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The Aligning practice with policy to improve

patient care

Volume 7, Issue 3

Startling SSI Statistics


Pink Glove Dance Video Competition Winners! Page 80

5 Tips for Reducing Perioperative Pressure Ulcers “Escape Fire�

U.S. Health Care in Crisis

Atul Gawande:

Can Health Care Be Run Like a Restaurant?

Free CE! Page 29

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In this issue, general and endocrine surgeon, writer, public health researcher and professor Atul Gawande shares his article, “Big Med,” in which he compares health care to a restaurant chain. Dr. Gawande has been a staff writer for The New Yorker magazine since 1998. He has also written three New York Times bestselling books: Complications, Better and The Checklist Manifesto. He has won two National Magazine Awards, AcademyHealth’s Impact Award for highest research impact on health care, a MacArthur Award, and selection by Foreign Policy Magazine and Time magazine as one of the world’s top 100 influential thinkers.

Editor Sue MacInnes, RD


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


“Escape Fire.” This eye-opening new documentary reveals the sad state of health care in the United States and how it is linked to financial incentives.


Big Med. Restaurant chains have managed to combine quality control, cost control and innovation. Can health care?

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



Surgical Site Infections Following Orthopedic Surgery. Learn new ways to stop the staggering numbers of preventable SSIs and related death and disability.


2012 Pink Glove Dance Video Competition Winners! Lexington Medical Center takes first place, winning $10,000 for the Vera Bradley Foundation for Breast Cancer.

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

Aligning practice with policy to improve patient care 3

Patient Safety

41 Five Ways to Avoid Perioperative Pressure Ulcers 44 Nine Sources of Danger with Patient Controlled Analgesia Pumps OR Issues

29 Surgical Site Infections Following Orthopedic Surgery 42 Perioperative Process Change to Reduce the Risk of Post-Operative Infection Following Orthopedic Procedures 55 Scalpel Safety; Staying Safe While Working on the Cutting Edge Special Features

Beat the Winter Blues, page 84

8 A New Year in Health Care: How Healthcare Reform Will Affect You and Your Hospital in 2013 16 “Escape Fire” 20 Big Med 49 What’s Your Cleaning and Disinfection IQ? 69 Evidence for the Validity of the Medline Pressure Ulcer Prevention Program 80 Pink Glove Dance Video Competition 2012 Winners

Page 8

Page 44

Page 49

Caring for Yourself

78 New Study Identifies Four Subtypes of Breast Cancer 84 Beat the Winter Blues 104 Healthy Eating: White Bean Chicken Chili Page 55

Forms & Tools

106 CMS FY 2014-2016 Measures for CMS Payment Determination 108 Pros and Cons of Common Sterilization Technologies 109 PCA Patient Safety Checklist 111 Now You See It, Now You Don’t 112 Ambulatory Surgery Patient Safety Checklist (Pre-Operative) 113 Ambulatory Surgery Patient Safety Checklist (Post-Operative) 115 Sharps Safety Begins with You


The OR Connection

Page 104

The OR Connection Letter from the Editor

Dear Readers, Over the last month or so, I’ve been on a mission to research and really understand healthcare reform and what it means to you and me and the organizations that we work for. Along the way, I’ve had some “Gidget” moments where I think to myself, how did I get here? I’m meeting people and having experiences I wouldn’t have thought possible years ago. I’ve been to The Forbes Healthcare Summit, Strategic Imperatives Beyond Healthcare Reform, National Center for Healthcare Leadership, The Joint Commission Advisory Board meeting ….but I am on a mission and I want to “get it.” For the first time in a very long time I wrote an article for The OR Connection. The article is about healthcare reform and trends we are seeing for 2013. After I wrote it, I sent it to several people who would not necessarily know the ins and outs of the topic…l wanted feedback…how do you make a dry subject interesting. I got feedback all right…all of it helped, but the underlying message was that for many of us we just have a hard time with the details of legislation. Any legislation. But I just couldn’t help myself. I wanted to know more. I feel it is important to understand what is going on and how we fit. I want to tell you things I found out and discuss areas that are clearer to me now. It would be a lot more entertaining to read a good novel, but we need to know this stuff…it’s our job, and how else can we make a difference if we don’t know what is going on? I went to dinner about a month ago with my friend Dale Bratzler. He had come to Chicago for a meeting so I decided to drive “downtown” to meet him for dinner before he had to leave for the airport. We went to Petterino’s, a Chicago feeling restaurant in the Theater area. Usually, it is very crowded but it was 5pm and the place was pretty empty. Dale formerly was the CMO of the Oklahoma Foundation for Medical Quality (the national Quallity Improvement Organization (QIO) for hospitals). He led the SCIP project, he is a member of HICPAC. In short, he knows his stuff. Currently, he oversees the physicians at the University of Oklahoma and teaches. We talked about physicians and medical schools and different areas working together. It was when we were leaving the restaurant that he told me about a film that he showed his medical students. He was quite passionate about it and said, “Sue you are going to really like this film.” Oh boy, was he right. So, as part of our research you have to look at pages 16 and 17. Because after I give you the

healthcare reform story, you have got to see this movie. Start with the trailer, and you will get excited too. The movie is called “Escape Fire.” After seeing it, you will want to save the world. You will want to push innovation. You will see your role in health care differently… I promise you. Once again I can’t help myself…I have included in this issue an article called “Big Med” by Atul Gawande. My staff thought it was too long, so they cut the 17-page article down to about 5 pages. As I was reviewing it…I’m thinking where is the good stuff in this article….what about the story about the Cheesecake Factory? And I made them put the whole article back in. I know, yikes. But I had to do it. It was that good. I just put most of it in the back so if you really don’t want to read it, you don’t have to, but it’s there. I’m giving you just a few of the things I learned in looking into health care reform, but there is so much more. We are fortunate to be a part of an evolving system. Yes right smack in the middle of change. We are going to be challenged with thinking smarter, of doing more with less, of being innovative, etc. because the way things have been done in the past aren’t going to work in the future. Aren’t you glad that you have a part in molding the future? 2013 is a year of change. Health care the way we have known it will begin to transform and have a new identity. And we are all lucky enough to be a part of it. Here is to the New Year! See you in San Diego in March at the Breast Cancer Breakfast during the AORN meeting! Cheers!


Aligning practice with policy to improve patient care 5

Contributing Writers Beth Boynton, MS, RN

Beth Boynton is an organizational development consultant specializing in issues that affect nurses and other healthcare professionals. She is a national speaker, coach, facilitator and trainer for topics related to communication, conflict management, teambuilding and leadership development and author of the book, Confident Voices: The Nurses’ Guide to Improving Communication & Creating Positive Workplaces. Michelle DeMeo

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

Pat Iyer, MSN, RN, LNCC

Pat Iyer is president of She is a legal nurse consutant with medical malpractice and pesonal injury cases. She has served as president of the AALNC and is the cheif editor of Legal Nurse Consulting: Principles and Practice (2nd ed.) and Business Principles for Legal Nurse. Atul Gawande, MD

Atul Gawande is a surgeon, writer, and public health researcher. He practices general and endocrine surgery at Brigham and Women’s Hospital in Boston. He is also Professor of Surgery at Harvard Medical School and Professor in the Department of Health Policy and Management at the Harvard School of Public Health. He has written several books, including The Checklist Manifesto and serves as lead advisor for the World Health Organization’s Safe Surgery Saves Lives program, which developed the Safe Surgery Checklist. Wolf Rinke, RD, CSP

Keynote speaker, seminar leader, management consultant, executive coach and editor of the free electronic newsletter Read and Grow Rich, available at In addition he has authored numerous CDs, DVDs and books including Make It a Winning Life: Success Strategies for Life, Love and Business, Winning Management: 6 Fail-Safe Strategies for Building High-Performance Organizations. Reach him at Daniel L. Young, PT, DPT

Daniel L. Young is an assistant professor in the Department of Physical Therapy at the University of Nevada, Las Vegas. A few of his many research interests include factors affecting use of physical therapists for inpatient wound care, prevalence and incidence of nosocomial wounds in various acute care populations and factors related to the success of programs to address the nosocomial wounds. He received his bachelor of science degree in biology from Southern Utah University and he was awarded his doctor of physical therapy (DPT) degree from Creighton University.


The OR Connection

Surgical Safety News

One in 7 SurgerieS reSultS in COmpliCatiOnS1,2 About 15 percent of surgical procedures result in complications within 30 days post-op, leading to SIGNIfICANTLY HIGHER HEALTHCARE COSTS, more frequent emergency department visits and higher readmission rates, according to researchers at the University of Alabama Birmingham who presented their findings at the annual meeting of the American College of Surgeons in October.

period, hospital lengths of stay for the procedure declined while readmissions for certain complications following knee replacement revisions more than doubled. According to the authors, findings from this and other recent studies suggest “an inherent tradeoff between shorter hospital LOS, greater need for post-acute care and higher readmission rates.” The Medicare Payment Advisory Commission has recommended that the Centers for Medicare & Medicaid Services publish readmission and complication information for knee replacement patients and incorporate such measures into payment programs.

One in seven cases of orthopedic, gastrointestinal, vascular or gynecological surgery resulted in a complication WITHIN 30 DAYS Of SURGERY. The authors of the study derived their results by analyzing data from nearly 60,000 surgical procedures performed at 112 VA hospitals from 2005 to 2009. The complications included surgical site infections, urinary-tract infections and respiratory problems. The researchers said their findings demonstrate hospitals’ need to boost patient education efforts and more effectively track complications following hospital stays.

Study examineS Knee replaCement trendS, readmiSSiOnS3

References 1. McKinney M. Post-discharge complications common after surgery, study finds. Modern Posted October 2, 2012. Available at: http://www.modernhealthcare. com. Accessed November 16, 2012. 2. Wasek S. One in 7 surgeries results in complications. Outpatient Surgery E-Weekly. October 9, 2012. Available at:

The number of Medicare enrollees receiving knee replacements more than doubled over the past 20 years, partly due to an aging population and increase in patients likely to benefit from the procedure, according to a new study in the Journal of the American Medical Association. Over the same

Accessed November 16, 2012. 3. Cram P, Lu X, Kates SL, Singh JA, Li Y, Wolf BR. Arthroplasty volume, utilization, and outcomes among medicare beneficiaries, 1991-2010. JAMA. 2012;308(12):1227-1236.

Aligning practice with policy to improve patient care 7

by Sue MacInnes


The OR Connection

Are you up to speed on healthcare reform and the impact it will have on you as a consumer and as a healthcare worker? 2013 may be one of the most impactful years we’ve had in healthcare since the 1960s when President Lyndon B. Johnson signed Medicare and Medicaid into law. Few people want to read the 906 pages of legislation that make up the Patient Protection and Affordable Care Act (PPACA) more commonly known as Obamacare, but many of us are curious about what healthcare reform really means and how it affects us.

Aligning practice with policy to improve patient care 9

Maybe a little background is in order The burning purpose of the PPACA was to provide healthcare coverage to the millions of Americans who do not have insurance (actually, 48.6 million or 15.7% of the U.S. population as of 2011).1 Now here is the irony. The United States is the only country that does not have universal health care, and the cost of health care is expensive. According to the Organisation for Economic Co-operation Development, in 2010 the cost of health care per capita in the United States was $8,233 – far greater than other wealthy countries.2 In fact, the United States ranks first in expenditure per capita. Norway ranks second with a per capita healthcare spending rate of $5,388, or 65 percent of the average per capita cost for healthcare in the United States. Other wealthy countries in the world spend an average of $3,265 per capita on health care.2 And yet, much higher spending does not equal better healthcare quality in the United States. In the same 2010 report by the Organisation for Economic Cooperation Development, the United States ranked 32nd out of 34 countries on infant mortality and 27th in life expectancy.2 We spend more than any other country for health care but our outcomes are a poor reflection of the price we pay. And, with over 48 million uninsured, many Americans cannot afford to get wellness care or go to the doctor when

10 The OR Connection

they detect a problem. In many cases, people with serious illnesses are left either going to the Emergency Room for care or suffering with no resources. Can you imagine having a child that is ill and not being able to get them care because you have no insurance? Or what if it was you who had a lump or a pain or had diabetes or needed

dialysis…and you couldn’t afford it? There are women who have felt lumps in their breasts who are trapped and unable to get help because they can’t pay for care. for some, no insurance is a death sentence. Under healthcare reform, 30 million currently uninsured Americans will have the opportunity to get insurance.

COST OF HEALTHCARE PER CAPITA: $ $ $ $ $ $ $ $ $ $ $ other wealthy $ United States2 $ countries2




#32 on infant mortality #27 on life expectancy





of 34 countries


How will 30 million people now get insurance? 1

Beginning in 2014, a person who does not have insurance will be able to “shop” for their own policy, just like car insurance, but with government-sponsored plans, like Medicaid or an exchange plan. There are some rules. • Medicaid will be available for individuals and families based on income. • Companies with under 50 employees are not required to provide health insurance coverage. Those who work for these companies will be able to participate in a new statebased competitive private health insurance plan known as an exchange plan. Exchange plans

What does all this mean?

rates, pressure ulcers, mortality rates, patient experience scores, and just like Consumer Reports, rate the hospital options you have in your geographic area. This could conceivably mean that the “patient” might be more willing to go to a high-scoring hospital for an acute MI, versus a hospital that is closer to home. The rise of “consumerism” is changing how hospital systems are strategizing. You will see hospitals marketing more and more to the patient. With this will come a rise of “consumerism” as consumers exercise choice due to considerations of transparency, plans and pricing, as well as transparency around outcomes. They will pay for value.

In addition to more Americans having coverage, the consumer will also have more choice. Information about healthcare providers is becoming transparent. You can look up infection

The big mystery will be how 30 million patients in exchange plans and Medicaid change the payor mix in the hospitals. Will hospitals be

will provide individuals and small businesses with a “one-stop shop” to find and compare affordable, private health insurance options.

• Based upon your income, the cost of health insurance could be capped at a certain percentage, earning you tax credits. 2


If a U.S. citizen does not get insurance, they will be penalized on their tax return. Large companies must meet specific minimum requirements on the mandatory healthcare insurance they offer.

The rise of “consumerism” is changing how hospital systems are strategizing.

Aligning practice with policy to improve patient care 11

– Cons = +Pros =

Corresponding decreases in revenue

Potential increases in revenue HEALTHCARE REFORM FINANCIAL PROS



required to do even more with less, as the exchanges and Medicaid will pay much lower than Medicare and private insurance? And so, 2013 will bring a shift in how hospitals get paid. Hospitals are strategizing around the advantages and disadvantages of healthcare reform.

Cons = Corresponding decreases in revenue

• Replacement of more highly reimbursed lives (commercial insurance) with less highly reimbursed (Medicare, Medicaid, exchange plans) • Reduction in Medicare and Medicaid reimbursement rates - Lower Medicare growth rate

Pros and cons of healthcare reform from a financial point of view, as described by McKinsey3

- Decreased DSH (Disproportionate Share Hospital) payments

Pros = Potential increases in revenue

- Reduced Medicaid reimbursement

• Increase in utilization due to coverage expansion in governmentsponsored plans • Reduction in uninsured bad debt as the formerly uninsured join Medicaid and exchange plans • Ongoing demographic aging may also increase utilization on a per capita basis

12 The OR Connection

So, there is an uncertainty about how healthcare reform will affect the revenue of your organization. Value based purchasing Now, in addition to these financial and coverage changes, quality of care has never been more important. Value based purchasing is now in effect, and hospitals are competing against each other as well as themselves. Value based purchasing will be rated on how well core measures are met (which

include SCIP measures in the OR) and HCAHPS, or patient experience scores. Dollars that were available in previous years are now at risk, depending on how well your hospital scores. Patient experience scores not only affect payments. They also affect the image of the hospital in the community.

Hospital-acquired conditions and readmissions Other financial incentives involve hospital-acquired conditions (HACS) – effective fY 2015 and readmissions – effective fY 2013. The chart on the opposite page summarizes the quality initiatives that affect your hospital now and in the years to come. Percentages increase as the years go on. Each of these comes with incentives to increase reimbursement if your organization performs well…or penalties for lesser performance. In some cases, such as value based purchasing, the penalties could be significant.


Fiscal Year

Value Based Purchasing

Hospital Aquired Conditions

Excessive Readmissions Penalty

































But with all of these things, an important aspect—maybe the most important—is the reputation of your organization. As performance scores are made public, it will be critical to market and engage the people in your community so that your organization is looked upon as the healthcare leader. Loyalty of patients and families and the reputation of your hospital are critical considerations. In 2013, you will see some trends occurring: 1

Hospitals will be enacting broadranging cost control programs

including lean operations, back office cost control and clinical transformations.3 Hospitals are looking to cut $5-10 million a year in costs each year for 5 years. Hospitals will be thinking “big picture” about costs…increase quality, increase patient satisfaction, outcomes versus costs, cost variation by docs, supply chain squeezed. Areas of consideration:3

a. Hospital labor productivity b. Clinical cost variation





c. Operational efficiency/lean methodology d. Purchasing and supply chain management

Aligning practice with policy to improve patient care 13



Cost saving is not always just “price.” It can also include

efficiencies, guarantees, waste reduction, and better outcomes. Has your OR engaged in a lean assessment? Has innovation and thinking out of the box been a more broadly accepted way for the future in your organization? 6 3

Markets are consolidating.

Increased merger & acquisition activity to capture perceived scale and synergy benefits and support new business models.3 Has your hospital partnered with another recently, or been purchased or merged? 4

Given competitive pressures, hospitals must carefully decide which service lines to prioritize,3

e.g., orthopedics (one of the most attractive and fastest growing service lines of the future). 5

A hospital’s “brand” identity has more value than ever. Some

hospital systems are investing heavily in a new look, new branding guidelines, new signage. They want to communicate their strengths on billboards and TV ads to gain consumer loyalty and community leadership.

14 The OR Connection


BETTER pricing


Cost reductions




Ways to improve the customer experience


Ways to improve market/consumer image


Ways to make their staff happy

Social media is a real business strategy and another way to

communicate and attract customers. 7

Accelerated strategy of hospitals employing physician groups to

help hospitals lock up markets, to improve contracting margins, to control outcomes, etc.3 8

Provider groups are considering innovative incentive relationships3 (e.g., ACO-like

or “clinical integration”), but they are cautious of appropriate strategic and business model rationale. Payors and providers are partnering to explore a variety of new reimbursement and risksharing models. You are in a unique position because you will get to see how healthcare reform will unfold as both the consumer and the healthcare worker. Take notes because you are making history as the biggest changes in health care get underway.

References 1. Census: uninsured rate falls as young adults gain coverage and government programs grow. Huffington Post. Posted September 12, 2012. Available at: http://www. Accessed December 12, 2012. 2. Health policies and data. Organisation for Economic Co-operation Development website. Available at: http://www. oecdhealthdata2012-frequentlyrequesteddata. htm. Accessed December 12, 2012. 3. Strategic Imperatives Beyond Healthcare Reform. Objective Health: A McKinsey Solution for Healthcare Services. Executive Breakfast Seminar. Presented September 13, 2012.

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“Escape Fire:

The Fight to Rescue American Healthcare”

is an exciting and timely documentary revealing the brokenness of the healthcare system in the United States and how it is linked to financial incentives. With a powerful combination of patient stories, objective data, and viewpoints of respected healthcare leaders, such as Drs. Don Berwick, Andrew Weil, and Dean Ornish, the movie raises critical awareness for creating the tipping point! This is key for the paradigm shift we need in our complex healthcare systems!

16 The OR Connection


our System Is Not Working!

Most of us who have close ties to U.S. health care will be more validated than shocked, as we see poor outcomes every day that can be tied to wasted treatments, unsafe staffing levels, insufficient time, and delayed care that are rooted in financial gain for a few and limited resources for many. But, they are tough to explain and not necessarily even safe or appropriate to talk about freely. This film is easy to follow, well-researched, and compelling. As such, it provides an effective tool for educating consumers about underlying problems in our system and making it safe to discuss. And, we are all consumers! The term “Escape Fire” comes from the story of a quick thinking firefighter that did something different in a crisis and lived to tell about it, unlike his colleagues who all died. (The movie starts out with this story so I won’t spoil it for you with more details.) But, it is a great analogy for us, because solutions are right in front of us!

Some of the heroes in the movie: Steve Burd, CEO of Safeway: Created healthiness incentives for employees.

Wendell Potter, Former Head of Communications, CIGNA: Had an awakening about how he was contributing to suffering. Shannon Brownlee, Medical Journalist (formerly of US News & World Report) through research became aware of harmful aspects aka “dark matter” of our medical system. Sgt. Robert Yates, Infantry, U.S. Army, injured in Afghanistan and his courageous recovery both from his injuries and over medication. I do take issue with two aspects of “Escape Fire“: First, nurses, as usual, are under-represented. With at least ten physicians highlighted and only one nurse leader (briefly at that), it is a little hard to swallow. Especially since nurses have been championing prevention and healthcare education forever and nurse practitioners as family practice clinicians are examples of the solutions that indeed are right in front of us! In addition, many physical therapists, psychotherapists, chiropractors, and holistic health practitioners have been advocating for cost-effective, helpful solutions for ages. Diet, exercise, alignment and emotional support are all keys to health care!

Second, there are a couple of places that seemed to me to avoid accountability and blame…. like comments about the “system being bad, but people being good,” or people having “good intentions.” For the most part, I am OK with this and don’t believe that blaming people is an effective strategy, However, it is a fine line between blame and ownership and ownership is extremely important. In fact, Wendell Potter, one of the heroes noted above recognized his own contribution to the problem and stopped. Since this is so integral to the “Escape Fire” analogy, it is worth mentioning! I would challenge any high paid hospital, pharmaceutical, or medical device, or nurse executive, malpractice attorney, or physician specialist to examine the possibility of personal accountability! Despite these two criticisms, please see the movie! Let’s generate some buzz and get this movie in high schools, libraries, theatres, and living rooms across the country. There are lots of awesome talking points that will spark dynamic discussion and fuel a growing power of the people. That is the fire that will save our system from burning!

Aligning practice with policy to improve patient care 17

Sterile Processing Corner

Misperceptions of “Immediate Use Sterilization” by Michele DeMeo

there is a relatively new term in use called “immediate use sterilization.” Its purpose is to better qualify and define what was once called “flash” sterilization, usually occurring in the operating room. It was created by a multi-disciplinary work team composed of experts from the Association of Medical Instrumentation (AAMI), the Association of perioperative nurses (Aorn), the International Association of Healthcare central Service Materiel Management (IAHcSMM), the Food and Drug Administration (FDA), the centers for Disease control and prevention (cDc), Association for professionals in Infection control and epidemiology (ApIc) and other key stakeholders including manufacturers and developers. even with hundreds of articles written on the subject, there are still some misunderstandings and myths surrounding “immediate use sterilization.” there are several reasons for this. For one, nurses are not specifically trained as sterile processing experts in all of the nuances and complexities of sterilization. this is understandable. the nurse’s role is so diverse, the focus should be on just the patient and other issues occurring in the operating room— not on tasks support staff should be performing. Immediate use sterilization is just that, for immediate use – not to be done half an hour or hour after the cycle finishes and not to be done because of poor planning, schedule changes or because an unsterile item might be remotely needed. Its function is to provide a means to process, once properly re-cleaned, sterilization for a critical item that may have been dropped or needed due to an emergency. It applies to a single item or two, never a full set or tray of instruments – you know the ones I mean, the orthopedic trays just dropped off by the sales rep 20 minutes before the scheduled cut time or the sets that have wrapper holes on them. Immediate use sterilization was never meant to replace traditional processing by the sterile processing department. nor was it meant to mask the task of fixing internal operation/administrative issues with your surgical instrumentation processing system and flow.

18 The OR Connection

Some reminders: • If you use “immediate use sterilization” formerly known as “flashing,” as a routine practice because you have internal operational mismanagement, team up with SPD leadership to fix the issues. They should be included; it is their role to provide instrumentation for you, period. • If you must use this cycle, use proper protocol. Follow manufacturer’s instructions (not every item can be immediately sterilized or the settings are not limited to just a three- or 10-minute cycle. Some items require 10 or more minutes, etc.) • Just because the integrator shows some parameters were met, it does not necessarily mean the item was properly sterilized. It simply “indicates” that the sterilizer functioned and the chamber was suitable for sterilization to have occurred – not that it actually did. Using any item that has been sterilized is not a “no-brainer.” Use critical thinking when processing any instrument. Your staff will likely be in a hurry, and that is exactly when an item could be unknowingly compromised and rendered unsterile. • Ensure you are properly testing your sterilizer. Document accurately. Interpret not only the integrator, but the item, the diagnostic information on the printout from the sterilizer, etc., to determine whether the just processed item is actually safe and appropriate to use. These are just a few of the key considerations when having to use “immediate use sterilization.” Enlist sterile processing to help fine tune your program or to take over this responsibility when necessary. Use it as intended for emergencies only. Strive for zero occurrences. That’s the best practice.

Editor’s Note: This is second in a series of 8 columns written by Michele DeMeo, a sterile processing expert with more than 20 years of experience in this field.

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

BIG MED Restaurant chains have managed to combine quality control, cost control and innovation. Can health care? by Atul Gawande, MD

20 The OR Connection

+ It was Saturday night, and I was at the local Cheesecake factory with my two teen-age daughters and three of their friends. You may know the chain: a hundred and sixty restaurants with a cataloguelike menu that, when I did a count, listed three hundred and eight dinner items (including the forty-nine on the “Skinnylicious” menu), plus a hundred and twenty-four choices of beverage. It’s a linen-napkinand-tablecloth sort of place, but with something for everyone. There’s wine and wasabi-crusted ahi tuna, but there’s also buffalo wings and Bud Light. The kids ordered mostly comfort food—pot stickers, mini crab cakes, teriyaki chicken, Hawaiian pizza, pasta carbonara. I got a beet salad with goat cheese, white-bean hummus and warm flatbread, and the miso salmon. The place is huge, but it’s invariably packed, and you can see why. The typical entrée is under fifteen dollars. The décor is fancy, in an accessible, Disney-cruise-ship sort of way: faux Egyptian columns, earth-tone murals, vaulted ceilings. The waiters are efficient and friendly. They wear all white (crisp white oxford shirt, pants, apron,

sneakers) and try to make you feel as if it were a special night out. As for the food—can I say this without losing forever my chance of getting a reservation at Per Se?—it was delicious.

Essentially, we’re moving from a Jeffersonian ideal of small guilds and independent craftsmen to a Hamiltonian recognition of the advantages that size and centralized control can bring. The chain serves more than eighty million people per year. I pictured semi-frozen bags of beet salad shipped from Mexico, buckets of precooked pasta and productionline hummus, fish from a box. And yet nothing smacked of mass production. My beets were crisp and fresh, the hummus creamy, the salmon like butter in my mouth. No doubt everything we ordered was sweeter, fattier, and bigger than it had to be. But the Cheesecake factory knows its customers. The whole table was happy (with the possible exception of Ethan, aged sixteen, who picked the on-

ions out of his Hawaiian pizza). I wondered how they pulled it off. I asked one of the Cheesecake factory line cooks how much of the food was premade. He told me that everything’s pretty much made from scratch—except the cheesecake, which actually is from a cheesecake factory, in Calabasas, California. I’d come from the hospital that day. In medicine, too, we are trying to deliver a range of services to millions of people at a reasonable cost and with a consistent level of quality. Unlike the Cheesecake factory, we haven’t figured out how. Our costs are soaring, the service is typically mediocre, and the quality is unreliable. Every clinician has his or her own way of doing things, and the rates of failure and complication (not to mention the costs) for a given service routinely vary by a factor of two or three, even within the same hospital. It’s easy to mock places like the Cheesecake factory—restaurants that have brought chain production to complicated sit-down meals. But the “casual dining sector,” as it is known, plays a central role in the ecosystem of eating, providing three-course, fork-and-

Aligning practice with policy to improve patient care 21

knife restaurant meals that most people across the country couldn’t previously find or afford. The ideas start out in élite, upscale restaurants in major cities. You could think of them as research restaurants, akin to research hospitals. Some of their enthusiasms—miso salmon, Chianti-braised short ribs, flourless chocolate espresso cake—spread to other high-end restaurants. Then the casual-dining chains reëngineer them for affordable delivery to millions. Does health care need something like this? Big chains thrive because they provide goods and services of greater variety, better quality, and lower cost than would otherwise be available. Size is the key. It gives them buying power, lets them centralize common functions, and allows them to adopt and diffuse innovations faster than they could if they were a bunch of small, independent operations. Such advantages have made Walmart the most successful retailer on earth. Pizza Hut alone runs one in eight pizza restaurants in the country. The Cheesecake factory’s major competitor, Darden, owns Olive Garden, LongHorn Steakhouse, Red Lobster, and the Capital Grille; it has more than two thousand restaurants across the country and employs more than a hundred and eighty thousand people. We can bristle at the idea of chains and mass production, with their homogeneity, predictability, and constant genuflection to the valuefor-money god. Then you spend a bad night in a “quaint” “one of a kind” bed-and-breakfast that turns

22 The OR Connection

out to have a manic, halitoxic innkeeper who can’t keep the hot water running, and it’s right back to the Hyatt. Medicine, though, had held out against the trend. Physicians were always predominantly self-employed, working alone or in small private-practice groups. American hospitals tended to be community-based. But that’s changing. Hospitals and clinics have been forming into large conglomerates. And physicians—facing escalating demands to lower costs, adopt expensive information technology, and account for performance— have been flocking to join them. According to the Bureau of Labor Statistics, only a quarter of doctors are self-employed—an extraordinary turnabout from a decade ago, when a majority were independent. They’ve decided to become employees, and health systems have become chains. I’m no exception. I am an employee of an academic, nonprofit health system called Partners HealthCare, which owns the Brigham and Women’s Hospital and the Massachusetts General Hospital, along with seven other hospitals, and is affiliated with dozens of clinics around eastern Massachusetts. Partners has sixty thousand employees, including six thousand doctors. Our competitors include CareGroup, a system of five regional hospitals, and a new for-profit chain called the Steward Health Care System. Steward was launched in late 2010, when Cerberus—the multi-

billion-dollar private-investment firm—bought a group of six failing Catholic hospitals in the Boston area for nine hundred million dollars. Many people were shocked that the Catholic Church would allow a corporate takeover of its charity hospitals. But the hospitals, some of which were more than a century old, had been losing money and patients, and Cerberus is one of those firms which specialize in turning around distressed businesses. Cerberus has owned controlling stakes in Chrysler and GMAC financing and currently has stakes in Albertsons grocery stories, one of Austria’s largest retail bank chains, and the freedom Group, which it built into one of the biggest gunand-ammunition manufacturers in the world. When it looked at the Catholic hospitals, it saw another opportunity to create profit through size and efficiency. In the past year, Steward bought four more Massachusetts hospitals and made an offer to buy six financially troubled hospitals in south florida. continued on page 90



How LEAN is your OR? Eliminate waste with Perioperative LEAN Solutions

Reducing waste is the cornerstone of lean. Poorly designed processes, or the lack of a refined process, can waste time, steps or supplies. Medline’s lean consulting services for the OR help reduce waste and increase efficiency. During our clinical assessment, we focus on building the right surgical pack bundles that match their current procedural landscape. Identifying all routine supplies that are used from beginning to end of a procedure, giving the surgical team the right supplies at the right time eliminates supply waste.

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Institute of Medicine Recommendation 6: Ensure that Nurses Engage in Lifelong Learning Medline Solution: A Targeted Course Curriculum that Addresses Surgical Safety The Institute of Medicine’s landmark report, The Future of Nursing: Leading Change, Advancing Health, is a thorough examination of the nursing workforce. Of the eight recommendations that came out of the report, Recommendation 6 calls for nurses to engage in lifelong learning. Medline’s commitment to provide free continuing education resources to facilities and their staff aligns with the IOM recommendation 6 and is just one example of our vision to improve core competencies among surgical clinical staff as a way to enhance the lives of patients. Overview of Courses presented by Kathleen Bartholomew, RN, MN and John Nance, JD

* Speak Your Truth: Create a Safer Patient Environment through Communication and Team Building • Why are people often afraid to tell the truth in the OR? How do you know when you have a great team? This course explores communication tools surgical staff can employ to openly communicate with colleagues and build a great team environment in the OR. • Available on and as an on-site educational evernt.

Speak Your Truth II: understanding Communication in a Culture of Change • Why do we need to change the culture in healthcare? How can communication play a role in cultural change? We continue the Speak Your Truth series and further investigate effective communication strategies in the OR to improve some of the most critical issues facing OR staff today. • Available on and as an on-site educational evernt.

To participate in these programs contact your Medline sales representative, or call 1-800-MEDLINE * The AORN Seal of Recognition confirms that the content has undergone thorough review by AORN and meets the guidelines set forth in AORN’s Recommended Practices and Standards. While not a product endorsement, the Seal of Recognition demonstrates that the promotional and informative material related to your product or service has met AORN standards for excellence in safe patient care.

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

Culture of Safety: Lessons Learned from the Operating Room with Martie Moore and colleagues • Listen and learn about the compelling intricacies a hospital experienced when they instituted a cultural shift in the operating room to enhance staff safety and ultimately patient care. • Available on and as an on-site educational evernt.

The Joint Commission Wrong Site Surgery Project with Mark Chassin, MD, President and Ana Pujols, MD, Executive VP and CMO • Where do we need to go in healthcare? Leadership from The Joint Commission address how the healthcare industry can and should prevent never events including wrong site surgery, wrong patient and wrong procedure. • Available on Join the thousands of clinicians nationwide that participate in Medline’s free educational resources and make a free educational investment in your profession. Go to www.medlineuniversity to set up your free account, contact your Medline sales representative, or call 1-800-MEDLINE.

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

Access courses on your computer, iPhone or iPad.

Medline University Education for Surgical Techs now trending worldwide Medline University continues to build its curriculum of Surgical Tech courses, available at Earn free CE credits with the following courses and more: • #2 on the Joint Commission List - Retained Foreign Objects • 9 on the Line to Improve Patient Safety • Applying Evidence-Based Information to Improve Hand-off • Communication in Perioperative Services * Courses are approved for continuing education credit by the Association of Surgical Technologists.

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

Surgical Site Infections (SSI) Following Orthopedic Surgery by Kimberly Haines, RN, CNOR

Taking a look back in time, before the mid-1800s, “surgical patients commonly developed postoperative ‘irritative fever,’ followed by purulent drainage from their incisions, overwhelming sepsis, and often death. It was not until the late 1860s, after Joseph Lister introduced the principles of antisepsis, that postoperative infectious morbidity decreased substantially.”1 Fast forward more than 150 years to 2012. We are doing surgery in modern ORs with high-tech equipment and advanced techniques, and yet…

…SSIs 20%

account for of all health care-associated infections in U.S. hospitals.2


estimated annual deaths caused by SSIs2


SSIs occur each year3


SSIs develop annually after orthopedic surgery4

up to


knee and hip replacement patients contract an SSI4

Aligning practice with policy to improve patient care 29

Astronomical costs of added care In addition to the burden of coping with the painful and disabling effects of an SSI, patients and providers face increased healthcare costs. According to the Institute of Medicine, hospitalacquired infections cost up to $5.7 billion per year.5 SSIs prolong a patient’s total hospital stay by an average of two weeks, double the chances of being rehospitalized and increase the total cost of health care by more than 300 percent.6 Clearly, there is a great need for all members of the healthcare team, including OR nurses, to help reduce the risks of SSIs.

Types of surgical site infections and how they relate to orthopedic surgery Two types of SSIs typically occur: incisional and organ/space. Incisional SSIs are subcategorized as superficial (for example, skin, subcutaneous tissue) or deep (for example, deep soft tissues). Organ-space SSIs manifest in any body part other than the site of the incision.3

According to an orthopedic surgery− specific executive summary of the Association for Professionals in Infection Control and Epidemiology (APIC) elimination guide,4 orthopedic surgery frequently involves “the placement of a foreign body, such as a prosthetic joint, various joint components, or hardware used to stabilize bony structures or repair fractures.” Unfortunately, placing these structures increases the risk of infection, either by introducing local contamination or by spreading microorganisms through the bloodstream.4 The APIC executive summary also states that “locally introduced contamination can occur during the perioperative period. Spread of microorganisms occurs after the perioperative period and is associated with primary bacteremia or infection at a site distant from the surgery. Secondary bacteremia from this distant infection leads to microbial seeding of the prosthetic joint.”4 In addition, biofilm from bacterial microorganisms that may be attached to a prosthetic implant can cause an SSI to develop.4

Skin Subcutaneous Tissue

Deep Soft Tissue (fascia & muscle)


Superficial Incisional SSI

Deep Incisional SSI

Organ/Space SSI

Layers of skin and deep space. 30 The OR Connection

Patient Risk Factors for Developing SSI3 • Advanced age • Poor nutritional status • Diabetes • Cigarette smoking • Obesity • Colonization with microorganisms • Coexisting infection at a remote body site • Altered immune response • Preoperative hospitalization

Common risk factors associated with SSI It is important for OR nurses to know the types of factors related to both an individual patient and the hospital environment that can increase the risk of a patient developing an SSI. The World Health Organization (WHO)3 outlined the following characteristics of patients who may have an increased risk: advanced age, poor nutritional status, diabetes, cigarette smoking, obesity, colonization with microorganisms, coexisting infection at a remote body site, altered immune response, and preoperative hospitalization.3 Also, WHO listed characteristics of the surgical procedure that can increase the likelihood of developing an SSI.3 These include inadequate preoperative skin preparation, inappropriate preoperative shaving, inadequate surgical team preoperative hand and forearm antisepsis, contaminated operating room environment, inappropriately sterilized surgical attire and drapes, inadequate sterilization of instruments, excessive duration of

SSIs following orthopedic surgery increase healthcare costs by more than 300% 6

operation, poor surgical technique, and inappropriate or untimely antimicrobial prophylaxis. Most hospital infection prevention teams use National Healthcare Safety Network (NSHN) definitions for postoperative surveillance of patients at risk for SSIs. Because most cases of SSIs appear after the patient has left the hospital, the NHSN protocol states that healthcare practitioners should monitor patients for SSIs for up to 30 days after the surgical procedure.4 OR nurses should refer to the APIC guide for examples of how to monitor patients4,7 and for descriptions of a variety of factors that may be associated with increased rates of SSI following orthopedic surgery.7

Preventing SSIs in orthopedic surgery patients Eliminating modifiable risk factors can help prevent SSIs,4 and there are many proven strategies to achieve this goal. for example, OR nurses can ensure that clean and disinfected equipment are used and that the surgical environment is pristine; they can also ensure that the team

uses evidence-based practices for hand hygiene and surgical site preparation.4 Preoperative skin preparation for patients is important because microorganisms commonly associated with patients predominate in orthopedic SSIs.4 In particular, OR nurses can verify that patients have showered before having an orthopedic-related surgery to reduce bacterial colonization of the skin.4 for more specific interventions, OR nurses can refer to the previously mentioned APIC guidelines for eliminating SSIs. Published in 2010, these guidelines are easily accessible online at the APIC website (http://apic.

org/Professional-Practice/Scientificguidelines).4 These guidelines offer comprehensive approaches for all healthcare professionals to consider as they develop the most effective orthopedic SSI prevention program for their specific hospital or ambulatory setting.4 Although no standardized clinical practice guidelines exist regarding which SSI prevention strategies can reliably reduce the risk of infection after a total hip arthroplasty (THA), Merollini and colleagues6 identified the following infection prevention measures to be critical based on a review of expert opinion and

Perioperative Conditions Often Related to SSI3 • Inadequate preoperative skin preparation • Inappropriate preoperative shaving • Inadequate surgical team preoperative hand and forearm antisepsis • Contaminated operating room environment • Inappropriately sterilized surgical attire and drapes • Inadequate sterilization of instruments • Excessive duration of operation • Poor surgical technique • Inappropriate or untimely antimicrobial prophylaxis

Antibiotic prophylaxis [an·ti·bi·ot·ic pro·phy·lax·is]

1 : The prevention of infection complications using antimicrobial therapy

clinical guidelines: preoperative antibiotic prophlyaxis, antiseptic skin preparation of patients, hand and forearm antisepsis by surgical staff, intraoperative use of sterile gowns/surgical attire, ultraclean/ laminar air operating room, antibiotic-impregnated cement, and postoperative surveillance. These investigators stressed that the degree to which these measures can be efficiently and effectively incorporated into practice depends on the cost-effectiveness and usefulness of each measure in any given healthcare setting.8 The experts whom Merollini and colleagues8 interviewed agreed primarily on the importance of the recommendation for appropriate antibiotic prophylaxis. They recognized this strategy as being highly effective in theory and in practice and as being established as a routine safety measure for patients undergoing THA.8 Merollini and colleagues8 also stressed that a comprehensive approach is necessary to successfully prevent SSIs after THA, and that nurses may need to use a combination of interventions.8 By identifying patients who are at high risk for developing an SSI

32 The OR Connection

after having a THA or total knee arthroplasty (TKA), healthcare professionals, including OR nurses, can help improve the reporting of the incidence of SSIs and verify or set in motion appropriate prevention strategies before surgery occurs.9 Berbari and colleagues9 developed a risk assessment tool for prosthetic joint infection in use at Mayo Clinic in Rochester, Minn. Their results highlighted the usefulness of a risk assessment tool in terms of both patient care and for the prevention of costly complications that may or may not be reimbursed by insurance providers. Because more than four million THAs or TKAs are estimated to be performed by 2030, healthcare professionals should diligently assess patients’ risk status and conduct preventive strategies.9 Minimizing a patient’s risk of developing an SSI after orthopedic surgery is useful for both the patient’s well-being and for the healthcare facility’s bottom line.9

Using teamwork to address SSIs Teamwork is essential for addressing the problem of SSIs. It is evident that fostering a culture in the healthcare facility that leans toward teamwork is important in preventing SSIs that occur following orthopedic surgery.4 continued on page 37

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Real Stories from People Affected by SSIs The following real patients share how infection following orthopedic surgery has changed their lives. They went into surgery disabled by a broken bone or a failing joint, hoping to come out stronger than before. Unfortunately these patients contracted a hospital-acquired infection, which led to a lesser quality of life, often accompanied by further surgeries and years of pain and loss. These stories and more are provided through the Safe Patient Project, a Consumers Union campaign focused on eliminating medical harm, improving FDA oversight of prescription drugs and promoting disclosure laws that give information to consumers about healthcare safety and quality. To learn more, visit

Alice Buehring Gold Bar, Washington After taking a bad fall in January 1999, I required surgery to replace the humeral head in my right shoulder. Unfortunately, my recovery was painful and mostly unsuccessful. By May 1999, I discovered why. It turned out that I developed a Pseudomonas aeruginosa infection in the surgical site, which was fast becoming septic. I spent the next week in the hospital on IV antibiotics to treat the infection. I was discharged to continue my IV treatments at home for another six weeks followed by oral antibiotics for another six weeks. By the end of these treatments, I hoped that the worst was behind me. But my recovery continued to be painful and difficult. For the next six years, I struggled to find relief. I began to work with some natural and alternative healthcare practitioners who believed my arm was still infected. Most of the time my arm hurt enough to require pain medication and was periodically hot. I would slowly gain range of motion in my arm, only to lose it again. Each year I would return to my surgeon when the pain became unbearable. And each time he would insist that the infection was no longer present and send me home with more pain medication. In May 2004, my pain became impossible to endure. I returned to my doctor who took another X-ray of my arm and finally determined that the infection was still present. By then, the infection had eaten through my humerus bone and destroyed my rotator cuff. I underwent a second surgery to remove the prosthesis, spent three days in the hospital recuperating and then continued my IV antibiotic treatments at home for another six weeks. Once the infection cleared up, I had a third surgery to insert a new prosthesis and then began physical therapy. Finally, I was infection free. My hospital infection experience has had a lasting impact. I now have only a 20 percent range of motion in my dominant arm, which has limited my abilities in my daily life and at work, and I still haven’t gotten my energy back. I am grateful to be alive, that I still have an arm, and that the damage was not more extensive, but angry that an infection I caught in the hospital turned my life upside down for so long. I continue to live my life upside down.

34 The OR Connection

Sandi Sampson

Glenn Cartrette

Boaz, Alabama

Castle Hayne, North Carolina

When I had ankle replacement surgery in December 2003, I looked forward to finally recovering from a broken ankle bone I injured in my backyard. Unfortunately, I left the hospital not only with a new ankle, but also a staph infection from my surgery. In the weeks following the operation, I felt tired and always seemed to run a low grade fever, but I didn’t think much of it. I was diagnosed with the infection after my cast was removed three months after my surgery, and it became clear during physical therapy that the ankle replacement had failed. Tests revealed that I had methicillin-resistant Staphylococcus aureus (MRSA), a difficult-to-treat infection. As a result, the prosthesis was removed and an antibiotic spacer was installed in its place. I underwent 12 weeks of Vancomycin treatments administered through a PICC line at home. The infection seemed to improve, and I had another ankle replacement surgery. But the prosthesis never bonded to the bone, and I experienced another outbreak of MRSA. I was put on Vancomycin for another month to treat the infection. In June 2005, I had another surgery to install a concrete spacer in place of my ankle, but again it failed to adhere to my bone. My doctor has told me that the MRSA, which is in my bone and blood, will never go away. It becomes dormant after it is treated, but trauma to my body – like a spider bite I got in November 2005 – can cause it to re-emerge. I underwent another surgery in May 2006 to address my ankle problem. I fought to save my life and leg for four years: 37 surgeries. Finally, the only way to save my life was to remove my leg. I had that done in February 2007.

On January 1, 2003, my husband, Glenn Cartrette had knee surgery. After three weeks he went back to work and found he had a new pain in his hip joint, which grew worse during his 17-hour work days. Glenn and Teri Cartrette Glenn had a full hip replacement in October. After the two surgeries, pain began to be a daily part of Glenn’s life. Finally the pain was so intense that he no longer could go to rehab. Then problems started with his lungs. The orthopedic surgeon said there was nothing wrong with his surgery but during one of his many hospital admissions Glenn and I were told he had MRSA. He was placed in a private room where visitors were required to wash their hands, put on a gown, gloves and mask before entering the room. He spent weeks in the hospital and continued to take Vancomycin for the MRSA after he was released. After returning home Glenn continued to have pain and difficulty breathing, which required visits to the emergency room often. I would beg for help because I could see the stress on him just to breathe. We also consulted with pain management doctors to monitor the pain medications needed in ever-increasing doses. Except for about 15 days in a nursing home, Glenn was in the hospital from July 2005 until January 2006. His lungs were infected with MRSA, and he was in a great deal of pain. He died on January 26, 2006, unaware of what was going on around him. Death was the only escape from the horrible things MRSA had done to him and his body.

Aligning practice with policy to improve patient care 35


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Medline’s Educational Packaging offers all the information you need, step by step, short and sweet, to help the Medline dressing do its job of healing. In a study involving 139 nurses at eight different facilities, 88% who used a wound care product with an education guide attached were able to apply the dressing to a wound correctly.1 Reference 1. Kent DJ. Effects of a just-in-time education intervention placed on wound dressing packages. Journal of Wound, Ostomy and Continence Nursing. 2010; 37(6):609-614. ©2012 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

Poor surgical instrument handling practices have been found to increase SSIs

continued from page 32 focusing on patient-centered care, communicating well with patients and healthcare colleagues in all positions, and having leaders who emphasize the need for all team members to understand the importance and the effects of SSIs in orthopedic surgery patients are useful strategies.6 Risk assessment tools and simple cleaning and presurgical checklists can be created or customized to fit each facility.4 Working together, one team (including infection control staff members, surgeons, nurses, and perioperative staff members) reduced the rate of SSIs in their orthopedic surgical setting by 60 percent; their results included not having a single patient develop a MRSA-related SSI over the course of one full year.7 Collaboration and a concerted effort to follow accepted preoperative prophylaxis protocols were critical components to their success. Another way a team can use communication to reduce the risk of SSIs is by taking a “time-out� before making the initial surgical incision.6 The time-out provides needed time for team members to check whether appropriate and timely antibiotic prophylaxis procedures have been completed and to ensure that the sterilization level is optimal.4 Effective infection prevention and control programs can help reduce the risk of patients developing SSIs.7 OR nurses, along with other specialists, must understand the common characteristics of patients undergoing orthopedic surgery, be able to identify and address the risk factors, use accepted methods for case


finding, analyze data, communicate outcomes, and implement evidencebased strategies to improve outcomes.7 To achieve these goals, collaboration among team members is critical.7 Abdul-Jabbar and colleagues10 analyzed a total of 6,628 patients who underwent spinal surgery. They found that 193 (2.9 percent) of all spinal surgery patients had an SSI, and that patients with SSIs exhibited many of the commonly known risk factors (for example, diabetes, revision surgery, extended operative time, and transfusion). Because they also noted risk factors for predicting whether a patient would develop an SSI that were unique to their own study participants (for example, diagnoses of neoplasm and coagulopathy and having had anterior or posterior surgery), they recommended that these factors be added to their facility’s preoperative risk assessment process. Richards and colleagues11 evaluated a large sample of patients who underwent orthopedic surgery. Based on their results of patients who had developed SSIs 30 days

after surgery, they determined that recognizing that a relationship exists between hyperglycemia and infectious complications could influence positively the postoperative care of orthopedic patients. Dancer and colleagues,12 in a study conducted in Scotland, linked a sharply increased rate of deep SSIs in orthopedic (and ophthalmic) patients with the contamination of sets containing surgical instruments that occurred after sterilization techniques had been done. They found that poor handling practices at the facilities participating in the study and at the sterilization plant were related to a sharp increase in SSIs. Their results highlighted the need for close cooperation and collaboration among sterile service providers, managers, and clinical staff members. They suggested a series of guidelines to lower the risk of sterile surgical instruments becoming contaminated before use that included using adequate cooling and drying procedures at the sterilization plant along with focusing their inspections on finding damp packs. Other key recommendations

Aligning practice with policy to improve patient care 37

included periodically visiting sterilization site locations; performing weekly audits of procedures and issuing reports to stay abreast of the results; regularly reviewing cleaning processes, inspection processes; and providing ongoing staff training and supervision related to these processes. As a result, infections rates among patients receiving clean surgical procedures returned to levels that were consistent with those noted before the sharp increase, which was the reason this study was conducted.

OR nurses play an integral role in assessing a facility’s risk of being a “host” for SSIs, which can lead to lowering the risk factors of patients’ developing SSIs in the future.

Gathering follow-up data to decrease patients’ likelihood of future SSIs Keeping track of the types and frequency of SSIs that occur in or as a result of a stay in a healthcare facility is important.11 Using guidelines for procedure categories described by the Centers for Disease Control and Prevention (CDC) as well as the NHSN guidelines is essential.13 Correct coding and other helpful details will ensure appropriate record keeping. OR nurses play an integral role in assessing a facility’s risk of being a “host” for SSIs, which can lead to lowering the risk factors of patients’ developing SSIs in the future.

In conclusion, all members of the healthcare team, particularly OR nurses, can help reduce the incidence of SSIs in patients who have had orthopedic surgery. Among the important steps to take are identifying patients who are at risk for developing SSIs and taking extra care to address these risk factors before, during and after surgery. Also, familiarity with the appropriate clinical guidelines that outline risk factors in patients and understanding and implementing recommended sterilization practices in the preoperative and surgical environment are extremely important. Working collaboratively with all members of the healthcare team is a critical strategy that serves patients, the team and the facility in the common goal of avoiding SSIs.

38 The OR Connection

References 1. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for Prevention of Surgical Site Infection, 1999. Infection Control and Hospital Epidemiology. 1999; 20(4): 251. 2. Klevens RM, Edwards JR, Richards CL Jr, et al. Estimating health care-associated infections and deaths in U.S. hospitals, 2002. Public Health Rep. 2007;122(2):160-166. Available at: http://www.ncbi. Accessed November 5, 2012. 3. World Health Organization. WHO Guidelines for Safe Surgery, 2009: Safe Surgery Saves Lives. Available at: resources/9789241598552/en/index.html. Accessed Nov. 1, 2012. 4. Greene LR. Guide to the elimination of orthopedic surgery surgical site infections: an executive summary of the Association for Professionals in Infection Control and Epidemiology elimination guide (published online ahead of print Aug. 25, 2011). Am J Infect Control. 2012;40(4):384-386. doi:10.1016/j.ajic.2011.05.011. 5. Sydnor ERM & Perl TM. Hospital epidemiology and infection control in acute-care settings. Clin Microbiol Rev. 2011; 24(1): 141–173. Available at: http://www. Accessed December 4, 2012. 6. Whitehouse JD, Friedman ND, Kirkland KB, Richardson WJ, Sexton DJ. The impact of surgical-site infections following orthopedic surgery at a community hospital and a university hospital: adverse quality of life, excess length of stay, and extra cost [abstract] Infect Control Hosp Epidemiol. 2002;23(4):183-189. 7. Green LR, Mills R, Moss R, Sposato K, Vignari M. Guide to the Elimination of Orthopedic Surgical Site Infections: An APIC Guide, 2010. Available at: Professional-Practice/Implementation-guides. Accessed Nov. 1, 2012. 8. Merollini K, Zheng H, Graves N. Most relevant strategies for preventing surgical site infection after total hip arthroplasty: guideline recommendations and expert opinion (published online ahead of print Sept. 21, 2012). Am J Infect Control. 2012; doi:10.1016/j. ajic.2012.03.027. 9. Berbari EF, Osmon DR, Lahr B, et al. The Mayo prosthetic joint infection risk score: implication for surgical site infection reporting and risk stratification (published online ahead of print June 20, 2012). Infect Control Hosp Epidemiol. 2012;33(8):774-781. 10. Abdul-Jabbar A, Takemoto S, Weber MH, et al. Surgical site infection in spinal surgery: description of surgical and patient-based risk factors for postoperative infection using administrative claims data. Spine. 2012;37(15):1340-1345. 11. Richards JE, Kauffmann RM, Zuckerman SL, Obremskey WT, May AK. Relationship of hyperglycemia and surgical-site infection in orthopaedic surgery. J Bone Joint Surg Am. 2012;94(13):1181-1186. 12. Dancer SJ, Stewart M, Coulombe C, Gregori A, Virdi M. Surgical site infections linked to contaminated surgical instruments (published online ahead of print June 15, 2012). J Hosp Infect. 2012;81(4):231-238. 13. Centers for Disease Control and Prevention. National Healthcare Safety Network (NHSN). ProcedureAssociated (PA) Module [follow link to Protocol and Instructions: Surgical Site Infection (SSI) Event (pdf)]. Available at: Accessed Nov. 1, 2012.



Exceeds FDA Requirements1

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Sterillium Rub is the only waterless, brushless surgical scrub with 80% (w/w) ethyl alcohol — the highest alcohol concentration of any surgical rub available in the US. Its long-lasting, persistent effect exceeds FDA requirements for surgical hand antisepsis. Sterillium Rub provides a rapid and comprehensive kill of transient and resident skin flora, with a 6 log reduction within two minutes.2

For more information on Sterillium Rub, contact your Medline representative, visit or call 1-800-MEDLINE.

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

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Specialized mattress overlays At risk for pressure ulcers All surgical patients should be considered at risk for pressure ulcer development because of the uncontrollable length of surgery and the effects of anesthesia, along with the use of vasoactive medications that affect blood pressure and heart rate during surgery.1

In a study of 446 patients undergoing elective major surgery, specialized foam mattress overlays on operating tables decreased the incidence of postoperative pressure ulcers.2



Ways to


Perioperative Pressure Ulcers

AORN’s “Recommended practices for positioning the patient in the perioperative setting” suggests that a patient should be repositioned routinely to prevent continuous pressure on pressure points and assist in decreasing the risk of adverse physiological responses.1

Preoperative assessment The preoperative assessment should include details of the patient’s skin status (e.g., presence of a rash, maceration, infection, breakdown, dermatitis, incontinence, lymphedema) along with a risk assessment noting whether the patient is a high-risk candidate for pressure ulcers based on the proposed procedure and extrinsic factors (shear, friction, and moisture) and intrinsic factors (advanced age, nutritional deficiencies).1

Medical devices Minimize/eliminate pressure from medical devices such as oxygen masks and tubing, catheters, cervical collars, casts, IV tubing and restraints.3

References 1. Walton-Geer P. Prevention of pressure ulcers in the surgical patient. AORN Journal. 2009; 89(3): 538-552. Available at: S0001-2092(08)00898-3/fulltext#section9. Accessed October 25, 2012. 2. Reddy M, Gill SS, Rochon, PA. Preventing pressure ulcers: a systematic review. Journal of the American Medical Association. 2006; 296(8):974-984. Available at: Accessed October 25, 2012.

3. Institute for Clinical Systems Improvement (ICSI). Skin safety protocol: risk assessment and prevention of pressure ulcers. Available at: skin_safety_protocol__risk_and_assessment_of/pressure_ulcer__skin_safety_ protocol__risk_assessment_and_prevention_of__protocol_.html. Accessed October 25, 2012.

Aligning practice with policy to improve patient care 41


Peri-operative process change to reduce the risk of post-operative infection following orthopedic procedures Melissa Lingle, RN, CNOR

INTRODUCTION Of an estimated annual 500,000 hospital acquired infection events, from Centers for Disease Control and Prevention data, as many as 16% involved post-operative surgical site infections (SSI).1 Risk of post-operative surgical site infections following orthopedic surgery is increased for patients with body mass index (BMI) >25 and compounded for those with a co-morbidity of diabetes, both growing population segments. Post-operative infections involving multi-drug resistant organisms (i.e., MRSA) for “at risk” patients leads to increased morbidity-mortality, costly hospitalizations, corrective surgeries, long-term antibiotic therapy, extended recovery time, and delay in return to functional activities of daily living. Hip and knee arthroplasty procedures have a predicted occurrence rate of 1 to 2.4% and cost rom $60,000 to more than $100,000. The economic burden to U.S. hospitals from joint arthroplasty infections is projected to exceed $1.62 billion annually by 2020.2, 3, 4, 5, 6 The goal of this study was to assess the efficacy of interventions to reduce the risk of post-orthopedic procedure infections by using pre-operative chlorhexidine cleansing in tandem with postoperative silver-impregnated dressings.7, 8, 9


In 2011, an orthopedic surgical site infection reduction task force was created, responding to an unacceptably high rate of infection events. Preintervention orthopedic procedure data was collected for a seven-month period of 2011, including hip, knee, and shoulder arthroplasty surgeries, as well as laminectomy and discectomy procedures. Four hundred eighty eight (488) procedures were performed during the base line period with 18 infections identified — occurrence rate of 3.7%. Interventions were instituted in 2012 to reduce pre-operative resident and transient opedic Procedure Totalsskin bacteria burden and post-operative incisional inoculation 498 of bacteria. Surgical sites were cleansed daily for three days with 2% chlorhexidine wipes prior to surgery and on the day of surgery. Surgical incisions 488 were then dressed for 10 days postoperatively with silver-impregnated, absorbent dressings*. The application of the wound dressings was initiated 2011 Procedures Procedures in the O.R. 2012 following incision closure and maintained during hospitalization.

42 The OR Connection

Further wound coverage following discharge was accomplished with written instructions and replacement dressings sent with each patient. Data for the seven-month intervention period in 2012 were compiled to compare outcomes.

RESULTS Of 498 orthopedic procedures performed to date in 2012, following the interventions, only three infection events were identified – an occurrence rate reduction from 3.7% to 0.6%. It is to be noted that the post-operative silver-impregnated absorbent dressing protocol was not used in one infection occurrences. By any estimate, the interventions instituted to reduce surgical site infections following orthopedic procedures have been successful. Unwanted negative outcomes for patients have been avoided, the overall quality of care improved, and significant cost savings realized.

CONCLUSION The results of our interventional study will continue to be monitored. Initial discussion of the results seen to-date are leading to strong consideration of applying the same peri-operative process and silverimpregnated dressing principles to additional surgical procedures. Our experience over seven months confirms the efficacy of these efforts, noted in prior clinical literature.

Orthopedic Surgical Site Infection Reduct


Orthopedic Procedure Totals 496 494 492 490 488 486 484





2011 Procedures

2012 Procedures

Orthopedic Surgical Site Infection Reduction 20

1. SSI case data reporting confirmed 18 20 unacceptable post-operative surgical 15 site infection rate (SSI) – comparison of performance for 10 orthopedic procedures to National Healthcare Safety Network (NHSN) 5 data base.

3. Review and discussion of pertinent literature for “best case” practices to reduce/prevent post-op. SSI events.


15 10 5


0 2011 SSI

2. Creation of surgical site infection 2011 SSI reduction task force with physician champion to lead multi-discipline team covering full peri-operative process.

2012 SSI

4. Follow the “Action Plan” to either improve or adopt as new processes.

2012 SSI


Thank you to the perioperative clinical team at Mercy Medical Center in Canton, OH, that made this study possible.

1. Mandatory education for all O.R. staff : a. Fundamentals of aseptic technique

Michael D. London, M.D. Board Certified Orthopedic Surgery

b. Followed by “technique of the week” reinforcement

Vicki Merrick, RN, CASC Administrative Director, Surgical Services

2. Pre-operative: a. Educate patients on SSI prevention. b. Screening, via nasal swabs, for MRSA with treatment as needed. c. Provision of 2% chlorhexidine wipes for patients to scrub operative site (i.e., knee, hip, shoulder) daily for 3 days immediately prior to arrival at hospital for surgery. d. Scrub operative site with 2% chlorhexidine wipes in pre-op holding prior to transport to O.R. 3. Intraoperative: a. Emphasis on strict adherence to aseptic technique by all staff b. Application of silver-impregnated absorbent dressing to incision site immediately post-closure 4. Post-operative: a. The silver-impregnated dressing is used for 10 days; placed post-operatively and changed at day 3. The second dressing remains in place for 7 days. If there is excessive bleeding noted, the wound is examined and the dressing is changed immediately. b. Upon discharge, additional silver-impregnated dressing accompanies patient to home, to home with home-health nursing, or rehabilitation facility with written application instructions to care provider. Goal is to of maintaining incision coverage for total of 10 days. 5. NOTE: a. Physician order sets changed in accordance with required ordering processes to above 6. DATA COLLECTION for all orthopedic procedures including: a. Pre-op scrubbing of operative site with chlorhexidine wipes b. Emphasis on strict adherence to aseptic technique by all staff c. Post closure application of silver-impregnated absorbent dressing d. Silver-impregnated dressings remain in place while in hospital e. After discharge, silver-impregnated dressing remains in place for a total of 10 days.

Melissa Lingle, RN, CNOR Clinical Manager, Surgical Services Richard G. Lyon, BA, MA, JD, RN, CIC Infection Control Coordinator Sue Passmore, RN, BSN, CPAN, CCRN Director PACU/SDU/P.E.A.T. Judith A. Melnyk, RN, MSN, CNOR, CSPDT Team Leader Orthopedics/Neuro/Podiatry O.R. Allison R. Goshay, BSN, BS,RN Nursing Director 2Main, 4Main, IV Team References 1. Mangram AJ, et al. Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. 2. Perencevich EN et al. Health and Economic Impact of Surgical Site Infections Diagnosed After Hospital Discharge. Emerging Infectious Diseases, CDC, Volume 9, Number 2, Feb., 2003. 3. Anderson DJ et al. Strategies to Prevent Surgical Site Infections in Acute Care Hospitals. Infection Control-Hospital Epidemiology 2008; 29:551-561 4. Kurtz SM et al. Economic Burden of Periprosthetic Joint Infection in the United States. J. Arthroplasty, May 2, 2012. 5. Study Identifies Risk Factors for Complications after Spine Surgery Information release per American Academy of Orthopaedic Surgeons, July 15, 2011. 6. Guide to the Elimination of Orthopedic Surgical Site Infections, 2010, Association for Professionals in Infection Control and Epidemiology 7. Zyweil MG. Advance pre-operative Chlorhexidine reduces the incidence of surgical site infection in knee arthroplasty. Int. Orthop. 2011 Jull; 35 (7): 1001-6. 8. Turner MS et al. Effect of silverimpregnated wound covers on neurosurgical infection rates. Poster presentation 2009 AANS Annual Meeting, San Diego, CA. 9. Working Toward Zero, Hospitalassociated infections are not tolerated. AORN Specialty Assemblies, October, 2005.

* Optifoam® AG+ Post-Op Strip. Optifoam is a registered trademark of Medline Industries, Inc.

Aligning practice with policy to improve patient care 43

44 The OR Connection


physicians and nurses can contribute to errors that harm patients receiving PCA pumps. These pumps are typically used primarily in the hospital for pain control. The premise behind the pumps is that the patient is the best judge of when he or she needs pain medication. Giving the patient control of the pump eliminates the time the patient has to wait for a nursing staff member to bring a pain pill or injection. The theory of the pumps is wonderful; the reality is that they are dangerous if not ordered correctly or their use monitored appropriately.

by Pat Iyer, MSN RN LNCC The Physician-Patient Alliance for Health and Safety Posted September 17, 2012 Reprinted with permission.

Aligning practice with policy to improve patient care 45

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PCA pumps

are filled with either Morphine or Dilaudid®. Both are strong narcotics that effectively and rapidly diminish pain; they may not entirely relieve pain. PCA pumps are usually ordered by a pain management team, if the hospital has one, an anesthesiologist, or a surgeon. The standard of care requires the healthcare provider who writes the order to be familiar with the options for ordering, the contraindications for a particular patient to receive this method of pain relief, and the risks. The order for a PCA pump will include the name of the medication, the dose that can be delivered when the patient pushes a button, the interval between doses, the lockout interval (how much medication the patient can receive in an hour), possibly a basal rate (defined below), the frequency of monitoring the patient, and orders for a rescue drug (Narcan®) in the event of oversedation.

1. Basal Rate It used to be common for the patient to receive a basal rate, or a continuous infusion of the narcotic, in addition to being able to push a button to get a dose. The basal rate is associated with the risk of oversedation of the patient. Oversedation can lead to respiratory depression (not breathing enough) and death. An order for a high basal rate puts the patient in even more jeopardy. It is much more common now for the order to include only a demand dose (when the patient pushes the button). This results in less oversedation and more diligence on the part of the patient to use the pump when needed.

2. Contraindications The PCA pump is not right for everyone. The risk of oversedation means that the buildup of narcotics can cause an obese patient or one with sleep apnea to stop breathing. I have reviewed several cases as an expert witness involving these kinds of patients. Additional patient selection issues include patients who are small children, confused, have chronic obstructive pulmonary disease, congestive heart failure, and pneumonia. But

it is not possible to proactively identify all patients who are at risk for respiratory depression and oversedation. This makes it even more important to astutely monitor patients.

3. Not Reporting Changes in Condition Nurses work as part of a healthcare team. They are obligated to inform the physician of significant changes in the patient’s condition. Signs of respiratory depression warrant changes in the orders so as to reduce the risks.

4. Interactions Only one person or service should be ordering pain medications and sedatives for a patient on a PCA pump. The patient can receive a deadly combination of Dilaudid or Morphine and other drugs that suppress awareness. Nurses need to be aware of the risks of interactions, and the way the medications can combine to cause oversedation. The combination of a narcotic, sleeping pill, and anti-anxiety medication, for example, can stop the patient’s breathing. Nurses are obligated to question healthcare providers who are not attending to this important risk.

5. Monitoring of the Patient Once the healthcare provider orders a Patient Controlled Analgesia pump, then nursing staff take over monitoring the patient. Many lawsuits have resulted from a failure of the nurses to perform this critical task. A PCA pump should never be taken for granted or viewed as a benign piece of equipment. The faster a problem is detected and acted upon, the better the outcome for the patient. Nurses are required to think of the risks of respiratory depression and to carefully observe the patient for their signs: u Snoring respirations u Inability to talk coherently when stimulated – it is not good enough if the patient can open his eyes; he has to be able to communicate. u Slowed respirations u Drop of pulse oximeter (measures oxygen saturation level) u Abnormal patterns on an end tidal carbon dioxide monitoring screen u Elevated end tidal carbon dioxide levels

Aligning practice with policy to improve patient care 47

6. Misprogramming the Pump Many errors can happen when the PCA pump is programmed to deliver the narcotic. A point by point checklist is a helpful safety measure that has not be available until now. Many facilities require two nurses to check the programming on the pump when it is set up. Some pumps have the capability of informing the nurse when the pump is programmed incorrectly. The nurses need to take action, look at the alarm information, and adjust the settings to the correct level. The nurse taking care of the patient records data throughout the shift, such as respiratory rate, sedation and pain levels. The nurse needs to use critical thinking skills to look for abnormal results. for example, if the patient is reporting consistently high levels of pain, the nurse will need to verify that the pump is set up correctly and the patient understands how to use it. Nurses record at the end of the nursing shift the amount of narcotic the patient received, the number of attempts to obtain a dose of narcotic, and the amount left in the pump. Oversedation can occur even if the pump is programmed correctly. This is why monitoring sedation level, which I discuss in part 2, is so important.

7. Not Using Narcan Naloxone or narcan is a fast acting medication that can reverse the effects of narcotics. If it is used in

48 The OR Connection

the early stages of oversedation, it can save lives. The healthcare providers who order PCA pumps should also provide standing orders for Narcan. This enables nurses to act quickly if they suspect oversedation has occurred. The standing orders should specify the safe use of Narcan. In one case I reviewed, the nurse found the patient not breathing, gave him a single dose of Narcan, and then walked away and did not check him for 45 minutes. Narcan is typically given in doses of 0.4- 2 mg IV every 2-3 minutes. It should be stocked on the nursing unit so it can be quickly located.

An order for a PCA pump might look like this.

9. Lack of Education 8. Not Responding Fast Enough Questions often arise in medical malpractice litigation about the timing of events. When a patient is found not breathing, it raises several questions: u How long was the patient like that? u When was the last time he was checked? u What was his condition at the time of the last check? u Did the nurse recognize snoring as a possible sign of oversedation and attempt to ascertain the patient’s ability to be coherent if awakened? u What were the readings of the patient’s blood gases taken at the time of the resuscitation effort? The pH and base excess may give some clues about how long the patient was not breathing.

The healthcare team, but primarily the nurses, should explain to the patient how to safely use the pump. The education begins before the pump is set up, while it is set up and throughout its use. Patients who first learn about the pump in the recovery room, for example, while coming out of anesthesia, may forget what they have been told. It used to be common for nurses to instruct family members or visitors to push the button for a dose of pain medication when the patient was unable to do so. This practice, called “PCA by proxy”, led to unintentional overdoses. If a patient is too groggy to push the button, it is dangerous for someone else to do so. families need to understand that the pump should be touched by the nurses and patient only. Some facilities mark the pump with a sign that says, “for patient use only.”

What’s Your Cleaning and Disinfection

IQ? Take this QUIZ and find out!

by Lorri A. Downs BSN, MS, RN, CIC Every year millions of invasive medical procedures are performed in inpatient and outpatient healthcare settings. Each one of these procedures carries the risk of introducing pathogenic microbes that can lead to infection in patients.1 Evidence increasingly shows that our healthcare environment can harbor various microbes for months if it is not properly cleaned and disinfected. In 2010, AJIC published an article by Carling and Bartley that reports: “Eight recent studies have now confirmed that patients occupying rooms previously occupied by patients with vancomycin-resistant enterococcus (VRE), MRSA, C.difficile and A. baumannii infection or coloniza-

1. When using pre-moistened cleaning and disinfecting wipes on non-critical items (i.e, items that come in contact with intact skin in the OR), the more wipes you use the better. A. True B. False

tion have on average a 73% increased risk of acquiring the same pathogen than patients not occupying such a room. Over the past 4 years, 8 studies using direct covert observation or a fluorescent targeting method have confirmed that only 40% of near patient surfaces are being cleaned in accordance with existing policies.”2 Are you shocked? Take a moment to check yourself on basic cleaning and disinfection principles using this quiz.

2. When selecting germicides use only EPA-registered cleaning and disinfecting products. A. True B. False

Aligning practice with policy to improve patient care 49

8. Which is the least safe practice for managing infectious fluid (i.e. blood, body fluids) in the OR?

3. Whose job is it to be sure the OR is clean and ready for patient use? A. Director of housekeeping B. The housekeeper assigned to clean the OR C. The perioperative nurses on the unit

4. Cleaning verification tools include: A. Visual inspection B. ATP testing (Adenosine Triphosphate testing) C. Chemical and biological indicators D. Checklists E. All of the above

5. Microfiber mops provide 94 percent microbial elimination all by themselves. A. True B. False

6. As a general rule, cleaning always comes before disinfection. A. True B. False

7. If you need an instrument in the OR, Immediate –use sterilization is the best solution; especially, if you are running short on instrument sets. A. True B. False

50 The OR Connection

A. Opening closed containers and pouring contaminated fluids into a hopper or drain B. Collecting contaminated fluid in large capacity, leak-proof, puncture-resistant containers with a solidifying agent added to the container. C. Using a closed system drain to drain disposal system

9. Which of the following types of products are considered low level disinfectants? A. Isopropyl alcohol (70%-90% concentration) B. Phenolic (mixed per manufacturer’s recommendations) C. Quaternary ammonium (mixed per manufacturer’s recommendations) D. Hydrogen peroxide (O.5-1.4%) E. All of the above F. B, C, D

10. Which of the following actions are most important in preventing healthcare acquired infections? A. Performing routine Hand hygiene B. Cleaning and disinfection of high touch surfaces C. Proper Isolation techniques D. Staff Immunizations E. All of the above F. None of the Above

Answers 1. False. Using more wipes to do the job may not be helpful. When using wipes to clean and disinfect, use each side of the wipe only once. The most important fact is to leave the surface wet for the proper length of time to adequately “kill” the microbes. If the manufacture says it takes one minute to kill the microbes, then you will need the surface to remain wet for one full minute. Always keep wipes closed so contamination or drying of the wipe does not occur.3 Remember to always wear gloves when cleaning and disinfecting. The chemicals in wipes can be harsh on your skin and cause it to dry, crack and bleed. This only leaves employees at risk for increased pain, infection and poor hand hygiene. 2. True. Regulations require the use of EPA-approved chemicals in healthcare settings.4 Surveyors will also quiz and observe you as you perform cleaning and disinfection procedures. It is critical for all staff to understand the proper application process. Procedures must be easily accessible to everyone. Other factors to consider when selecting cleaning and disinfection products are ease of use, intent of the product (is this product recommended for this type of surface?) and efficacy of the product. In other words, will this product kill a broad spectrum of microbes and will it impact your OR turnover time? Safety and cost of the product also should be considered. for example, a product might work well and be cost effective, however, you might not want to use it if fumes from the product are affecting patients and staff.



e ER




ith t

ed w

d Inclu

dlin e Me



Medline’s Foley InserTag tells you when. Know exactly when your patient’s catheter was placed Foley InserTag

SCIP Measure #9 recommends removal of urinary catheters in surgical patients by postoperative day one or two,1 and CDC guidelines advise prompt removal of catheters.2 However, 74 percent of hospitals do not keep track of how long patients have catheters in place!3 Medline’s Foley InserTag is a sticker that goes on each catheter bag as part of the insertion procedure. It captures when the catheter was placed to minimize duration and encourage timely removal. Medline’s Foley InserTag. The one little sticker that can make all the difference.


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

Answers 3. C is correct. Although it is everyone’s responsibility to keep the perioperative area clean and sanitary, AORN guidelines assign the ultimate responsibility to the perioperative nurses.4 It is their responsibility to visually inspect the OR suite for cleanliness before case carts, supplies, equipment and instruments are brought into the room. If any items are unsatisfactory, it is up to the perioperative nurses to implement cleaning procedures. 4. E is correct. We all want to know that surfaces, instruments, and equipment are truly clean. Best practices include everything listed above. Visual inspection for soil, swabbing surfaces (ATP testing) and looking for residual protein left on surfaces from blood of bodily fluids can all help to verify that surfaces are clean. Chemical and biological indicators assure sterility of instruments and checklists help everyone to consistently clean and reduce cleaning practice variations, producing sustainable results each and every time. 5. True. Microfiber is an amazing product. Alone microfiber will eliminate 94 percent of microbes located on the floor surface.3 The use of a disinfectant with a microfiber mop has demonstrated 95 percent microbial elimination.3 The least effective is the cotton loop mop alone, which elminates 68 percent of microbes. If you add a chemical disinfectant, the microbial elimination jumps to 95 percent.3

52 The OR Connection

You may be wondering why there is such a difference. Microfiber alone has a positive charge that attracts dust. Microfiber also can be wet and continue to absorb fluids. The best part about microfiber is that pads are for single use only, so you avoid the risk of cross contamination.3 Microfiber is also lightweight, causing less of a strain on employees’ backs. 6. True. In general the first rule is to clean any reusable medical equipment and then disinfect. It is important to remove any visual soiling and bio burden which is remaining on the item. Some chemicals are actually cleaners and disinfectants in combination. This makes it critical that you understand exactly what types of chemicals you are using, what microbes they “kill,” and how to properly apply. 7. False. Immediate- use sterilization or the older term “flash” sterilization is not a solution for lack of inventory. Immediate –use sterilization should only be used when an instrument is dropped but never as routine reprocessing of instruments. Review your reprocessing logs and you may find you need to invest in additional equipment.

8. A is the correct response. Opening closed containers and pouring contaminated fluids into a hopper can splash the healthcare worker, not to mention the cumbersome and physical challenges this can present. Just think about one orthopedic case, thousands of milliliters of fluids from flushing scopes to site irrigation can be generated during just one procedure. The more you contain this medical waste and efficiently and safely dispose of these fluids, the more comfortable cleaning and nursing staff will be. When trying to determine which method is most cost effective, consider the volume of red bag-regulated waste you are generating. Are there options to reduce expensive regulated waste?

9. E is the correct response. What is most important to understand about disinfectants is that if you use an ineffective disinfectant (too dilute, expired) or you use an effective disinfectant improperly ( all surfaces were not disinfected) this can be as harmful as not using a disinfectant at all. It is up to each organization to specify which disinfectant is to be used where, when and for what purpose. 10. E is the correct answer. All of these actions performed in concert are important steps to reduce a patient’s risk for acquiring healthcare infections. Hand hygiene performed routinely can significantly reduce transfer of microbes from patient to patient or from the environmental surface to the patient. We know that providing good sanitation reduces the spread of disease especially when large groups of people are confined in one location. You can look to history at large outbreaks of infection to know cleaning and disinfection works. Proper isolation of patients with contagious diseases helps prevent the spread to others and minimizes exposure to those that are frail or compromised by chronic diseases. Immunizations of staff reduce the

spread of vaccine preventable diseases; the CDC has published many guidelines on this topic. The key to infection prevention is implementing multiple strategies in collaboration to achieve the safest patient care.

References 1. Rutala WA and Weber DJ. Cleaning, disinfection, and sterilization. In: Carrico R, ed. APIC Text of Infection Control and Epidemiology: Volume I, Essential Elements. 3rd ed.Washington, DC: Association for Professionals in Infection Control and Epidemiology, Inc. (APIC); 2009:21-1-21-27. 2. Carling PC and Bartley JM. Evaluating hygienic cleaning in health care settings: what you do not know can harm your patients. AJIC. 2010;38(5):S41-S50. 3. Pettis AM. Infection prevention: take our surface disinfection quiz. Outpatient Surgery Magazine. October 2012. Available at: http:// Accessed November 8, 2012. 4. Nucci D. Wipe out the confustion over surface disinfection. Outpatient Surgery Magazine: Manager’s Guide to Infection Control. May 2011: 8-12

Aligning practice with policy to improve patient care 53

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octylseal seal

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Introducing Medline’s octylseal high viscosity tissue adhesive for closure of simple wounds • Flexible structure moves with the skin, minimizing the chance of cracking • Acts as a barrier to microbial penetration as long as the adhesive film remains intact • 40 percent more glue per container than most other tissue adhesives (0.7 grams versus 0.5 grams) • Easy, versatile application – interchangeable tips (swab and nozzle) included in every package; easier identification on skin Indications for use

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

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


STAYING SAFE WHILE WORKING ON THE CuTTING EDGE Marc Crandall had been a trauma surgeon for more than 10 years when he suffered a serious cut on his right hand during a fast-paced coronary procedure during which he was trying to save the life of a gravely injured 25-year-old gang member. Environment of Care News. March 2009, Volume 12, Issue 3. Reprinted with permission from the Joint Commission.

Aligning practice with policy to improve patient care 55

The doctor and his colleagues had known for years that scalpels are the second most frequent cause of injury, after needlesticks among operating room personnel.1 But by the time Crandall had undergone the time-consuming and expensive work needed to repair the wound on his hand and allow it to heal, that medical error had cost him months of time and tens of thousands of dollars of income. On top of that was the gut-wrenching fear of suffering and possibly dying from infection by a bloodborne pathogen such as HIV/AIDS, hepatitis B virus, or the hepatitis C virus. Like so many of his colleagues, Dr. Crandall knew that the cost of even an uncomplicated injury could range from $500 to $2,000—or if the injury required microsurgery, it might cost as much as $100,000 plus up to three months of rehabilitation, along with the loss of his salary.2 Although Dr. Crandall is fictitious, the threat of injuries from scalpel blades and other sharps injuries was real enough to spur the Occupational Safety and Health Administration (OSHA) to issue in 1992 the Bloodborne Pathogens

56 The OR Connection

Standard (29 CfR 1910.1030)3 to protect workers from this risk. In 2001, in response to the Needlestick Safety and Prevention Act, OSHA revised the Bloodborne Pathogens Standard. The revised standard clarifies the need for employers to select safer needle and sharps devices and to involve employees in identifying and choosing these devices. The updated standard also requires employers to maintain a log of injuries from contaminated sharps. The Centers for Disease Control and Prevention (CDC) estimates that each year 385,000 needlesticks and other sharps-related injuries are sustained by hospital-based health care personnel—an average of 1,000 sharps injuries per day.4 Scalpel blade injuries account for 7% to 8% of those sharps injuries.5 “It’s very unfortunate that injuries such as these occur,” says Jerry Gervais, C.H.f.M., C.H.S.P., associate director, Standards Interpretation Group, The Joint Commission. “And it’s not just clinicians who are at risk. Potential victims include other health care workers such as maintenance, laundry, and housekeeping personnel who pick up

The Centers for Disease Control and Prevention (CDC) estimates that each year 385,000 needlesticks and other sharps-related injuries are sustained by hospital-based health care personnel—an average of 1,000 sharps injuries per day.

Medline Safety Syringes

Protect yourself and your patients from needlestick injuries Don’t become a statistic A staggering 74 percent of nurses report being stuck by a contaminated needle,1 which can lead to infection with Hepatitis B and C, HIV, and other dangerous bloodborne pathogens. Slide the safety shield forward, twist, and when you hear the click, the syringe is safe for disposal.

To Prevent Transmission of Infections in Healthcare

Medline Safety Syringes: • Low dead-space design reduces waste • Easy-to-read bold markings • Insulin and tuberculin syringes available

Injection Safety is Every Provider’s Responsibility

See for yourself how Medline safety syringes protect and perform. Ask your Medline sales representative for a sample, or call 1-800-MEDLINE.

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

Reference 1. American Nurses Association. 2008 Study of Nurses’ Views on Workplace Safety and Needlestick Injuries. Available at: Accessed March 16, 2012.

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

trash. Needles and scalpel blades must be put in self-sealing containers where the door shuts behind them, then sent to an approved medical destruction site that’s regulated by the state and the federal Environmental Protection Agency so they can be disposed of properly.”

Why Is the injury rate so high? One reason the rate of injuries from scalpel cuts is so high is the nature of scalpel blades themselves. While relatively small, scalpel blades are razor-sharp instruments designed and used to penetrate skin and other tissue during surgery. A scalpel blade is affixed to a handle that may be flat or round but is often slippery with blood and other body fluids. In case of an accident, the risk of injury and potential infection from bloodborne pathogens is very high. Scalpel blades are likely to penetrate the flesh of the surgeon or other personnel in the operating room more deeply than needle-stick injuries and therefore can cause more serious harm.

Safety Scalpels Safety scalpels require users to retract the blade into the handle after use or to slide a cover over the blade and before passing the scalpel to another member of the surgical team. Some users contend that the term safety scalpel is a misnomer because no evidence exists that they’re safer than traditional scalpels. Many surgeons feel that safety scalpels compromise the care they give their patients. To them, these scalpels feel too light and/or too clumsy or

don’t accommodate their grip. According to others, the retractable shields and other safety mechanisms interfere with their view of the blade and make the devices a bad choice for a deep incision. Another objection is that a clinician has to deliberately activate the product’s safety features to retract or shield the blade between use. Some surgeons are concerned that injuries could occur as these steps are taken.


Scalpel Safety

EC.02.02.01, EP 1: The hospital maintains a written, current inventory of hazardous materials and waste that it uses, stores, or generates. The only materials that need to be included on the inventory are those for which the handling, use, and storage are addressed by law and regulation.

Michael Sinnott, MD, is a senior emergency physician in the emergency department at Princess Alexandra Hospital in Brisbane, Australia. Sinnott coined the term scalpel safety (vs safety scalpel) to emphasize the choice of techniques to reduce the risk of staff injury from scalpel blades. The new technique— which involves using a single-handed scalpel blade remover and hands-free passing technique (HfPT)—avoids potential patient safety concerns by allowing the surgeon to continue using a traditional reusable scalpel handle. In HfPT, staff members never pass the scalpel from hand to hand. Instead, the scrub nurse places the item on a passing tray or in a neutral zone. The surgeon then picks it up. The process is reversed for the surgeon to return the item to the scrub nurse. HfPT is not a new concept, and many surgical suites have now prohibited hand-to-hand passing of scalpels in favor of using passing trays in an effort to reduce injuries. This move is supported by OSHA, the Association of periOperative Registered Nurses (AORN), the American College of Surgeons (ACS),6 and the International Sharps Injury Prevention Society (ISIPS).7

The Joint Commission standards that relate to scalpel safety include the following: EC.02.01.01, EP 3: The hospital takes action to identify, minimize, or eliminate safety risks in the physical environment.

EC.04.01.01, EP 1: The hospital establishes processes for continually monitoring and internally reporting and investigating … occupational illnesses and staff injuries. IC.02.01.01 EP 6: The hospital minimizes the risk of infection when storing and disposing of infectious waste.

Aligning practice with policy to improve patient care 59 Aligning practice with policy to improve patient care 59

The same warming, no waste.

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: Flexible and durable carbon heating element for uniform heating.

• Efficient underbody warming as effective as forced-air systems for preventing unintentional hypothermia1 (SCIP Measure #10) • Pressure redistribution to aid in pressure ulcer prevention (CMS Hospital-Acquired Condition) • Complete patient access • Silent operation • Reduced staff time • No blowing air

1-800-MEDLINE I PerfecTemp is custom-fit to your table configuration. Ask Medline for a free quote.


OR Patient Warming System Reference 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. ©2012 Medline Industries, Inc. Medline and PerfecTemp are registered trademarks of Medline Industries, Inc.

Another option is combining a reusable traditional metal handle with a single-handed scalpel blade remover and HfPT. Another point of danger for operating room personnel is when a disposable blade is detached from the scalpel handle. Sinnott cites an OSHA interpretation8 which states that “in situations where an employer has demonstrated that the use of a scalpel with a reusable handle is required, that blade removal must be accomplished through the use of a mechanical device or a one-handed technique. The use of a single-handed scalpel blade remover meets these criteria.” Sinnott advocates a method in which the scalpel blade remover is held in a single-handed fashion and the top half of the scalpel blade is placed into the remover. The handle is withdrawn, leaving the blade inside the remover cartridge. “While some removers call for the user to use two hands,” he says, “the best are those that are single-handed and give the user an audible signal as the blade drops into the remover cartridge.”

comprehensive program that includes engineering and work practice controls. Proper work practice controls include a no-hands procedure for handling contaminated sharps and eliminating hand-to-hand instrument passing in the surgical suite.

happens, there will be a whole new era of safety for operating room personnel.” The mythical Dr. Crandall might well agree.

This does not mean that every instrument has to be passed using the hands-free technique, but instruments that are sharps hazards should be passed using the hands-free technique. This includes items such as hypodermic and suture needles and, of course, scalpels, which are transferred from one person to another via a passing tray.

1. Perry J., Parker G., Jagger J.: Scalpel Blades: reducing injury risk. Advances in Exposure Prevention 6(4):37–40, 2003.

“I believe that the traditional scalpel handle will remain the first choice of the surgeon and that to ensure staff safety, a single-handed scalpel blade remover and hands-free passing technique will become the norm in all operating suites in the next five years,” says Sinnott. “When that


2. Jagger J., et al.: Estimated cost of needlestick injuries for six major needled devices. Infect Control Hosp Epidemiol 11(11):584–588. 3. Occupational Safety and Health Administration: Bloodbourne Pathogens and Needlestick Prevention. SLTC/ bloodbornepathogens/index.html (accessed Jan. 27, 2009). 4. Centers for Disease Control and Prevention: Overview: Risks and Prevention of Sharps Injuries in Healthcare Personnel. Sharpssafety/wk_ overview.html#overViewIntro (accessed Jan. 27, 2009). 5. Perry J., Parker G., Jagger J.: EPINet report: 2001 percutaneous injury rates. Advances in Exposure Prevention 6(3):32–36, 2003. 6. American College of Surgeons: Statement on Sharps Safety. 7. Stoker, R.: Scalpel safety: Protecting patients and clinicians. Managing Infection Control May 2008. 8. document?p_table=INTERPRETATIONS&p_ id=25339

OSHA Requirements No matter which of these two types of strategies is selected—safety scalpels or scalpel safety—safety should be the primary consideration. In fact, OSHA requires that frontline workers participate in identifying, evaluating, and implementing which safety products best meet the needs of patients and staff. Many surgeons and safety experts advocate HfPT, which ensures that the surgeon and the scrub nurse never touch the same instrument at the same time. The OSHA requirements for sharps injury prevention assert that preventing exposures requires a

Aligning practice with policy to improve patient care 61

Catheter-associated urinary tract infections Education, product and teamwork help Mercy Medical Center reduce CAUTIs Editor’s Note: In the United States, 75 percent of all healthcare-acquired infections are either urinary tract infections, surgical site infections, bloodstream infections or pneumonia, according to The Joint Commission. Experts believe that many of these infections are largely preventable when evidence-based practices are followed consistently over time. Recently a joint “call to action” to move toward the elimination of healthcare-acquired infections was set forth by a number of organizations, including the Centers for Disease Control and Prevention, the Association for Professionals in Infection Control and Epidemiology, the Society for Healthcare Epidemiology of America, and the Infectious Diseases Society of America. Understanding and tackling healthcare-acquired infections is a complex process. Although contracting executives won’t be clinical experts on the topic, they can play an important role in the fight against infections. Reprinted with permission from the Journal of Healthcare Contracting.

62 The OR Connection

Hospitals and patient care providers are under more pressure than ever to prevent CAUTI s, and their rates need to be trending towards zero.” – Michelle Christiansen, MS, PA, clinical resource team, urology, Medline Industries Inc.

Striving for a 50 percent reduction in catheter-associated urinary tract infections is not an unrealistic goal, says Rich Lyon, BA, MA, JD, RN, CIC, infection control coordinator for Mercy Medical Center in Canton, Ohio. But for Lyon and the team at Mercy, it’s only the beginning. “We’ve nearly reached that goal [of 50 percent reduction], and have set our targets on ‘zero tolerance,’” says Lyon. In the meantime, he and the Mercy team are watching with pride the steady downward curve of the incidence of CAUTIs in their facility. A catheter-associated urinary tract infection is caused by germs that enter the urinary system through a catheter that has been inserted into the bladder to drain urine, according to Partnership for Patients, a public-private entity created in April 2011 by the Department of Health and Human Services in an attempt to make hospital care safer and less costly. These infections affect the bladder, and may also affect the kidneys. Urinary catheters are used in almost all hospital patients receiving major surgery and in many other

situations. In recent years, up to 560,000 healthcare-associated urinary tract infections have occurred annually, 40 percent of which are preventable, according to Partnership for Patients. “Patient safety concern alone is a good enough reason to establish protocols to reduce the incidence of CAUTIs, but now there is definitely a financial incentive as well,” says Michelle Christiansen, MS, PA, clinical resource team, urology, Medline Industries Inc. “CAUTI can have a significant impact on a health system’s bottom line and, given the frequency of these infections, costs add up quickly. “Research shows that CAUTI increases hospital costs and length of stay,” continues Christiansen, whose company offers the ERASE CAUTI program, which encompasses education, a new tray design, and implementation process. “Research also shows that these infections can, in some cases, be deadly.” CAUTIs are patient-safety indicators and are publicly reported, says

Christiansen. What’s more, as of 2008, these preventable infections are no longer reimbursable by the Centers for Medicare & Medicaid Services, as a result of the Medicare Modernization Act of 2003 and the Deficit Reduction Act of 2005. “Hospitals and patient care providers are under more pressure than ever to prevent CAUTIs, and their rates need to be trending towards zero,” she says.

CAUTI reduction program Mercy’s efforts to eradicate catheterassociated urinary tract infections began in late fall 2011, explains Lyon. “We were dissatisfied with our own performance compared with the [National Healthcare Safety Network] measures,” he says. (The NHSN is a Centers for Disease Control and Prevention reporting program, which allows healthcare facilities to electronically share information regarding the safety of patient and healthcare personnel.) The hospital established a CAUTI reduction team, which included infection ontrol, nursing and urology. Step 1 was to review where Mercy stood with UTI events dur-

Aligning practice with policy to improve patient care 63


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©2012 Medline Industries, Inc. ERASE CAUTI and Medline are registered trademarks and Buddy the Brave is a trademark of Medline Industries, Inc.

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Studies have shown that often physicians don’t know a Foley has been placed in a patient, or that its use has been continued beyond necessity.” – Rich Lyon, BA, MA, JD, RN, CIC, infection control coordinator for Mercy Medical Center

ing the previous 12-month period, says Lyon. Step 2 was to talk with Mercy’s prime vendor, Medline Industries, about potential solutions, including the company’s one-layer foley catheter kit.

CAUTI occurrence data had already been collected prior to the changes, so patient care managers and directors could see their performance on a unit-by-unit basis.

Training Older kits stack their components, so that the nurse ust take them out, stack them somewhere on the sterile field, and retrieve them as needed, explains Lyon. “That’s inconvenient for the nurse, and nurses have so much more to do now than they did in the past.” In contrast, Medline’s kit is in one layer, so nurses don’t have to stack or unstack anything. Choosing a catheter wasn’t difficult, he says. “We wanted to go latexfree, which we had prior to this. And we wanted silver-coated catheters because of their antimicrobial action.” Medline offered both, and Mercy proceeded to trial the kit in three patient care units. After a successful trial, the new product (and mandatory training program) was rolled out to the rest of the hospital. A baseline of

Lyon was especially attracted to the ERASE CAUTI online training program. All staff involved in inserting foley catheters or in foley catheter care were instructed to view the online training modules and take tests on the material presented. They were able to access the modules via terminals at the hospital (including those in the medical library) and on their home computers. After three or four days, each additional day that a foley catheter is in, the risk of infection increases by 5 to 8 percent, says Lyon, citing studies. So Mercy stressed education on insertion technique, particularly in the emergency department and the OR. In the ICU, where many catheterassociated urinary tract infections occur, the emphasis was on post-insertion catheter care. That means cleaning of the insertion

site at least daily, and more if the patient’s condition necessitates it; and discontinuing catheterization as soon as possible. “With any major change in products, you will often encounter misgivings or resistance by the end-user staff,” says Lyon. “It is crucial that they be provided adequate product change rationale and support training to help ease the transition.” In fact, when asked to identify the single most important factor in Mercy’s success in reducing CAUTIs, he answers, “Education, education, education, reinforcement and continual performance feedback to the nursing staff and physicians.”

Physicians and patients Nurses and OR techs aren’t the only ones involved in Mercy’s CAUTI reduction program. Physicians and patients are part of the program as well. “Studies have shown that often physicians don’t know a foley has been placed in a patient, or that

Aligning practice with policy to improve patient care 65

It is important that the patient understand why the Foley is being used, how it must be cared for, and that it needs to be removed as soon as circumstances will allow.”

its use has been continued beyond necessity,” says Lyon. That’s why, after 48 hours of catheterization, Mercy places a reorder sheet, which reminds the doctor that a catheter’s additional usage time must be ordered. Patients themselves can play a role in reducing catheterassociated urinary tract infections, he continues. “It is important that the patient understand why the foley is being used, how it must be cared for, and that it needs to be removed as soon as circumstances will allow,” he says. The ERASE CAUTI kits include a patient education card which explains, in English and Spanish, why the foley has been used and if it’s still needed. “This education card encourages a patient to become an advocate in their own care,” says Christiansen. The card reviews information such as, “What is a urinary catheter?” and “What you should know

66 The OR Connection

about your catheter.” It also reviews ways the patient can reduce the risk of acquiring a catheterassociated urinary tract infection, including washing their hands and asking their doctor daily if the catheter is still clinically needed. “If the catheter can be removed from the patient when it is no longer needed, their risk of getting an infection is dramatically decreased. “One of the biggest misconceptions regarding catheterization is

that nothing can be done to prevent CAUTI, because the colonization of bacteria is inevitable,” she says. “Going up against that mindset is quite the obstacle.” But with training, teamwork and the right products, hospitals and patients can overcome it. Reprinted with permission. Journal of Healthcare Contracting.





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

Aligning practice with policy to improve patient care 67

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Medline’s Pressure Ulcer Prevention Program (PUPP) Tracking and reporting of clinical data – know what works to reduce pressure ulcers at your facility.

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• Average annual savings: $215,190 1

• Average reduction in facility-acquired pressure ulcers: 72.6%1 Source: 1. Data on file

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

The only way to get PuPP - and PuPP results - starts with a call to Alice Kiehl, PuPP Program Manager, 847-949-2294.

Evidence for the Validity of the Medline Pressure Ulcer Prevention Program (mPUPP) by Daniel L Young, Debashish Chakravarthy, Kiarash Mirkia

ABSTRACT Introduction: Pressure ulcers (PrU) develop on 1 million people every year and the costs for treating this problem approach $11 billion. While not all PrUs can be prevented, most can be and Medicare has begun to deny payment for PrUs that develop in hospitals. A pressure ulcer prevention program has been developed and the researchers sought to evaluate the impact of the program. Methods: The program was based on previously published evidence that clinician involvement, patient, family, and caregiver education, and good skin care are important components of a successful prevention program. All facilities participating in the program, for which pre and post program PrU incidence data were available, were included in the study. Pre-program PrU incidence data were collected from 99 facilities and compared to post-program PrU incidence data. Results: The mean pre-program PrU incidence was 6.18 (range 38 to 0) and the mean post program incidence was 2.82 (range 24 to 0), yielding an average improvement for the entire sample of 3.36 (range -8 to 34), a 54% improvement. This difference was statistically significant, t (98) = 6.349, p<.001. No statistical differences between PrU rates or changes in facilities of different types or sizes were observed. Conclusions: The program demonstrated validity by reducing PrU incidence in facilities of different types. Whether this improvement is different from other pressure ulcer reduction programs is not known.

Daniel L Young, PT, DPT, Corresponding author, Assistant Professor, Department of Physical Therapy, School of Allied Health Sciences, University of Nevada, Las Vegas, 4505 S. Maryland Parkway Box 453029, Las Vegas, NV 891543029. Phone: 702-895-2704, Fax: 702-895-4770, email: Debashish Chakravarthy, PhD, Medline Industries, Inc., Mundelein,Illinois. Kiarash Mirkia, MD, FACS, Sunrise Hospital, Las Vegas, NV. Medline Industries, Inc provided financial support for this study and the writing of the manuscript

JACPT. Volume 3, Number 2. 2012. Reprinted with permission.

Aligning practice with policy to improve patient care 69

Pressure Ulcers (PrU) have long been a problem for individuals and institutions caring for people with disability, illness, or advanced age. Recent information indicates that more than 1 million people develop a PrU every year and that the cost of care for these wounds exceeds $11 billion.1-4 The magnitude of the problem has attracted the attention of the largest payer for the care of these people, Medicare. With enforcement of the Deficit Reduction Act (DRA) of 2005 beginning October 1, 2008, hospitals can no longer collect the additional payment for PrUs acquired in the hospital.5 The new Patient Protection and Affordable Care Act signed into law March 23, 2010 stipulates that Medicaid will not pay for stage III or IV PrU if they are hospital acquired.6 This means that unless a PrU is documented as being present when the patient is admitted, the hospital will care for the new wound without payment from patients insured by either Medicare or Medicaid.

facility PrU reduction program with a specific component for heel ulcers, like other programs, combined caregiver education, pressure reduction equipment, skin care products, and focused documentation to reduce its incidence.14 In addition to the elderly and heel ulcers, young injured war veterans have been studied for their PrU risk and incidence reduction program components.15 An increasing level of consensus in the literature demonstrates that clinician led efforts, education, and evidence based practice for risk assessment and prevention are more successful in terms of patient outcomes.16-18 The NDNQI (established by the American Nurses Association (ANA) in 1998) has established an effective training program for nurses on pressure ulcers to combat poor knowledge among staff nurses regarding PrU identification, staging, and prevention.19 A connection between PrU risk (as seen with a drop in Braden score) and the implementation of the Registered Nurses Intervention Checklist interventions has also been shown.20 In addition, involvement of hospital management may improve outcomes in pressure ulcer reduction programs.21 Despite all of the effort and attention, Jankowski highlights that deficiencies exist in: â&#x20AC;&#x153;lack of physician involvement; limited involvement of unlicensed nursing staff; lack of plan for communicating at-risk status; and limited quality improvement evaluations of bedside practices.â&#x20AC;?22 This clearly indicates that more work needs to be done in the area of PrU reduction.

Implementation of a comprehensive pressure ulcer prevention program can lead to significant reductions in PrU incidence.

With this change in reimbursement policy, and the published knowledge that the cost of PrU prevention is more cost effective than standard care,7 facilities are looking for effective ways to reduce PrU incidence. Several examples from the published literature highlight these efforts and their findings or effectiveness. Sharkey et. al., describe a program implemented in long term care facilities to reduce PrU incidence. The program focuses on using certified nursing assistant observations through electronic documentation to generate reports that could be used to drive interventions and highlight at risk patients.8,9 An earlier version of this program was described the year before.10 A hospital group in Minnesota implemented a program involving education of providers and patients, point-of-care resources, and nutrition assessment.11 A Seattle hospital improved its system for monitoring PrU incidence, implemented monthly multidisciplinary reviews on hospital acquired PrUs, and applied an algorithm to determine whether the PrUs were avoidable.12 PrU prevention efforts for specific populations or vulnerable areas of the body have been given special attention in the literature. In the acute orthopedic patient population, efforts included a simple foam wedge after getting input from stakeholders and had positive results in heel ulcer elimination.13 A long term care

70 The OR Connection

While not all PrUs are avoidable,23 implementation of a comprehensive pressure ulcer prevention program can lead to significant reductions in PrU incidence. In addition, changes to existing PrU reduction programs can improve their effectiveness and specific skin care products may contribute to this improvement.24 This growing need for improved prevention of facility acquired PrU and the growing evidence of comprehensive program success has led to the development of a program by Medline Industries, Inc., Medline Pressure Ulcer Prevention Program (mPUPP). This paper will describe the mPUPP and provide evidence for the validity of the program to effect PrU reduction among participating facilities.

Figure 1.

Screenshot of the Medline University homepage for the Pressure Ulcer Prevention Program

Users click here to choose the Pressure Ulcer Prevention Program. Medline University offers several other clinical programs as well.

Program participants can show their knowledge with hands-on virtual competency.

Users choose from an array of course materials on pressure ulcers.

Aligning practice with policy to improve patient care 71

MEDLINE PRESSURE ULCER PREVENTION PROGRAM The mPUPP program is organized and administered by a program team. This team includes three groups of people. Two program administrators report to executive level company leaders. These administrators are responsible for program development and oversight. They track program participants, oversee marketing materials, and coordinate the efforts of others working to administer the program. The second group in the program team is the program service representatives. They are responsible for data collection and follow up with participating facilities on a quarterly basis to review progress and provide support. These individuals work with local representatives, the third group, who identify facilities that may benefit from mPUPP and ensure they have the support they need. The mPUPP team contacts each facility at the initiation of the program to provide orientation and explanation of all aspects of the program. During this contact, usually via phone call, they also collect baseline data on the PrU incidence in these facilities. Currently, the program is expanding its online resources for facilities to access interactive quarterly reports. These reports will allow the facility to view progress, track improvements, and quantify savings that come from PrU reductions. The second piece of the program is education for caregivers who work for the facility and for families. All participating facilities have access to an education resource at www. (MedlineU). MedlineU is a web-based suite of interactive educational material. Figure 1 shows the home page for material specific to the mPUPP while Figure 2 shows how the educational courses related to PrU are presented. MedlineU combines foundational information about integument anatomy and physiology, PrU development and healing with evidence based guidelines on risk assessment and treatment interventions. Figure 3 is a screen shot of one of the interactive course modules on PrU risk assessment. Assessment pieces are also available to allow individuals and facilities track and measure the change in knowledge realized through use of the individual modules. Figure 4 illustrates an assessment page on

which the learner can respond to a specific question. Family education materials can be provided by clinicians to families to support the prevention efforts of the facility or to guide families as they take their loved ones home. Beginning in the summer of 2012 these materials will also be available through MedlineU. The third aspect to the program is the product component. An advanced line of skin care products for cleaning, moisturizing and barrier protection, as well as pads and briefs for incontinence management have been made an integral part of the mPUPP program.* These products support other caregiver interventions like positioning, mobility training, attention to the choice of support surfaces, and scheduled voiding. These products have been designed to ensure integument integrity by maintaining appropriate moisture balance through bathing and cleansing and episodes of incontinence. Clinical representatives involved with these products have extensive knowledge of the material science and clinical benefits of these products, and are trained on the evidence base associated with the clinical use of these products in various settings. Clinicians involved in PUPP can also help facilities select product lines that synergistically support the educational components of mPUPP. Even with the evidence supporting the components of the mPUPP, clear and objective analysis of the program was desired to validate the impact on PrU reduction. With IRB approval, deidentified data on all mPUPP program facilities for which preprogram and post-program PrU incidence data were available were provided to the researchers for further analysis. Thus, the researchers were unaware of facility names and locations. Interim data provided for a snapshot analysis resulting in a sample of 99 facilities further broken down into 55 hospitals and 44 nursing homes. The mean number of beds for the sample was 166 and the median was 120. All facilities had fully implemented the educational components of the program and any product use changes prior to data

The extensive line of competitive skin care products available with the custom mPUPP may be one of the major reasons why this program has been remarkably successful.

72 The OR Connection

Figure 2.

Screenshot of the Medline University pressure ulcer prevention course list (not all courses are visible)

In addition to pressure ulcer prevention, courses are available on a wide variety of clinical topics.

Aligning practice with policy to improve patient care 73

Figure 3. Screenshot of a Medline University interactive course on pressure ulcer risk assessment

Users maneuver through this virtual patient room. As questions appear at the top of the screen, users click on the object that answers the question.

Figure 4. Screenshot of a Medline University pressure ulcer prevention assessment question

74 The OR Connection

collection. PrU incidence values represent the number of PrUs present in the facility for one month. The PrU values came from the most recent full month prior to program implementation and the most recent full month prior to the call to collect the PrU numbers. All programs self counted and reported these PrU numbers. Comparisons were then made among facilities of different types (skilled care and hospital) using the pre and post PrU incidence data.

Figure 6

Figure 6. Pre Program Pressure Ulcers

Pre Program Pressure Ulcers


Figure 7 Post Program Pressure Ulcers 3.10 4.88

2.33 3.25

RESULTS For all facilities combined, the mean pre-program PrU incidence was 6.18 (range 38 to 0) and the mean postprogram incidence was 2.82 (range 24 to 0), yielding an average improvement for the entire sample of 3.36 (range -8 to 34), which is more than a 54% improvement (see Figure 5). A paired samples t-test comparing the pre (mean = 6.18, SD = 6.88) to post (mean = 2.82, SD = 4.10) PrU incidence indicated a statistically significant difference between the means, t(98) = 6.349, p<.001. Comparisons between nursing homes and hospitals revealed no differences. Specifically, no difference was found between the pre-program PrU incidence for nursing homes (mean = 5.84, SD = 5.25) and hospitals (mean = 6.45, SD = 7.98), F(1,97)=.193, p=.661 (Figure 6); no difference between postprogram PrU incidence for nursing homes (mean = 3.05, SD = 3.84) and hospitals (mean = 2.64, SD = 4.33), F(1,97)=.241, p=.624 (Figure 7); and finally no difference between the change in PrU incidence for nursing homes (mean = 2.80, SD = 4.26) and hospitals (mean = 3.82, SD = 5.96), F(1,97)=.919, p=.340 (Figure 8).

Figure 55. Graphs represent 54% improvement after Figure implementing Medlineâ&#x20AC;&#x2122;s Overall Pressure Ulcer Prevention Program Change in Mean 7.00



Nursing Home Mean

Hospital Mean


Nursing Home Mean Ulcers Hospital Mean Figure 77. Post Program Figure Pressure Post Program Pressure Ulcers 3.10





Nursing Home Mean

Hospital Mean

Figure Figure 88. Change in Pressure Ulcers Change in Pressure Ulcers 4.00







1.55 1.63


Pre Program

Post Program


Figure 8

Nursing Home Mean

Hospital Mean

Change in Pressure Ulcers 4.00

Continued on page 49

Aligning practice with policy to improve patient care 75 3.00

This study provides compelling evidence that significant pressure ulcer reductions can be facilitated by Medlineâ&#x20AC;&#x2122;s Pressure Ulcer Prevention Program.

The results of this study indicate that the mPUPP can produce significant reductions in PrU rates for both hospitals and nursing homes. While the mean change was larger for hospitals, the statistical analysis did not indicate that this difference was greater than chance alone could have produced. The nonsignificant results of the comparisons between the hospitals and nursing homes provide evidence for the validity of this study as well as the ability of the program to succeed in different settings. If the pre or post program PrU numbers had been significantly different, any comparisons involving both hospitals and nursing homes together would affect the impact of the other. Because no difference was observed, the data can be confidently analyzed in the aggregate. It also supports the value of the individualized approach to program implementation, as the same overall mPUPP can be just as effective for hospitals and nursing homes. Several aspects of the mPUPP have good support in the literature. Clinician-focused education is one component of several other successful PrU reduction programs.8,9,11-14,16-19 In mPUPP, clinician education is provided through MedlineU and adds the ability for facilities and clinicians to quantify their knowledge and learning. Specific attention to skin care and even specific products can help in PrU prevention.24 The extensive line of competitive skin care products available with the custom mPUPP may be one of the major reasons why this program has been remarkably successful. Similar to other studies in the field this work had some limitations. The PrU data for each facility were self reported and bias might have influenced the reporting. However, this collection method was consistent across facilities and is used by regulatory agencies for quality monitoring. This study evaluated 99 facilities using mPUPP, but did not compare these to facilities using any other PrU reduction activities or programs and such comparison would strengthen the analysis. In addition, over 700 facilities today are at some stage of mPUPP implementation. Some were just learning

76 The OR Connection

about the program, some were still working to get all clinical staff through the MedlineU education modules and complete the assessments there, and others had not been participating long enough to have 30 days of post program PrU incidence data. Furthermore not all of these facilities could be included in this study because they had not provided information about their PrU incidence before or after and they may have results quite different than what has been found in our sample.

CONCLUSIONS The mPUPP is effective in reducing PrU incidence in participating hospitals. This effect may be the result of a combination of program features such as individualized assessment of facility needs, caregiver education, and the use of specific skin and wound care products. Further work is needed to quantify the impact of these individual program elements and to make comparison between this and other PrU reduction programs. Despite these unanswered questions this study provides compelling evidence that significant PrU reductions can be facilitated by mPUPP.* The core consumable or disposable products involved in the mPUPP program are the RemedyÂŽ skin care line and the UltrasorbsÂŽ brand of pads and briefs. References 1. Cuddigan J, Berlowitz D, Ayello E. Pressure ulcers in america: Prevalence, incidence, and implications for the future. an executive summary of the national pressure ulcer advisory panel monograph. Adv Skin Wound Care. 2001;14(4):208215. Accessed 2/2/2011. 2.

Kuhn BA, Coulter SJ. Balancing the pressure ulcer cost and quality equation. Nurs Econ. 1992;10(5):353-359. Accessed 12/30/2010.


Whittington KT, Briones R. National prevalence and incidence study: 6-year sequential acute care data Adv Skin Wound Care. 2004;17(9):490-494.


Reddy M, Gill SS,Rochon PA. Preventing pressure ulcers: A systematic review. JAMA. 2006;296(8):974-984.


Overview hospital-acquired conditions (present on admission indicator). http:// Accessed 2/2/2011.


Medicaid program; payment adjustment for provider-... [fed regist. 2011] -PubMed result Accessed 7/13/2011, 2011.


Padula WV, Mishra MK, Makic MB, Sullivan PW. Improving the quality of pressure ulcer care with prevention: A cost-effectiveness analysis Med Care. 2011;49(4):385-392.

16. Young J, Ernsting M, Kehoe A, Holmes K. Results of a clinician-led evidence-based task force initiative relating to pressure ulcer risk assessment and prevention J Wound Ostomy Continence Nurs. 2010;37(5):495-503.


On-time quality improvement for long-term care: Download information http://www. Accessed 7/13/2011.


Sharkey S, Hudak S, Horn SD, Spector W. Leveraging certified nursing assistant documentation and knowledge to improve clinical decision making: The on-time quality improvement program to prevent pressure ulcers Adv Skin Wound Care. 2011;24(4):182-8; quiz 188-90.

17. van Gaal BG, Schoonhoven L, Hulscher ME, et al. The design of the SAFE or SORRY? study: A cluster randomised trial on the development and testing of an evidence based inpatient safety program for the prevention of adverse events BMC Health Serv Res. 2009;9:58.

10. Horn SD, Sharkey SS, Hudak S, Gassaway J, James R, Spector W. Pressure ulcer prevention in long term-care facilities: A pilot study implementing standardized nurse aide documentation and feedback reports Adv Skin Wound Care. 2010;23(3):120-131. 11. Sendelbach S, Zink M, Peterson J. Decreasing pressure ulcers across a healthcare system: Moving beneath the tip of the iceberg. J Nurs. Adm. 2011;41(2):84-89. 12. Zaratkiewicz S, Whitney JD, Lowe JR, Taylor S, O’Donnell F, Minton-Foltz P. Development and implementation of a hospital-acquired pressure ulcer incidence tracking system and algorithm J Healthc Qual. 2010;32(6):44-51. 13. Campbell KE, Woodbury MG, Houghton PE. Implementation of best practice in the prevention of heel pressure ulcers in the acute orthopedic population. Int Wound J. 2010;7(1):28-40 14. Lyman V. Successful heel pressure ulcer prevention program in a long-term care setting. J Wound Ostomy Continence Nurs. 2009;36(6):616-621. 15. Crumbley DR, Kane MA. Development of an evidence-based pressure ulcer program at the national naval medical center: Nurses’ role in risk factor assessment, prevention, and intervention among young service members returning from OIF/OEF Nurs Clin North Am. 2010;45(2):153-168.

18. Blankenship JS, Denby AS. Empowering UAP to champion pressure ulcer prevention Nursing. 2010;40(8):12-13. 19. Bergquist-Beringer S, Davidson J, Agosto C, et al. Evaluation of the national database of nursing quality indicators (NDNQI) training program on pressure ulcers J Contin Educ Nurs. 2009;40(6):252-8. 20. Magnan MA, Maklebust J. Braden scale risk assessments and pressure ulcer prevention planning: What’s the connection? J Wound Ostomy Continence Nurs. 2009;36(6):622-634. 21. Bales I, Padwojski A. Reaching for the moon: Achieving zero pressure ulcer prevalence J Wound Care. 2009;18(4):137-144. 22. Jankowski IM, Nadzam DM. Identifying gaps, barriers, and solutions in implementing pressure ulcer prevention programs Jt Comm J Qual Patient Saf. 2011;37(6):253-264. 23. National Pressure Ulcer Advisory Panel (NPUAP). Not all pressure ulcers are avoidable. http://npuap. org/A_UA%20Press%20Release.pdf. Accessed 7/13/2011. 24. Shannon RJ, Coombs M, Chakravarthy D. Reducing hospital-acquired pressure ulcers with a silicone-based dermal nourishing emollient-associated skincare regimen. Adv Skin Wound Care. 2009;22(10):461-467.

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new Study Identifies Four Subtypes of breast cancer May help guide future treatment strategies

78 The OR Connection

The researchers hope these discoveries will be a crucial step toward improving breast cancer therapies.

Each year about 1.3 million new cases of breast cancer arise worldwide, contributing to about 450,000 deaths, according to the World Health Organization. It’s the most common cancer among women. Men can also develop breast cancer but account for a small fraction of cases. The majority of breast cancers are sporadic, meaning there is no family history of the disease. However, many genes can predispose a person to breast cancer. A careful analysis of genomic data showed that there are four primary subtypes of breast cancer, each with its own biology and survival outlook. one subtype shares many genetic features with high-grade serous ovarian cancer. the findings may help guide future treatment strategies. each subtype has its own biology and survival outlook. the four subtypes are called: • HER2-enriched (HER2E) • Luminal A (LumA) • Luminal B (LumB) • Basal-like

the scientists found that the basal-like subtype shares many genetic features with high-grade serous ovarian cancer, suggesting that the two cancers are of similar molecular origin. Serous ovarian cancer has proven difficult to treat.

“ The molecular similarity of one of the principal subtypes of breast cancer to that found in ovarian cancer gives us additional leverage to compare treatments and outcomes across these two cancers.”

the broad scale of this study will lead to a deeper understanding of the changes essential for cancer progression. the researchers hope these discoveries will be a crucial step toward improving breast cancer therapies. For the new study, researchers performed a comprehensive genomic characterization of samples from 825 breast cancer patients. the study was a collaborative effort funded by the national Institute of Health’s national cancer Institute (ncI) and national Human Genome research Institute (nHGrI).

NCI Director Dr. Harold Varmus Source: National Institutes of Health

Aligning practice with policy to improve patient care 79

80 The ORâ&#x20AC;&#x2C6;Connection

Pink Glove Dance

Competition VIDEO

Lexington Medical Center wins with 15,000+ votes

2012! Tens of thousands of doctors, nurses, firefighters,

cheerleaders and even entire towns joined forces to produce videos for the 2012 Pink Glove Dance Video Competition, which featured dancing hospital CEOs, bopping nuns, and octogenarians popping wheelies in their wheelchairs, all for a good cause.

First Place

Lexington Medical Center, West Columbia, SC Medline will donate $10,000 to Lexington Medical Centerâ&#x20AC;&#x2122;s breast cancer charity of choice, the Vera Bradley foundation for Breast Cancer.

Aligning practice with policy to improve patient care 81

Medline Product Manager Emily Somers (second from right) and Medline Chief Marketing Officer Sue MacInnes (far right) present a check for $10,000 to Catherine Hill, Executive Director of the Vera Bradley Foundation for Breast Cancer (second from left). Also pictured, Lexington Medical Center CEO Michael Biediger (far left).

With more than 200,000 votes cast in the competition, Lexington Medical Center in West Columbia, S.C., won first place with almost 15,000 votes. This marks the second consecutive year Lexington Medical Center won the competition. Their creative video focused on a young nurse’s battle, and ultimate victory, over breast cancer, including her first time skydiving, as well as more than 700 hospital staff and a number of breast cancer survivors, all dancing in pink gloves to Katy Perry’s hit song “Part of Me.” Second place was captured by Penn State Milton S. Hershey Medical Center in Hershey, Pa., with more than 8,000 votes. Penn State Hershey’s entry features more than 600 faculty, staff, patients, survivors and the Nittany Lion, all donning pink gloves and dancing to Katy Perry’s song “Part of Me” in support of breast cancer awareness and prevention. The video was produced completely by in-house hospital staff. “We had fun making the video, especially knowing it was for a good cause and that many of the participants have been touched by breast cancer in some way,” said Kathleen

82 The OR Connection

Law, RN, director of nursing, perioperative services. “We’re excited that our efforts brought awareness to the important issue of breast cancer and will support the good work of the Pennsylvania Breast Cancer Coalition.” The Carle foundation in Urbana, Ill., took home third place honors with more than 6,000 votes. Carle’s video features more than 600 medical center staff, 50 departments and 12 breast cancer survivors, all dancing in pink gloves to Katy Perry’s hit song “Part of Me” in an effort to show that no one is alone in the fight against breast cancer. Employees with Carle at the fairchild and Vermilion sites in Danville were involved, as well. The video was developed, coordinated and filmed in part by in-house hospital staff, with additional production from Shatterglass Studios. “We appreciate the opportunity to raise awareness and funds for breast cancer research in our community, and are thrilled to have placed in this national competition,” said James C. Leonard, MD, president and CEO of The Carle foundation.

Carle received almost 6,000 votes out of more than 200,000 votes cast during the three-week competition. To date, there have been more 17,000 views for Carle’s video. “Congratulations to the winners, and to all of the competing organizations, for honoring the hundreds of thousands of men and women who are diagnosed each year with breast cancer,” said Andy Mills, president of Medline. “The passion and energy displayed by the thousands of participants is infectious and inspiring. They are all helping to make Medline’s Pink Glove Dance a ‘movement’ in every sense of the word.” In all, more than 60,000 people from hospitals, nursing homes, schools and other organizations in 42 U.S. states, Puerto Rico and Canada participated in the three-week competition. Sponsored by Medline — the world’s leading manufacturer of exam gloves — the national competition quickly became a national social media phenomenon with more than 3.2 million views, 200,000 votes and thousands of tweets, blogs and texts.

Second Place Penn State Milton S. Hershey Medical Center, Hershey, PA

With the win, comes a $5,000 check from Medline, made payable to the Pennsylvania Breast Cancer Coalition.

Third Place The Carle Foundation, Urbana, IL

for placing third in the competition, Medline will contribute $2,000 to Carleâ&#x20AC;&#x2122;s breast cancer research charity of choice, the local office of the American Cancer Society in Champaign.

All of the Pink Glove Dance videos are available for viewing at Aligning practice with policy to improve patient care 83


the WinteR


by Wolf J. Rinke, PhD, RD, CSP

According to data reported in the Wall Street Journal, one in four American adults who visits a primary-care physician suffers from a mental health problem.1 And I suspect that those findings may be even worse in the winter. So here is what you can do to beat the winter blues, and hopefully avoid more serious mental health issues.

84 The OR Connection

Aligning practice with policy to improve patient care 85

1. Commit Random Acts of kindness to do this right, you must do something for someone else without expecting anything in return. According to professor Marti Seligman, known to many as the father of the positive psychology Movement, and author of Flourish: “We scientists have found that doing a kindness produces the single most reliable momentary increase in well-being of any exercise we have tested.” For example, get the family together and serve a meal at a shelter for the homeless, or visit your local nursing home and talk with an elderly person in need of companionship. According to Jonathan Haidt, ph.D., assistant professor of psychology at the university of Virginia, when you do a good deed, you are helping not just the recipient, you are helping everybody. Haidt’s research demonstrates that people witnessing others performing good deeds also benefit. they experience an emotion called “elevation,” which is triggered if you see someone help

86 The OR Connection

others, show gratitude, behave honorably or act heroically. “elevation makes people more open and loving toward others; it makes them feel better about humanity.”

you do while sitting on the throne? on second thought, let’s not go there. (I’m hoping that you are smiling.) Here is what I do that enables me to start every day with an attitude of gratitude.

2. Start Each Day with an Attitude of Gratitude no matter how badly things may be going for you, focus on what you have left, not what you have lost. (According to Seligman’s research this is the second most powerful thing you can do to improve your mental health.) one way to do this is to draw a line down the middle of a piece of paper. Label the left column “What’s gone,” and the right “What’s left.” Fill in both columns. even though things may be tough, you will typically find much you can be thankful for. now use your mental energy to develop an attitude of gratitude by focusing on all you have left. I start this process every morning shortly after I get up while I sit on the “throne.” Let me ask you what do

• First, I’m thankful that I’m married to Marcela my Superwoman. I’m often asked why I call her my Superwoman. one reason is that she is responsible for 85% of my success. Without her I would never have gotten to where I am today. You see, she was born with a positive gene and helped me transform myself from an eternal pessimist to an eternal optimist. plus she has always loved me unconditionally, and she is a cpA, and my business partner who keeps me straight financially. • Typically the second thing I’m thankful for is the privilege of being a father to two wonderful daughters and the grandfather to Kylie age 5 (going on 9) and Aliana, age 2.

• Thirdly I’m grateful for the privilege of being able to impact you in a positive way. (You are reading this, aren’t you?) After all, there is nothing more gratifying than being in the business of helping other people, but you probably know that already— that’s why you do what you do. After getting your day started with an attitude of gratitude, you are going to face many negatives, starting with the news, which tells you all the things that are wrong in the world. the media’s operating slogan is “if it bleeds it leads.” the problem with this is that we are repeatedly exposed to this negative stuff, and we begin to believe that’s the way life is, forgetting that whatever gets reported in the media represents the exception. otherwise it wouldn’t even be in the media. So do what I do. For the paper, electronic or hard-copy, skim the headlines—you can’t be out of touch. read only those parts that are of specific interest to you. Skim the rest. For tV, avoid watching the local news, except perhaps the weather. Have you ever really listened to the local news? over 85 percent has to do with bad stuff— shootings, killings, beatings, fires etc. So turn off the local news. Instead do what Superwoman and I do. tape the national news—that way you don’t have to watch the commercials—and then watch it at a convenient time sometime in the evening, but not right before going to bed! to avoid programming your mind with negative stuff, watch a couple minutes of something light.

3. Master the PIN Technique the pIn technique is a powerful way to reframe your perceptions and turn negatives into positives. Here is how it works. When you are confronted with anyone or anything that would cause you to react negatively, pIn it. For example, your daughter brings home a new boyfriend with rings in all the wrong places. or your team member says: “boss, you know how morale has gone down the tube, let’s close up shop and go on a cruise for a week.” Instead of nIping “weird” ideas, focus your mental energy first on: P—the positive. Ask yourself what’s positive about your daughter’s boyfriend—for example, he may be courteous, or at least she has a boyfriend. After you’ve done that in your mind’s eye, evaluate the:

I—the interesting or innovative. Ask what could be interesting or innovative about closing the office for a week and going on a cruise, such as “She seems interested in helping making things better.” And once you’ve evaluated that, and only after you’ve exhausted all the p’s and I’s, then ask yourself, what is the down side, the: N—the negative. because in life nothing ever goes one way, there is Ying and Yang, health and sickness, life and death, high real estate market and low real estate market, strong economy and weak economy...and if you want to beat blues then you must evaluate both the upside and downside of everything. However, if you nIp ideas in the bud, it’s like closing the proverbial shade which prevents you from seeing all the positive stuff that is all around you.

Aligning practice with policy to improve patient care 87

When someone asks you

4. Take Advantage of Every “Moment of Truth” When people meet for the first time they typically greet you with, “How are you?” Let me ask you, do they really want to know? of course not! It’s just a figure of speech. In fact, 97% of the people you meet don’t care how you’re doing, and the other 3% are just glad that you are worse off than they are. However, how you respond to that rhetorical question will determine your attitude, because your response will program your subconscious. And your subconscious can’t tell right from wrong. It’s like working on your word processor with the spell checker turned off. It doesn’t ever say: “Hey, what’s that word? I’ve never seen that before.” Instead, it accepts everything as if it were reality. And your subconscious works just like that. It simply can’t tell right from wrong, fiction from fact or reality from imagination. to take advantage of this phenomenon you want to get in the habit of programming your subconscious with positive messages so it can work for you, instead of against you. Here is how: When someone asks you how you’re doing, consider that your moment of truth and answer with what I refer to as a minimum response. It’s a five-letter word that starts with a G and ends with a t. What’s the word?

88 The OR Connection

how you’re doing, consider that your moment of truth and answer with what i refer to as a minimum response. it’s a five-letter word that starts with a G and ends with a t. What’s the word? the word is GRRREAT!

the word is GrrreAt! the trick is you’ve got to say it as if you really mean it, even if you don’t quite feel that way. At this point you might be saying: “What if I don’t feel great; but I say I’m great? that is telling a lie, or at least a fib.” no you’re not. You’re just telling the truth in advance. If you don’t feel great, and you respond over and over again with GrrreAt, your subconscious says, “Hey what do I know, maybe she is doing great!” And before you know it, your subconscious has created a more positive reality for you. by the way, this is such a powerful technique that it single handedly can beat the winter blues in your family or organization forever. You see, this positive stuff is contagious, and spreads like a “virus.” except this virus, according to research conducted by Seligman, cranks up your immune system and has the potential to keep you, and everyone around you, healthy. It can even help you heal faster and live longer. © 2012 Wolf J. rinke reference 1. How Doctors try to Spot Depression. Wall Street Journal. December 7, 2010. Available at: 703471904576003520708615998.html. Accessed october 18, 2012.

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BIG MED continued from page 22 It’s trying to create what some have called the Southwest Airlines of health care—a network of highquality hospitals that would appeal to a more cost-conscious public. Steward’s aggressive growth has made local doctors like me nervous. But many health systems, forprofit and not-for-profit, share its goal: large-scale, production-line medicine. The way medical care is organized is changing—because the way we pay for it is changing. Historically, doctors have been paid for services, not results. In the eighteenth century B.C., Hammurabi’s code instructed that a surgeon be paid ten shekels of silver every time he performed a procedure for a patrician—opening an abscess or treating a cataract with his bronze lancet. It also instructed that if the patient should die or lose an eye, the surgeon’s hands be cut off. Apparently, the Mesopotamian surgeons’ lobby got this results clause dropped. Since then, we’ve generally been paid for what we do, whatever happens. The consequence is the system we have, with plenty of individual transactions—procedures, tests, specialist consultations—and uncertain attention to how the patient ultimately fares. Health-care reforms—public and private—have sought to reshape that system. This year, my employer’s new contracts with Medicare, BlueCross BlueShield, and others

90 The OR Connection

link financial reward to clinical performance. The more the hospital exceeds its cost-reduction and quality-improvement targets, the more money it can keep. If it misses the targets, it will lose tens of millions of dollars. This is a radical shift. Until now, hospitals and medical groups have mainly had a landlord-tenant relationship with doctors. They offered us space and facilities, but what we tenants did behind closed doors was our business. Now it’s their business, too. The theory the country is about to test is that chains will make us better and more efficient. The question is how. To most of us who work in health care, throwing a bunch of administrators and accountants into the mix seems unlikely to help. Good medicine can’t be reduced to a recipe. Then again neither can good food: every dish involves attention to detail and individual adjustments that require human judgment. Yet, some chains manage to achieve good, consistent results thousands of times a day across the entire country. I decided to get inside one and find out how they did it. Dave Luz is the regional manager for the eight Cheesecake factories in the Boston area. He oversees operations that bring in eighty million dollars in yearly revenue, about as much as a medium-sized hospital. Luz (rhymes with “fuzz”) is forty-

seven, and had started out in his twenties waiting tables at a Cheesecake factory restaurant in Los Angeles. He was writing screenplays, but couldn’t make a living at it. When he and his wife hit thirty and had their second child, they came back east to Boston to be closer to family. He decided to stick with the Cheesecake factory. Luz rose steadily, and made a nice living. “I wanted to have some business skills,” he said—he started a film-production company on the side—“and there was no other place I knew where you could go in, know nothing, and learn top to bottom how to run a business.” To show me how a Cheesecake factory works, he took me into the kitchen of his busiest restaurant, at Prudential Center, a shopping and convention hub. The kitchen design is the same in every restaurant, he explained. It’s laid out like a manufacturing facility, in which raw materials in the back of the plant come together as a finished product that rolls out the front. Along the back wall are the walkin refrigerators and prep stations, where half a dozen people stood chopping and stirring and mixing. The next zone is where the cooking gets done—two parallel lines of countertop, forty-some feet long and just three shoe-lengths apart, with fifteen people pivoting in place between the stovetops and grills on the hot side and the neatly laid-out bins of fixings (sauces, garnishes, seasonings, and the like) on

the cold side. The prep staff stock the pullout drawers beneath the counters with slabs of marinated meat and fish, serving-size baggies of pasta and crabmeat, steaming bowls of brown rice and mashed potatoes. Basically, the prep crew handles the parts, and the cooks do the assembly. Computer monitors positioned head-high every few feet flashed the orders for a given station. Luz showed me the touch-screen tabs for the recipe for each order and a photo showing the proper presentation. The recipe has the ingredients on the left part of the screen and the steps on the right. A timer counts down to a target time for completion. The background turns from green to yellow as the order nears the target time and to red when it has exceeded it. I watched Mauricio Gaviria at the broiler station as the lunch crowd began coming in. Mauricio was twenty-nine years old and had worked there eight years. He’d got his start doing simple prep—chopping vegetables—and worked his way up to fry cook, the pasta station, and now the sauté and broiler stations. He bounced in place waiting for the pace to pick up. An order for a “hibachi” steak popped up. He tapped the screen to open the order: medium-rare, no special requests. A ten-minute timer began. He tonged a fat hanger steak soaking in teriyaki sauce onto the broiler and started a nest of sliced

onions cooking beside it. While the meat was grilling, other orders arrived: a Kobe burger, a blue-cheese B.L.T. burger, three “old-fashioned” burgers, five veggie burgers, a “farmhouse” burger, and two Thai chicken wraps. Tap, tap, tap. He got each of them grilling. I brought up the hibachi-steak recipe on the screen. There were instructions to season the steak, sauté the onions, grill some mushrooms, slice the meat, place it on the bed of onions, pile the mushrooms on top, garnish with parsley and sesame seeds, heap a stack of asparagus tempura next to it, shape a tower of mashed potatoes alongside, drop a pat of wasabi butter on top, and serve. Two things struck me. First, the instructions were precise about the ingredients and the objectives (the steak slices were to be a quarter of an inch thick, the presentation just so), but not about how to get there. The cook has to decide how much to salt and baste, how to sequence the onions and mushrooms and meat so they’re done at the same time, how to swivel from grill to countertop and back, sprinkling a pinch of salt here, flipping a burger there, sending word to the fry cook for the asparagus tempura, all the while keeping an eye on the steak. In producing complicated food, there might be recipes, but there was also a substantial amount of what’s called “tacit knowledge”—knowledge that has not been reduced to instructions.

Second, Mauricio never looked at the instructions anyway. By the time I’d finished reading the steak recipe, he was done with the dish and had plated half a dozen others. “Do you use this recipe screen?” I asked. “No. I have the recipes right here,” he said, pointing to his baseballcapped head. He put the steak dish under warming lights, and tapped the screen to signal the servers for pickup. But before the dish was taken away, the kitchen manager stopped to look, and the system started to become clearer. He pulled a clean fork out and poked at the steak. Then he called to Mauricio and the two other cooks manning the grill station. “Gentlemen,” he said, “this steak is perfect.” It was juicy and pink in the center, he said. “The grill marks are excellent.” The sesame seeds and garnish were ample without being excessive. “But the tower is too tight.” I could see what he meant. The mashed potatoes looked a bit like something a kid at the beach might have molded with a bucket. You don’t want the food to look manufactured, he explained. Mauricio fluffed up the potatoes with a fork. I watched the kitchen manager for a while. At every Cheesecake factory restaurant, a kitchen manager is stationed at the counter where

Aligning practice with policy to improve patient care 91

BIG MED the food comes off the line, and he rates the food on a scale of one to ten. A nine is near-perfect. An eight requires one or two corrections before going out to a guest. A seven needs three. A six is unacceptable and has to be redone. This inspection process seemed a tricky task. No one likes to be second-guessed. The kitchen manager prodded gently, being careful to praise as often as he corrected. (“Beautiful. Beautiful!” “The pattern of this pesto glaze is just right.”) But he didn’t hesitate to correct. “We’re getting sloppy with the plating,” he told the pasta station. He was unhappy with how the fry cooks were slicing the avocado spring rolls. “Gentlemen, a halfinch border on this next time.” He tried to be a coach more than a policeman. “Is this three-quarters of an ounce of Parm-Romano?” And that seemed to be the spirit in which the line cooks took him and the other managers. The managers had all risen through the ranks. This earned them a certain amount of respect. They in turn seemed respectful of the cooks’ skills and experience. Still, the oversight is tight, and this seemed crucial to the success of the enterprise. The managers monitored the pace, too—scanning the screens for a station stacking up red flags, indicating orders past the target time, and deciding whether to give the cooks at the station a nudge or an extra

92 The OR Connection

pair of hands. They watched for waste—wasted food, wasted time, wasted effort. The formula was Business 101: Use the right amount of goods and labor to deliver what customers want and no more. Anything more is waste, and waste is lost profit. I spoke to David Gordon, the company’s chief operating officer. He told me that the Cheesecake Factory has worked out a staff-tocustomer ratio that keeps everyone busy but not so busy that there’s no slack in the system in the event of a sudden surge of customers. More difficult is the problem of wasted food. Although the company buys in bulk from regional suppliers, groceries are the biggest expense after labor, and the most unpredictable. Everything—the chicken, the beef, the lettuce, the eggs, and all the rest—has a shelf life. If a restaurant were to stock too much, it could end up throwing away hundreds of thousands of dollars’ worth of food. If a restaurant stocks too little, it will have to tell customers that their favorite dish is not available, and they may never come back. Groceries, Gordon said, can kill a restaurant. The company’s target last year was at least 97.5-per-cent efficiency: the managers aimed at throwing away no more than 2.5 per cent of the groceries they bought, without running out. This seemed to me an absurd target. Achieving it would require knowing in advance almost

exactly how many customers would be coming in and what they were going to want, then insuring that the cooks didn’t spill or toss or waste anything. Yet this is precisely what the organization has learned to do. The chain-restaurant industry has produced a field of computer analytics known as “guest forecasting.” “We have forecasting models based on historical data—the trend of the past six weeks and also the trend of the previous year,” Gordon told me. “The predictability of the business has become astounding.” The company has even learned how to make adjustments for the weather or for scheduled events like playoff games that keep people at home. A computer program known as Net Chef showed Luz that for this one restaurant food costs accounted for 28.73 per cent of expenses the previous week. It also showed exactly how many chicken breasts were ordered that week ($1,614 worth), the volume sold, the volume on hand, and how much of last week’s order had been wasted (three dollars’ worth). Chain production requires control, and they’d figured out how to achieve it on a mass scale. As a doctor, I found such control alien—possibly from a hostile planet. We don’t have patient forecasting in my office, push-button waste monitoring, or such stringent, hour-by-hour oversight of the

work we do, and we don’t want to. I asked Luz if he had ever thought about the contrast when he went to see a doctor. We were standing amid the bustle of the kitchen, and the look on his face shifted before he answered. “I have,” he said. His mother was seventy-eight. She had early Alzheimer’s disease, and required a caretaker at home. Getting her adequate medical care was, he said, a constant battle. Recently, she’d had a fall, apparently after fainting, and was taken to a local emergency room. The doctors ordered a series of tests and scans, and kept her overnight. They never figured out what the problem was. Luz understood that sometimes explanations prove elusive. But the clinicians didn’t seem to be following any coördinated plan of action. The emergency doctor told the family one plan, the admitting internist described another, and the consulting specialist a third. Thousands of dollars had been spent on tests, but nobody ever told Luz the results. A nurse came at ten the next morning and said that his mother was being discharged. But his mother’s nurse was on break, and the discharge paperwork with her instructions and prescriptions hadn’t been done. So they waited. Then the next person they needed was at lunch. It was as if the clinicians were the customers, and the

patients’ job was to serve them. “We didn’t get to go until 6 P.M., with a tired, disabled lady and a long drive home.” Even then she still had to be changed out of her hospital gown and dressed. Luz pressed the call button to ask for help. No answer. He went out to the ward desk. The aide was on break, the secretary said. “Don’t you dress her yourself at home?” He explained that he didn’t, and made a fuss. An aide was sent. She was short with him and rough in changing his mother’s clothes. “She was manhandling her,” Luz said. “I felt like, ‘Stop. I’m not one to complain. I respect what you do enormously. But if there were a video camera in here, you’d be on the evening news.’ I sent her out. I had to do everything myself. I’m stuffing my mom’s boob in her bra. It was unbelievable.” His mother was given instructions to check with her doctor for the results of cultures taken during her stay, for a possible urinary-tract infection. But when Luz tried to follow up, he couldn’t get through to her doctor for days. “Doctors are busy,” he said. “I get it. But come on.” An office assistant finally told him that the results wouldn’t be ready for another week and that she was to see a neurologist. No explanations. No chance to ask questions. The neurologist, after giving her a two-minute exam, suggested

tests that had already been done and wrote a prescription that he admitted was of doubtful benefit. Luz’s family seemed to encounter this kind of disorganization, imprecision, and waste wherever his mother went for help. “It is unbelievable to me that they would not manage this better,” Luz said. I asked him what he would do if he were the manager of a neurology unit or a cardiology clinic. “I don’t know anything about medicine,” he said. But when I pressed he thought for a moment, and said, “This is pretty obvious. I’m sure you already do it. But I’d study what the best people are doing, figure out how to standardize it, and then bring it to everyone to execute.” This is not at all the normal way of doing things in medicine. (“You’re scaring me,” he said, when I told him.) But it’s exactly what the new health-care chains are now hoping to do on a mass scale. They want to create Cheesecake factories for health care. The question is whether the medical counterparts to Mauricio at the broiler station —the clinicians in the operating rooms, in the medical offices, in the intensive-care units—will go along with the plan. fixing a nice piece of steak is hardly of the same complexity as diagnosing the cause of an elderly patient’s loss of consciousness. Doctors and patients have not had a positive experience with outsiders second-guessing

Aligning practice with policy to improve patient care 93

BIG MED decisions. How will they feel about managers trying to tell them what the “best practices” are? In March, my mother underwent a total knee replacement, like at least six hundred thousand Americans each year. She’d had a partial knee replacement a decade ago, when arthritis had worn away part of the cartilage, and for a while this served her beautifully. The surgeon warned, however, that the results would be temporary, and about five years ago the pain returned. She’s originally from Ahmadabad, India, and has spent three decades as a pediatrician, attending to the children of my small Ohio home town. She’s chatty. She can’t go through a grocery checkout line or get pulled over for speeding without learning people’s names and a little bit about them. But she didn’t talk about her mounting pain. I noticed, however, that she had developed a pronounced limp and had become unable to walk even moderate distances. When I asked her about it, she admitted that just getting out of bed in the morning was an ordeal. Her doctor showed me her X-rays. Her partial prosthesis had worn through the bone on the lower surface of her knee. It was time for a total knee replacement. This past winter, she finally stopped putting it off, and asked me to find her a surgeon. I wanted her to be treated well, in both the technical and the human sense. I

94 The OR Connection

wanted a place where everyone and everything—from the clinic secretary to the physical therapists— worked together seamlessly. My mother planned to come to Boston, where I live, for the surgery so she could stay with me during her recovery. (My father died last year.) Boston has three hospitals in the top rank of orthopedic surgery. But even a doctor doesn’t have much to go on when it comes to making a choice. A place may have a great reputation, but it’s hard to know about actual quality of care. Unlike some countries, the United States doesn’t have a monitoring system that tracks joint-replacement statistics. Even within an institution, I found, surgeons take strikingly different approaches. They use different makes of artificial joints, different kinds of anesthesia, different regimens for post-surgical pain control and physical therapy. In the absence of information, I went with my own hospital, the Brigham and Women’s Hospital. Our big-name orthopedic surgeons treat Olympians and professional athletes. Nine of them do knee replacements. Of most interest to me, however, was a surgeon who was not one of the famous names. He has no national recognition. But he has led what is now a decade-long experiment in standardizing jointreplacement surgery. John Wright is a New Zealander in his late fifties. He’s a tower crane

of a man, six feet four inches tall, and so bald he barely seems to have eyebrows. He’s informal in attire—I don’t think I’ve ever seen him in a tie, and he is as apt to do rounds in his zip-up anorak as in his white coat—but he exudes competence. “Customization should be five per cent, not ninety-five per cent, of what we do,” he told me. A few years ago, he gathered a group of people from every specialty involved—surgery, anesthesia, nursing, physical therapy—to formulate a single default way of doing knee replacements. They examined every detail, arguing their way through their past experiences and whatever evidence they could find. Essentially, they did what Luz considered the obvious thing to do: they studied what the best people were doing, figured out how to standardize it, and then tried to get everyone to follow suit. They came up with a plan for anesthesia based on research studies—including giving certain pain medications before the patient entered the operating room and using spinal anesthesia plus an injection of local anesthetic to block the main nerve to the knee. They settled on a postoperative regimen, too. The day after a knee replacement, most orthopedic surgeons have their patients use a continuous passive-motion machine, which flexes and extends the knee as they lie in bed. Large-scale stud-

ies, though, have suggested that the machines don’t do much good. Sure enough, when the members of Wright’s group examined their own patients, they found that the ones without the machine got out of bed sooner after surgery, used less pain medication, and had more range of motion at discharge. So Wright instructed the hospital to get rid of the machines, and to use the money this saved (ninety thousand dollars a year) to pay for more physical therapy, something that is proven to help patient mobility. Therapy, starting the day after surgery, would increase from once to twice a day, including weekends. Even more startling, Wright had persuaded the surgeons to accept changes in the operation itself; there was now, for instance, a limit as to which prostheses they could use. Each of our nine knee-replacement surgeons had his preferred type and brand. Knee surgeons are as particular about their implants as professional tennis players are about their racquets. But the hardware is easily the biggest cost of the operation—the average retail price is around eight thousand dollars, and some cost twice that, with no solid evidence of real differences in results. Knee implants were largely perfected a quarter century ago. By the nineteen-nineties, studies showed that, for some ninety-five per cent of patients, the implants worked magnificently a decade after surgery. Evidence from the Australian

registry has shown that not a single new knee or hip prosthesis had a lower failure rate than that of the established prostheses. Indeed, thirty per cent of the new models were likelier to fail. Like others on staff, Wright has advised companies on implant design. He believes that innovation will lead to better implants. In the meantime, however, he has sought to limit the staff to the three lowest-cost knee implants. These have been hard changes for many people to accept. Wright has tried to figure out how to persuade clinicians to follow the standardized plan. To prevent revolt, he learned, he had to let them deviate at times from the default option. Surgeons could still order a passive-motion machine or a preferred prosthesis. “But I didn’t make it easy,” Wright said. The surgeons had to enter the treatment orders in the computer themselves. To change or add an implant, a surgeon had to show that the performance was superior or the price at least as low. I asked one of his orthopedic colleagues, a surgeon named John Ready, what he thought about Wright’s efforts. Ready was philosophical. He recognized that the changes were improvements, and liked most of them. But he wasn’t happy when Wright told him that his knee-implant manufacturer wasn’t matching the others’ prices and would have to be dropped.

“It’s not ideal to lose my prosthesis,” Ready said. “I could make the switch. The differences between manufacturers are minor. But there’d be a learning curve.” Each implant has its quirks—how you seat it, what tools you use. “It’s probably a ten-case learning curve for me.” Wright suggested that he explain the situation to the manufacturer’s sales rep. “I’m my rep’s livelihood,” Ready said. “He probably makes five hundred dollars a case from me.” Ready spoke to his rep. The price was dropped. Wright has become the hospital’s kitchen manager—not always a pleasant role. He told me that about half of the surgeons appreciate what he’s doing. The other half tolerate it at best. One or two have been outright hostile. But he has persevered, because he’s gratified by the results. The surgeons now use a single manufacturer for seventy-five per cent of their implants, giving the hospital bargaining power that has helped slash its knee-implant costs by half. And the start-to-finish standardization has led to vastly better outcomes. The distance patients can walk two days after surgery has increased from fifty-three to eighty-five feet. Nine out of ten could stand, walk, and climb at least a few stairs independently by the time of discharge. The amount of narcotic pain medications they required fell by a third. They could also leave the hospital nearly a full day earlier on average

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BIG MED (which saved some two thousand dollars per patient). My mother was one of the beneficiaries. She had insisted to Dr. Wright that she would need a week in the hospital after the operation and three weeks in a rehabilitation center. That was what she’d required for her previous knee operation, and this one was more extensive. “We’ll see,” he told her. The morning after her operation, he came in and told her that he wanted her getting out of bed, standing up, and doing a specific set of exercises he showed her. “He’s pushy, if you want to say it that way,” she told me. The physical therapists and nurses were, too. They were a team, and that was no small matter. I counted sixty-three different people involved in her care. Nineteen were doctors, including the surgeon and chief resident who assisted him, the anesthesiologists, the radiologists who reviewed her imaging scans, and the junior residents who examined her twice a day and adjusted her fluids and medications. Twenty-three were nurses, including her operating-room nurses, her recovery-room nurse, and the many ward nurses on their eight-to-twelve-hour shifts. There were also at least five physical therapists; sixteen patient-care assistants, helping check her vital signs, bathe her, and get her to the

96 The OR Connection

bathroom; plus X-ray and EKG technologists, transport workers, nurse practitioners, and physician assistants. I didn’t even count the bioengineers who serviced the equipment used, the pharmacists who dispensed her medications, or the kitchen staff preparing her food while taking into account her dietary limitations. They all had to coördinate their contributions, and they did. Three days after her operation, she was getting in and out of bed on her own. She was on virtually no narcotic medication. She was starting to climb stairs. Her knee pain was actually less than before her operation. She left the hospital for the rehabilitation center that afternoon. The biggest complaint that people have about health care is that no one ever takes responsibility for the total experience of care, for the costs, and for the results. My mother experienced what happens in medicine when someone takes charge. Of course, John Wright isn’t alone in trying to design and implement this kind of systematic care, in joint surgery and beyond. The Virginia Mason Medical Center, in Seattle, has done it for knee surgery and cancer care; the Geisinger Health Center, in Pennsylvania, has done it for cardiac surgery and primary care; the University of Michigan Health System standardized how its doctors give blood transfusions to patients, reducing

the need for transfusions by thirtyone per cent and expenses by two hundred thousand dollars a month. Yet, unless such programs are ramped up on a nationwide scale, they aren’t going to do much to improve health care for most people or reduce the explosive growth of health-care costs. In medicine, good ideas still take an appallingly long time to trickle down. Recently, the American Academy of Neurology and the American Headache Society released new guidelines for migraine-headache-treatment. They recommended treating severe migraine sufferers—who have more than six attacks a month— with preventive medications and listed several drugs that markedly reduce the occurrence of attacks. The authors noted, however, that previous guidelines going back more than a decade had recommended such remedies, and doctors were still not providing them to more than two-thirds of patients. One study examined how long it took several major discoveries, such as the finding that the use of beta-blockers after a heart attack improves survival, to reach even half of Americans. The answer was, on average, more than fifteen years. Scaling good ideas has been one of our deepest problems in medicine. Regulation has had its place, but it has proved no more likely to produce great medicine than food

inspectors are to produce great food. During the era of managed care, insurance-company reviewers did hardly any better. We’ve been stuck. But do we have to be? Every six months, the Cheesecake Factory puts out a new menu. This means that everyone who works in its restaurants expects to learn something new twice a year. The March, 2012, Cheesecake factory menu included thirteen new items. The teaching process is now finely honed: from start to finish, rollout takes just seven weeks. The ideas for a new dish, or for tweaking an old one, can come from anywhere. One of the Boston prep cooks told me about an idea he once had that ended up in a recipe. David Overton, the founder and C.E.O. of the Cheesecake factory, spends much of his time sampling a range of cuisines and comes up with many dishes himself. All the ideas, however, go through half a dozen chefs in the company’s test kitchen, in Calabasas. They figure out how to make each recipe reproducible, appealing, and affordable. Then they teach the new recipe to the company’s regional managers and kitchen managers. Dave Luz, the Boston regional manager, went to California for training this past January with his chief kitchen manager, Tom Schmidt, a chef with fifteen years’ experience. They attended lectures, watched videos, participated in workshops. It sounded like a surgi-

cal conference. Where I might be taught a new surgical technique, they were taught the steps involved in preparing a “Santorini farro salad.” But there was a crucial difference. The Cheesecake instructors also trained the attendees how to teach what they were learning. In medicine, we hardly ever think about how to implement what we’ve learned. We learn what we want to, when we want to.

dishes would go live in two weeks. I asked a couple of the line cooks how long it took them to learn to make the new food. “I know it already,” one said.

On the first training day, the kitchen managers worked their way through thirteen stations, preparing each new dish, and their performances were evaluated. The following day, they had to teach their regional managers how to prepare each dish—Schmidt taught Luz—and this time the instructors assessed how well the kitchen managers had taught.

I asked Schmidt how much time he thought the cooks required to master the recipes. They thought a day, I told him. He grinned. “More like a month,” he said.

The managers returned home to replicate the training session for the general manager and the chief kitchen manager of every restaurant in their region. The training at the Boston Prudential Center restaurant took place on two mornings, before the lunch rush. The first day, the managers taught the kitchen staff the new menu items. There was a lot of poring over the recipes and videos and fussing over the details. The second day, the cooks made the new dishes for the servers. This gave the cooks some practice preparing the food at speed, while allowing the servers to learn the new menu items. The

“I make it two times, and that’s all I need,” the other said. Come on, I said. How long before they had it down pat? “One day,” they insisted. “It’s easy.”

Even a month would be enviable in medicine, where innovations commonly spread at a glacial pace. The new health-care chains, though, are betting that they can change that, in much the same way that other chains have. Armin Ernst is responsible for intensive-care-unit operations in Steward’s ten hospitals. The I.C.U.s he oversees serve some eight thousand patients a year. In another era, an I.C.U. manager would have been a facilities expert. He would have spent his time making sure that the equipment, electronics, pharmacy resources, and nurse staffing were up to snuff. He would have regarded the I.C.U. as the doctors’ workshop, and he would have wanted to give them the best possible conditions to do their work as they saw fit.

Aligning practice with policy to improve patient care 97

BIG MED Ernst, though, is a doctor—a new kind of doctor, whose goal is to help disseminate good ideas. He doesn’t see the I.C.U. as a doctors’ workshop. He sees it as the temporary home of the sickest, most fragile people in the country. Nowhere in health care do we expend more resources. Although fewer than one in four thousand Americans are in intensive care at any given time, they account for four per cent of national health-care costs. Ernst believes that his job is to make sure that everyone is collaborating to provide the most effective and least wasteful care possible. He looked like a regular doctor to me. Ernst is fifty years old, a native German who received his medical degree at the University of Heidelberg before training in pulmonary and critical-care medicine in the United States. He wears a white hospital coat and talks about drips and ventilator settings, like any other critical-care specialist. But he doesn’t deal with patients: he deals with the people who deal with patients. Ernst says he’s not telling clinicians what to do. Instead, he’s trying to get clinicians to agree on precise standards of care, and then make sure that they follow through on them. (The word “consensus” comes up a lot.) What I didn’t understand was how he could enforce such standards in ten hospitals across three thousand square miles.

98 The OR Connection

Late one Friday evening, I joined an intensive-care-unit team on night duty. But this team was nowhere near a hospital. We were in a drab one-story building behind a meat-trucking facility outside of Boston, in a back section that Ernst called his I.C.U. command center. It was outfitted with millions of dollars’ worth of technology. Banks of computer screens carried a live feed of cardiac-monitor readings, radiology-imaging scans, and laboratory results from I.C.U. patients throughout Steward’s hospitals. Software monitored the stream and produced yellow and red alerts when it detected patterns that raised concerns. Doctors and nurses manned consoles where they could toggle on high-definition video cameras that allowed them to zoom into any I.C.U. room and talk directly to the staff on the scene or to the patients themselves. The command center was just a few months old. The team had gone live in only four of the ten hospitals. But in the next several months Ernst’s “tele-I.C.U.” team will have the ability to monitor the care for every patient in every I.C.U. bed in the Steward health-care system. A doctor, two nurses, and an administrative assistant were on duty in the command center each night I visited. Christina Monti was one of the nurses. A pixie-like thirty-yearold with nine years’ experience as a cardiac intensive-care nurse, she

was covering Holy family Hospital, on the New Hampshire border, and St. Elizabeth’s Medical Center, in Boston’s Brighton neighborhood. When I sat down with her, she was making her rounds, virtually. first, she checked on the patients she had marked as most critical. She reviewed their most recent laboratory results, clinical notes, and medication changes in the electronic record. Then she made a “visit,” flicking on the two-way camera and audio system. If the patients were able to interact, she would say hello to them in their beds. She asked the staff members whether she could do anything for them. The tele-I.C.U. team provided the staff with extra eyes and ears when needed. If a crashing patient diverts the staff’s attention, the members of the remote team can keep an eye on the other patients. They can handle computer paperwork if a nurse falls behind; they can look up needed clinical information. The hospital staff have an OnStar-like button in every room that they can push to summon the tele-I.C.U. team. Monti also ran through a series of checks for each patient. She had a reference list of the standards that Ernst had negotiated with the people running the I.C.U.s, and she looked to see if they were being followed. The standards covered basics, from hand hygiene to measures for stomach-ulcer prevention. In every room with a

patient on a respirator, for instance, Monti made sure the nurse had propped the head of the bed up at least thirty degrees, which makes pneumonia less likely. She made sure the breathing tube in the patient’s mouth was secure, to reduce the risk of the tube’s falling out or becoming disconnected. She zoomed in on the medication pumps to check that the drips were dosed properly. She was not looking for bad nurses or bad doctors. She was looking for the kinds of misses that even excellent nurses and doctors can make under pressure. The concept of the remote I.C.U. started with an effort to let specialists in critical-care medicine, who are in short supply, cover not just one but several community hospitals. Two hundred and fifty hospitals from Alaska to Virginia have installed a version of the tele-I.C.U. It produced significant improvements in outcomes and costs—and, some discovered, a means of driving better practices even in hospitals that had specialists on hand. After five minutes of observation, however, I realized that the remote I.C.U. team wasn’t exactly in command; it was in negotiation. I observed Monti perform a video check on a middle-aged man who had just come out of heart surgery. A soft chime let the people in the room know she was dropping in. The man was

unconscious, supported by a respirator and intravenous drips. At his bedside was a nurse hanging a bag of fluid. She seemed to stiffen at the chime’s sound. “Hi,” Monti said to her. “I’m Chris. Just making my evening rounds. How are you?” The bedside nurse gave the screen only a sidelong glance. Ernst wasn’t oblivious of the issue. He had taken pains to introduce the command center’s team, spending weeks visiting the units and bringing doctors and nurses out to tour the tele-I.C.U. before a camera was ever turned on. But there was no escaping the fact that these were strangers peering over the staff’s shoulders. The bedside nurse’s chilliness wasn’t hard to understand.

she figured out that a doctor had already ordered a potassium infusion for the woman with the low level. flipping on a camera, she saw that the patient with the high heart rate was just experiencing the stress of being helped out of bed for the first time after surgery. But the unsecured breathing tube and the forgotten blood-clot medication proved to be oversights. Monti raised the concerns with the bedside staff.

In a single hour, however, Monti had caught a number of problems. She noticed, for example, that a patient’s breathing tube had come loose. Another patient wasn’t getting recommended medication to prevent potentially fatal blood clots. Red alerts flashed on the screen—a patient with an abnormal potassium level that could cause heart-rhythm problems, another with a sudden leap in heart rate.

Sometimes they resist. “You have got to be careful from patient to patient,” Gerard Hayes, the tele-I.C.U. doctor on duty, explained. “Pushing hard on one has ramifications for how it goes with a lot of patients. You don’t want to sour whole teams on the tele-I.C.U.” Across the country, several hospitals have decommissioned their systems. Clinicians have been known to place a gown over the camera, or even rip the camera out of the wall. Remote monitoring will never be the same as being at the bedside. One nurse called the command center to ask the team not to turn on the video system in her patient’s room: he was delirious and confused, and the sudden appearance of someone talking to him from the television would freak him out.

Monti made sure that the team wasn’t already on the case and that the alerts weren’t false alarms. Checking the computer,

Still, you could see signs of change. I watched Hayes make his virtual rounds through the I.C.U. at St. Anne’s Hospital, in fall River,

Aligning practice with policy to improve patient care 99

BIG MED near the Rhode Island border. He didn’t yet know all the members of the hospital staff—this was only his second night in the command center, and when he sees patients in person it’s at a hospital sixty miles north. So, in his dealings with the on-site clinicians, he was feeling his way. Checking on one patient, he found a few problems. Mr. Karlage, as I’ll call him, was in his mid-fifties, an alcoholic smoker with cirrhosis of the liver, severe emphysema, terrible nutrition, and now a pneumonia that had put him into respiratory failure. The I.C.U. team injected him with antibiotics and sedatives, put a breathing tube down his throat, and forced pure oxygen into his lungs. Over a few hours, he stabilized, and the I.C.U. doctor was able to turn his attention to other patients. But stabilizing a sick patient is like putting out a house fire. There can be smoldering embers just waiting to reignite. Hayes spotted a few. The ventilator remained set to push breaths at near-maximum pressure, and, given the patient’s severe emphysema, this risked causing a blowout. The oxygen concentration was still cranked up to a hundred per cent, which, over time, can damage the lungs. The team had also started several broad-spectrum antibiotics all at once, and this regimen had to be dialled back if they were to avoid breeding resistant bacteria.


The OR Connection

Hayes had to notify the unit doctor. An earlier interaction, however, had not been promising. During a video check on a patient, Hayes had introduced himself and mentioned an issue he’d noticed. The unit doctor stared at him with folded arms, mouth shut tight. Hayes was a former Navy flight surgeon with twenty years’ experience as an I.C.U. doctor and looked to have at least a decade on the St. Anne’s doctor. But the doctor was no greenhorn, either, and gave him the brushoff: “The morning team can deal with that.” Now Hayes needed to call him about Mr. Karlage. He decided to do it by phone. “Sounds like you’re having a busy night,” Hayes began when he reached the doctor. “Mr. Karlage is really turning around, huh?” Hayes praised the doctor’s work. Then he brought up his three issues, explaining what he thought could be done and why. He spoke like a consultant brought in to help. This went over better. The doctor seemed to accept Hayes’s suggestions. Unlike a mere consultant, however, Hayes took a few extra steps to make sure his suggestions were carried out. He spoke to the nurse and the respiratory therapist by video and explained the changes needed. To carry out the plan, they needed written orders from the unit doctor. Hayes told them

to call him back if they didn’t get the orders soon. Half an hour later, Hayes called Mr. Karlage’s nurse again. She hadn’t received the orders. for all the millions of dollars of technology spent on the I.C.U. command center, this is where the plug meets the socket. The fundamental question in medicine is: Who is in charge? With the opening of the command center, Steward was trying to change the answer—it gave the remote doctors the authority to issue orders as well. The idea was that they could help when a unit doctor got too busy and fell behind, and that’s what Hayes chose to believe had happened. He entered the orders into the computer. In a conflict, however, the on-site physician has the final say. So Hayes texted the St. Anne’s doctor, informing him of the changes and asking if he’d let him know if he disagreed. Hayes received no reply. No “thanks” or “got it” or “O.K.” After midnight, though, the unit doctor pressed the video call button and his face flashed onto Hayes’s screen. Hayes braced for a confrontation. Instead, the doctor said, “So I’ve got this other patient and I wanted to get your opinion.” Hayes suppressed a smile. “Sure,” he said. When he signed off, he seemed ready to high-five someone. “He called us,” he marvelled. The

command center was gaining credibility. Armin Ernst has big plans for the command center—a rollout of full-scale treatment protocols for patients with severe sepsis, acute respiratory-distress syndrome, and other conditions; strategies to reduce unnecessary costs; perhaps even computer forecasting of patient volume someday. Steward is already extending the command-center concept to in-patient psychiatry. Emergency rooms and surgery may be next. Other health systems are pursuing similar models. The command-center concept provides the possibility of, well, command. Today, some ninety “super-regional” health-care systems have formed across the country—large, growing chains of clinics, hospitals, and home-care agencies. Most are not-for-profit. financial analysts expect the successful ones to drive independent medical centers out of existence in much of the country—either by buying them up or by drawing away their patients with better quality and cost control. Some small clinics and stand-alone hospitals will undoubtedly remain successful, perhaps catering to the luxury end of health care the way gourmet restaurants do for food. But analysts expect that most of us will gravitate to the big systems, just as we have moved away from small pharmacies to CVS and Walmart.

Already, there have been startling changes. Cleveland Clinic, for example, opened nine regional hospitals in northeast Ohio, as well as health centers in southern florida, Toronto, and Las Vegas, and is now going international, with a three-hundred-and-sixty-four-bed hospital in Abu Dhabi scheduled to open next year. It reached an agreement with Lowe’s, the homeimprovement chain, guaranteeing a fixed price for cardiac surgery for the company’s employees and dependents. The prospect of getting better care for a lower price persuaded Lowe’s to cover all out-of-pocket costs for its insured workers to go to Cleveland, including co-payments, airfare, transportation, and lodging. Three other companies, including Kohl’s department stores, have made similar deals, and a dozen more, including Boeing, are in negotiations. Big Medicine is on the way. Reinventing medical care could produce hundreds of innovations. Some may be as simple as giving patients greater e-mail and online support from their clinicians, which would enable timelier advice and reduce the need for emergency-room visits. Others might involve smartphone apps for coaching the chronically ill in the management of their disease, new methods for getting advice from specialists, sophisticated systems for tracking outcomes and costs, and instant delivery to medical teams of up-to-date care

protocols. Innovations could take a system that requires sixty-three clinicians for a knee replacement and knock the number down by half or more. But most significant will be the changes that finally put people like John Wright and Armin Ernst in charge of making care coherent, coördinated, and affordable. Essentially, we’re moving from a Jeffersonian ideal of small guilds and independent craftsmen to a Hamiltonian recognition of the advantages that size and centralized control can bring. Yet it seems strange to pin our hopes on chains. We have no guarantee that Big Medicine will serve the social good. Whatever the industry, an increase in size and control creates the conditions for monopoly, which could do the opposite of what we want: suppress innovation and drive up costs over time. In the past, certainly, health-care systems that pursued size and market power were better at raising prices than at lowering them. A new generation of medical leaders and institutions professes to have a different aim. But a lesson of the past century is that government can influence the behavior of big corporations, by requiring transparency about their performance and costs, and by enacting rules and limitations to protect the ordinary citizen. The federal government has broken up monopolies like Standard Oil

Aligning practice with policy to improve patient care 101

BIG MED and A.T.&T.; in some parts of the country, similar concerns could develop in health care. Mixed feelings about the transformation are unavoidable. There’s not just the worry about what Big Medicine will do; there’s also the worry about how society and government will respond. For the changes to live up to our hopes— lower costs and better care for everyone—liberals will have to accept the growth of Big Medicine, and conservatives will have to accept the growth of strong public oversight. The vast savings of Big Medicine could be widely shared—or reserved for a few. The clinicians who are trying to reinvent medicine aren’t doing it to make hedge-fund managers and bondholders richer; they want to see that everyone benefits from the savings their work generates—and that won’t be automatic. Our new models come from industries that have learned to increase the capabilities and efficiency of the human beings who work for them. Yet the same industries have also tended to devalue those employees. The frontline worker, whether he is making cars, solar panels, or wasabi-crusted ahi tuna, now generates unprecedented value but receives little of the wealth he is creating. Can we avoid this as we revolutionize health care?


The OR Connection

Those of us who work in the health-care chains will have to contend with new protocols and technology rollouts every six months, supervisors and project managers, and detailed metrics on our performance. Patients won’t just look for the best specialist anymore; they’ll look for the best system. Nurses and doctors will have to get used to delivering care in which our own convenience counts for less and the patients’ experience counts for more. We’ll also have to figure out how to reward people for taking the time and expense to teach the next generations of clinicians. All this will be an enormous upheaval, but it’s long overdue, and many people recognize that. When I asked Christina Monti, the Steward tele-I.C.U. nurse, why she wanted to work in a remote facility tangling with staffers who mostly regarded her with indifference or hostility, she told me, “Because I wanted to be part of the change.” And we are seeing glimpses of this change. In my mother’s rehabilitation center, miles away from where her surgery was done, the physical therapists adhered to the exercise protocols that Dr. Wright’s knee factory had developed. He didn’t have a video command center, so he came out every other day to check on all the patients and make sure that the staff was following the program.

My mother was sure she’d need a month in rehab, but she left in just a week, incurring a fraction of the costs she would have otherwise. She walked out the door using a cane. On her first day at home with me, she climbed two flights of stairs and walked around the block for exercise. The critical question is how soon that sort of quality and cost control will be available to patients everywhere across the country. We’ve let health-care systems provide us with the equivalent of greasy-spoon fare at four-star prices, and the results have been ruinous. The Cheesecake Factory model represents our best prospect for change. Some will see danger in this. Many will see hope. And that’s probably the way it should be.

THE OR GOES GREEN – the first and only bio-based surgical drape Medline’s EcoDrape is the only bio-based surgical drape available today. It’s made of more than 96% wood pulp and 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. Try the new EcoDrape and take your OR to the next level of green!

Composition Comparison EcoDrape



More than 96% wood pulp

No wood pulp

Petrochemical ingredients (plastics)


100% Polypropylene




For a quick online video demonstration, visit


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

Healthy Eating

Nutrition Information Servings: 8 Fat: 11.6 g Fiber: 27.8 g Calories: 1040 Sodium: 514

White Bean Chicken Chili As the sun sets on a wintry afternoon in Beach Park, Illinois, Maria Biddle turns on her kitchen light, and soon the sounds of laughter and conversation fill the room. “I love to cook with my husband and parents. They also share a love for cooking and we make a pretty good team in the kitchen.” .................................... Maria, who has been with Medline since 2007, recently returned to work after taking maternity leave and plans to make homemade baby food for her new baby boy. But they’re not making baby food this evening; they’re making the recipe that won first prize in Medline’s 2011 Chili Cook-Off: Maria’s White Bean Chicken Chili. “I feel like chili is just such a good hearty soup that is so comforting, especially during the winter.” The recipe is based on her father-in-law’s chili recipe with some alterations and different spices. The chili’s chunky chicken makes for a pleasant change from the usual ground beef, and might have been the reason it won first place.

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


The OR Connection


Ingredients 2 tbsp olive oil 2 cup of chopped celery 1 yellow, orange and red bell pepper chopped 1 large white onion chopped 4 cloves garlic minced 2 tbsp chili powder 3 tbsp cumin 3 tbsp paprika 1 tsp cayenne pepper 1 tsp thyme 2 tsp oregano ½ tsp ground cloves 1 tsp of salt A pinch of black pepper 4 cans (14.5 oz. each) of diced tomatoes 1 can of tomatoes with green chilies 8 cans (9.75 oz. each) of cooked chicken or about 5 lbs of cooked chicken in chunks 2 tbsp of chicken bouillon 1 3-lb jar of northern beans (rinsed – you don’t need the liquid) Directions In a big pot add the oil and sauté the celery, bell peppers, onion and garlic on medium heat. Stir constantly to make sure they cook and not burn. Once the vegetables have been cooked, start stirring in the spices (chili powder, cumin, paprika, cayenne pepper, thyme, oregano, clove, salt and black pepper). Once the spices have been added, start adding the cans of tomatoes with all the liquid. Add the chicken with the broth included and add the chicken bouillon. Add the beans and stir chili constantly. Let it come to a boil and then simmer for a half hour.

Forms & Tools

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

CMS Measures

CMS FY 2014-2016 Measures for CMS Payment Determination . . . . 106 Sterile Processing

Pros and Cons of Common Sterilization Technologies . . . . . . . . . . . . 108 Patient Safety

PCA Patient Safety Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109 Ambulatory Surgery Patient Safety Checklist (Pre-Operative) . . . . . . . 112 Ambulatory Surgery Patient Safety Checklist (Post-Operative) . . . . . . 113 Sharps Safety

Now You See It, Now You Donâ&#x20AC;&#x2122;t. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 Sharps Safety Begins with You . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115

Aligning practice with policy to improve patient care 105

Forms & Tools

CMS Measures

Premier healthcare alliance CMS FY 2014-2016 measures for CMS payment determination: Hospital IQR, hospital-acquired conditions, IPPS-exempt cancer hospitals quality reporting, VBP program quality measures and long term care hospitals quality reporting.

Hospital IQR Program Measures for FYs 2014, 2015 and 2016 2014



AMI-2 Aspirin prescribed at discharge




AMI-7a Fibrinolytic (thrombolytic) agent received within 30 minutes of hospital arrival




AMI-8a Timing of Receipt of Primary Percutaneous Coronary Intervention (PCI)




AMI-10 Statin Prescribed at Discharge




HF-1 Discharge instructions




HF-2 Evaluation of left ventricular systolic function




HF-3 Angiotensin Converting Enzyme Inhibitor (ACE-I) or Angiotensin II Receptor Blocker (ARB) for L ventricular systolic dysfunction




Acute Myocardial Infarction (AMI) Measures

Heart Failure (HF) Measures

Stroke (STK) Measure Set STK-1 VTE prophylaxis



STK-2 Antithrombotic therapy for ischemic stroke



STK-3 Anticoagulation therapy for Afib/flutter



STK-4 Thrombolytic therapy for acute ischemic stroke



STK-5 Antithrombotic therapy by the end of hospital day 2



STK-6 Discharged on Statin



STK-8 Stroke education



STK-10 Assessed for rehabilitation services



VTE-1 VTE prophylaxis



VTE-2 ICU VTE prophylaxis



VTE-3 VTE patients with anticoagulation overlap therapy



VTE-4 VTE patients receiving un-fractionated Heparin with doses/labs monitored by protocol



VTE-5 VTE discharge instructions



VTE-6 Incidence of potentially preventable VTE



Venous Thromboembolism (VTE) Measure Set

Pneumonia (PN) Measures PN-3b Blood culture performed before first antibiotic received in hospital




PN-6 Appropriate initial antibiotic selection




Surgical Care Improvement Project (SCIP) Measures


SCIP INF-1 Prophylactic antibiotic received within 1 hour prior to surgical incision




SCIP-INF-2: Prophylactic antibiotic selection for surgical patients




SCIP-INF 3 Prophylactic antibiotics discontinued within 24 hours after surgery end time (48 hours for cardiac surgery)




SCIP-INF-4: Cardiac surgery patients with controlled 6AM postoperative serum glucose




SCIP窶的NF-9: Postoperative urinary catheter removal on postoperative day 1 or 2 with day of surgery being day zero




SCIP-INF-10: Surgery patients with perioperative temperature management




SCIP-Cardiovascular-2: Surgery Patients on a Beta Blocker prior to arrival who received a Beta Blocker during the periop period




The OR Connection


Forms & Tools

CMS Measures Hospital IQR Program Measures for FYs 2014, 2015 and 2016




SCIP-VTE-1: Surgery patients with Venous thromboembolism (VTE) prophylaxis ordered



SCIP-VTE-2: Surgery patients who received appropriate VTE prophylaxis within 24 hours pre/post surgery




AMI 30-day mortality rate




Heart Failure 30-day mortality rate




Pneumonia 30-day mortality rate






AMI 30-Day Risk Standardized Readmission




Heart Failure 30-Day Risk Standardized Readmission




Pneumonia 30-Day Risk Standardized Readmission




Mortality Measures (Medicare Patients)

Patientsâ&#x20AC;&#x2122; Experience of Care Measures HCAHPS survey

1 Expanded

Readmission Measures (Medicare Patients)

30-Day Risk Standardized Readmission following Total Hip/Total Knee Arthroplasty



Hospital-Wide All Cause Unplanned Readmission



AHRQ Patient Safety Indicators (PSIs), Inpatient Quality Indicators (IQIs) and Composite Measures PSI 06: Iatrogenic pneumothorax, adult



PSI 11: Post Operative Respiratory Failure



PSI 12: Post Operative PE or DVT



PSI 14: Postoperative wound dehiscence



PSI 15: Accidental puncture or laceration



IQI 11: Abdominal aortic aneurysm (AAA) mortality rate (with or without volume)



IQI 19: Hip fracture mortality rate



Complication/patient safety for selected indicators (composite)


Mortality for selected medical conditions (composite)


PSI 04 Death among surgical inpatients with serious, treatable complications




Participation in a Systematic Database for Cardiac Surgery




Participation in a Systematic Clinical Database Registry for Stroke Care




Participation in a Systematic Clinical Database Registry for Nursing Sensitive Care




Participation in a Systematic Clinical Database Registry for General Surgery





X Removed

Structural Measures

Safe Surgery Checklist Use


Healthcare-Associated Infections Measures Central Line Associated Bloodstream Infection (CLABSI)




Surgical Site Infection




Catheter-Associated Urinary Tract Infection (CAUTI)




MRSA Bacteremia



Clostridium Difficile (C.Diff)



Healthcare Personnel Influenza Vaccination





Surgical Complications Hip/Knee Complication: Hospital-Level Risk Standardized Complication Rate following Elective Primary Total Hip Arthroplasty

Aligning practice with policy to improve patient care 107 8-31-12

Forms & Tools Sterilization Method Steam

Pros and Cons of Common Sterilization Technologies Advantages


· Nontoxic to patient, staff, environment

· Deleterious for heat-sensitive instruments

· Cycle easy to control and monitor

· Microsurgical instruments damaged by repeated exposure

· Rapidly microbicidal

· May leave instruments wet, causing them to rust

· Least affected by organic/inorganic soils among sterilization processes listed

- Potential for burns

· Rapid cycle time · Penetrates medical packing, device lumens Hydrogen Peroxide Gas Plasma

· Safe for the environment

· Cellulose (paper), linens and liquids cannot be processed

· Leaves no toxic residuals

· Sterilization chamber size from 1.8-9.4 ft3 total volume (varies with model type)

· Cycle time is 28-75 minutes (varies with model type) and no aeration necessary · Used for heat- and moisture-sensitive items since process temperature <50oC · Simple to operate, install (208 V outlet), and monitor

· Requires synthetic packaging (polypropylene wraps, polyolefin pouches) and special container tray

· Compatible with most medical devices

- Hydrogen peroxide may be toxic at levels greater than 1 ppmTWA

. Only requires electrical outlet 100% Ethylene Oxide (ETO)

· Some endoscopes or medical devices with long or narrow lumens cannot be processed at this time in the United States (see manufacturer’s recommendations for internal diameter and length restrictions)

· Requires aeration time to remove ETO residue

· Penetrates packaging materials, device lumens

· Sterilization chamber size from 4.0-7.9 ft3 total volume (varies with model type)

· Single-dose cartridge and negativepressure chamber minimizes the potential for gas leak and ETO exposure

· ETO is toxic, a carcinogen, and flammable · ETO emission regulated by states but catalytic cell removes 99.9% of ETO and converts it to CO2 and H2O

· Simple to operate and monitor · Compatible with most medical materials

· ETO cartridges should be stored in flammable liquid storage cabinet · Lengthy cycle/aeration time

ETO Mixtures

· Penetrates medical packaging and many plastics

· Some states (e.g., CA, NY, MI) require ETO emission reduction of 90-99.9%

10% ETO/90% HCFC

· Compatible with most medical materials

8.5% ETO/91.5% CO2

· Cycle easy to control and monitor

· CFC (inert gas that eliminates explosion hazard) banned in 1995

8.6% ETO/91.4% HCFC

· Potential hazards to staff and patients · Lengthy cycle/aeration time . ETO is toxic, a carcinogen, and flammable

Peracetic Acid

· Rapid cycle time (30-45 minutes)

· Point-of-use system, no sterile storage

· Low temperature (50-55oC liquid immersion sterilization

· Biological indicator may not be suitable for routine monitoring

· Environmental friendly by-products

· Used for immersible instruments only

· Sterilant flows through endoscope which facilitates salt, protein and microbe removal

· Some material incompatibility (e.g., aluminum anodized coating becomes dull) · One scope or a small number of instruments processed in a cycle - Potential for serious eye and skin damage (concentrated solution) with contact

Abbreviations: CFC=chlorofluorocarbon, HCFC=hydrochlorofluorocarbon.


The OR Connection

Source: Centers for Disease Control and Prevention. Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008. Available at:

Patient is electronically monitored with both: pulse oximetry and capnography

Two healthcare providers have independently doublechecked: patientâ&#x20AC;&#x2122;s identification all patient allergies appear prominently on medication administration record (MAR) drug selection and concentration confirmed as that which was prescribed any necessary dose adjustments completed PCA pump settings line attachment to patient and tubing insertion into pump

Patient has been provided with information on proper patient use of PCA pump (other recipients of information -family/visitors) and purpose of monitoring

Pre-procedural cognitive assessment has determined patient is capable of participating in pain management (note: pediatric patients may not be suitable for PCA)

Risk factors that increase risk of respiratory depression have been considered: obesity low body weight concomitant medications (opiates and non-opiates) that potentiate sedative effect of opiate PCA pre-existing conditions such as asthma, COPD, and sleep apnea advanced age

PCA Pump Initiation, Refilling, or Programming Change

PCA Safety Checklist


Patient assessment/condition has been added to flow sheet/ chart documenting PCA dosing and monitoring

Electronic monitoring verified: pulse oximetry and capnography

PCA pump settings verified

Patient satisfactorily assessed for: level of pain alertness adequacy of ventilation

PCA Pump Check at Shift Change and Every Hour Since Last Assessment (Recommended)

Physician-Patient Alliance for Health & Safety

PCA Patient Safety Checklist Forms & Tools

Aligning practice with policy to improve patient care 109

Medline natural OR towels


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. • An OR suite with 10 rooms 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 two to five months.


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

©2012 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc. greensmart and EcoDrape are trademarks of Medline Industries, Inc.

Sharps Safety


Forms & Tools

NOW YOU DONâ&#x20AC;&#x2122;T.


and prepare the patient and work area with prevention in mind. Use a sharps device with safety features whenever it is available.

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

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

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

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

Aligning practice with policy to improve patient care 111

Forms & Tools

Pre-Op Patient Safety Checklist


Patient Safety Checklist — Pre-Operative — Clip this checklist to the patient chart and upon completion, insert in file. Prior to bringing the patient into the OR, the orthopaedic surgeon is to complete and sign the patient safety checklist. Patient’s Name:




Sheduled Procedure: I have considered the following as they relate to the safety of my patient undergoing this procedure:  History and Physical Examination Performed  Labs and EKG Attached  Medications:  Prescription  Over the Counter (OTC) Drugs  Herbals or Other Products  Patient Risk Factors/Co-Morbidities  Prior Anesthetic Complications The following processes have been performed:      

Patient Identifier Checked Surgeon Signed in the Site Appropriate ASA Classification Assigned Equipment Checked — Present and Functioning Properly Primary Care Physician Notified of Procedure Time-Out Prior to Procedure

Orthopaedic Surgeon’s Signature:

American Academy of Orthopedic Surgeons


The OR Connection


Forms & Tools

Post-Op Patient Safety Checklist


Patient Safety Checklist — Post-Operative — Clip this checklist to the patient chart and upon completion, insert in file. The orthopaedic surgeon is responsible for the completion of the checklist prior to discharge Date:

Patient’s Name:



Being discharged to: In care of: Follow-up appointment:



I have attended to the following issues as they relate to my patient’s safe discharge: Patient was provided with and reviewed written discharge instructions. Patient was provided with and reviewed written medication instructions. Patient follow-up has been arranged for a specific date and time. Patient is determined safe to go home.



Patient will be accompanied by a responsible adult. Patient has been given emergency contact phone number(s)

Orthopaedic Surgeon’s Signature:

American Academy of Orthopedic Surgeons

2 practice with policy to improve patient care 113 Aligning


11:13 PM

Page 1




Letâ&#x20AC;&#x2122;s get to the point.

Sharps Safety begins with you.

Anticipate injury risks.

Keep exposed sharps in view

Be responsible for

features. Dispose in sharps containers.

the sharps you use. Activate safety


beds and waste receptacles.

inspect for unprotected sharps in trays,

and under your control. Visually


work area with prevention in mind.

Prepare the patient and organize the


Sharps Safety Forms & Tools

Aligning practice with policy to improve patient care 115

Award-winning PerforMAX scrubs

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

Standard scrub top

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

MKT1222364 / LIT396 / 25M / JBK5

OR Connection Volume 7 Issue 3  

Medline's OR Connection Magazine, Volume 7, Issue 3 - FREE CE: Surgical Site Infection (SSI) Following Orthopedic Surgery

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