantly, cutaneous heat transfer depends on skin temperature. Nearly all commercially available patient-warming systems are electrically powered; there is, therefore, no intrinsic physical limit to the calories that can be provided. Instead, the limitation is always the skin temperature that can be tolerated without undue risk of burns. Despite the high heat capacity and thermal conductivity of water, the efficacy of conventional circulating-water mattresses is modest. Poor efficacy results because 1) the posterior surface is a relatively small fraction of the body surface area, 2) this area is poorly perfused because the weight of the body compresses cutaneous capillaries, and, 3) most heat is lost via radiation and convection from the anterior surfaces rather than conduction

Despite the high heat capacity and thermal conductivity of water, the efficacy of conventional circulating-water mattresses is modest.


For most patients, raising the room temperature to more than 73.4º F may reduce the severity of hypothermia. into the operating-table mattress. As might thus be expected, the circulating-water garment transferred only 21 kcal/h across the posterior skin surface. This is more than reported previously with a conventional circulating-water mattress, possibly because of a better interface material. However, it is roughly the same change in cutaneous heat transfer that is provided by a single cotton blanket in a normothermic subject. Anterior surface heat transfer was comparable with each warming system, and the change in anterior surface heat gain from 0 to 0.5 elapsed hours averaged ≈65 kcal/h with each treatment. Heat transfer per anterior unit area was thus similar with each system. A corollary of this observation is that virtually the entire difference between the two tested warming systems resulted from heat transfer into posterior surfaces, that is from the portion of the circulating-water garment that acts as mattress. Core temperature increased 0.4 degrees Celsius/h faster with circulating water than forced air, a result that is consistent with Janicki et al. Although not tested in this study, our results suggest that heat transfer and core rewarming with the circulating-water garment would be similar to that provided by combining a forced-air cover and a conventional circulating-water mattress. The core and peripheral thermal compartments were of similar size (e.g., weight). However, active warming increased peripheral tissue heat content roughly three times as much as the core over the course of the study. The differences were even more pronounced during the initial warming phase. For example, peripheral heat content after one hour of circulating water increased 114 kcal whereas core content increased only 34 kcal. The analogous values for forced air were 71 and 9 kcal. Peripheral compartment heat content thus increased 60-80 kcal more than the core compartment with each device. These data indicate that tissue insulation restricted rapid flow of heat from the periphery to the core. In other words, applied heat was constrained by the insulating properties of peripheral tissues, thus significantly limiting the rate at which core temperature increased. That peripheral tissues insulated the core and slowed heat transfer in our volunteers is consistent with observations of Plat-

CE Article

tner et al. who found that peripheral tissues isolate the core from heat applied to the skin surface in the post-anesthetic period. Similarly, Szmuk et al. found that core rewarming was slowed by postoperative vasoconstriction. In contrast, peripheral-to-core heat transfer is unimpeded during anesthesia, whether subjects are vasodilated or vasoconstricted. The critical distinction amongst these studies is that volunteers were fully anesthetized in the later protocols whereas they were unanesthetized in the former ones. Although our volunteers remained intubated, they were very lightly anesthetized and fully vasoconstricted. It is thus unlikely that they were given sufficient anesthesia to cause direct arteriolar vasodilation that seems to be critical for rapid peripheral-to-core heat transfer. Although core temperatures were virtually identical at onset of warming, peripheral tissue temperature was slightly cooler on the circulating-water day. This lower initial skin temperature and greater initial core-to-peripheral tissue-temperature gradient increases the apparent efficacy of circulating water. However, the tissue temperature difference was only a few tenths of one degree Celsius and thus unlikely to have substantially altered the results. Traditional circulating-water mattresses are associated with ‘pressure-heat necrosis’ (i.e., burn) that results when tissue compressed by the weight of the patient is simultaneously warmed. Gali et al. recently reported the case of a 67-year-old woman who developed burns on her back after 6.5 hours of surgery while being warmed with the same circulating-water garment we used. Thus, when using this system, clinicians should consider any risk factors such as age, length of surgery, and nutritional status, which may predispose a patient to skin injury. In summary, the circulating-water garment transferred more heat than forced air, especially during the first hour of warming, with the difference resulting largely from posterior heating. Excessive heating of peripheral thermal compartment indicates that peripheral tissues insulated the core, thus slowing heat transfer. ” Increasing operating room temperature. When active skin warming is not feasible or skin warming by itself is inadequate for maintaining normothermia, increasing the room temperature is

Aligning practice with policy to improve patient care 25


an option. For most patients, raising the room temperature to more than 23 degrees Celsius (73.4 degrees Fahrenheit) may reduce the severity of hypothermia.22

Combining warming techniques Some have suggested the need for a holistic approach incorporating several different warming techniques to adequately warm a patient. Overall, depending on the surgeon, the surgical team, and patient and the circumstances, the best method of active warming may vary.23

Conclusion Looking to the future, as surgical team awareness and further research into normothermia continues to develop, even more effective patient-temperature management devices are sure to follow. Warming device experts predict the development of more sustainable technologies that can be cleaned and re-used, unlike forced air warming which creates environmental waste with its disposable blankets. In addition, developing effective equipment that covers less of the body surface than forced-air warming or circulating water devices can offer greater convenience and access for anesthesiologists and surgical teams.23 References 1

Measure Information Form. SCIP-Inf-10. Available at: http://www.hsag.com/App_Resources/Documents/SCIP_LS3_Inf10_MIF.pdf. Accessed February 25, 2011.

2

Surgical Care Improvement Project. The Joint Commission Web site. Available at: http://www.jointcommission.org/surgical_care_improvement_project/. Accessed March 4, 2011.

3

National SCIP Partnership Developing to Reduce Surgical Complications. The Leapfrog Group website. Available at: http://www.leapfroggroup.org/news/leapfrog_news/144968. Accessed February 27, 2011.

4

Gunn M. SCIP expanded normothermia measure to go into effect for all surgical patients in October. AORN Management Connections. July 2009. Available at: http://www.aorn.org/News/Managers/July2009Issue/Normothermia. Accessed February 25, 2011.

5

Wagner VD. Patient safety chiller: unplanned perioperative hypothermia. AORN Journal. 2010; 92(5):567-571.

26 The ORâ&#x20AC;&#x2C6;Connection

6

Taguchi A, Ratnaraj J, Kabon B, Sharma N, Lenhardt R, Sessler DI, et al. Effects of a circulating-water garment and forced air warming on body heat content and core temperature. Anesthesiology. 2004; 100(5):1058-1064.

7

Lynch S, Dixon J, Leary D. Reducing the risk of unplanned perioperative hypothermia. AORN Journal. 2010; 92(5):553-562.

8

Weirich TL. Hypothermia/warming protocols: why are they not widely used in the OR? AORN Journal. 2008;87(2):333-344.

9

Sessler D & Todd M. Perioperative heat balance. J Amer Soc Anesth. 2000; 92(2):578.

10 Paulikas CA. Prevention of unplanned perioperative hypothermia. AORN Journal. 2008; 88(3):358-364. 11 Wagner VD. Patient safety chiller: unplanned perioperative hypothermia. AORN Journal. 2010; 92(5):567-571. 12 Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. The New England Journal of Medicine. 1996;334(19):1209-1215. 13 Rajagopaian S, Mascha E, Na J, Sessler DI. The effects of mild perioperative hypothermia on blood loss and transfusion requirement. Anesthesiology. 2008;108(1):71-77. 14 Schmied H, Kurz A, Sessler DI, Kozek S, Reiter A. Mild hypothermia increases blood loss and transfusion requirements during total hip arthroplasty. The Lancet. 1996; 347(8997):289-292. 15 Frank SM, Beattie C, Christopherson R, Norris EJ, Perler BA, Williams GM et al. Unintentional hypothermia is associated with postoperative myocardial ischemia. Anesthesiology. 1993; 78(3):468-476. 16 Mayo Clinic Researchers Confirm Value of Therapeutic Hypothermia. February 18, 2011. Available at: http://www.mayoclinic.org/news2011-rst/6184.html. Accessed March 4, 2011. 17 Rogan J. Pressure ulcer risk during the perioperative period focusing on surgery duration and hypothermia. Wounds. 2007; 3(4):66-74. 18 Scott EM, Leaper DJ, Clark M, Kelly PJ. Effects of warming therapy on pressure ulcersâ&#x20AC;&#x201D;a randomized trial. AORN Journal. 2001; 73(5):921-938. 19 Lenhardt R, Marker E, Goll V, Tschernich H, Kurz A, Sessler DI, et al. Anesthesiology. 1997;87(6):1318-1323. 20 Waddle JP, Evers AS, Piccirillo JF. Postanesthesia care unit length of stay: quantifying and assessing dependent factors. Anesthesia and Analgesia 87. 1998; 87(3):628-633. 21 Mathias JM. Taking steps to keep OR patients warm. OR Manager. 2006;22(12):14-16. 22 Recommended Practices for Prevention of Unplanned Perioperative Hypothermia. In: 2010 Perioperative Standards and Recommended Practices. Denver, CO: Association of PeriOperative Register Nurses; 2010. 23 Cantrell S. New normothermia measure heats up patient-temperature management. Healthcare Purchasing News. March 1, 2010. Available at: http://www.hpnonline.com/inside/2010-03/1003-IC.html. Accessed February 25, 2011.


Patient Safety Quality Measures for the Surgical Care Improvement Project Measure

Strategy

Rationale x

Prophylactic antibiotics are administered one hour prior to incision.

Studies find that the lowest incidence of postoperative infection is associated with antibiotic administration during the one hour prior to surgery. The risk of infection increases progressively with greater time intervals between administration of the antibiotic and the skin incision.

x

SCIP-Inf-2

Prophylactic antibiotics are consistent with current guidelines (specific to each type of surgical procedure).

Use an agent that is safe, cost-effective, and has a spectrum of action that covers most of the probable intraoperative contaminants for the operation. First- or second-generation cephalosporins satisfy these criteria for most operations, although anaerobic coverage is needed for colon surgery. Administration of antibiotics for more than a few hours after the incision is closed offers no additional benefit to the surgical patient. Prolonged administration increases the risk of Clostridium difficile infection and the development of antimicrobial resistant pathogens.

x x

SCIP-Inf-3

Prophylactic antibiotics are to be discontinued within 24 hours after anesthesia end time. The discontinuation time extends to 48 hours for cardiac surgery patients.

Hyperglycemia in the immediate postoperative phase increases the risk of infection in both diabetic and non-diabetic patients; the higher the level of hyperglycemia, the higher the potential for infection in both patient populations.

x

SCIP-Inf-4

Cardiac surgery patients with controlled 6 a.m. blood glucose (Â&#x201D;0 mg/dL) for the first two postoperative days.

x

Blood glucose levels are monitored from preop through 48 hours post operative. The use of an insulin protocol for treating hyperglycemia with an insulin drip is strongly recommended.

SCIP-Inf-6

Surgery patients with appropriate surgical site hair removal. No hair removal, hair removal with clippers, or depilatory is appropriate.

There is no strong evidence to contraindicate preoperative hair removal; however, there is strong evidence against hair removal with a razor. Shaving is considered inappropriate.

x x

Take ALL razors out of the peri-operative area. Instruct patients not to shave the surgical site.

It is well-established that the risk of catheterassociated urinary tract infection (UTI) increases with increasing duration of indwelling urinary catheterization.

x

SCIP-Inf-9

Surgical patients with urinary catheter removed on Postoperative Day 1 or Postoperative Day 2 with day of surgery being day zero. (This measure does not apply to certain urological, gynecological or perineal procedures.)

Create a system of alerts or reminders to identify all patients with urinary catheters and assess the need for continued catheterization. Develop guidelines and protocols for nursedirected removal of unnecessary urinary catheters and management of postoperative urinary retention. Consider the use of external catheters for cooperative males

SCIP-Inf-1

x

x

x

x

x

Include administration and documentation of the antibiotic in the surgical time out. For one-hour antibiotics, the antibiotic is hung in pre-op, a surgical team member administers and documents the antibiotic infusion.

The use of pre-printed orders that include the recommended antibiotic will assist surgeons with choosing appropriate antibiotics. Vancomycin is appropriate if there is a risk of MRSA.

Begin antibiotics in the PACU. Administer cephalosporins every 6 hours rather than every 8 hours. Antibiotics are not provided for more than 24 hours after surgery without appropriate documentation.

Aligning practice with policy to improve patient care 27


Measure

S

Research has correlated impaired wound healing, adverse cardiac events, altered drug metabolism, and coagulopathies with unplanned perioperative hypothermia. A study by Kurtz, et al. (1996), found that incidence of culture-positive surgical site infections among those with mild perioperative hypothermia was three times higher than the normothermic perioperative patients.

x

The American College of Cardiology and the American Heart Association recommend continuation of beta-blocker therapy in the perioperative period as a class I indication, and accumulating evidence suggests that titration to maintain tight heart rate control should be the goal.

x

x

Surgery patients with recommended venous SCIP-VTE- thromboembolism (VTE) 1 prophylaxis ordered anytime from hospital arrival to 48 hours  after Anesthesia End Time.

Despite the evidence that VTE is one of the most common postoperative complications and prophylaxis is the most effective strategy to reduce morbidity and mortality, it is often underused. The frequency of venous thromboembolism (VTE), which includes deep vein thrombosis and pulmonary embolism, is related to the type and duration of surgery, patient risk factors, duration and extent of postoperative immobilization, and use or nonuse of prophylaxis.

x

Surgery patients who received appropriate venous thromboembolism (VTE) prophylaxis within 24 hours prior to Anesthesia Start Time to 24 hours after Anesthesia End Time.

Timing of prophylaxis is based on the type of procedure, prophylaxis selection, and clinical judgment regarding the impact of patient risk factors. The optimal start of pharmacologic prophylaxis in surgical patients varies and must be balanced with the efficacy-versusbleeding potential. Due to the inherent variability related to the initiation of prophylaxis for surgical procedures, 24 hours prior to surgery to 24 hours post surgery was recommended by consensus of the SCIP Technical Expert Panel in order to establish a timeframe that would encompass most procedures.

SCIP-Inf10

SCIPCARD-2

Surgical patients should be actively warmed during surgery or have at least one recorded body temperature equal to or greater than 96.8° F within 30 minutes prior to the end of anesthesia to 15 minutes after anesthesia end time. (Patients with intentional hypothermia are excluded from this measure.)

Strategy

Rationale

Surgery patients on betablockers prior to admission should continue beta-blocker therapy during the perioperative period.

T

SCIP-VTE2

x

x

x

x x x

x

Use aggressive warming measures during surgery. Ensure accurate documentation of postoperative temperature.

Instruct patients to take their beta blockers the day of surgery. Educate in-house clinicians about the importance of patients receiving their beta blockers the day of surgery, even while the patients are otherwise NPO. Meet with physician office staff to ensure consistent instructions to the patients. Use pre-printed orders that include nationally recommended guidelines for VTE prophylaxis. A “hard stop” would be not to allow patients to leave the recovery area until VTE orders are completed by the surgeon. Ensure that surgeon “preference” cards mirror national guidelines. Pharmacists should assist surgeons with understanding the risk of bleeding with pharmacological interventions. (Please note that rates for SCIP-VTE- 2 may be lower than those for SCIP-VTE-1 as a result of more stringent criteria. SCIP-VTE-2 requires documentation that prophylaxis was ordered and actually started, whereas SCIP-VTE-1 requires only documentation of an order. ) Organizations with decreased VTE 2 rates should assess their processes to determine why physician orders are not being implemented.

This material was prepared by Health Services Advisory Group, Inc., the Medicare Quality Improvement Organization for Arizona, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication No. AZ-9SOW-6.2.3-110609-01

28 The OR Connection


CE Test

Turn Up the Heat Avoiding Surgical Complications with Adequate Patient Warming

True/False 1. Extremely thin and malnourished patients are more susceptible to perioperative hypothermia T F 2. SCIP Inf.-10 went into effect April 1, 2007.

T F

3. Forced air warming is a widely used option for patient warming. T F 4. Cool air temperature in the operating room can contribute to unplanned perioperative hypothermia. T F 5. Perioperative hypothermia can cause a drastic drop in blood pressure. T F 6. Some surgical professionals reject the use of forced air warming because it can contribute to field contamination. T F

Multiple Choice 7. A 2008 study by Sessler and colleagues found that less than one degree of hypothermia during surgery is enough to increase blood loss by about ___ percent. a. 25 b. 46 c. 16 d. None of the above

8. In the Scott study, what was the incidence of pressure ulcers among patients who were not warmed during surgery? a. 72.5 percent b. 15.3 percent c. 65.4 percent d. 22.8 percent 9. Which of the following is NOT a known complication of perioperative hypothermia? a. Surgical site infection b. Prolonged recovery c. Myocardial ischemia d. Pneumonia 10. During anesthesia, core body temperature changes occur in ____ stages. a. Three b. Five c. Two d. Seven

Visit www.medlineuniversity.com and login or create an account. Choose your course to take the test and receive 1 FREE CE credit.

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

Aligning practice with policy to improve patient care 29


Patient Safety

ClearCount Clearly Makes a Difference in Patient Safety at Hunt Regional Hospital By Rebecca McPherson, MSN, RN

The following is a true story shared by nurses Kathy Magee and Emily Sundee from Hunt Regional Hospital, Greenville, TX.

Imagine this scenario A patient arrives at the hospital for a scheduled abdominal surgery. Everything is running on time. The patient is placed on the operating room table, a Time Out is called, and anesthesia is administered. The patient is intubated and placed on a mechanical ventilator. The sponges are counted by the circulator nurse and the scrub nurse. The surgery begins. The procedure is going well; however, the surgery extends through a shift change for the scrub nurses. Upon arrival of the second shift, the patient experiences a large amount of blood loss and packs of sponges are counted and quickly used. As the surgeon focuses on recognizing the reasons for blood loss, the nurses are instructed to order a back up blood supply for the patient. The surgeon controls the bleeding and begins to close the patient’s incision. The staff realizes there is an unreconciled sponge count. The staff attempts to recover the missing sponge.

Many questions and concerns arise such as: • Could it be in the patient’s cavity? • Was it thrown away in the linens? • Did we miscount? • Is it possible the previous shift made the error? The surgeon quickly decides to use the SmartWand-DTX and is able to locate and retrieve the missing sponge. The patient has a good outcome.

Exploring technology Hunt Regional is community-based hospital with 192 beds located in Greenville, Texas. The organization takes pride in a culture of innovation and transparency. If any staff member says “this is a safety issue” it’s viewed as very important and the leadership team is committed to following up and resolving the concern. Hunt Regional is dedicated to patient safety and quality outcomes. That is one of the reasons they were the first hospital in the state of Texas to begin using ClearCount. Hunt Regional realizes that retained objects is a standard problem for hospitals nationwide. Continued on Page 32

30 The OR Connection


INTRODUCING

“Retained Surgical Items” AORN’s latest confidence-based learning (CBL) module. AORN’s Confidence Based Learning (CBL) is a unique educational program that is designed to help you achieve mastery in both knowledge and confidence of that knowledge when providing care that meets AORN Standards and Recommended Practices. CBL is used to train, teach and retain perioperative professionals. CBL supports the learner in reducing time to master knowledge and increasing retention of critical information.

©2011 Medline Industries, Inc.

Visit Medline booth # 3408 or Clear Count booth # 537 at AORN Congress for a FREE DEMO of the “Retained Surgical Items” module.


The retention of a foreign object is considered a serious and preventable event by the National Quality Forum.1 The Centers for Medicare & Medicaid Services (CMS) includes the retention of foreign objects in its list of hospital-acquired conditions for which reimbursement will not be provided.2 The Joint Commission categorizes the unintended retention of a foreign object as a sentinel event.3 The Joint Commission’s sentinel event statistics reported 360 instances of unintentional retention of a foreign body during the period of 2005 through March 2010.4 National adverse event data demonstrates that retained surgical items are the most frequent and costly surgical “Never Events,” with surgical sponges representing the bulk of these incidents. According to CMS, the cost of a retained foreign object (RFO) after surgery is $62,631 per hospital stay.5 In addition to hospital costs, RFOs can produce major litigation expenses. The total cost of an RFO, including legal defense, indemnity payments, and surgical costs unreimbursed by CMS, would be approximately $166,135. At the previously quoted incidence of 1 in 5,500 operations, the cost of an RFO amortizes to approximately $30 per operation. The concern of retaining sponges or foreign objects can occur even when the staff follows procedures. The risk elevates with emergency procedures, deviation from planned procedures, type of procedure, patients with a higher mean body-mass index (obesity), and failure to count or inaccurate counts during the procedure.7 The longer the patient spends on the operating table, the greater the chance of developing pressure ulcers. The incidence of postoperative pressure ulcers may be as high as 66 percent.8 The Institute for Healthcare Improvement (IHI) estimates nearly one million people develop pressure ulcers each year, with some 60,000 deaths related to complications. The cost of treatment ranges up to $11 billion annually.9 Hunt Regional made the commitment to reducing or eradicating the incidence of retained surgical sponges by recognizing that even one such event is one too many. ClearCount benefits the patient and the organization by: • reinforcing safe, efficient, quality care • creating reassurance for the physician and staff that there is another system they can rely on to account for all sponges • increasing staff productivity, avoiding time spent to relocate sponges Using ClearCount does not take the place of manually counting sponges; however, it serves as reinforcement that the sponges have all been accounted for. Practitioners should continually check for RFOs before closing body cavities and develop safety practices to minimize errors. Hunt Regional is committed to ending retained lab sponges; they created a policy to use ClearCount for all open abdominal cases in addition to the nurse counting.

32 The OR Connection

Hunt Regional Hospital

Human error is a reality; however, Hunt Regional Hospital accepted responsibility, and their objective is to address retained surgical sponges head-on. They could not accept just any solution. Efficiency is important to them as well, particularly in the healthcare reform climate. The nursing team was highly focused on patient safety. After further research, they discovered publications from AORN that made them aware of new technology for the prevention of retained sponges. Surgeons also prefer using ClearCount and SmartWand. According to Joshua K. Trussell, MD, board certified general surgeon, Primary Care Associates Affiliated and medical director of the Trauma Program at Hunt Regional Medical Center in Greenville, Texas, “Using the lap sponge and raytec (X-ray gauze) have not changed practice or the way I operate, in fact, they are very user friendly and increase the level of confidence of the physician.” About the author

Rebecca McPherson, MSN, RN, is vice president of clinical services for Medline Industries, Inc. Prior to joining Medline, Rebecca worked at Sherman Healthcare Systems as the director of operations for the immediate care centers. Her background also includes emergency nursing. 1. Centers for Medicare & Medicaid Services. Hospital-acquired conditions (present on admission indicator)[online]. 2009 Feb 19 [cited 2009 March11]. 2. National Quality Forum. Serious reportable events in health-care 2006 update: a consensus report. Washington (DC): National Quality Forum; 2007. 3. Joint Commission. Facts about the sentinel event policy [online]. 2008 Mar 20 [cited 2009 Mar 11]. 4. The Joint Commission. Sentinel event statistics: updated through March 31, 2010. 5. Centers for Medicare & Medicaid Services. CMS fact sheets. CMS proposes additions to list of hospital-acquired conditions for fiscal year 2009 [online]. 2008 Apr 14 [cited 2009 Apr 7]. 6. Cima, RR, Kollengode A, Garnatz J, et al. Incidence and characteristics of potential and actual retained foreign object events in surgical patients. J Am Coll Surg 2008;207(1):80-7. 7. The Joint Commission. Foreign Objects retained After Surgery. Patient Safety Link e-Zine. 2009; 5(1). 8. ERCI. Pressure Ulcers. HRC Risk Analysis. 2006;3(Nursing 4):1-37. 9. OR Manager. Save Our Skin: Periop team rally to prevent pressure ulcers in the OR. 2008; (24)3.


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.

©2011 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.


VA

34 OR Connection


What is the Perioperative Nurse’s Role in Prevention? By Lorri A. Downs RN, BSN, MS, CIC

Healthcare-acquired ventilator-associated pneumonia (VAP) can be very costly. According to the available literature, the average cost associated with this complication can be as high as $40,000 per patient.1 With all organizations looking to prevent costly complications and provide evidence-based medicine, it is critical for every nurse to understand ventilator-associated pneumonia (VAP) and how to prevent it.

AP VentilatorAssociated Pnemonia

The main role for perioperative nurses is awareness. Awareness is key, as the most concerning aspect of VAP is the high mortality rate. Data published in February 2011 suggest that catheter-associated bloodstream infection (CABSI) and VAP cause more than two-thirds of the deaths resulting from healthcare-acquired infections (HAIs), and that they are five times as deadly as the other HAIs.2 Certainly, in the operative arena, the anesthesiologist manages the patient’s airway. Once the patient is recovering in the PACU the VAP bundle of activities can be implemented promptly. The current literature suggests that 55 percent of VAP cases are preventable with current evidence-based strategies.2 The Institute for Healthcare Improvement (IHI) published a “ventilator bundle” in 2006 and updated this bundle in May 2010. The bundle is a set of strategies healthcare workers can implement to help reduce the risk of VAP. The recent update has placed oral care with a Chlorhexidine (CHG) mouth rinse on the list of activities to help reduce the risk of developing VAP.

The IHI Ventilator Bundle as of May 20103 ➢ Elevation of the head of the bed 30-45 degrees unless medically contraindicated ➢ Daily “sedation vacations” and assessment of readiness to extubate ➢ Peptic ulcer disease prophylaxis ➢ Deep venous thrombosis prophylaxis ➢ Daily oral care with Chlorhexidine (CHG)

Aligning practice with policy to improve patient care 35


Joint Commission 2012 National Patient Safety Goal NPSG.07.06.01 Elements of Performance4 11. During 2012, plan for full implementation of this

6

Perform daily sedation interruption in accordance with the patient’s medical plan of care. Note: This requirement is not applicable for patients that do not have a medical plan for weaning off the ventilator.

7

Measure and monitor ventilator-associated pneumonia prevention processes and outcomes by doing the following:

NPSG January 1, 2013. Note: Planning may include a number of activities, such as assigning responsibility for implementation activities, creating timelines, identifying resources, and pilot testing.

2 3

4 5

Perform hand hygiene before and after providing care to ventilated patients. (See also PSG.07.01.01) Position and maintain ventilated patients (except those with medical contraindications) in semirecumbent positions. Provide regular antiseptic oral care to patients in accordance with product guidelines. Perform daily assessment of ventilated patients to determine their readiness to wean off the ventilator or to be extubated. Note: This requirement is not applicable for patients that do not have a medical plan for weaning off the ventilator.

36 The OR Connection

• Selecting measures using evidence-based guidelines or best practices • Monitoring compliance with evidence-based guidelines or best practices • Evaluating the effectiveness of prevention efforts


“55 percent

of VAP cases are preventable with current evidence-based strategies.

Additional focus on VAP Other healthcare organizations, including The Joint Commission and the Centers for Medicare and Medicaid Services, are also looking to target VAP prevention. The Joint Commission will be adding VAP to the 2012 National Patient Safety Goals under NPSG.07.06.01. “Medicare stopped providing reimbursement for treatment of eight largely preventable conditions, three of which it deemed “never events” and five “reasonably preventable.” Three of the five “reasonably preventable” conditions are HAIs; namely, CBSI, CAUTI, and SSI. VAP is being considered for inclusion in an expanded list scheduled for release in 2011.”2

What’s new? Oral care! Oral care! Oral care! Oral care with 0.12% Chlorhexidine gluconate oral rinse twice a day has been found to significantly decrease the risk of acquiring ventilator-associated pneumonia. A 2009 study published in the Journal of Intensive Care Medicine found that “simple low cost oral care protocols implemented in the SICU can significantly decrease the rate of infection and subsequently the costs associated with these infections. The cost savings were $140,000 – $560,000 savings related to infection of prevention of VAP. The total cost of the oral care program was $2187.49.”1 So, how do we hardwire the importance of oral care into all patient care providers? Education and competency testing is the key to sustainability of clinical practices. Clinical education programs with these components can help move the needle to hospital wide compliance as opposed to unit-based compliance. Oral care and VAP prevention activities do not stop once the patient leaves the PACU, the SICU or the medical/ surgical units for ventilated patients. At the end of the day “it may not be an attainable goal of preventing 100% of HAIs, but comprehensive implementation of prevention strategies could prevent hundreds of thousands of HAIs and save tens of thousands of lives and billions of dollars.”2

About the author

Lorri Downs, RN, BSN, MS, CIC is a boardcertified 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 has lectured on various infection prevention topics.

References 1. Sona CS, Zack JE, Schallom ME, McSweeney M, McMullen K, Thomas J, et al. The impact of a simple, low-cost oral care protocol on ventilator-associated pneumonia rates in a surgical intensive care unit. Journal of Intensive Care Medicine. 2009; 24(1):54-62. 2. Umscheid CA, Mitchell MD, Doshi JA, Agarwal R, Williams, K, Brennan PJ. Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs. Infection Control and Hospital Epidemiology. 2011; 32(2):101-114. 3. Implement the Ventilator Bundle. Institute for Healthcare Improvement (IHI) website. Available at: http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/ Changes/ImplementtheVentilatorBundle.htm. Accessed February 28, 2011. 4. The Joint Commission 2012 National Patient Safety Goals. Hospital Accreditation Program. NPSG.07.06.01.

Aligning practice with policy to improve patient care 37


Ventilator-Associated Pneumonia can be deadly. VAPrevent can be easy. Convenient, space-saving packaging

VAPrevent follows IHI Ventilator Bundle guidelines. With this checklist, you can too.

Sequential dispensing system and thumb grip for easy, one-at-a-time access â&#x20AC;&#x201D; in the right order


Evidence-based innovation in oral care for ventilator patients VAPrevent is a comprehensive system to give your staff the tools to deliver excellent oral care. And for ventilator patients, excellent oral care may be part of the difference between ventilator-associated pneumonia and staying healthy. The three parts of the VAPrevent program you’ll want to know:

Product Only Medline gives you these three options for oral care: IHI-recommended chlorhexidine gluconate (CHG), the alcohol-free moisturizing of Biotene®, or the proven antisepsis of hydrogen peroxide. Procedure kits feature innovative components, like graduated suction catheters and toothbrushes with integrated gum and tongue scrubbers. Breakthrough package design communicates and educates, all while leaving less waste behind. And the intuitive stack-pack design with its one-at-a-time dispenser makes it easy for caregivers to stay on track with care protocols.

Clear visuals let you identify the right kit quickly for your patient’s needs

Program When your staff knows how to use a product appropriately, its effectiveness increases greatly. That’s why Medline developed the Medline VAP program, which helps build knowledge and clinical skills with educational modules for both novice and experienced clinicians, as well as an online interactive competency for oral care. A program manager helps you implement your program and stays active as you progress, providing 90-day reports to help you track your incidence of VAP.

Price If you expected a VAP program this innovative would come at a price premium, you’re in for a pleasant surprise. VAPrevent from Medline comes to you for five to ten percent lower than competitors. In a tough, pay-for-performance environment, VAPrevent represents a major value.

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. ©2011 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.


THE INS AND OUTS OF HERNIAS AND WAYS TO REPAIR THEM

40 The OR Connection


OR Issues

By Alecia Cooper, RN, BS, MBA, CNOR

Documentation of hernias goes back to ancient times. Physicians in Alexandria used tightly-fitting bandages as treatment for a hernia, and a Phoenician statuette circa 900 BC portrays the bandaging.1 Itâ&#x20AC;&#x2122;s debatable, however, whether hernia surgeries were performed at that time. Fast forward to 1884, when Bassini introduced a surgical hernia repair that resulted in a very low (2.7 percent) recurrence rate. Today, the Lichtenstein procedure continues to dominate the world of hernia repair.2 What is a hernia?

Types of hernias

A hernia is the abnormal protrusion of part of an organ or tissue through a weak spot or other abnormal opening in a wall of muscle or other tissue. The condition can develop in various parts of the body, but hernias occur most commonly in the abdominal region, where part of the intestines or intra-abdominal fat bulge through the weak spot in the abdominal muscle.

Each type of hernia has its own descriptive name, and the list of types is quite extensive. The most common types of hernias, however, are inguinal (in the groin), umbilical (at the belly button), and incisional (at the site of a previous operation).

Patients with hernias may notice a bulge under the skin and feel pain when lifting heavy objects, coughing or during prolonged standing or sitting. Any motion or action that increases intra-abdominal pressure will exacerbate the symptoms of a hernia. The pain may be sharp and immediate or a dull ache that gets worse toward the end of the day. Hernias can be congenital, meaning they occur during fetal development, or acquired. A hernia can be acquired from increased intra-abdominal pressure causing by heavy lifting, prolonged coughing, prostate problems or bowel irregularity. A common property of all hernias is that once they are present, they are permanent until surgically repaired.

An inguinal hernia occurs in the groin where the abdominal folds of flesh meet the thighs. It is often the result of increased pressure within the abdomen due to lifting, coughing or straining. This type of hernia occurs more often in males because it follows the tract that develops when the testes descend into the scrotum before birth. In females, the inguinal hernia follows the course of the round ligament of the uterus. An umbilical hernia occurs with weakness in the umbilicus (belly button). This type of hernia occurs most often in infants and children. An incisional hernia is a frequent complication of abdominal surgery, with a reported incidence of up to 20 percent.3 This type of hernia that can develop at the site of a surgical incision that fails to heal properly, causing tissue weakness. This hernia also can occur when excessive strain is placed on the tissue at the incision site.

Aligning practice with policy to improve patient care 41


Any type of hernia may become strangulated. This is a very dangerous condition that can appear suddenly and requires immediate medical attention. A strangulated hernia is one that is tightly constricted. As any hernia progresses and bulges out through the weak point in its containing wall, the opening in the wall tends to close behind it, forming a narrow neck. If this neck is pinched tightly enough to cut off the blood supply, the hernia will quickly swell, becoming strangulated. Severe, continuous pain, redness, and tenderness are signs that the hernia may be entrapped or strangulated. Unless the blood supply is restored promptly, gangrene can set in and may cause death.4

Surgical repair of a hernia Although various supports and trusses are available to try to contain a hernia, the most effective treatment is surgical repair of the weakness in the muscle wall where the hernia protrudes. Approximately 700,000 hernia repair operations are performed annually in the United States.5 Many are performed by the conventional open surgical method. The rest are performed using a laparoscope.6 Several different surgical techniques have been developed over the years to repair hernias. Most techniques are based on the simple idea of closing the opening in the muscle wall. In the past, the opening was simply sutured closed, however, the preferred repair method today is the use of mesh fabric placed over the area for reinforcement. Outpatient surgery is clinically feasible for at least 75 percent of adults with primary inguinal hernias whether the operation is performed using an open or laparoscopic technique, and most patients can go home the same day the operation is performed.7 Open surgery. Before the introduction of hernia mesh, all hernias were repaired by simply suturing together the opening where the hernia was protruding. A 2004 follow up of a randomized controlled trial of suture versus mesh repair of an incisional hernia concluded that mesh repair results in a lower recurrence rate and less abdominal pain and does not result in more complications than suture repair. The researchers who conducted the study even recommended abandoning suture repair of incisional hernia altogether.3

Surgical hernia mesh In the United States, as of 2003, more than 90 percent of all inguinal and incisional hernias were repaired with mesh, and that number is likely higher today. This method has proven to be more secure than closing the hernia using only sutures and nearly eliminates the possibility of the hernia opening up again.7 The tension-free hernioplasty with mesh, known as the Lichtenstein operation, was introduced in the 1980s by Irving Lichtenstein and colleagues. The technique is known for its quickness and simplicity to perform. It is also generically referred to as the plug and patch technique. Itâ&#x20AC;&#x2122;s nearly painfree for patients and allows for a prompt return to work. Whatâ&#x20AC;&#x2122;s more, it is the recommended operation of first choice for uncomplicated unilateral inguinal hernia in men.7 The open hernia repair is performed from the outside through an incision in the groin or the area of the hernia. The incision extends through the skin and subcutaneous fat, allowing the surgeon to get to the level of the defect. This technique is usually done with a local anesthetic and sedation, but may be performed using a spinal or general anesthetic. Laparoscopic surgery. Laparoscopic hernia repair uses small incisions, telescopes, a camera and a square of surgical mesh material that acts as a patch over the opening. Compared to open surgery, laparoscopic hernia repair may offer a quicker return to work and normal activities with decreased pain for some patients. Continued on Page 44

42 The ORâ&#x20AC;&#x2C6;Connection


Revolutionary technology for exceptional results.

ASSURE™ Surgical Mesh – for the repair of ventral hernias

REVIVE™ Surgical Mesh – for the repair of inguinal hernias

Both ASSURE and REVIVE feature our proprietary polyurethane Biomaterial, which offers the advantages of both a synthetic and a biologic mesh: • The architecture and design to mimic tissue in-growth of a biologic mesh1,2 • The strength and economical price of a synthetic mesh

References: 1. “A Comparative Morphologic Evaluation of Synthetic Surgical Mesh Materials in a Rat Model of Body Wall Repair” (ASSURE 26W Rat Study). 2. “In-Vivo Evaluation of Biomerix Polypropylene Composite Mesh in a Rat Body Wall Model” (REVIVE 26W Rat Study).

For more information, contact your Medline representative at 1-800-MEDLINE or visit Medline.com.

©2011 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc. Assure and Revive are trademarks of Biomerix Corporation.


“ On the downside, laparoscopic surgery most often requires general anesthesia, which poses more risks to the patient. It’s also more difficult to perform than open surgery, it takes longer and it costs more. In the United States less than 20 percent of all hernias are treated laparoscopically.5 The first report of hernia repair with laparoscopy was made by Ralph Ger in 1982.7 To perform laparoscopic hernia surgery, a laparoscope connected to a special camera is inserted into the body after making a small (1/4 inch) hole in the abdomen, allowing the surgeon to view the hernia and surrounding tissue on a video screen. Two other holes are also made, which allow the surgeon to work inside the body. A small piece of surgical mesh is inserted through the surgical hole and placed either outside or inside the hernia defect and held in place with sutures, staples or surgical tacks. Surgical mesh An ideal surgical mesh is strong, pliable, non-allergenic and non-biodegradable. It should also stimulate tissue growth for optimum assimilation into the body. Although there are more than 80 different prosthetic biomaterials that can be used to repair inguinal and incisional hernias,7 they are all somewhat similar. The most significant difference is whether or not the mesh is designed to be used inside the peritoneum, the body’s natural barrier to adhesion formation. This peritoneum is more or less a slippery sack that gives the internal organs position and allows them to move freely past one another. Mesh used inside the peritoneum must have an anti-adhesive nature. This is achieved by making the mesh out of materials that are antiadhesive themselves (polytetrafluoroethylene [PTFE]) or coating the mesh with an anti-adhesive film (caprolactone-coated polypropylene [PP] or cellulose-coated polyethylene terephthalate [PET]). Outside the peritoneum, this factor is less important. Common materials are PP and PET because they have good mechanical properties at an economic price point.

44 The OR Connection

The large proportion of mankind who are afflicted with this complaint; – the great variety of forms in which it appears; – the fatality which results from its improper treatment, and the ample resources of surgery in preventing its evil consequences, are circumstances which combine to render the investigation of hernia peculiarly interesting.

John Syng Dorsey, 18185

All types of flat mesh are available in a variety of sizes and can be cut to cover over any size hernia. The main difference between the materials is the tightness of the weave, the variation in the weave, and the thickness, suppleness, pliability and weight of the mesh.7 The other large differentiation for types of mesh is the shape. Many mesh products are simple flat mesh. However, there are a few techniques like the Lichtenstein repair that incorporate mesh that with a unique three-dimensional shape. These shapes work in concert with the local anatomy. As a result, many surgeons use these products and feel they lead to a lower recurrence rate for their hernia repairs.

References 1 Lau WY. History of treatment of groin hernia. World Journal of Surgery. 2002; 26(6):748-759. 2 Read RC. Herniology: past, present, and future. Hernia. 2009; 13(6):577-580. 3 Burger JW, Luijendijk RW, Hop WC, Halm JA, Verdaasdonk EG, Jeekel J. Long-term follow-up of a randomized controlled trial of suture versus mesh repair of incisional hernia. Annuals of Surgery. 2004;240(4):578-585. 4 Encyclopedia and Dictionary of Medicine, Nursing and Allied Health. 4th ed. Benjamin F. Miller and Claire Brackman Keane. W.B. Saunders Company. Philadelphia. 1987. pp. 570-572. 5 Lowenfels AB. Managing inguinal hernias. Medscape General Surgery. 6 Patient Information for Laparoscopic Inguinal Hernia Repair from SAGES. Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). March 2004. 7 Kingsnorth A & LeBlanc K. Hernias: inguinal and incisional. The Lancet. 2003; 362(9395):1561-1571.


Medline Suction Canisters and Liqui-Loc™ Solidifiers Easy, convenient fluid management for the OR Introducing a fluid management system that saves time, adds convenience and reduces waste. Medline Suction Canister with patent pending all-in-one tank turret lid • No more elbows to lose or misplace • Shorter OR setup times (less time spent looking for lost parts) • Designed and tested with help from our customers • FREE accessory program! Eligible customers may receive free suction canister carriers and holders.

Medline advanced Liqui-Loc solidifiers Dissolvable PVA packs are: • Safer - Add solidifier before the procedure, maintaining a closed system • Environmentally friendly Eliminate bottle disposal • More convenient Save time setting up and cleaning the OR

To request a sample of the advanced Liqui-Loc Solidifier in the PVA pack, send an e-mail to Dynacorsamples@medline.com. ©2011 Medline Industries, Inc. Medline is a registered trademark and Liqui-Loc is a trademark of Medline Industries, Inc.


The final piece to complete the latex-free puzzle in your OR

SensiCare® Surgical Gloves The protection, performance and comfort of latex – without the latex. • SensiCare® with Aloe – standard thickness, smooth grip • SensiCare® LT with Aloe – standard thickness, textured grip • SensiCare® Green with Aloe – Dark green color, 10% thinner for enhanced tactile sensitivity • SensiCare® Ortho – 40% thicker for extra protection • SensiCare® SLT – 5% thinner, textured grip

Most supplies in the OR are latex-free these days, but for many operating rooms, surgical gloves remain the last piece of the latex-free puzzle. Transitioning to latex-free surgical gloves has been challenging because historically, the latex-free gloves available have offered inferior fit and feel compared to natural rubber latex. Medline's SensiCare latex-free surgical gloves are different because they are made from Isolex, our self-manufactured synthetic polyisoprene. SensiCare is actually softer and more elastic than latex. Choose the SensiCare glove option that best fits your needs.

Participate in a BE FREE Day at your facility. Medline will provide a day’s worth of SensiCare latex-free surgical gloves to trial at no cost. Call 1-800-MEDLINE or e-mail glovedivision@medline.com to get started.

©2011 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.


The Quest to Improve Staff and Patient Safety: How one health district converted to latex-free surgical gloves by Heather Francis RN MBA, Cindy Fulmore RN BN CPN(c), Deborah Garnier RN MN CPN(c)

Who is Capital Health? Healthcare Group: Capital District Health Authority Location: Nova Scotia, Canada Size: Nine facilities with 11,000 employees Challenge: Move the operating room staff, including surgeons, to latex-free surgical gloves

Capital District Health Authority (CDHA) is the largest integrated academic health district in Atlantic Canada. It provides tertiary health services to Atlantic Canadians and to 40 percent of Nova Scotiaâ&#x20AC;&#x2122;s population. Capital Health consists of nine facilities with 11,000 employees, physicians, learners and volunteers providing medical and surgical care, mental health care, community health programs, addiction prevention and treatment and environmental health services. There are 38 operating rooms across the district, performing approximately 33,845 operations per year. As an academic district, CDHA helps educate tomorrow's healthcare providers and administrators and engages in research on new treatments, cures, processes and practices. With an operating budget of almost $800 million, CDHA serves the 400,000 residents of the district and provides specialist services to the rest of Nova Scotia and Atlantic Canada.

Aligning practice with policy to improve patient care 47


Victoria General Hospital, Halifax, Nova Scotia

Our Challenge Capital Health is on a journey to become a world-leading haven for people-centered health, healing and learning. For the last several years, CDHA has implemented a proactive latex-free glove program aimed at protecting its staff and patients from the complications caused by allergic reactions to latex. The serious consequence of latex allergies for patients and staff are well-documented, including the costs associated with staff disability, teardown of surgical sets, worker’s compensation claims and adverse events of patients. Recent technological advancements have enabled most products previously made with latex to now be manufactured using non-latex materials that look, feel and perform like the latex version – only safer. A good example of where this has occurred is with exam gloves. As a result of new technologies and materials improving the properties of latex-free exam gloves, by the end of 2006, all CDHA sites had converted to the latex-free version. Staff had shown broad acceptance for this new glove and continue to do so more than three years after the conversion. Moving the operating room staff, including surgeons, to latexfree surgical gloves – one of the last and most important pieces of the latex-free glove puzzle – would prove to be more challenging. The desire to change existed on the part of the surgical team, but not everyone had the information about the improved quality of latex-free gloves. Latex-free gloves, to this point, were used on a limited basis for cases known to involve a latex-sensitive patient or OR staff member. There were many reasons for this, including the fact that the fit, feel and performance of latex-free gloves had historically been unacceptable to most clinicians and surgeons. The initial products tore easily, rolled down in the cuffs and did

48 The OR Connection

“For the last several years, CDHA has implemented a proactive latex-free glove program aimed at protecting its staff and patients from the complications caused by allergic reactions to latex.” not have the tactile sensitivity of the latex version. This resulted in the staff and surgeons having to compromise the fit, feel and protection of the latex gloves. Surgeon preference was expected to be a barrier to overcome, as gloves can be a very personal item for most doctors. The overwhelming choice for many was latex gloves because they liked the fit and feel of latex. Convincing them to change was going to be a challenge. Cost was also a factor, as latex-free gloves cost more than the latex version. While the impact to our glove budget was significant, (approximately double the cost), the overall OR supply cost increase was only going to be approximately less than one half of a percent (0.4%) or about $5.00 per procedure if we totally converted to latex-free gloves. For us to change, we needed a supply partner who not only had the right products, but also the staff to provide education and clinical resources to execute a successful evaluation – and ultimately – a conversion to latex-free gloves.

The Solution In 2006, the glove contract with the current supplier was expiring. This provided an opportunity for further exploration of powder-free, latex-free gloves, as a change was going to occur anyway. At that time CDHA joined a group purchasing organization. Medline Industries, Inc., a major manufacturer and distributor of healthcare supplies, had won the surgical gloves contract with this purchasing organization. Medline was the North American market leader in many product categories, including exam gloves, and was rapidly growing within the surgical glove market.


We determined that gaining approval for latex-free gloves from the surgical team required the following key strategies: • Have the surgical chief of staff and surgical department heads support a trial and get them involved in the selection process. Without acceptance by senior OR leadership, convincing the rest of the OR staff to trial the gloves would be extremely challenging. • Do not dictate the team to go latex free. If there was pressure to accept the change, staff may resist the process. It would be key to provide choices, so the end users feel empowered to choose a glove that suits them personally. • Prior to a switch, educate staff on the properties of latex and latex-free gloves, as well as benefits of latex-free, powder-free gloves. • Share with staff the support of occupational health and risk management and share personal examples of latex reactions.

Key players at CDHA, including management, clinical educators and supply management, were convinced with education and existing information regarding latex reactions, that moving to latex-free surgical gloves was the right thing to do. At a minimum it was agreed there would be a conversion to powderfree gloves with the goal of moving to a latex-safe environment. The initial plan was to convert to powder-free, latex gloves to reduce exposure to latex proteins by staff and to prevent aerosolization of the latex proteins in the OR environment while keeping the look and feel of latex. This would significantly reduce the risk of a latex reaction for staff and patients. At this time, 78% of surgical gloves being used were powdered latex and 22% were powder-free latex. Medline introduced its new powder-free, latex-free surgical glove manufactured with a state-of-the-art polyisoprene synthetic formula, which was well-received by the perioperative leadership group. This glove appeared to have the look and feel of a latex glove, but contained no latex. They also introduced a neoprene latex-free glove. The decision was made by materials management, purchasing and OR executives to introduce these latex-free options to staff and to have three powder-free latex gloves as alternatives. This became the idea for a “Be Free Day” during which latex-free gloves could be evaluated. Continued on Page 51

Aligning practice with policy to improve patient care 49


FREE Informational

Webinars

Now Available On Demand 24/7! Click on the links below to participate in a webinar any time.

Perioperative Pressure Ulcer Prevention www.medline.com/PUPP-webinar Hand Hygiene Compliance Improvement Strategies www.medline.com/handhygiene Innovation in the Prevention of CAUTI www.medline.com/erase/webinar.asp


Prior to the “Be Free Day,” a glove provider representative was a constant presence to provide support and education sessions and tirelessly meet with many of the surgical staff to talk about the differences between latex and latex-free gloves, all in an effort to garner support for the new gloves. As in any large hospital group, there were a few surgeons that would be a challenge to convert, and convincing this group required addressing them in a more personalized manner. The glove representative met separately with the surgical chief in each specialty to explain the gloves, and the process of changing to latex-free. She found out from the chiefs who would be the ‘challenging’ surgeons to convince. She then met with them individually over several months to ensure as many end users as possible were on board with the move to latex-free. Each chief also sent emails to the respective surgical specialties to ensure all end users were reached. Communication and choice would prove to be key in a successful conversion to latex-free. In addition, a poster campaign was launched to introduce the concept of the “Be Free Day.”

brought in clinical support for the day to answer questions and provide information on the latex-free gloves. Tables were set up near the ORs where clinicians and surgeons could try on the gloves, test them and ask questions in a casual atmosphere. Staff members who wanted to try the gloves during surgery were encouraged to do so. It was clear to the staff that they were not being forced to go latex-free. There were no pressure tactics involved. Each person was asked to complete a simple form indicating if the new glove was “better than/ equal to/or worse than” their current latex glove. To encourage participation, each form was entered into a prize drawing. The results from the “Be Free Day” were very positive:

90%

answered “better than” or “equal to”

10%

answered “worse than”

Based on the success of “Be Free Day,” CDHA investigated the cost implications of a primarily latex-free surgical glove choice. Cost was going to increase (see page 2), but not enough to prevent the switch, as executives were convinced it was the right thing for patient and staff safety. The conversion also gave us the opportunity to standardize the number of different glove types in the organization, which would reduce our inventory and costs associated with inventory management. At this point, the organization was using nine different glove types from different glove vendors. The goal was to standardize to three or four glove types.

Be Free Day

Phase II – Two-week Evaluation Based on the acceptance from “Be Free Day,” a two-week evaluation period started the week of October 15, 2007. All of the old gloves were removed from every area during the evaluation period so staff did not have the option of reverting to the old gloves. The glove supplier provided a clinical support team at each site to work with individual staff members to determine the right glove based on their specialty, glove practices, sensitivities and other considerations.

Phase I – “Be Free Day” “Be Free Day,” Phase I of the latex-free surgical glove process, took place on June 25, 2007. It was a chance to try/evaluate the latex-free gloves with each surgeon’s group at all OR sites in CDHA. The purpose of the exercise was to gauge the response of the OR staff toward the gloves. The glove provider

Staff members wore gloves in their surgical cases to determine which glove was most appropriate for them. After wearing the gloves for several days, staff members filled out an evaluation form indicating if the gloves were “acceptable” or “unacceptable.” If a glove was “unacceptable,” the staff member worked

Aligning practice with policy to improve patient care 51


with the glove provider’s clinical expert to find a glove with an acceptable fit and feel. Ongoing information-sharing was also available from the glove supplier’s on-premise representatives. Key to the evaluation phase was for the glove supplier to work closely with materials management to ensure an adequate supply of all gloves were on hand throughout the entire evaluation period. If we ran out of gloves, it would negatively impact the entire process.

The results of the evaluation were overwhelmingly positive. The acceptance rate was 96.4%. A sampling of staff comments and/or observations from the evaluations included: “I love the zero latex concept. Thanks” “Happy! Happy! Happy!” “Feels good, fits well” “The best I’ve ever tried” “I actually like them” “I like the fit and feel. Very comfortable”

Phase III - Conversion Based on the acceptance rate during the trial and the overall cost justification, the OR leadership team and materials management decided to officially move forward with a conversion. The implementation phase was expedited as it was thought a conversion would go smoother for surgical teams if they began using the new gloves they tried during the evaluation immediately, rather than switching back to old gloves while the decision-making occurred. This also eliminated stocking challenges for supply staff, as they did not have to pull evaluation gloves from the stock shelves and reintroduce them at a later date. The glove provider and our distributor ensured order numbers were provided to the supply staff and that the initial implementation order was distributed to all appropriate areas. Staff responsible for picking case carts were engaged at this time and introduced to the new product. Implementation was facilitated by the extensive preliminary work/education provided by the glove provider, which also ensured that our OR staff members were engaged in the process. Continued on Page 54

52 The OR Connection

“Based on the acceptance rate during the trial and the overall cost justification, the OR leadership team and materials management decided to officially move forward with a conversion.”


Finally! A way to know when the catheter was placed

MEDLINE’S FOLEY INSERTAG™ This easy documentation tool lets you know exactly when your patient’s catheter was placed Foley InserTag

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.

To learn more about Medline’s Foley InserTag and the ERASE CAUTI program, attend an informational webinar at www. medline.com/erase/webinar.asp.

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: http://qualitymeasures.ahrq.gov/content.aspx?f=rss&id=16275. Accessed December 7, 2010. 3 Guideline for Prevention of Catheter-associated Urinary Tract Infections, 2009. Centers for Disease Control and Prevention. Available at: http://www.cdc.gov/hicpac/cauti/001_cauti.html. Accessed December 7, 2010. ©2011 Medline Industries, Inc. Medline is a registered trademark and InserTag is a trademark of Medline Industries, Inc.


8

Steps to a Successful Glove Conversion

1

Engage key decision makers

2

Ask risk management and occupational health to provide evidence on the hazards of latex

3

Educate, educate, educate

4

Be transparent and facilitate ongoing communication

5

Provide choices and options

6

Consider cost, but not as the only deciding factor

7

Make sure product is available to ensure a successful trial and evaluation

8

Ask glove supplier to provide on-site experts to support all staff, including the supply team, surgeons, nursing and sterile processing

54 The ORâ&#x20AC;&#x2C6;Connection


Current Status We are a little more than two years into the conversion to the latex-free surgeon’s gloves, and the acceptance and satisfaction rates among the OR staff continue to be high. At one site, the number of glove types have been reduced to four from nine at the time of conversion.

Next steps There are a still a few staff members from the original conversion who have not found a glove with the fit or durability they enjoyed with their latex glove. Since the original conversion, Medline has developed four new latex-free gloves, including a latex-free orthopedic glove. These new options should provide more acceptable choices for those staff members who were not satisfied with the initial latex-free gloves.

“We are a little more than two years into the conversion to the latex-free surgeon’s gloves, and the acceptance and satisfaction rates among the OR staff continue to be high.”

About the Authors Heather Francis, RN BN MBA – Heather was the Health Service Director for Perioperative Services for eight years until fall 2009. She has 15 years of perioperative experience. She is currently the Health Services Director of Dartmouth General Hospital. She graduated from St. Rita's School of Nursing and earned her Bachelor of Nursing and Master of Business from Dalhousie University.

Cynthia Fulmore RN BN CPN(c) – Cindy has been the clinical educator for the operating rooms at Victoria General Hospital in Halifax for the past seven years. She is a graduate of Dalhousie University Halifax. She is certified in perioperative nursing (Canada), and has 20 years perioperative experience.

Deborah Garnier RN MN CPN(c) – Deborah has been the Health Service Manager for the operating rooms at Victoria General Hospital in Halifax for the past four years. Previously she held positions as OR supervisor, perioperative educator and perioperative staff nurse. She is a graduate of SA Grace General Hospital School of Nursing, St. Johns NL, St. Francis Xavier University, Antigonish NS and Athabasca University, Athabasca, Alberta. She is a certified perioperative nurse (Canada) with over 20 years of perioperative experience.

Aligning practice with policy to improve patient care 55


Special Feature

Patient experience is #1 Nurse leaders rank priorities in national survey

According to the newly released HealthLeaders Media Industry Survey 2011, nurse leaders are most concerned about 1. Patient experience/ patient satisfaction 2. Quality/patient safety 3. Cost reduction

73% of nurse leaders said their organization plans to encourage more nurses to pursue bachelor’s degrees over the next three years; 18 percent plan to encourage nurses to pursue master’s degrees.

With the advent of the HCAHPs (Hospital Care Quality Information from the Consumer Perspective) survey and more government pay-for-performance requirements, nurses are making the connection that reimbursement will be tied to patient satisfaction and quality of care, and patient safety beginning next year. Regarding hand hygiene compliance,

48% of nurse leaders agreed that the primary reason behind failure to achieve hand-washing compliance is lack of spine to self-police and report colleagues’ violations.

39%

When ranking the most important factors for providing high-quality patient care, nurse leaders reported: #

53% of nurse leaders confirmed that their organization will be part of an accountable care organization within the next five years.

of nurse leaders say that nursing research is being effectively translated into practice at the bedside.

1 MOST IMPORTANT

Nurse-to-patient staffing ratio 2 MOST IMPORTANT Nurse experience level # 3 MOST IMPORTANT Nurse education/certification level #

Source: HealthLeaders Media Industry Survey 2011: Nurse Leaders. Available at: www.healthleadersmedia.com/intelligence

56 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 www.erasecauti.com/alternatives.asp 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 www.medline.com/erase/webinar.

Š2011 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.


1

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 tips for the clinician.

2

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.

3

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.


SAFER CATHETERIZATION FOR KIDS Pediatric Catheter Tray

Children’s Activities

Introducing Medline’s new Pediatric Catheter Tray. The latest addition to the innovative ERASE CAUTI product line.

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©2011 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

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To learn more about Medline’s ERASE CAUTI program and alternatives to catheterization, visit http://erasecauti.com.

e

You trust Medline for clinical innovations, such as our industry-leading catheter tray design. Now, we can be your patient’s buddy, too.

e

But it’s more than just fun. There’s published evidence that distraction helps children tolerate unpleasant procedures better than adult reassurance does.

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Sometimes, you just need a buddy. Buddy the Brave lion cub is here to help your youngest catheter patients. Along with some serious patient (and parent) education resources, you’ll find some upbeat fun and even a bravery award sticker in every tray.


OR Issues

Unity Hospital: Utilizing Medline’s ERASE CAUTI® Program to Reduce Hospital Acquired Infections in the Delivery of Safe, Quality Care By Erica Perez BSN, RN, Clinical Educator, Unity Hospital

Hospital: Unity Hospital Location: Rochester, NY Size: 340-bed Challenge: To develope a proactive approach to infection prevention and to raise awareness of the significance of hospital-acquired infections on our patients and the facility. Results: Decreased urine NIMs by 32% demonstrating: • Significant cost-avoidance of $3,637 per urine NIM • Reduced risk of patients developing a catheter-associated urinary tract infection (CAUTI) • Improved standard of care for patients receiving a Foley catheter

Quality Improvement Goal Unity Hospital continuously monitors for hospital-acquired infections (HAIs), including catheter-associated urinary tract infections (CAUTI). Through data monitoring of infection markers, Unity Health System has identified areas for improvement to reduce urine Nosocomial Infection Markers (NIMs), and reduce the number of CAUTIs to enhance outcomes. Opportunities identified include: increasing nurse/provider communication/collaboration; educating nurses regarding best practice techniques for catheter insertion; empowering nurses to actively evaluate clinical indications or need for catheter insertion, along with early Foley discontinuation; and reinforcing patient education. By focusing on these initiatives, Unity Health System is able to provide safe, quality care and reduce the risk of HAIs. The reduction of urine NIMs not only enhances patient outcomes but also promotes organizational efficiency. With the implementation of the Value Based Purchasing (VBP) program by Centers for Medicare & Medicaid Services (CMS), reimbursement is directly linked to quality outcomes and efficiency. Many organizations, including Unity Health System, continue to strive for best quality and care outcomes. Facility Demographics Unity Hospital is a 340-bed, nonprofit hospital. It is accredited by The Joint Commission, and the hospital’s intensive care unit ranks in the Top 100 in the United States. In 2009 Unity Hospital had 14,687 discharges and a total of 147,265 patient days.

Aligning practice with policy to improve patient care 61


“The ERASE CAUTI program ties education, nursing power and industry product to promote best processes and decrease the opportunity for a CAUTI to develop.”

Unity Health System offers a wide range of services including: • Emergency center • Endoscopy unit • Family birth place • Intensive care unit • Joint replacement center • Spine center with pain management • Residency program • Stroke center • Surgical center • Vascular center Unity Hospital strives to offer the latest advancements in treatment while giving the personal attention patients expect and deserve from a community health system. Not only are the physicians able to provide high quality medical services, clinical staff also provides compassionate care to make the patient feel as comfortable as possible. The Challenge Unity closely monitors HAIs, including catheter-associated urinary tract infections (CAUTI). Instances in which a CAUTI developed, data was evaluated to determine the cause of the infection. While examining the cause of the infection in retrospect was valuable, a more proactive approach in infection prevention was imperative. It was essential to raise awareness of CAUTI and the significance of HAIs within the facility, but more importantly the outcomes these have on our patients. Throughout this process, we identified gaps in standardization and knowledge regarding the proper insertion technique and clinical indications of a Foley catheter. The decision to insert a Foley involves collaboration between medical and nursing staff; however, nurses must possess a sense a responsibility for ensuring the appropriate clinical decision. In addition, the nurses sought to feel more empowered to monitor a patient’s ongoing need for a Foley, ensuring its timely removal.

62 The OR Connection

Inconsistencies were observed in the technique nurses used to insert Foley catheters. This was due to: 1. Variance in how nurses were initially taught the procedure; 2. Differing protocols at previous facilities where nurses have practiced; 3. Different types of Foley trays nurses have used in the past. Given these challenges, Unity Hospital established the following new goals: • Raise awareness of CAUTI prevention; • Reduce catheter utilization; • Provide clinical education for proper Foley insertion techniques; • Enhance patient education; • Reduce urine NIMs and overall CAUTI rate. The Solution Medline’s ERASE CAUTI Foley catheter management program was introduced to Unity Hospital in April, 2010. The ERASE CAUTI program ties education, nursing power and industry product to promote best processes and decrease the opportunity for a CAUTI to develop. The Medline program offered the tools to reduce the inconsistencies identified. 1.The one-layer tray presents the procedure components in an intuitive manner, guiding the nurse through the procedure from left to right. It is also more efficient to handle all the components in one layer, making it easier to maintain aseptic technique. The one layer tray is a neatly packaged clinical solution, not just a supply solution. 2.The accompanying education program is provided online through the e-learning site, Medline University. The education encompasses a video overview, three learning modules, and an interactive competency that the clinician uses to demonstrate knowledge of proper foley insertion.


3. Awareness tools are also included in the program to communicate program goals engaging the nurses in the education process, and to encourage the participation in the facility-wide effort to reduce CAUTI.

were conducted for two weeks. These online modules have since been added to clinical orientation as a mandatory core competency for new nursing staff. To date, over 500 nurses have completed the education classes online.

4. The patient education card resembles a greeting card, which every nurse reviews with their patients before insertion. This allows the patients to become an active participant in their care. The card, included in the tray, helps to bridge the knowledge gap for patients caring for their catheter once it is in place.

It’s essential to note that because the education is web-based, it was critical to evaluate the technical standards of the work station computers, as well as the facility network capability. When we experienced initial usability issues, Medline worked with the information technology (IT) department to make adjustments to the facility firewall and other technical concerns.

Awareness tools, education, and the tray design all emphasize evidence- based techniques that standardize practices for Foley catheters. The checklist on the front of the tray also serves as a useful tool that guides nurse’s practice when a Foley insertion is necessary.

Step 3- Trial the Tray Following the completion of the competency, four units - - (the Emergency Department (ED), the Operating Room (OR), and medical surgical units 2300 and 2400) - - trialed the ERASE CAUTI Foley catheter tray for three weeks. As a supplement to the online education program, Medline support staff was available to demonstrate the

Execution After learning more about the program and demonstrating its capabilities to a group of staff members and nurse leaders, Unity Hospital decided to trial the program in June 2010. Step 1- Process Improvement Plan The organization’s first step was to create an overall process improvement plan. Team leaders, staff champions, directors and the Infection Prevention team collaborated to draft the plan. Meetings were held to discuss all components of the program including: steps of implementation, necessary tasks to complete, delegation of tasks, and the estimated date of completion for each task. The plan was communicated to all staff involved in the project and updated to reflect the current status of each step. Step 2- Education The team worked to educate the end user clinical staff regarding the ERASE CAUTI program by utilizing the tools available on Medline’s e-learning site: Medline University. The program was rolled out to nurses and the education classes

components of the tray to all nurses in the participating units. Medline staff was on site throughout the trial process to support clinical staff, ensure communication and documentation of feedback. The outcomes of the trial were monitored and hospital- wide implementation was discussed. Step 4- Implementation Following a successful trial period, the program was rolled out facility- wide to all acute units in August 2010. Medline provided product support staff to assist during distribution and rollout. Educators demonstrated the product design and layout to familiarize the nursing staff with the new product. The mandatory online education and interactive competency taught the indications and alternatives to catheterization, aseptic technique and proper insertion of a Foley catheter, care and maintenance, signs and symptoms of CAUTI and timely removal. Ensuring proper education is a crucial step in the ongoing sustainability and success of the program.

Aligning practice with policy to improve patient care 63


“This decrease in urine NIMs demonstrates safe care delivery and a significant cost-avoidance for Unity Hospital.”

Results Unity Hospital was satisfied with the results experienced within one month of implementing Medline’s ERASE CAUTI program. Data collected from the same time period one year prior to implementation (August 2009) revealed a marked reduction in urine NIMs. Reduction in urine NIMs: Unity Hospital uses a data surveillance system to track NIMs. This data collection system increases efficiency for reporting and internal process improvements by prescreening likely causes of HAIs. During the implementation of Medline’s ERASE CAUTI program, the rate of urine NIMs was closely monitored. Compared to the control period of August 2009, Unity Hospital observed a decrease in urine NIMs of 32% in August 2010. The data surveillance provider that Unity utilizes calculates a dollar amount associated with each NIM identified. The associated cost for each urine NIM is $3,637, which demonstrates a significant cost-avoidance based on the reduction in urine NIMs after the ERASE CAUTI Program implementation. This reduction in urine NIMs indicates fewer patients may be at risk for developing a CAUTI. Unity Hospital is very proud to share this demonstration of reduction in urine NIMs.

Summary of Clinical Outcomes Standardization of Foley insertion technique, increased education, nurse/physician communication and collaboration, along with overall awareness of proper indications for use contributed to a 32% decrease in urine NIMs. This decrease in urine NIMs demonstrates safe care delivery and a significant cost-avoidance for Unity Hospital. Achieving these outcomes was possible thanks to Medline University’s online ERASE CAUTI education and competency course that simulates proper insertion technique. The education combined with a single layer tray design that follows the Center for Disease Control (CDC) Guidelines, plus the dedication and commitment to clinical excellence demonstrated by the clinical care team at Unity has made this initiative a success. As a result, Unity has improved the standard of care for patients receiving a Foley catheter and has reduced the risk of CAUTI. Through continued use of the online education program for new clinical nurses, enhanced patient education and sustained use of the ERASE CAUTI tray, Unity anticipates continued clinical excellence and safe patient care delivery to better serve our community and our patients. About the author

Reduction in CAUTI: Although Unity Hospital experienced a very low rate of CAUTI in 2009, after implementing the ERASE CAUTI Program rates continue to trend downward. Because Unity Hospital had few incidences of CAUTI prior to implementation, success has been measured by demonstrating a decrease in NIMs post implementation of this program.

64 The OR Connection

Erica Perez is the Clinical Educator at Unity Hospital in Rochester, New York. In this position, Erica has the responsibility of overseeing clinical education in the acute inpatient areas, developing and delivering inservices on new products, communicating updates of hospital policy and procedures and serves as the Infection Control liaison. Erica brings 18 years of nursing experience to this position with a specialty in Emergency Medicine and serves as a member of the New York State Emergency Nurses Association Genesee Valley Chapter. Serving the past roles of CNA, LPN, RN and BSN throughout her career allows Erica to effectively implement education programs while remaining sensitive to the participation of all roles in nursing practice. Most recently Erica has earned her Masters of Science in Nursing from Roberts Wesleyan College.


709 facilities have joined the program. Are you one of them? Get results with

Medline’s Pressure Ulcer Prevention Program • Average reduction in facility-acquired pressure ulcers: 70.5% • Average annual savings: $306,0001 How does it work?

With a compelling combination of products and education: 1. Medline’s strategic product bundle, including skin care and incontinence products 2. Medline’s free educational program for nurses and nursing assistants, including 4 CE credits for nurses plus online, interactive competencies

Interested in:

Implementing a program that allows you to achieve these results and sustain them over time Reducing the incidence of pressure ulcers at your facility Learning more about Medline’s Pressure Ulcer Prevention Program

Call Medline Pressure Ulcer Prevention Program Manager Karen Frey at 1-847-643-4805 to get started today!

1. Medline Industries, Inc. Data on file.

©2011 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.


Check out booth #3408

Visit Medline’s exhibit at the 2011 AORN Congress to learn more about: ❑ Sterillium Rub ❑ Medline University® live demos at the booth ❑ AORN new confidence-based learning course – “Retained Surgical Items” ❑ ClearCount RFID sponge counting/tracking device ❑ OctylSeal tissue adhesive ❑ Hernia mesh ❑ Surgeon’s gloves ❑ ReeTrakt hands free retractor ❑ PerfecTemp patient warming device ❑ EcoDrape

Introducing

Ally! Medline University Lifelong Student Ally provides top quality care to her patients by continually staying educated on current clinical practice via Medline University®. From infection control to patient satisfaction, MU provides hundreds of FREE continuing education credits. Ally stays plugged in to MU on her computer, MP3 player, iPhone® and iPad®.

Come join Ally at Medline University! Go to medlineuniversity.com to register now.

❑ Procedural packs ❑ Greensmart components for surgical packs ❑ Gold Standard TIME OUT program ❑ Ally – Medline’s newest doll! ❑ CDS ❑ Reusable textiles ❑ Surgical masks ❑ Electrosurgical

To order your own Ally doll, visit

www.medline.com/dolls

66 The OR Connection

Courses are approved for continuing education by the Florida Board of Nursing, the California Board of Registered Nursing, or the American Nurses Credentialing Center's Commission on Accreditation.


50% less friction than the leading competitor3

Relieve Pressure on Vulnerable Heels HEELMEDIX™ Heel Protector

Two Strapping Methods

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.

Straight-back strapping provides extra room, ventilation and protection against foot drop

Criss-cross strapping isolates the foot and floats the heel

Mention this ad to receive a 10 percent discount on your first order. Contact your Medline sales representative or call 1-800-MEDLINE. 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.

©2011 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.


68 The ORâ&#x20AC;&#x2C6;Connection


Special Feature

12

Ways to Reduce Hospital Readmissions

By Cheryl Clark for HealthLeaders Media December 27, 2010

Time flies. In just 21 months, the federal government will start penalizing hospitals with higher than expected readmission rates. And even though much about the regulations-to come remains unclear, clinicians along the care continuum are scrambling to get ready. Or they should be. It’s not just important for a hospital’s bottom line. It’s important for the patient. We’ve been talking with some of the nation’s experts on the subject, including Stephen F. Jencks, M.D., whose April 2009 article in the New England Journal of Medicine set the tone for today’s readmission prevention energy. His review of nearly 12 million beneficiaries discharged from hospitals between 2003 and 2004 found that nearly 21 percent, or one in five, were re-hospitalized within 30 days and 34 percent were readmitted within 90 days.

We also spoke with Amy Boutwell, MD, an internist at NewtonWellesley Hospital in Newton, MA and Director of Health Policy Strategy for the Institute for Healthcare Improvement; Timothy Ferris, MD, medical director of the Massachusetts General Physicians Organization, and Estee Neuhirth, director of field studies at Kaiser Permanente in California. Some of these strategies aren’t yet proven to work in all settings, of course. And many are still in the demonstrations phase. But with national readmission rates as high one in five, and higher for certain diseases, many providers are trying anything that sounds plausible. Here are some of the prevention strategies that these and other experts think might be worth a shot. Many involve—to a greater or lesser degree —following the patient out of the hospital,

Aligning practice with policy to improve patient care 69


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 www.medline.com/offers/dash.

©2011 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

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either in-person, electronically, or by phone, but others involve upside-down introspection and re-evaluation by providers along the care continuum.

Jencks adds that “senders and receivers, for example hospital discharge planners and skilled nursing facility staff and home health” meet often enough so they can learn about the realities of the transitions they initiate and receive.

1. Discharge Summaries Dictate discharge summaries within 24 hours of discharge. Boutwell says that standard practice and policy at most hospitals is that discharge summaries are completed within 30 days of the discharge. “I was trained that the summary is a retrospective report of what happened in hospitalization. But what we need today is anticipatory guidance. Patients get discharged and go home. They can’t fill their meds, insurance doesn’t cover the med or they have questions. They’re nervous and worried. They call their primary care provider, who didn’t even know they were admitted. Boutwell says that 30-day-discharge summary policies “might have sufficed in a time gone by. But that doesn’t work anymore. Information needs to be available at the time of discharge. There’s a growing recognition of this need, but staff bylaws haven’t changed.”

2. Lengthen the Handoff Process At every juncture in patient care process, especially discharge, have teams talk to each other about the patient. And by the way, don’t call them discharges. Call them “transitions.” Standardize them for a variety of providers, from hospital to rehabilitation facility to skilled nursing facility to home and back. Boutwell says that “taking this person-centered approach shifts the concept from discharge, which is a moment in time and you’re done with it, to a transition—a shared accountability. We need to make sure the receiving providers understand who this patient is, with a 360-degree view.

3. Provide Medication on Discharge Send the patient home with a 30-day medication supply, wrapped in packaging that clearly explains timing, dosage, frequency, etc. Some health centers with Medicaid patients may be trying this strategy, which is difficult for hospitals to do with Medicare patients because of distinctions between Part A and Part B payment. Still, for some high-risk populations, such as patients with congestive heart failure and those who have been readmitted before, it might be worth it for the hospital to absorb the cost.

4. Make a Follow-up Plan Before Discharge Have hospital staff make follow-up appointments with patient’s physician and don’t discharge patient until this schedule is set up. A key is to make sure the patient has transportation to the physician’s office, understands the importance of meeting that time frame, and following up with a phone call to the physician to assure that the visit was completed.

5. Telehealth We couldn’t find anyone using video monitors to communicate on a daily basis with the use of such software as Skype, for example, but some readmission experts say it’s an interesting approach to keep up visual as well as verbal communication with patients, especially those that are high risk for readmission. On a more practical scale, Home Healthcare Partners in Dallas uses health coaches, intensive care clinicians, and wireless technology to record vital signs on a daily basis for about 2,100 discharged Medicare fee-for-service beneficiaries for between

Aligning practice with policy to improve patient care 71


60 to 120 days. So far, they have done this for about 7,000 unduplicated patients in the last two years, for several hundred hospitals in Dallas and Louisiana, says HHP’s CEO, Wayne Bazzle. The target population for intense monitoring includes those with four or five co-morbidities and who have a primary diagnosis of congestive heart failure, chronic obstructive pulmonary disease, diabetes, Alzheimer’s and hypertension. Bazzle says that the effort involves phone calls of between five and 15 minutes, and is frequent enough with the same team “so we have their trust. We can help them stay out of the hospital if they'’re more truthful with us about what’s going on, and if we see some deterioration, we can help them cope. Normally it’s a medication management issue, or they’ve become a little too relaxed with their diet.”

7. Understand What's Happening After Discharge Kaiser Permanente is using video cameras to chronicle home settings and the entire care process to determine what’s happening to the patient after discharge that provoked a readmission. The team is also using video of the care team, from the pharmacist, home care providers, nurses, and physicians about their care of that patient, to highlight wrinkles and cracks in the system that brought the patient back to the hospital. So far, Kaiser officials say that the video project has contributed to a reduction in readmission rates at some hospitals where it has been tried, such as from 15.7 percent to 9 percent at Kaiser’s South Bay Medical Center near Los Angeles, because it gave the team information to streamline care, says Kaiser’s Neuwirth.

6. Identify Frequent Flyers Customize your hospita’s admission and re-admission rates for demographic and disease characteristics to identify those at highest risk, and expend extra resources on their care needs. This may involve special programs for homeless patients, such as the one effort by a cohort of Los Angeles hospitals who grappled with how to safely discharge homeless patients without violating city laws. The Los Angeles project now discharges homeless patients who meet certain criteria to a half-way type of house in nearby Bell, and saved $3 million for hospitals in its first few months. Expansions in other parts of Southern California are underway.

8. Provide Home Care on Wheels Just like Meals-on-Wheels can be scheduled in advance, so can case management, housekeeping services, transportation to the pharmacy and physician’s office. At Piedmont Hospital in Atlanta, in collaboration with the Area Agency on Aging, patients having elective knee surgery get coupons and prescheduling, “so that by the time you get out of the hospital, it’s waiting there for you,” Boutwell says. She adds that this kind of a pre-arrangement for post-transition care is “spreading like wildfire” among a number of hospitals, but so far it’s mainly being tried with elective patients. Continued on Page 74

Many strategies involve—to a greater or lesser degree —following the patient out of the hospital, either in-person, electronically, or by phone.

72 The OR Connection


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9. Consider Physician Medication Reconciliation A recent paper in the New England Journal of Medicine by Yuting Zhang of the University of Pittsburgh noted the wide geographic variation among physicians’ prescribing practices with medications that should be avoided in patients over age 65. She also noted variation in prescribing practices for drugs that have a high risk for negative drug-disease interaction. Jencks says that Zhang and colleagues “are pointing us to a rather important gap in the most common thinking about transitions—that we are to make sure that patients are able to get and take medications, get recommended follow-up, and generally do as they are told. But we know that medication plans can be in life-threatening error, that physicians often recommend a time-tofollow-up that is too long, that discharge plans are often written in ignorance of the patient’s pre-admission history and experience. In general, we need to be much more critical of the plans patients get.”

For surgical patients, those with vascular surgery had the highest readmission rate, 23.9 percent, followed by those with hip or femur surgery, 17.9 percent. Perhaps these are the places where readmissions can be most quickly reduced. States with the Highest Hospital Readmission Rates

Washington, D.C.

23.2%

Maryland

22%

Louisiana

21.9%

New Jersey Illinois

21.9% 21.7%

West Virginia

21.3%

Kentucky

21.2%

Mississippi

21.1%

Missouri

20.8%

New York

20.7%

Massachusetts

20.2%

Oklahoma

20.1%

10. Make Sure Patients Understand Patients may nod, and say they understand what they’re supposed to do after they leave the hospital. But “teach back,” in which they and their caregivers repeat back those instructions, even to more than one hospital caregiver, needs to be constantly reinforced, readmission experts say. Jencks says that caregivers need to understand that their patients are often heavily medicated, stressed, groggy and confused. And that their disease state may impair their ability to understand what they are being told, much less remember it two days later.

11. Focus on Highest-risk Patients Examine the readmission patterns at your hospital and see which patients, with which conditions, diseases or procedures, have the most readmissions. If resources are limited as they are at most hospitals, push them toward a select group of patients in a more intense way to see if increased effort makes a difference. For example, in his New England Journal of Medicine paper, Jencks showed that for certain diseases or conditions, and in certain parts of the country, readmission rates are even higher than the national average of one in five. For example, for medical patients, the readmission rate for heart failure patients was 27 percent; for those with psychoses, 24.6 percent; chronic obstructive pulmonary disease, 22.6 percent. Patients with pneumonia and gastrointestinal problems were re-hospitalized at rates of 21 percent and 19.2 percent respectively.

74 The OR Connection

12. Listen to the Patient Involve the emergency room, hospice or home health providers to make sure patients don’t come to the emergency room for non-emergent end-of-life care issues. Providing patients and their family members with informed choices, opportunities for advance directives, and counseling in the emergency room setting may avert painful, unnecessary admissions. Look for this to be a major expansion of palliative care professionals inside the ED. “There really needs to be a care plan that reflects the patient’s wishes,” Jencks says. “This is quite different from either a medical power of attorney or what is often called a living will because it lays out the goals of treatment. “Cure? Palliation? Functional independence? Playing dominoes with friends? Hospice? This kind of plan has little relevance to persons without substantial chronic conditions, but it is totally relevant to a patient with one or more chronic conditions that have required hospitalization. With such a plan, one can often avoid readmissions that really do not serve the patient’s needs or values. What is, after all, worse than a readmission? Readmission of a patient who does not want to be readmitted,” Jencks says. Reprinted with permission from HCPro, Inc. (February 2011) Copyright HCPro, Marblehead, MA. For more information, call 800/639-7477 or visit www.HealthLeadersMedia.com.


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Aligning practice with policy to improve patient care 75


Medline natural OR towels

A LITTLE CHANGE

A LOT OF DIFFERENCE The greensmart™ collection of OR products helps reduce your impact on the environment. • Natural OR towels are dye-free and bleach-free. They produce less lint and are more absorbent than traditional blue towels. • The typical 10-OR suite that switches from blue OR towels to natural OR towels could save up to one half ton of dye, bleach and other chemicals from polluting the environment every year. • 100% biodegradable trays are made of compressed paper with an eco-friendly, water-resistant coating. • The revolutionary EcoDrapeTM has all the features and protection you expect. It breaks down in landfills in about two to five months. To learn more about Medline’s green products, visit www.medline.com/greensmart or www.medline.com/ green-initiatives/pdf/medline_eco_product_guide.pdf.

©2011 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc. greensmart and EcoDrape are trademarks of Medline Industries, Inc.


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 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 www.greeningtheor.org. Reference 1. Esaki RK & Macario A. Wastage of supplies and drugs in the operating room. Medscape Anesthesiology.

Aligning practice with policy to improve patient care 77


Medline Launches Sustainability Program Healthcare facilities, which generate an estimated 6,600 tons of waste per day, are almost the largest generator of waste in the country, second only to the food industry. That translates to the equivalent of 5,110 pounds of waste per patient bed annually. Medline is addressing this industry-wide concern through their Sustainability Program, which will include hospital management consulting, staff education, and facility-wide awareness campaigns. For more information on Medline’s Sustainability Program, contact Francesca Olivier at 847-643-3821. Hospital operating rooms contribute between 20 and 30 percent of the hospital’s total waste. Medline is a co-sponsor of Practice Greenhealth’s Greening the Operating Room™ initiative, a collaborative effort of hospitals, manufacturers and related stakeholders to develop guidance documents to reduce the environmental impact of the nation’s operating rooms. Practice Greenhealth’s vision for this initiative is to help every provider in the country offer the best available patient care in operating rooms that utilize product and practices that are patient-, worker-, and environmentally safe while minimizing costs. Nearly 100 hospitals have already pledged their participation by completing the Participation Commitment Form, which is included on the next page. The Commitment allows hospitals to participate in whichever way is best for their needs. Resources and educational materials for hospitals can be found at www.practicegreenhealth.org or by calling 502-727-8658.

78 The OR Connection


Green Facts

Upcoming Green Events CleanMed 2011 Medline will be an exhibitor at CleanMed 2011, a conference that brings together leaders in environmentally sustainable healthcare and features topics from environmentally preferable products and purchasing, to green building design. Medline will exhibiting our greensmart products such as the EcoDrape, Natural OR Towels and Pigment-Free Plastics. The conference is in Phoenix, Arizona April 6-8, 2011. Webinars To register for these events go to http://www.practicegreenhealth.org/tools/webinars/calendar

Apr 12 Free

Climate Change and the Role of the Health Care Professional: Education, Mitigation and Adaptation

Apr 14 Free

Climate Change and the Role of the Health Care Clinician: Education, Mitigation and Adaptation

Apr 27 $150

Green Design & Construction Series: Regulatory Impact on Healthcare Greening

May 05 Free

Introduction to Greenhealth Tracker

May 10 Free

Getting Started with PGH - Intro for New Members

May 11 $150

Green Operations Series: Community Organizing 101: How a Corner Office Can Cultivate a Sustainable Local Food Program for Patient Health, Healing and Wellness.

May 19 Greening the OR: Energy Efficiency in the OR Free May 25 $150

Green Design & Construction Series: Greening the Community Hospital: Re-scaling the Management of Benefits and Costs vier at 847-643-3821.

An avera g percent e of 24 of waste is medical cla as hazard ssified ous a regulate nd d

86% of total hospital costs are attributed to this waste

90% of red bag waste does not actually meet criteria for red-bag waste

By switching to reusable surgical gowns, one hospital saved $60,000 per year By switching from blue wrap storage to hard cases, a hospital saved $26,000 per year

40 25

Percent of red-bagged medical waste from ORs that is actually just packaging material (Another 40% is suction canister waste) Percent estimated portion of hospital operating costs that are consumed by energy use

Source: Kwakye G, Brat GA, Makary, MA Arch Surg. 2011;146(2):131-136.

121 ft per day

Amount of material the average 10-OR Suite could save if they replaced half of their full-size natural OR towels with the slightly smaller natural OR hand towel Medline Industries, Inc. Data on file.

Aligning practice with policy to improve patient care 79


The OR Goes Green – the only TRULY eco-friendly surgical drape Medline’s new patent-pending EcoDrape is the only dye-free 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 and performance as other Medline drapes, including hook-and-loop line holders, large reinforcement zones, and premium tape and incise film flush to the fenestration.

Composition Comparison EcoDrape

SMS

Fibers

More than 96% wood pulp

No wood pulp

Petrochemical ingredients (plastics)

0%

100% PP

Additives

Bio-based

Fluorine

For a quick online video demonstration, visit www.medline.com/ecodrape

Try the new EcoDrape and take your OR to the next level of green! ©2011 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc. EcoDrape and greensmart are trademarks of Medline Industries, Inc.


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Aligning practice with policy to improve patient care 81 !


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Other reasons to try MediClip • • • • •

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©2011 Medline Industries, Inc. Medline and MediClip are registered trademarks of Medline Industries, Inc.


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©2011 Medline Industries, Inc. Medline and Medline University are registered trademarks of Medline Industries, Inc.


Study of Breast Biopsies Finds Surgery Used Too Extensively Too many women with abnormal mammograms or other breast problems are undergoing surgical biopsies when they should be having needle biopsies, which are safer, less invasive and cheaper, new research shows. A study in Florida found that 30 percent of the breast biopsies there from 2003 to 2008 were surgical. The rate should be 10 percent or less, according to medical guidelines. The figures in the rest of the country are likely to be similar to Floridaâ&#x20AC;&#x2122;s, researchers say, which would translate to more than 300,000 women a year having unnecessary surgery, at a cost of hundreds of millions of dollars. Many of these women do not even have cancer: about 80 percent of breast biopsies are benign. For women who do have cancer, a surgical biopsy means two operations instead of one, and may make the cancer surgery more difficult than it would have been if a needle biopsy had been done. Dr. Stephen R. Grobmyer, the senior author of the Florida study, said he and his colleagues started their research because they kept seeing patients referred from other hospitals who had undergone surgical biopsies (also called open biopsies) when a needle should have been used. By Denise Grady

84 The ORâ&#x20AC;&#x2C6;Connection


OR Issues

Hospitals charge $5,000 to $6,000 for a needle biopsy, and double that for an open biopsy,

“After a while you keep seeing this, you say something’s going on here,” said Dr. Grobmyer, who is director of the breast cancer program at the University of Florida in Gainesville. The reason for the overuse of open biopsies is not known. Researchers say the problem may occur because not all doctors keep up with medical advances and guidelines. But they also say that some surgeons keep doing open biopsies because needle biopsies are usually performed by radiologists. The surgeon would have to refer the patient to a radiologist, and lose the biopsy fee. A surgical biopsy requires an inchlong incision, stitches and sometimes sedation or general anesthesia. It leaves a scar. A needle biopsy requires only numbing with a local anesthetic, uses a tiny incision and no stitches and carries less risk of infection and scarring. If the abnormality in the breast is too small to be felt and has been detected by a mammogram or other imaging method, the needle biopsy must also be guided by imaging — mammography, ultrasound or M.R.I. — and will often have to be performed by a radiologist. If a lump can be felt, imaging is not needed to guide the needle, and a surgeon can perform it. “Surgeons really have to let go of the patient when they have an image abnormality,” said Dr. I. Michael Leitman, the chief of general surgery at Beth Israel Medical Center in Manhattan. “They are giving away a potential surgery. But the standards require it. And I’m a surgeon.” Dr. Grobmyer’s study, published by The American Journal of Surgery, is based on 172,342 biopsies entered into a state database in Florida. It is the largest study of open biopsy rates in the United States, and the first to include patients with and without cancer.

About 1.6 million breast biopsies a year are performed in the United States. But in 2010, only about 261,000 found cancer (207,000 women had invasive breast cancer, and another 54,000 had a condition called ductal carcinoma in situ, in which cancer cells have not invaded the surrounding tissue). Hospitals charge $5,000 to $6,000 for a needle biopsy, and double that for an open biopsy, according to Dr. Grobmyer’s article. Doctors’ fees for an open biopsy range from $1,500 to $2,500, he said, and $750 to $1,500 for a needle biopsy. A surgeon who was not part of Dr. Grobmyer’s study said she often encountered patients referred from other hospitals whose open biopsies should have been done with a needle. “I see it all the time,” said the surgeon, Dr. Elisa R. Port, the chief of breast surgery at Mount Sinai Medical Center in Manhattan. “People are causing harm and should be held accountable.” Dr. Melvin J. Silverstein, a breast cancer surgeon at Hoag Memorial Hospital Presbyterian in Newport Beach, Calif., and a clinical professor of surgery at the University of Southern California, said it was “outrageous” that 30 percent of breast biopsies were done by surgery. He said some of the unnecessary procedures were being performed by surgeons who did not want to lose biopsy fees by sending patients to a radiologist. “I hate to even say that,” Dr. Silverstein said. “But I don’t know how else to explain these numbers.” A study at Beth Israel Medical Center in Manhattan (Dr. Leitman was an author), published in 2009, found that the rate of open breast biopsies in 2007 varied with the type of surgeon.

Aligning practice with policy to improve patient care 85


One way for hospitals to stop excess open biopsies is to ban them, Dr. Silverstein said, unless they are truly necessary, as in uncommon cases in which a needle cannot reach the spot.

Breast surgeons employed by the hospital and involved in teaching had a 10 percent rate. Breast surgeons in private practice who operated at Beth Israel had a 35 percent rate. Among general surgeons, who do not specialize in breast surgery (some who were on staff at the hospital and some who were not), the rate was 37 percent. All the doctors earn biopsy fees, so they all had the same incentive. The lead author of the study, Dr. Susan K. Boolbol, chief of breast surgery at Beth Israel, said the difference could be explained, in part, by training. She said the academic breast surgeons on the hospital staff were more likely than the others to keep up with new developments in the field and to work closely with radiologists. As for the idea that the motivation was money, she said, “A huge part of me doesn’t want to believe it’s true.” She said that when she asked surgeons in the study why they were doing open biopsies, many said patients wanted them. “My comeback was, ‘Do you think you had an inherent bias in the way you explained it?’ ” In the past seven years, she said she had only one patient choose an open biopsy over a needle biopsy. Dr. Boolbol says some patients fear that sticking a needle into a cancer will cause it to spread, and she spends a lot of time explaining that it is not true. She said that open biopsy rates declined among surgeons at Beth Israel who were told about her study’s findings, but newcomers still tended to have higher rates. “This is a constant education process for surgeons,” she said.

86 The OR Connection

One way for hospitals to stop excess open biopsies is to ban them, Dr. Silverstein said, unless they are truly necessary, as in uncommon cases in which a needle cannot reach the spot. “We made a rule,” he said. “If it can be done with a needle, it has to be. We embarrass you if you do an open biopsy. We bring you before a tumor board to explain.” Dr. Silverstein says that when he lectures and asks how many surgeons in the audience perform open biopsies, no hands go up. “Nobody will admit it,” he said. He said there is more to be gained by taking his message straight to the patients. He and other doctors say that any woman who is told that she needs a surgical biopsy should ask why, and consider a second opinion. “Maybe we have to get patients to say, ‘This guy took a big chunk out of me and I didn’t even have cancer, and now I’m deformed,’ ” Dr. Silverstein said. “Who just overthrew Mubarak? The people. This is exactly the same thing.”

From The New york Times, February 19, 2011. © 2011 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.


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

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

©2011 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc. Arglaes is a registered trademark of Giltech Limited Corporation.


Special Feature

Celebrating Six Years of Spreading Breast Cancer Awareness to Healthcare Professionals Across the Nation

Since 2006, Medline has been hosting “Together We Can Save Lives Through Early Detection” breast cancer awareness breakfast forums at the Association of PeriOperative Registered Nurses (AORN) Annual Congress as part of the company’s efforts to raise breast cancer awareness and share the importance of early detection. Spreading this message to nursing professionals is a key goal of Medline’s campaign. Nurses are not only caregivers, but major influencers of women when it comes to early detection. Every year, Medline invites a celebrity breast cancer survivor to share her survival story and her own inspirational message of hope at the breakfast. Past keynote speakers include Ann Jillian, the late Rue McClanahan, Dr. Marla Shapiro, Linda Ellerbee and Peggy Fleming.

2011 Breakfast Forum at the AORN 58th Congress – Philadelphia, Pennsylvania

This year, Medline’s 6th annual breakfast, held in conjunction with the AORN 58th Congress in Philadelphia, Pennsylvania, features Jill Eikenberry, a breast cancer survivor, and her husband Michael Tucker. Eikenberry and Tucker are veteran stage, film and television actors, perhaps best known for their portrayals of Ann Kelsy and Stuart Markowitz on the long-running hit television series l.A. law.

88 The OR Connection


A look back at the breakfast forums over the past five years

2010 Breakfast Forum at the AORN 57th Congress – Denver, Colorado An audience of more than 1,200 operating room nurses, the largest yet, gathered to hear Olympic gold medalist Peggy Fleming talk about her skating career and battle with breast cancer. She did not disappoint the early morning crowd, who were also treated to a surprise appearance by several other celebrities of sorts – the staff members from Providence St. Vincent Medical Center in Portland, Oregon, who starred in the “Pink Glove Dance,” a YouTube video sensation that has more than 13.1 million views to date.

AORN breakfast participants are inspired by Peggy Fleming’s story about her battle with breast cancer

Aligning practice with policy to improve patient care 89


2009 Breakfast Forum at the AORN 56th Congress – Chicago, Illinois One of the funniest, frankest and most distinctive journalists to ever appear on television, keynote speaker Linda Ellerbee touched and inspired the crowd of 1,000 with her candid talk about her treatment and recovery. A 17-year breast cancer survivor, she said she was lucky because her training as a journalist taught her to ask questions. Photo by Gordon Munro

2008 Breakfast Forum at the AORN 55th Congress – Anaheim, California Dr. Marla Shapiro, author of life in the Balance: My Journey with Breast Cancer, a renowned Canadian on-air medical expert and a physician with a thriving medical practice, delivered a dynamic presentation on coping with stress, balancing life and battling breast cancer. She candidly told the audience that on August 13, 2004, she went from being a doctor to a patient in a matter of moments. And that despite her medical training, she was not fully prepared for the path her life would take.

2007 Breakfast Forum at the AORN 54th Congress – Orlando, Florida The late Rue McClanahan, an award-winning actress who played Blanche Devereaux on the hit TV series Golden Girls, filled the room with laughter as the keynote speaker of Medline’s 2nd annual breast cancer awareness breakfast forum. She was diagnosed with breast cancer in 1997 and was treated successfully. Janelle Hail, president of the National Breast Cancer Foundation (NBCF) also spoke, reminding everyone that each day is a gift.

2006 Breakfast Forum at the AORN 53rd Congress – Washington, D.C. Medline held its first “Together We Can Save Lives Through Early Detection” breakfast forum during the AORN 53rd Congress in Washington, D.C. Attendees were inspired by the words of Ann Jillian, actress, singer and breast cancer survivor. At 35 years old, the actress made headlines when she was diagnosed with breast cancer and she became a vocal advocate for cancer research and prevention.

To see more photos from the breakfast forums visit medline.com/breast-cancer-awareness. 90 The OR Connection


A World Without Breast Cancer Is in Our Hands™

Medline started the Generation Pink movement with a single vision: A World Without Breast Cancer Is in Our Hands. It’s now the largest philanthropic cause in the company, where Medline partners with the National Breast Cancer Foundation (NBCF) to support free mammograms for underserved women, build awareness at forums for nurses and other healthcare workers, and even spread awareness virally through social media and events such as The Pink Glove Dance.™ Pink ribbon products, including pink gloves, help Medline support the National Breast Cancer Foundation. Medline donates a portion of the proceeds to the NBCF: more than $800,000 to date. Their mission of awareness, early detection and prevention lines up perfectly with Medline’s: A World Without Breast Cancer Is in Our Hands.™

Healthcare Sites Appearing in the Pink Glove Dance Sequel Providence St. Vincent Medical Center, Portland, Oregon University of Minnesota Medical Center, Fairview, Minneapolis, Minnesota Indiana University Melvin and Bren Simon Cancer Center, Indianapolis, Indiana Tallahassee Memorial Healthcare, Inc., Tallahassee, Florida Saint Michael’s Medical Center, Newark, New Jersey The Medical Center of Plano, Plano, Texas HCA Johnston-Willis Hospital, Richmond, Virginia Sky Ridge Medical Center, Lone Tree, Colorado Thibodaux Regional Medical Center, Thibodaux, Louisiana Capital Health, Halifax, Nova Scotia Burgess Square Healthcare and Rehab Centre, Westmont, Illinois Isabella Geriatric Center, New York, New York Lorien Health Systems, Ellicot City, Maryland Scripps Memorial Hospital La Jolla, La Jolla, California

The Dance Goes On and On… Seen over 13 million times since it went viral in 2009, the Pink Glove Dance kicked off a huge wave of awareness, joy and caring. The 2010 sequel features more than 4,000 healthcare workers and breast cancer survivors from 14 separate facilities all over the United States and Canada. Visit pinkglovedance.com


Straight From the Heart

Quotes about the Pink Glove Dance

Watching this video is the first time I’ve cried over my breast cancer. I hadn’t realized how alone I felt, even though surrounded by caring family and friends. The fact that so many healthcare workers were donning gloves and dancing to show that I am not alone touched me deeply. Thank you from my heart for this video.

Jenny W. Ft. Collins, Colo.

I have just watched these videos for the 5th time. Each time tears stream down my face. I have shared these with my family and work family to help them realize just how important breast cancer awareness is. It saved my life not once, but twice. Let’s hear it for all those great people dancing all over the United States … THANKS from the bottom of my heart.

Louise C. Haverhill, Mass.

92 The OR Connection


Caring For Yourself

Medline Breast Cancer Awareness By the Numbers

$809,606 4,000

6

Dollars Medline has donated to the National Breast Cancer Foundation to date. Healthcare workers and breast cancer survivors participated in the Pink Glove Dance sequel. Number of breast cancer awareness breakfast forums Medline has hosted in conjunction with AORN Congress.

13,178,145 Views of the Pink Glove Dance and Pink Glove Dance Sequel on YouTube. 5,700

Healthcare workers who have attended Medline breast cancer awareness breakfast forums since 2006.

14

Facilities that participated in the Pink Glove Dance Sequel.

4,567

People that like Medlineâ&#x20AC;&#x2122;s Breast Cancer Awareness Facebook page.

Aligning practice with policy to improve patient care 93


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

For more information, contact your Medline representative, call 1-800-MEDLINE or visit www.medline.com. ©2011 Medline Industries, Inc. Medline is a registered trademark and Pink Pearl is a trademark of Medline Industries, Inc.


Special Feature

Beyond a Reasonable Doubt: Open Communication Helps Jill Eikenberry Raise the Bar for Breast Cancer Awareness

Aligning practice with policy to improve patient care 95


Most everyone has heard the saying “your life can change in an instant.” Actress Jill Eikenberry is one who can definitely appreciate it

After struggling for more than a decade on the New York City stage, Eikenberry and her husband Michael Tucker finally felt they’d made it when, in 1986, they landed regular roles on a new television show called L.A. Law. Their son was starting kindergarten. She was celebrating her thirteenth wedding anniversary. “We were going to get the fame and fortune we thought we always wanted,” says Eikenberry. And then in a moment, everything changed. She found a tiny lump in her right breast. It would later test malignant. The diagnosis was breast cancer. “I didn’t know anybody who’d survived breast cancer,” she recalls. “And I thought I was going to die for sure.”But while breast cancer is one of society’s common denominators, so fortunately, are hope and survival. All it took was a chance meeting with a woman who had survived – with her breast intact – to provide Eikenberry with a belief in both. Eikenberry’s breast cancer story began as she and Tucker were packing up their lives and children in New York to move to the West Coast. They had finished shooting the pilot for L.A. Law and were heading to Los Angeles for the rest of the series. “I reached up while driving and felt something, and instantly when I felt this thing I knew that something was wrong. This wasn’t what was supposed to be there,” said

96 The OR Connection

Eikenberry. “I had never checked myself before. I don’t know what made me do it, but I think somehow we know. We have some sort of intuitive feelings sometimes.” She called her gynecologist, who acknowledged that she had felt something during Eikenberry’s last exam and had, in fact, already scheduled a mammogram without telling her. At age 39, it would be her first. The result wasn’t good: the lump was malignant. “I was terrified. In those days, no one was talking about surviving breast cancer,” she said. “The only person that I knew that had had it was the woman that lived upstairs from us in our New York apartment. She had died the year before, leaving three children.” Eikenberry and Tucker consulted a breast surgeon, who recommended either a lumpectomy or a mastectomy. The surgeon leaned toward a mastectomy. Eikenberry’s first panicky impulse was to agree. “I said ‘Whatever you have to do get it out of here – get it off.’ And we went home in despair.” It wasn’t until a couple of days later – “I sort of laid on the bed and cried, didn’t want to tell anybody” – that she decided to attend a screening of a movie she had recently completed called The Manhattan Project. The cast included her friends John Lithgow and Cynthia Nixon.


While Eikenberry has a long list of theater, film and television credits, she is perhaps best known for her portrayal of L.A. Law’s Ann Kelsey

She walked into the lobby of the movie theater, determined not to tell anybody about her situation. However, “Cynthia took one look at me and said ‘what happened to you?’ And I poured the whole story out.” Nixon brought Eikenberry into the audience to see her mother, Ann. Nixon’s mother then took her hand and dragged her up the aisle into the ladies room. “Ann hiked up her blouse and said, ‘You see this little scar on my right breast? That’s all I have to remind me of my breast cancer 11 years ago.’ And all of a sudden, I felt hope,” said Eikenberry. That hope persuaded Eikenberry to seek a second opinion. The news was better this time as her doctor said she was a perfect candidate for a lumpectomy. “I saved my breast,” she said. “It was amazing what Ann Nixon did for me.” Amazing is a description that Eikenberry herself has heard over the years in reference to her stellar career and odds-defying, long-term Hollywood marriage to Tucker. Born in New Haven, Connecticut, she was raised in Madison, Wisconsin before moving to Missouri. She began her college studying anthropology

at Barnard College in New York. In her second year, however, she auditioned for and was accepted into the Yale School of Drama in New Haven, Connecticut. She met Tucker while the two of them were performing at the Arena Stage in Washington, D.C. They were later cast in the play Moonchildren, which eventually took them to Broadway in 1972. They married the following year. While Eikenberry has a long list of theater, film and television credits, she is perhaps best known for her portrayal of L.A. Law’s Ann Kelsey alongside Tucker’s Stuart Markowitz. Over the course of the series’ long-run, she received four Emmy nominations, two Golden Globe nominations and a Golden Globe Award. One of the most decorated dramas in television history, the show followed a group of lawyers at the fictitious law firm McKenzie, Brackman, Chaney and Kuzak. In its prime, blessed with a plumb Thursday time slot behind “Cosby” and “Cheers,” the series regularly finished in the top 15. Its legal cases covered big issues of the day, such as the outing of prominent gays and the morality of the death penalty, as well as unusual ones like dwarf tossing and the culpability of a Jewish mohel sued for snipping a bit too much at a circumcision ceremony. The compelling stories would often intermix with the lawyers’ sexy personal entanglements – including the famous storyline where Tucker employs a secret sexual technique called the “Venus Butterfly” to win the hand of Eikenberry. The episode was one of the most talked about of the entire season, and although the “V.B.” was a fictional figment of a writer’s fertile imagination, hordes of viewers wrote the show asking what the ancient sexual practice was.

Aligning practice with policy to improve patient care 97


The chemistry between Eikenberry and Tucker made them instantly identifiable as a TV couple, and a hit show put them squarely in the public eye. The fame would make it challenging for Eikenberry, who by now had undergone surgery at Mt. Sinai in New York, to keep her ensuing radiation therapy treatments a secret. That privacy was very important to Eikenberry, as she was very concerned about the word getting out and people thinking of her as “the actress with cancer.” “After the surgery Steven Bochco, who was producing L.A. Law, called a friend at UCLA who agreed to administer my radiation therapy in private so nobody would know,” she recalled. “So every night we would have to get off the set without anybody noticing and sneak over to UCLA and have my radiation treatments.” However, despite being able to keep the treatments from the public, she wasn’t, by her own admission, dealing very well with the up-and-down emotions she was experiencing. “On one hand, I think that it was really good for me to play that character because Ann Kelsey was a fighter. She could walk into a room filled with men, CEOs, and level the room. She was really tough. I think for me it was the most positive thing to play somebody that tough when I was feeling as vulnerable as I was,” she said. “But I wasn’t really talking to myself about my fears. I was just trying to bury them in the character and work the character and be famous instead of being the person with cancer.”

Eikenberry was among the first to be installed into the Cancer Survivors Hall of Fame in October 2000.

Things began to change when Eikenberry was approached by Linda Otto, a documentary film maker who also had breast cancer. She had an idea for a new documentary film based on interviews with women who have survived the disease. Her pitch resonated with Eikenberry: “I don’t think anyone knows you can survive. I think that if people know there is a good chance of survival, especially if you catch it early, people would be less afraid to check themselves and to get their mammograms.”

Tucker was having a hard time as well. Even so, Eikenberry was very reluctant at first to do it. “My focus was on Jill – helping her and making her feel confident. I completely forgot about myself,” said Tucker. “Because of that fear of loss, I went into a phase of denial for two years. It wasn’t until later that the penny dropped and I realized that I was going through something too.”

98 The OR Connection

“I thought there was going to be a terrible stigma if I went on television and said I have breast cancer,” she said. “I was a celebrity now. I had done L.A. Law for a couple of years and I was terrified of what people would think.”


Eikenberry received four Emmy nominations for playing lawyer Ann Kelsey, noting that “She was a fighter. I think for me it was the most positive thing to play somebody that tough when I was feeling as vulnerable as I was.”

But in her car after meeting with Otto, she thought about her own initial reaction to her diagnosis and her subsequent encounter with Ann Nixon – and tearfully decided that it was time to go public.

anti-cancer bias, and their forthrightness becoming the program’s spiny strength as it helps to further lift the stigma from a disease that was once considered unmentionable.”

“I knew that I had to talk about it because it had been so important to me when somebody talked about it.”

When the documentary went on the air it was a revelation for Eikenberry.

Eikenberry not only agreed to participate, but also became the interviewer for the project. The result became the 1988 NBC special Destined to Live: 100 Roads to Recovery, with subjects ranging from Gloria Steinem and Nancy Reagan to a gruff-talking female deputy sheriff and a woman whose supportive husband bought her a Frederick’s of Hollywood negligee after her breast surgery.

“I thought there would be a stigma, when in fact it was the beginning for a whole new career for me really because people had felt as alone as I had. When they saw the documentary they were given hope. It was just this amazing thing to realize that I had friends everywhere who were so grateful to be able to share their story once they heard all the stories we told on the show.”

“It was very important for me to do this documentary,” said Eikenberry in an interview with the Los Angeles Times. “On a personal level I have a tendency, because I’m optimistic, to put it away and pretend it didn’t happen. But being able to face one’s own mortality does give one a new lease on life.”

The success of Destined to Live: 100 Roads to Recovery led to Eikenberry receiving the Vital Options Vital Spirit Award 1991. At the awards ceremony, emcee Meryl Streep praised “the ease with which the information was given” within the documentary, noting that Eikenberry “really got the women to talk about it. It was moving and heartening. It made you understand what they went through.”

The Los Angeles Times praised the special, noting that “the candor is remarkable considering society’s lingering

Aligning practice with policy to improve patient care 99


“I think that the most important thing that I have learned is that silence is not golden in this situation,” said Eikenberry. “The more that we are able to try and understand what we are feeling and communicate it, the better we feel and the more we are able to go into the experience and be present and make our own decisions. It’s just so important to be open with ourselves and other people. It’s a very different environment now. People are not feeling the way they were feeling back then.” Eikenberry witnessed the difference first hand, because in February of 2009 she faced what every breast cancer survivor fears most – a check-up mammogram that detected a recurrence.

“Each of us has changed a lot and grown a lot,” said Eikenberry. “And I think the main thing is that we allowed the change in the other person and did not try to keep things in a status quo situation. I think that’s big. We’re very good communicators. We make a point of it.” It’s also why both Eikenberry and Tucker continue to travel the country, telling their story. It’s not only cathartic, it makes them stronger and feel more connected. “Every time I go out and talk about the cancer, even though it is difficult to say the words, it ends up eliciting all kinds of responses in people out there in the audience – the nods, the compassionate faces. And I feel suddenly that I am so not alone. Everyone should know that feeling.”

“My mammogram discovered another tiny tumor in exactly the same spot as my old one,” she said. “But this time was so different. There’s a lot more people vocal about their breast cancer now. My radiologist said to me on the phone when she gave me the news, ‘you have nothing to worry about.’ They would have newer said that to me in 1986.” Another big change noted by Eikenberry: the communication between her caregivers and herself. “I had so much communication with everybody all along the way this time and last time I felt completely in the dark,” she says. “This time I didn’t have to have chemo or radiation; I was able to have a lumpectomy again in the same spot. But I felt like it was my choice every step of the way, and that I was being part of the experience instead of the victim of the experience.” And like he has for more than four decades, Tucker was there to help her through it. “My husband was able to be so present with me because he wasn’t afraid the same way as last time,” she said. “We were really able to have our eyes open and talk about it every step of the way instead of feeling like we had to push it all down. And that was just really an eye opener in many respects. The medical profession has changed and I have changed a lot for the better.” It’s open communication that has kept Eikenberry and Tucker – or Tuckerberry as they refer to themselves – together both personally and professionally since 1970.

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Eikenberry originally was very concerned with word getting out that she had breast cancer, and was “terrified that people would think of me as the actress with cancer.”


OR Issues

Less Invasive Surgery Just as Effective for Some Breast Cancer Patients by Allison Bierly, PhD

When breast cancer has spread to nearby lymph nodes, many doctors believe that removing several more nodes provides better treatment. But a new study suggests otherwise. The finding may change the way early-stage breast cancer is treated in some patients. Doctors often begin with sentinel lymph node dissection (SLND)—only removing one or two lymph nodes—to determine if cancer has spread. If these sentinel nodes don’t contain tumor cells, no more surgery is performed. However, if the sentinel nodes do contain tumor cells, the next step is to perform axillary lymph node dissection (ALND)—removing at least 10 nodes. ALND can lead to a number of side effects, including seromas (swelling due to clear fluid pockets), tingling sensations and buildup of lymph fluid called lymphedema. Moreover, studies haven’t definitively shown whether ALND improves survival or staves off reoccurrence of the disease compared to SLND alone. Dr. Armando Giuliano of the St. John’s Health Center in Santa Monica, California, and his colleagues set out to investigate.

Complication rates following lymph node removal

25 % complications

70 % complications

axillary lymph node dissection

sentinel lymph node dissection

The team recruited almost 900 patients from 115 different treatment centers. All had tumor cells in 1 or 2 sentinel lymph nodes. Patients were randomly divided into 2 groups. One underwent ALND while the other did not. All the patients received radiation therapy. The study, which was funded by NIH’s National Cancer Institute (NCI), appeared in the February 9, 2011, issue of the Journal of the American Medical Association. Overall, an average of 17 lymph nodes per patient was removed from the ALND group, while just 2 were removed from patients who underwent SLND alone. Strikingly, 5 years after surgery, the research team saw no difference between the 2 groups in the percentage of patients who survived or who remained disease-free. The team also compared how many patients in each group had complications from surgery, including wound infection, seromas and tingling sensations. In the group that received SLND alone, only 25 percent suffered from these complications, while 70 percent of the ALND group experienced them. These results show that SLND is no less effective than ALND at preventing death or reoccurrence of disease after 5 years, while dramatically reducing the risk of side effects from surgery. Giuliano notes that several treatment centers—including St. John’s Health Center and the Memorial Sloan-Kettering Cancer Center—are already using the findings to make treatment decisions for early metastatic breast cancer. “It’s ready to go for these patients,” he says.

Source: National Institutes of Health http://www.nih.gov/researchmatters/ february2011/02282011surgery.htm

Aligning practice with policy to improve patient care 101


How to

ENERGIZE 102

The OR Connection


by Wolf J. Rinke, PhD, RD, CSP

YOUR TEAM Aligning practice with policy to improve patient care 103


...the fastest way to achieve peak performance is to treat all employees as if they were volunteers Let’s face it—health care is a team “sport.” No matter what your current role, sooner or later you’ll end up being a team leader. And when that happens, your success depends on your team members’ willingness to go the extra mile. (Hint: if you are not yet a team leader, read this anyway because the time to practice is now.) Here are six strategies to keep your team members “juiced.” 1. Treat all team members as if they are volunteers. I refer to this as the most important leadership principle of all time. I discovered it while I was a Board member of one of my professional associations and the Chair for the Council on Education. In that role the Board looked to me to implement new Standards of Education, which had been in limbo for countless years. A team of 12 professionals was on my committee. All highly educated, all volunteers, all having their own agenda. I quickly became aware that all the “crutches” that I relied on during my “day job” did not work. For example, one of my committee members, let’s call her Julie, was really gung-ho. Any time there was a project to be done she was the first one to volunteer. There was only one problem—Julie seldom delivered. Forget delivering on time, she just did not deliver. At work, when any of my team members did that, I could counsel them and if that did not work I could use the ultimate “crutch”— I could fire them. Trying that with Julie, however, produced just the opposite results. Her response: “Hey I don’t need this; I’m outta here—more time with the family.” After banging my head against the proverbial brick wall several times I finally figured out that my autocratic strategies simply did not work with volunteers. I had to develop an entirely different skill set to motivate these people. And after I had mastered them, I transferred these new strategies to my “day job.” For me this was a defining moment that enabled me to transform myself from an autocratic manager to a highly effective leader. What was that concept? Are you ready for it? This is BIG! Drum roll please! Treat all employees as if they are volunteers.

Now, stop and think, what would you say to your team members if indeed they were volunteers? How about: "Please." "Thank you!" "Can I count on you?" "I need your help." "I really appreciate what you’ve done." "Thanks for being on my team!" "Thanks for showing up." And now the one that blows the autocratic managers away: "Could you do me a favor?" That one just doesn’t sit well with lots of managers. Here are some of the things they’ve said to me: "What are you talking about? You’re paying them; they owe you a good job." Or "You’ve got to be nuts. They are not doing you any favor, it’s their job," and so on. All really good arguments, and all really, really incorrect. (If you agree with any of these, it’s time to wake up and smell the coffee. Because the only thing pay will do is get team members to show up, and stay with you. (Not bad, but certainly not peak performance.) And the fastest way to achieve peak performance is to treat all employees as if they are volunteers. 2. Catch team members doing things almost right! Most of us were taught to supervise team members by catching them making mistakes. Someone even gave it a name: management by exception. Unfortunately most team members will live up or in this case down, to your expectation. To reverse this, you will need to learn to catch team members doing things right. No wait, let me modify that, catch team members doing things almost right! The problem is that if you are a perfectionist some of your team members just have a tough time getting it right, especially if right is defined as the way you would have done it. Then you must compliment or recognize that positive performance in some way. In other words, you must learn to Continued on page 106


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I learned a long time ago that if it’s fun, it gets done.

practice management by appreciation (MBA). Although difficult to master, this is a more powerful strategy than you will ever learn in any university MBA program. Catching team members doing things almost right means you use your abundant mental energy to look for your team members moving in the right direction, instead of using the same amount of energy to catch them messing up. If you look hard enough, you will find that most team members do several things each day that they feel really great about. Find it, and then be sure to make a big deal about it, ideally in public. If you still find yourself slipping back into old habits use the 10 penny system. Put 10 pennies in your left pocket or in case you don’t have pockets, the left side of your desk. Every time you catch one of your team members doing something almost right and let them know about it, transfer one penny from your left pocket to your right pocket. On the other hand if you provide negative reinforcement to one of your team members, reverse the process; but this time move three pennies back to the left pocket. Your goal is to have all pennies in your right pocket at the end of each day.

3. Make work fun. I learned a long time ago that if it’s fun, it gets done. So ask yourself, are your team members having fun? Better yet ask them. It’s very hard to be motivated and energized if work is a big pain. In fact Sigmund Freud got this right when he identified the Pleasure Principle, which basically says that all human beings move themselves in the direction of pleasure and move themselves away from pain. So if you have a high turnover rate, have team members who abuse sick leave or have trouble getting team members to show up for work on time, you can be sure that working for you is painful. What to do? Ask five of your team members to serve on a “Celebration or Fun Team.” Give them a budget. If you don’t have one, suggest that they contact local merchants who’d love to achieve greater visibility in your organization. Suggest that they ask those merchants to make donations to your Celebration Team. Example: movie tickets, a weekend for two at a local resort, etc., etc. Just be sure to give those who donate lots of visibility. Now ask the Celebration Team to get together to identify specific things they are planning to do each month that make work fun. Tell them anything goes, provided that they stay within their allocated budget and it does not violate any laws, rules or regulations. 4. Be positive and energetic Attitudes, just like colds are catching. Positive attitudes are caught just as easily as negative attitudes. The only problem is that negative attitudes suck the energy out of your team members like a giant sponge—something your peak performers are just not going to put up with. On the other hand, positive attitudes are like the little Energizer bunny. They will keep your team mem-

Continued on page 108

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Recognize that positive language energizes you.

bers going, and going, and going (well, you get it.) To build a positive attitude, become aware of your conversations including the ones that you have inside of your head. Recognize that positive language energizes you, and negative, cynical, “stinking thinking” conversations de-energize you and your team members. Make it a practice to say positive things, especially about other people, or say nothing at all. Also recognize that your mind can hold only one thought at a time. It can either be positive or negative, it is your choice! So when you catch yourself thinking positive thoughts, congratulate yourself. On the other hand when you are thinking negative thoughts, catch yourself, change those thoughts, then give yourself credit. Remember because of “mirror neurons” your team members take their cue from you! You must be the role model for the kind of behaviors you want them to exhibit. (For in-depth strategies of how to make this happen read Make It a Winning Life--Success Strategies for Life, Love and Business available at http://wolfrinke.com/miwlbook.html.) 5. Build on team members' strengths. Statistics tell us that 25% of the US population hates what they do, another 56% could take it or leave it, and only 19% love what they do. Typically team members who love what they do are in jobs that let them build on their strengths. So find out what your team members love to do and do everything in your power to assign them to those projects or place them in those positions. What if you end up losing them? Think about it: would you rather have team members who love what they do and hence are peak performers, or those who stick with you because they can’t get a job anywhere? Even your most dedicated team members are going to get burnt out really fast if they are not building on their strengths. So you would be much better served to get team members in positions or projects that enable them to build on their strengths even if you lose them. Just remember that whoever inherits one of your team members will be much more likely to reciprocate in the future. Plus the team member who has left you will become an "ambassador of goodwill" for you. And in today's competitive health care industry, good will is a very valuable commodity when you need to fill your next vacancy.

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6. Get team members to listen to motivational audio programs. Mary Kay sales associates, or for that matter all highly successful sales professionals, have this figured out. You must provide team members with external motivation if you want them to consistently perform at peak performance. So start building an audio-program library. Suggest to your team members that they listen to a program every day on their way to work. Meet in brief weekly meetings and have team members share one powerful principle they learned from each program. That way everyone can learn from everyone else, and energize each other at the same time. Supplement these activities by showing a motivational program during your next in-service. (Aren’t your team members getting tired of the same mandatory training?) Or better yet hire a motivational speaker to energize your next "all hands" team meeting. Your team members will be positively surprised, feel honored and energized. And when they are energized everyone’s job will be much more enjoyable, and to top it all off, your patients will be less grumpy and may even get better faster. © 2011 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 www.easyCPEcredits.com. In addition he has authored numerous CDs, DVDs and books including Make It a Winning Life: Success Strategies for Life, Love and Business, Winning Management: 6 Fail-Safe Strategies for Building High-Performance Organizations and Don’t Oil the Squeaky Wheel and 19 Other Contrarian Ways to Improve Your Leadership Effectiveness; available at www.WolfRinke.com. His company also produces a wide variety of quality pre-approved continuing professional education (CPE) self-study courses, available at www.easyCPEcredits.com. Reach him at WolfRinke@aol.com.


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Healthy Eating

Nutrition Information Servings: 9 Calories: 166 Fat: 15.6 g Sodium: 159 mg Fiber: 0.1 g

Aunt Judy’s Tortilla Roll-Ups 1 ½ 8 1 12 3

cup finely shredded cheddar cheese cup sour cream oz. cream cheese, softened pkg. taco seasoning green olives or green chiles/pimentos large tortillas

Directions: Mix ingredients together, and spread onto the tortillas. Roll up tortillas. Place into a zip lock bag and chill. When ready to serve, slice and serve with salsa. Hint: Healthier alternative ~ low fat cheese and low fat sour cream and whole wheat tortillas may be used. Judy DeSalvo, Marketing Business Manager – Mundelein Judy DeSalvo has been working at Medline for nine years. She basically “does it all” to keep the Marketing Department running efficiently. Judy sees print projects through to completion, making sure vendor estimates are correct on invoices, all the way down to ensuring marketing materials arrive on time and in the right location at trade shows and meetings. She’s often been sighted moving boxes of brochures and Medline dolls, and she’s even been known to wield a screwdriver to repair a piece of office equipment in a pinch so coworkers can get their jobs done.

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This recipe is Judy’s favorite appetizer, which she inherited from her Aunt Judy a year ago. It’s a highly requested dish at the many events Judy attends. Judy was also involved in creating Medline’s first and second edition cookbooks, which feature recipes from Medline employees. The latest edition is available for purchase, and the proceeds go to Medline’s Spirit of Giving fund, which helps support Medline employees in times of need. The Medline employee cookbook is $10. To purchase your own copy, please e-mail Judy at jdesalvo@medline.com. 


Forms & Tools

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

Surgical Attire

Highlights of AORNâ&#x20AC;&#x2122;s Revised Recommended Practices for Surgical Attire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .113 Hand Hygiene

CDC Clean Hands Poster . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .120 Pressure Ulcer Prevention

How Well Do You Know Pressure Points? . . . . . . . . . . . . . . . . . .121

Aligning practice with policy to improve patient care 111


KEEP YOUR SURGICAL PATIENTS DESERT DRY. Medline’s Sahara® Super Absorbent OR table sheets are designed with your patients’ skin integrity in mind.

QuickSuite® OR Clean Up Kit

The Braden Scale tells us that moisture is one of the major risk factors for developing a pressure ulcer.1 We also know that as many as 66 percent of all hospital-acquired pressure ulcers come out of the operating room.2 That’s why we developed the Sahara Super Absorbent OR table sheet. The Sahara’s super-absorbent polymer technology rapidly wicks moisture from the skin and locks it away to help keep your patients dry. Sahara OR table sheets are available on their own or as a component in our QuickSuite® OR Clean Up Kits, which were designed to help you dramatically improve your OR turnover time and help reduce cross contamination risk through a combination of disposable products.

To sign up for a FREE webinar on perioperative pressure ulcer prevention, go to www.medline.com/pupp-webinar.

References 1

Braden Scale for Predicting Pressure Sore Risk. Available at: www.bradenscale.com/braden.PDF. Accessed November 6, 2008.

2

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.


AORN’s Recommended Practices

Forms & Tools

Highlights of AORN’s Revised Recommended Practices for Surgical Attire

November 2010

Highlights of AORN’s Revised Recommended Practices for Surgical Attire

The following report includes excerpts from AORN’s “Recommended Practices for Surgical Attire.” For a complete copy, refer to AORN’s 2011 Perioperative Standards and Recommended Practices.

Aligning practice with policy to improve patient care 113


Forms & Tools

AORN’s Recommended Practices

Italicized wording throughout the document represents language quoted directly from AORN’s Recommended Practices for Surgical Attire.

AORN recently revised its Recommended Practices for Surgical Attire to include stronger recommendations for donning safe surgical attire, based on emerging evidence showing a connection between attire and possible risk of infection. The following are some of the major changes: •

The biggest change: All recommendations for home laundering of surgical attire have been removed. AORN recommends that surgical attire should be laundered in a health care-accredited laundry facility

New information on characteristics of safe surgical attire fabrics, including recommendations that fabrics should be low linting, tightly woven, stain resistant and durable, and that 100% cotton fleece should not be worn

A new recommendation that cover apparel (lab coat, cover gown) should be laundered daily

A new recommendation that nonscrubbed personnel in the semirestricted and restricted areas should wear a freshly laundered or single-use long sleeve warm-up jacket

A new recommendation on quality assurance monitoring of laundering processes

Recommendation I Surgical attire should be made of low-linting material, contain skin squames, provide comfort, and promote a professional appearance. Researchers have found that tightly woven and/or synthetic surgical attire helps contain bacterial shedding and promotes environmental control. The design of the surgical attire is not as important as the material from which it is made. I.a. Surgical attire fabrics should be: • Tightly woven • Stain resistant • Durable • Comfortable in terms of design, fit, breathability and weight of the fabric I.b. Surgical attire made of 100% cotton fleece should not be worn. Some fabrics made of cotton fleece collect and shed lint. Lint may harbor microbial-laden dust, skin squames, and respiratory droplets. 114

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AORNâ&#x20AC;&#x2122;s Recommended Practices

Forms & Tools

Recommendation II Clean surgical attire, including shoes, head covering, masks, jackets, and identification badges should be worn in the semirestricted and restricted areas of the surgical or invasive procedure setting. Clean attire minimizes the introduction of microorganisms and lint from health care personnel to clean items and the environment. II.a.2. When wearing a two-piece scrub suit, the top of the scrub suit should be secured at the waist, tucked into the pants, or fit close to the body. II.a.3

Health care personnel should change into street clothes whenever they leave the health care facility or when traveling between buildings located on separate campuses.

II.e.

Identification badges should be worn by all personnel authorized to enter the perioperative setting. Health care personnel as well as patients should be able to identify caregivers.

II.e.1. Identification badges should be secured on the surgical attire top, be visible, and be cleaned if they become soiled. II.f.1

Cover apparel should be laundered daily in a health care-approved or accredited laundry facility (See Recommendation V.) In one study of cover coats worn by 100 physicians, Staphylococcus aureus was isolated from 25 of the cover coats. The cuffs and pockets of the coats were the most contaminated.

Aligning practice with policy to improve patient care 115


Forms & Tools

AORNâ&#x20AC;&#x2122;s Recommended Practices

Recommendation III All individuals who enter the semirestricted and restricted areas should wear freshly laundered surgical attire that is laundered at a health care-accredited laundry facility or disposable surgical attire provided by the facility and intended for use within the perioperative setting. III.a.

Surgical attire should be changed daily or at the end of the shift. Surgical attire may have bacterial colony counts that are higher when scrub clothing is removed, stored in a locker, and used again.

III.a.1. Reusable or single-use contaminated attire should be placed in appropriately designated containers after use. Worn reusable surgical attire should be left at the health care facility for laundering. III.a.2. Surgical attire that has been penetrated by blood or other potentially infectious materials should be removed immediately or as soon as possible and replaced with freshly laundered, clean surgical attire. When extensive contamination of the body occurs, a shower or bath should be taken before donning fresh attire. III.a.3. Wet or contaminated surgical attire should not be rinsed or sorted in the location of use. III.a.4. Surgical attire contaminated with visible blood or body fluids must remain at the health care facility for laundering or be sent to an accredited laundry facility contracted by the health care organization. III.b.

When in the semirestricted or restricted areas, all nonscrubbed personnel should wear a freshly laundered or single-use long sleeved warm-up jacket snapped closed with cuffs down to the wrists.

III.b.1. All personal clothing should be completely covered by the surgical attire. Undergarments such as T-shirts with a V-neck, which can be contained underneath the scrub top may be worn; personal clothing that extends above the scrub top neckline or below the sleeve of the surgical attire should not be worn. Personal clothing is not laundered by a health care-accredited laundry.

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Appropriate surgical attire, including warm-up jacket, for semirestricted and restricted areas.


AORN’s Recommended Practices

Forms & Tools

Recommendation V Surgical attire should be laundered in a health care-accredited laundry facility. Accredited health care laundering facilities provide a monitored laundering process and must adhere to established standards set forth by the Healthcare Laundry Accreditation Council (HLAC). These standards require that facilities demonstrate regulated practices for every step of the laundering process, from transferring soiled laundry, to sorting it, washing with specified wash formulas, time and temperature according to manufacturer guidelines, drying, pressing, packing and transporting clean laundry. The new AORN Recommended Practices for Surgical Attire cites many studies showing the ineffectiveness of home laundering in removing infectious bacteria from fabrics. Surgical attire; street clothing; PPE; and other hospital textiles (e.g., bed linens, towels, privacy curtains, washcloths) may become contaminated by bacteria and fungi during wear or use. In one study, researchers found that microbes can survive on hospital textiles for extended periods of time. These textiles included: • 100% cotton clothing • 60% cotton/40% polyester blends (e.g., scrub suits, lab coats) • 100% polyester clothing; and • polyethylene plastic aprons The shortest time for enterococci survival on textiles was 11 days.1,2 It has been postulated that these fabrics can become vectors for fungi.2 Health care-accredited laundry facilities are preferred because they follow industry standards. V.a.

Laundered surgical attire should be protected during transport to the practice setting to prevent contamination.

V.a.1. Surgical attire should be transported in a clean vehicle and enclosed carts or containers. V.b.

Clean surgical attire should be stored in a clean, enclosed cart or cabinet.

V.b.1

Surgical attire may be stored in a dispensing machine. Dispensing machines should be routinely emptied and cleaned according to the manufacturer’s directions.

1. Neely AN, Maley MP. Survival of enterococci and staphylococci on hospital fabrics and plastic. J Clin Microbiol. 2001;38(2):724-726. 2. Neely AN, Orloff MM. Survival of some medically important fungi on hospital fabrics and plastics. J Clin Microbiol. 2001;39(9):3360-3361.

Aligning practice with policy to improve patient care 117


Forms & Tools

AORN’s Recommended Practices

Recommendation VII Health care personnel should receive initial and ongoing education and demonstrate competency on appropriate surgical attire. Competency assessment verifies that health care personnel have an understanding of the articles and purpose of surgical attire. This knowledge is essential for reducing the risk of health care-associated infections.

Recommendation IX The health care organization’s quality management program should evaluate compliance with surgical attire policies and identify and respond to opportunities for improvement. IX.a.1. Quality indicators for surgical attire may include, but are not limited to, • head coverings completely cover the hair and scalp; • warm-up jackets with wrist-length sleeves are worn and are snapped; • identification badges are worn, visible, and clean; • shoes are clean and protect health care personnel’s feet; • visibly soiled or wet surgical attire is removed and cleaned at an accredited health care laundry facility; • masks, when worn, are tied securely and are discarded after each procedure; and • cover apparel, if worn, is laundered daily at the organization or an accredited laundry facility.

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AORNâ&#x20AC;&#x2122;s Recommended Practices

Forms & Tools

These recommended practices are intended as guidelines adaptable to various practice settings, including traditional operating rooms (ORs), ambulatory surgery centers, physiciansâ&#x20AC;&#x2122; offices, cardiac catheterization laboratories, endoscopy suites, radiology departments and all other areas where surgery and other invasive procedures may be performed.

GLOSSARY Restricted Area: Includes the OR and procedure room, the clean core, and scrub sink areas. People in this area are required to wear full surgical attire and cover all head and facial hair, including sideburns, beards and necklines. Semirestricted Areas: Includes the peripheral support areas of the surgical suite and has storage areas for sterile and clean supplies, work areas for storage and processing instruments, and corridors leading to the restricted areas of the surgical suite. Surgical Attire: Nonsterile apparel designated for the OR practice setting that includes two-piece pantsuits, cover jackets, head coverings, shoes, masks, protective eyewear, and other protective barriers.

Aligning practice with policy to improve patient care 119


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Influenza

www.cdc.gov/handhygiene

Klebsiella

RSV

Enterococcus

Pseudomonas

Staphylococcus

Candida

Protect patients, protect yourself

Alcohol-rub or wash before and after EVERY contact.

CENTERS FOR DISEASE CONTROL AND PREVENTION

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CLEAN HANDS SAVE LIVES

Forms & Tools Hand Hygiene Poster


Forms & Tools

Pressure Point Quiz

How well do you know

Pressure Points? 6

Feel free to use this quiz for skill fairs, training and in-services.

7 1

Choose from (some may be used twice) Dorsal thoracic area Ear Elbow Foot Greater trochanter Heel Ischial tuberosity Lateral aspect of foot Lateral aspect of knee Lateral malleolus Medial aspect of ankle Medial malleolus Occiput Posterior knee Ribs Sacrum/Coccyx Shoulder Shoulder blade

2

3

5

4

10

8

12

11

9

13

19

1. _____________________ 2. _____________________ 3. _____________________

14

20

4. _____________________ 5. _____________________ 6. _____________________ 7. _____________________ 8. _____________________ 9. _____________________

15

10. _____________________ 11. _____________________ 12. _____________________ 13. _____________________ 14. _____________________ 15. _____________________

Answer key to quiz on page 123

16

16. _____________________ 17. _____________________ 18. _____________________ 19. _____________________

17

18

20. _____________________

Aligning practice with policy to improve patient care 121


Just what I was looking for.

NEW CE Courses for Surgical Techs! Medline University continues to build its curriculum with another group of NEW Surgical Tech courses, available at www.medlineuniversity.com Visit today to earn free CE credits with the following courses: • The Different Types of Wounds • Debridement • Using DIMES to Your Advantage • Infection Prevention • Wound and Skin Care Education • Hand Hygiene Improvement Strategies

Access courses on your computer, iPhone or iPad.

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

Be the first to know when we add new courses and content.


Pressure point answers From page 121

1. Lateral malleolus 2. Lateral aspect of foot 3. Lateral aspect of knee 4. Greater trochanter 5. Ribs 6. Shoulder 7. Ear 8. Occiput 9. Ear 10. Elbow 11. Dorsal thoracic area 12. Sacrum/Coccyx 13. Heel 14. Shoulder blade 15. Sacrum/Coccyx 16. Ischial tuberosity 17. Posterior knee 18. Foot 19. Medial malleolus 20. Lateral malleolus

PERIOPERATIVE PRESSURE ULCER EDUCATION. MORE IMPORTANT THAN EVER BEFORE

I have seen an increase in the number of legal issues linking facility-acquired pressure ulcers to post-surgical patients. A pressure ulcer program for the OR is more critical than ever.” Diane Krasner, PhD, RN, CWCN, CWS, BCLNC, FAAN

Medline’s Pressure Ulcer Prevention Program now has a component designed specifically for the perioperative services. The easy-to-use interactive CD addresses the following: • Hospital-acquired conditions • CMS reimbursement changes • Best practices for pressure ulcer prevention • Perioperative assessment tools • Critical patient and equipment risk factors

To learn more about Medline’s Pressure Ulcer Prevention Programs for long-term care, acute care and perioperative services, call your Medline representative or visit www.medline.com/pupp-webinar. ©2011 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

Aligning practice with policy to improve patient care 123


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OR Connection Volume 6 Issue 1