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OR Connection Magazine - Volume 3; Issue 3

OR Connection Magazine - Volume 3; Issue 3

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08/04/2013

The

Aligning practice with policy to improve patient care

Volume 3, Issue 3

OR Pressure Ulcer

Risk Assessment
Back to Basics: Hand-Off Communication
Find Out How to Go Latex-Free
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with Surgical Gloves

APIC’s

Targeting Zero

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OR Connection
Aligning practice with policy to improve patient care

The

Never miss an issue of The OR Connection!
Subscribing to The OR Connection guarantees that youʼll continue to receive this info-packed magazine and wonʼt miss out on our industry updates, articles addressing on-the-job issues and tips on caring for yourself!

Subscriptions are free and signing up is a snap!

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

To subscribe, simply go to www.medline.com/ orconnection. You will need to provide: Your name Facility and position Mailing address Email address

We've coded the articles and information in this magazine to indicate which patient care initiatives they pertain to. Throughout the publication, when you see these icons you'll know immediately that the subject matter on that page relates to one or more of the following national initiatives: • IHI's 5 Million Lives Campaign • Joint Commission 2009 National Patient Safety Goals • Surgical Care Improvement Project (SCIP)

Content Key

We've tried to include content that clarifies the initiatives or gives you ideas and tools for implementing their recommendations. For a summary of each of the above initiatives, see pages 6 and 7.

Editor Sue MacInnes, RD, LD Clinical Editor Alecia Cooper, RN, BS, MBA, CNOR Contributing Editor Andy J. Mills, MBA Art Director Mike Gotti Copy Editor Laura Kuhn Clinical Team Jayne Barkman, RN, BSN, CNOR Rhonda J. Frick, RN, CNOR Anita Gill, RN Megan Giovinco, RN, CNOR, RNFA Jeanne Jones, RNFA, LNC Carla Nitz, RN, BSN Claudia Sanders, RN, CFA

PATIENT SAFETY

Kimberly Haines, RN, Certified OR Nurse Connie Sackett, RN, Nurse Consultant Angel Trichak, RN, BSN, CNOR

6 Three Important National Initiatives for Improving Patient Care 9 A Focus on Prevention 18 Back to Basics: Applying Evidence-Based Information to Improve Hand-Off Communication in Perioperative Services 30 Patient Safety in Surgery 32 A Spotlight on “Never Events” 50 Why Is Pressure Ulcer Risk Assessment So Important?
OR ISSUES

Page 18

Perioperative Advisory Board Gail Avigne, RN Shands Teaching Hospital (UFL), Florida

Caroline Copeland, RN MPH Southern Hills Hospital & Medical Center Larry Creech, RN, MBA, CDT Carilion Health System, Virginia Barbara Fahey, RN CNOR Cleveland Clinic, Ohio

Cathy Crandall, RN HealthTrust Purchasing Organization, Tennessee Pat DʼErrico, RN, CNOR Medical Center of Central Georgia, Georgia Zaida Jacoby, RN, MA, M.Ed NYU Medical Center, New York Wayne Malone, RN Physicians Hospital, Texas

15 26 33 42 44 58 14 28 36 62 77 91

Targeting Zero Healthcare-Associated Infections Care Bundle for Surgical Site Preparation A Latex-Free Victory! Supply Management for Perioperative Services A New Way to “Pack” It All In Fluid Flow Disruption?
SPECIAL FEATURES

Page 30

Sherron Kurtz, RN, MSA, MSN, CNOR, CNAA Wellstar Kennestone Hospital, Georgia Lynda Mansfield, RN, CNOR Orange County Memorial, California Jackie Minor, RN CNOR Huntsville Hospital, Alabama Jennifer Misajet, BSN, MHA, CNOR Exempla St. Joseph Hospital, Colorado

Prevention Above All Discoveries Grants Measuring What You Manage Organ Donation Why Can’t We All Just Get Along? Mark Your Calendar: Linda Ellerbee Ami Lends a Hand
CARING FOR YOURSELF

Page 33

66 Hot to Set Priorities and Get the Job Done 68 Conquer Stress During Tough Economic Times 78 Recipe: Bruschetta Delizioso
FORMS & TOOLS

Page 36

Pricilla Ranseur, RN, MSN, CNOR Duke University Hospital, North Carolina Margery Woll, RN, MSN, CNOR Rush North Shore, Illinois

Margie Voyles, RN, MS, CNOR Lakeland Regional Medical Center, Florida

80 82 85 89

Summary of SCIP Measure Changes Hand-Off Communication in the Perioperative Setting SBAR Hand-Off Communication Pressure Ulcer Prevention Checklist: Perioperative Services
Page 66 Meeting the highest level of national and international quality standards, Medline is FDA QSR compliant and ISO 13485 registered. Medline serves on major industry quality committees to develop guidelines and standards for medical product use including the FDA Midwest Steering Committee, AAMI Sterilization and Packaging Committee and various ASTM committees. For more information on Medline, visit our Web site, www.medline.com.

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.

© 2008 Medline Industries, Inc. The OR Connection is published by Medline Industries, Inc. One Medline Place, Mundelein, IL 60060. 1-800-MEDLINE.

Aligning practice with policy to improve patient care 3

THE OR CONNECTION I Letter from the Editor
Dear Reader,
October 1, 2008, seems like the distant past as we break open the New Year with a new president, new regulations, new goals and many new processes. Many of you are addressing the 11 hospital-acquired conditions that will no longer trigger higher DRG payments if they are acquired during the hospital stay. Those conditions include: Objects left in surgery Blood incompatibility Air embolism Catheter-associated urinary tract infections Pressure ulcers Vascular catheter-associated infections Falls and trauma (including burns) Surgical site infections – mediastinitis after CABG 9. Surgical site infections following certain elective surgeries 10. Certain manifestations of poor control of blood sugar levels 11. Deep vein thrombosis of pulmonary embolism following total knee replacement/hip replacement procedure 1. 2. 3. 4. 5. 6. 7. 8. detection of foreign bodies left during surgery, to name a few. Look on Page 32 for an index of articles offering solutions that will address many of the 11 conditions.

The best solutions come from those of you who are in the trenches. For that reason, Medline wants to support and encourage these great ideas through the Prevention Above All Discoveries Grant Program. Medline will be awarding $1 million in grant money over several years. These awards are designed to assist healthcare providers in developing and testing creative solutions or interventions for reducing or preventing hospital-acquired harms. For more information on the Discoveries Grants, see Page 14. Finally, STOP and take time for yourself. Destress and refocus. Read how you can communicate peacefully with other departments, set priorities and conquer stress. Let 2009 be the start of a great year! Best Regards,

This edition of

The OR Connection solutions to help reduce hospital-

is all about providing acquired conditions.”

Patient safety is not a trend, but a part of our daily activities. 2009 will be a springboard for change as more and more hospitals embrace the inevitable. This edition of The OR Connection is all about providing solutions to help reduce hospital-acquired conditions. In reviewing Medlineʼs Prevention Above All campaign (Pages 9-14), you will find one solution after another on ways to reduce infections, programs to reduce pressure ulcers and products to assist in the

Sue MacInnes RD, LD

P.S. Take a look below at the Reader Question for this edition. The winning response will receive a copy of Take Big Bites by Linda Ellerbee, our keynote speaker at our breast cancer awareness breakfast at AORN Congress in March.

What have you done to improve patient safety in your operating room?

This Editionʼs Question

4

The OR Connection

Please submit your response to orconnection@medline.com. Each issue will feature a new question of the month and a winner will be chosen for the best submission. Please submit early and often as the best solutions are created by those who deliver patient care every day!

News Flash

DNV Joins Joint Commission and AOA for Accreditation for CMS Payment

The Centers for Medicare & Medicaid Services (CMS) has approved the first new hospital accreditation organization in more than 40 years, giving hospitals another choice when seeking to participate in Medicare or Medicaid. The approval by Det Norske Veritas Healthcare Inc. for conferring deemed status on hospitals adds to accreditation programs by the Joint Commission and the American Osteopathic Association, or certification by a state survey agency.
To learn more about DNV go to:

UCLA study reveals smoking's effect on nurses' health, death rates

A new UCLA School of Nursing study is the first to reveal the devastating consequences of smoking on the nursing profession. Published in the November- December edition of the journal Nursing Research, the findings describe smoking trends and death rates among U.S. nurses and emphasize the importance of supporting smoking cessation programs in the nursing field.

http://www.dnv.com/news_events/index.asp

The current UCLA research explored changes in smoking trends and death rates among female nurses enrolled in the Nurses' Health Study between 1976 and 2003, a span of 27 years. According to the most recent data, the smoking rate among registered nurses nationwide is nearly 12 percent.

Older Blood Raises Infection Risk

A study conducted at Cooper University Hospital, Camden, NJ, and presented at the annual scientific meeting of American College of Chest Physicians in late October, found that those who received a transfusion of blood stored for 29 days or longer were twice as likely to develop pneumonia, sepsis and other serious infections compared with those who received stored blood kept for 28 days or less. Additional studies are needed to determine the optimal storage period for blood to prevent infections. Rules currently permit blood to be stored for 42 days.
To learn more about this study, go to:

The rate of smoking among women in the Nurses' Health Study declined from 33.2 percent in 1976 to 8.4 percent in 2003. The number of cigarettes smoked per day also dropped. However, the daily number among current smokers still averaged more than 15 cigarettes, or over half a pack. The entire story can be found at: http://newsroom.ucla.edu/portal/ucla/new-ucla-studyreveals-smoking-71590.aspx?link_page_rss=71590

http://www.chestnet.org/about/press/releases/200 8/CHEST/PDF/BloodStorage.pdf?zbrandid=3032&zidType =CH&zid=1342800&zsubscriberId=751519175

Aligning practice with policy to improve patient care 5

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

1

Origin: Purpose: Goal:

5 Million Lives Campaign
Launched by the Institute for Healthcare Improvement (IHI) in December of 2006 To prevent unintended physical injury resulting from or contributed to by medical care that requires additional monitoring, treatment or hospitalization, or that results in death To prevent five million incidents of medical harm over the next two years and to enroll more than 4,000 hospitals and their communities in the project.

Hospitals sign up through IHI and can choose to implement some or all of the recommended changes. IHI provides how-to guides and tools for data measurement and submission. IHI tracks Acute Care Inpatient Mortality rates for all participating hospitals.

The new campaign incorporates the six original planks from the 100,000 Lives Campaign and adds six additional planks to prevent harm.

2

Origin: Purpose:

Joint Commission 2008 National Patient Safety Goals
Developed by Joint Commission staff and a Sentinel Event Advisory Group To promote specific improvements in patient safety, particularly in problematic areas

Joint Commission-accredited organizations are evaluated for compliance with these goals. The Joint Commission offers guidance to help organizations meet goal requirements. This yearʼs new requirements have a one-year phase-in period that includes defined expectations for planning, development and testing (“milestones”) at 3, 6 and 9 months in 2008, with the expectation of full implementation by January 2009.

3

Origin: Purpose: Goal:

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

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

6

The OR Connection

Patient Safety

5 Million Lives Campaign: Twelve Interventions
1. Prevent pressure ulcers 2. Reduce methicillin-resistant staphylococcus aureus (MRSA) infection 3. Prevent harm from high-alert medications 4. Reduce surgical complications 5. Deliver evidence-based care for congestive heart failure 6. Get boards on board 7. Deploy rapid response teams 8. Prevent adverse drug events (ADEs) An IHI forum, “Celebrating 20 Years: The Future of Health Care is Ours to Imagine,” was held in Nashville on December 8-11, 2008. www.ihi.org 9. Deliver evidence–based care for acute myocardial infarction 10.Prevent surgical-site infections 11. Prevent central-line infections 12.Prevent ventilator-associated pneumonia

By the numbers: • Over 4,000 hospitals currently enrolled • The Top 4 Interventions: 1. Adverse Drug Events (ADEs) – 3,152 2. Surgical Site Infection (SSI) – 3,047 3. Acute Myocardial Infarction (AMI) – 3,016 4. Rapid Response Teams – 2,853

• • • • • •

To learn more about the 2009 National Patient Safety Goals, go to www.jointcommission.org. New in 2009: New numbering system for sorting in new electronic manuals and minor language changes for consistency.

Improve accuracy of patient identification Improve effectiveness of communication among caregivers Improve medication safety Reduce risk of healthcare-associated infections (Expanded in 2008 to include either WHO or CDC Hand Hygiene Guidelines) Reduce risk of patient harm from falls Reduce risk of influenza and pneumoccocal disease through immunization

Joint Commission 2009 National Patient Safety Goals
• • • • • •

Reduce risk of surgical fires Encourage patientʼs active involvement in their care Prevent healthcare-associated pressure ulcers (decubitus ulcers) Identify safety risks inherent in patient population (suicide, home fires) Improve recognition and response to changes in a patients condition Implementation of Universal Protocol for preventing wrong-site, wrong-person, wrong-procedure surgery

1. Surgical-site infections • Antibiotics, blood sugar control, hair removal, normothermia 2. Perioperative cardiac events • Use of perioperative beta-blockers 3. Venous thromboembolism • Use of appropriate prophylaxis
SCIP is targeting two new measures for October 2009:

Surgical Care Improvement Project (SCIP): Target Areas
By the numbers: • 3,740 hospitals are submitting data on SCIP measures, representing 75 percent of all U.S. hospitals • Currently, SCIP has more than 36 association and business partners

• Removal of urinary catheters within 48 hours post surgery • A new, updated normothermia measure To learn more, go to Page 9.
Visit www.qualitynet.org

Aligning practice with policy to improve patient care 7

A Focus on Prevention
Highlights from the Prevention Above All Forum
At the Prevention Above All Forum in August, nearly 100 chief nursing officers, chief medical officers and healthcare quality executives from across the U.S. came to Chicago to hear some of health careʼs top thought leaders discuss policy changes, patient safety strategies and targeted, evidence-based solutions for improving patient outcomes. There was a lot of information and excitement around the new reimbursement regulations that CMS put into practice October 1, as well as the patient safety themes that the quality improvement organizations are working on. If you didn't get a chance to attend this yearʼs meeting, here are five key things that you missed hearing about:

“This conference was absolutely terrific, My knowledge has been increased greatly. Our ‘assigned row rep’ was terrific, very helpful, anticipated our needs before we knew them and was overall great!”
Karin L. Boylard, Clinical Nurse Educator Johnson Memorial Hospital

With CMS revamping reimbursement for hospital-acquired conditions (HACs) and expanding implementation of the Quality Indicator Survey for long-term Nance care facilities into more states, it wasnʼt too surprising to hear Keynote Speaker John J. Nance, JD open the Prevention Above All Forum by saying “the core culture of medical practice has to be drastically changed.” Nance, founding member of the National Patient Safety Foundation and author of Why Hospitals Should Fly: The Ultimate Flight Plan to Patient Safety and Quality Care, touched on how the October 1 CMS reimbursement milestone for HACs provides the opportunity for healthcare providers to “re-commit” to improving patient safety by becoming engaged professionals dedicated to barrierless communication. “Youʼre not only going to solve the CMS problems (of HAC prevention),” said Nance. “But you are going to get to the point of asking doctors ʻWhy donʼt we have 100 percent compliance on handwashing?ʼ and ʻIs it okay if my nurses remind you?ʼ That consistent cross-checking of each other, completely devoid of professional defensiveness, and a real caring for each other as full members of a team dedicated to the patientʼs best interests, is the key to safe practice. Why Hospitals Should Fly by John Nance is available at www.whyhospitalsshouldfly.com.

The key to cultural change: mutual cooperation built on real mutual respect

In terms of healthcare policy changes and their implications for care, one with an astounding impact discussed at the forum was CMSʼs new community approach to pressure ulcer prevention and care as outlined in the 9th Scope Bratzler of Work. Dale Bratlzer, DO, MPH, Medical Director of the Oklahoma Foundation for Medical Quality, provided some early information on how the epidemic of the “ambulance acquired” pressure ulcer will be something of the past and how this is the number one initiative for the Quality Improvement Organizations (QIOs) right now.

CMSʼ new community approach to pressure ulcers

Previously, CMS reviewed captured MDS data to help identify nursing homes that have high rates of pressure ulcers. With the Be sure to visit the Prevention Above All Web CMS 9th Scope site at www.medline.com/special/PAA/ for of Work, which continued updates and additional resources. took effect on August 1, CMS now directs QIOs to focus not only on nursing homes with a high incidence of pressure ulcers, but to take a closer look at hospitals in the same county and hold them accountable as well. So the QIOs are tasked with going in and working with both the hospital and the nursing home to reduce the rates of pressure ulcers. You can learn more about the 9th Scope of Work by visiting www.providers.ipro.org/index/9SOW_summaries - 39k.

Aligning practice with policy to improve patient care 9

A Focus on Prevention
Highlights from the Prevention Above All Forum
According to Bratzler, CMS is actively working on building performance measures that will publicly report hospital pressure ulcer rates, and once they complete that there will be a strong incentive for nursing homes and hospitals to work together to figure out the best way to prevent pressure ulcers. This new community focus represents how CMS is starting to look at data outside of the hospital to see what is happening in the hospital. For example, they are looking at things that happen in surgery and the effects 30 days and 60 later, so the tracking systems from whether you are in the acute care setting or leave is going to ultimately look at every setting of healthcare not just one. Learn more about Medlineʼs Pressure Ulcer Prevention Program on Page 13. The following documents – currently in use at Krasnerʼs facility, Rest Haven-York – are also available: • Pressure Ulcer Protocol • Pressure Ulcer Protocol – Avoidable versus Unavoidable Pressure Ulcers • Pressure Ulcer Notification Fax • Pressure Ulcer Risk Factors tracking chart • Wound Photo Documentation • Pressure-relieving products • Proper application and usage of prevention products

If you are interested in receiving any of these documents, please email us at orconnection@medline.com.

“I want to take the [Medline] pressure ulcer program to our executive nursing team – this program would be excellent in helping us to prevent pressure ulcers and to improve our overall patient care delivery.”
Debra Williams, Vice President/CNO Garden City Hospital

“This was the ultimate forum, unsurpassed, professional, phenomenal speakers with the most up-to-date reliable education with statistical evidence. Kudos to Medline.”
Charles Gizara, Director, Clinical Operations Atlantic General Hospital

Thereʼs a great variability in terms of how organizations prepared for the October 1 deadline and where they are at on that continuum of preparation. Krasner According to Diane Krasner, PhD, RN, CWCN, CWS, BCLNC, FAAN, Wound and Skin Care Consultant. A lot of that preparedness comes down to education. “If you just look at the pressure ulcer part of the CMS ruling, thereʼs a high training and education component that each facility is going to have to grapple with,” said Krasner. Krasnerʼs presentation highlighted the need for nurses to receive more education on: • Risk assessment (interpretation of Braden Scale) • Pressure ulcer staging • Proper positioning (including bed and chair) • Effects of moisture on the skin (including incontinence, humidity and maceration)

Implications of the CMS Guidelines on pressure ulcer prevention and treatment

The proposed performance measure focuses specifically on whether the healthcare provider attempted to remove the catheter by the second post operative day (with surgery being Wald day zero). This important performance measure that is now National Quality Forum endorsed will be rolling out in October of 2009. A main driver behind this measure was a study led by Heidi Wald, MD, MPH, who discussed the connection.

A proposed new SCIP measure for October 2009 on timely catheter removal.

Wald, along with her co-authors of the study “Indwelling Urinary Catheter Use in the Postoperative Period,” reviewed data from 35,904 Medicare patients at 2,965 acute care hospitals across the United States to determine the relationship between catheter use and postoperative outcomes. From that large number of patients that were operated on, they found that 86% of the patients had been catheterized, and that half of them had their catheter for more than two days –

10 The OR Connection

a concern since patients whose catheters are in for a long period of time post-operatively are at an increased risk of infection.

Previously research had already demonstrated the doubling of mortality rate with something as simple as a urinary tract infection, but Dr. Wald and her colleagues were able to confirm that indwelling urinary catheters that are left in place for longer than two days postoperatively may result in catheter-acquired urinary tract infections (CAUTI) as well as an increase in 30day mortality and an increased length of stay (to view the study, please visit http://archsurg.ama-assn.org/cgi/content/ short/143/6/551).

Warye distributed copies of APICʼs MRSA guidelines and a DVD on hand hygiene geared toward patients. To download a copy of the DVD video, please visit www.cdc.gov/handhygiene. For more APIC resources, please visit www.apic.org.
Medline President Andy Mills confers with presenter Dea Kent

How big of an issue is this? There are an estimated 26-36 million operations performed in the United States each year and Bratzler notes that every single study looking at patients with similar risks, having the same operation, shows the mortality rate doubling if they get a surgical infection. And in fact, a University of Pennsylvania study reviewing a large number of operations performed demonstrated that when a patient has a major complication of surgery, the risk of death is increased by threefold within the next 60 days.

“I didn’t know Medline had these types of products. And the supportive evidence was excellent, how can we work together?”
Mary R. Lopez, Vice President, Quality Initiatives Hospital Council Northern & Central California Guests get involved at the Prevention Above All Presentation

Sometimes a few changes need to be made in order to clarify goals and continue to move toward them. Kathy Warye, CEO of the Association for Professionals in Infection Control and Epidemiology, Warye Inc. (APIC) shared the associationʼs recommendation of changing the title of Infection Control Professional to Infection Preventionist with Prevention Above All forum attendees. “Language creates culture, and if the goal is around prevention, then our name needs to incorporate prevention,” Warye said.

APIC: Spreading knowledge, preventing infection

A sampling of the items presented at the forum

Aligning practice with policy to improve patient care 11

Prevention Above All
Targeted interventions, practical solutions
Medlineʼs six practical and targeted interventions to help improve outcomes.
There is compelling evidence that many hospital-acquired conditions (HACs), specifically those targeted by CMS as “never events,” are preventable. And there are plenty of great products and evidenced-based solutions available. The challenge is implementing these solutions. There is a need to educate caregivers, organize data and assist the healthcare provider with process improvement. The innovative packaging design is an improved delivery and communication system to help healthcare professionals better understand and more easily deliver wound care at the patient's bedside. It replaces confusion with clear, step-by-step information, eliminating the clutter and highlighting critical information. Target: Objects retained after surgery The Prevention Above All Intervention: RF Detect RF system designed to alert the OR nurse when a RF-tagged surgical item remains in the patient before closing the procedure. This provides an added level of safety and an adjunct to the counting procedure.

Combining innovative products with evidence-based solutions, Medline strategically integrated a portfolio of focused and achievable evidence-based solutions designed to fit into the everyday processes and systems most healthcare providers already have in place. The six conditions targeted by Prevention Above All and their complementary Medline product and program solutions are: Target: Catheter-Associated Urinary Tract Infection (CAUTIs) The Prevention Above All Intervention: Silvertouch Catheters A bundled solution of advanced silver technology with Medlineʼs Silvertouch™ Foley catheters and educational training to reduce CAUTIs. Silvertouch Foley catheters incorporate the power of silver through a patented process that binds silver ions to the catheterʼs lubricious coating, delaying the onset of biofilm formation. Educational materials provide summarizations of the major recommendations from the CDC, SHEA, APIC and others provide a policy and procedure template guide for proper catheterization. Also included are validation tools that can be utilized during training or re-education classes, and a troubleshooting guide book and a poster to help caregivers work through issues.

The system consists of three components: a micro RF tag embedded in gauze, sponges and towels and a sterile handheld wand that is connected to the third component, an easyto-use, self-calibrating console. By passing the wand back and forth and side to side over the patient, hospital personnel will be able to accurately detect, within seconds, retained surgical disposables before site closure and rectify incorrect counts.

Target: Harm Avoidance and Patient Satisfaction The Prevention Above All Intervention: Educational Packaging To help reduce medical errors, Medline redesigned its Advanced Wound Care packaging in a format that allows each package to serve as a 2-minute course on advanced wound care.

The Hand Hygiene Compliance Program contains three products – Sterillium Comfort Gel™, Medline Remedy™ Skin Repair Cream and Aloetouch® exam gloves – clinically proven to nourish dry skin. The program includes an intensive educational module developed by an expert panel of infection control professionals. Healthcare workers can earn up to four continuing education credits by completing the training program. Additional components include testing for skill and competency validation through the use of Visirub and a UV light box. Patient education pamphlets, facility posters and a rewards program are also included to reinforce positive behavior change.

Target: HospitalAcquired Infections The Prevention Above All Intervention: Hand Hygiene Compliance Program A program of products that stresses appropriate application techniques and education to achieve hand hygiene compliance while dramatically improving the skin condition of healthcare workers.

12 The OR Connection

The Pressure Ulcer Prevention Program is a strategic product bundle to assist in reducing or preventing pressure ulcers and incontinence-associated skin conditions, which may include dermatitis and skin tears. Products include Remedy™ Advanced Skin Care Products, Ultrasorbs® AP Dry Pads, Restore®/Remedy™ Adult Brief, and Supra DPS alternating pressure and low-air-loss mattresses. The Perioperative Pressure Ulcer Prevention Program includes an educational DVD addressing pressure ulcer risk assessment and prevention methods and strategies. Its accompanying product bundle includes Sahara OR Table Sheets, Medline Gel Positioners and Pressure Redistribution Table Pads.

Target: Pressure Ulcers The Prevention Above All Intervention: Pressure Ulcer Prevention Program Medline offers a Pressure Ulcer Prevention Program to fit all disciplines, from physicians and OR nurses to CNAs, RNs and LPNs. A program of products, tools and resources to implement an effective prevention program and immediately begin reducing the incidence of pressure ulcers.

Target: Wrong Site Surgery The Prevention Above All Intervention: S.T.O.P. Drape A surgical drape that incorporates a “Time Out” sticker strip that must be removed prior to the surgical case and provided to the circulating nurse to be placed on the patientʼs chart.

The Medline S.T.O.P drape has a sticker in the shape of a red stop sign and tells the staff to stop, forcing them to remember to perform the time-out procedure required prior to beginning surgery. The sticker provides a location to write and confirm the patientʼs name, procedure, site and side, date, time and surgeonʼs initials. By requiring the surgeon to initial the sticker, the surgical team is again reminded to perform the time-out immediately prior to the incision.
Wayne Brannock, vice president of clinical services for Lorien Health Systems in Maryland asks a question during a session.

The comprehensive program also packages together education and training tools so a healthcare team can implement an effective pressure ulcer prevention program and immediately begin reducing the incidence of healthcare-acquired pressure ulcers. Included are workbooks, patient and family education brochures and a rewards program.

Dr. Andrew Kramer speaks to attendees about patient safety.

Attendees review Medlineʼs Pressure Ulcer Prevention Program materials.

Medline Chief Marketing Officer Sue MacInnes addresses attendees during the Prevention Above all Forum.

Aligning practice with policy to improve patient care 13

Special Feature

PREVENTION ABOVE ALL DISCOVERIES GRANTS:

Supporting the adoption of solutions into everyday clinical practice
Medline is committing up to $1 million in over several years to stimulate the gathering of solid evidence that supports the adoption of solutions into clinical practice. A review panel, whose members represent a breadth of research and practice knowledge, will select grant recipients to be awarded up to $25,000 each for pilot studies or $100,000 each for empirical studies. Objectives To stimulate research that will lead to the development of new targeted interventions aimed at reducing medical risks and harms associated with hospital-acquired conditions (identified by CMS in 2008 IPPS final rule). • To test the costs and effectiveness of interventions and programs designed to reduce the incidence of hospitalacquired conditions. • To disseminate practical, evidence-based solutions within and across hospitals, leading to a reduction in hospital-acquired conditions. 2. The review committee will review letters of intent on a rolling basis (see list of review committee members). Acceptable letters will be assigned to the most appropriate research mentor, who will contact the applicant and work with him/her to develop the letter into a full proposal of 5-7 pages in length, including a complete budget. Proposal and budget guidelines will be sent after approval of letter of intent.

3. The review committee will review full proposals and budgets on a rolling basis. Most of the projects that are chosen for full proposal submission will be funded; however, this process may involve a subsequent resubmission of a revised proposal so that the funded research plan is clear. 4. Pilot studies will generally be up to six months in duration with a budget of about $25,000. Empirical studies can be up to $100,000 and last up to a year or more in duration. Pilot study grantees can go on to submit an empirical study proposal at the successful conclusion of the pilot project, or applicants can apply for a full empirical study grant based on their initial letter of intent if they have an existing practice with evidence that they wish to evaluate.

These awards are designed to assist healthcare providers in developing and testing creative solutions or interventions for reducing or preventing hospital-acquired conditions. Recipients of grant awards will be paired with a research mentor/consultant through the grant program to develop methods and guide the conduct of the study, ensuring that a rigorous research process is followed. These studies can be small pilot studies aimed at developing and testing the feasibility of new solutions or larger evaluation studies to more fully test the costs, effectiveness or dissemination of evidence-based solutions. Award Process 1. In response to our request for applications (RFA), providers will submit a 2-3 page letter of intent providing the following information: • The HAC(s) that the study will address • Whether the letter is for a pilot or empirical study • The proposed solution • The objective of the study • The proposed approach in as much detail as you have thought it through at this point • Expected output of the study • Brief biography about the individuals involved, including any experience in the area of focus • Budget estimate, including the major expenditure categories

5. The final report for a pilot grant study should be a brief paper written for a Medline publication (Healthy Skin, The OR Connection or Infection Prevention Now) whether the grant is successful or not. The final report for an empirical study is a paper to be submitted for publication in a peer-reviewed journal. GRANT PROGRAM SCHEDULE Nov. 15 to Jan. 31, 2009 Accept and review letters of intent on a rolling basis

Dec. 1 to Feb. 28, 2009 Notification of acceptance and authorization to begin full proposal (due one month after notification of letter of intent) Jan. 1, 2009 to Apr. 30, 2009 Full proposals funded and projects started within two months of proposal submission

OR Issues

Targeting

Healthcare-Associated Infections

ZERO

An exclusive report from APIC
By Kathy Warye, APIC executive director In January of 2006, the Association for Professionals in Infection Control and Epidemiology published APIC Vision 2012, a strategic approach to the future of the practice and profession. The first goal of the plan stated that APIC will “promote prevention and zero tolerance for healthcare-associated infections (HAIs).”1 Since that time, APICʼs approach has evolved and focused instead on promoting a culture where targeting zero healthcare-associated infections is fully embraced. Insertion of the word “culture” was an important addition, as APICʼs intent is to promote a cultural change within health care wherein providers strive to eliminate preventable HAIs. While few organizations in the early 2006 time frame were contemplating the possibility of reaching zero HAIs, zero tolerance first emerged in 2000 when Julie Gerberding, director of the CDC, introduced the concept. She noted that, over time, the goal of elimination had been applied to other public health concerns, such as TB and polio. Elimination might not have occurred, but ambitious goals drove positive change and dramatic reductions.

Making prevention a priority

As APICʼs strategic plan was taking shape, a small but influential group of healthcare organizations were discovering that many more infections are preventable than previously

thought. They were setting goals to reduce HAIs significantly below previously accepted benchmarks, reaching and sustaining them. With a declining arsenal of antibiotics to treat infections, it was increasingly clear that the traditional orientation toward control of HAIs needed to shift to one where preventing the occurrence was the priority throughout the institution. APIC was hearing from leaders across the spectrum of health care, from providers to patients and patient safety advocates. It was in this context that APICʼs leaders agreed that the Association should be at the forefront in promoting significant and sustained reductions in preventable healthcare-associated infections. Since that time, APIC has moved forward to promote prevention and provided members with a host of resources to help them set and reach ambitious goals for the reduction of HAIs. Targeting Zero encourages all organizations to set the goal of elimination rather than remain comfortable when local or national averages or benchmarks are met. Every single HAI impacts the life of a patient and family – even one should feel like too many.

• Prompt investigation of HAIs of greatest concern to the organization and/or community and • Focus on providing real-time data to front line staff for the purpose of driving improvements.

Culture change in the OR

Creating the culture change required to eliminate surgical site and other infections that begin in the OR will require commitment on the part of the entire OR team, from surgeons and anesthesiologists to operating room managers, nurses and technicians. The institutionʼs infection prevention experts can assist in the provision of real-time data, application of performance improvement concepts (such as root cause analysis) and ongoing education and training for OR staff in the consistent application of key infection prevention measures. New technologies and procedures, more virulent pathogens and increasing resistance will continue to challenge the healthcare community in its efforts to reduce HAIs. Because of this, even where large-scale cultural change and consistent application of IPC measures exists – even when no break in practice can be identified – healthcare-associated infections will still occur. However, where the goal of zero has been set and the culture is consistent with this goal, APIC is confident that new approaches will emerge to better protect patients from healthcare-associated infections. To view APICʼs evidence-based guides on the elimination of infection, archived webinars and other resources in the Targeting Zero program, please visit www.apic.org.

“Zero tolerance” explained

APIC also believes that willful non-adherence by healthcare workers with proven infection prevention and control measures should be unacceptable. References to “zero tolerance” today are generally intended as a response to unsafe behaviors and practices that place patients and healthcare workers at risk. In the context of HAIs, zero tolerance doesnʼt mean that people or organizations should be penalized for infections that might not be preventable, but this language may be used to stress the need for accountability and a culture built on inquiry and learning as opposed to punishment. A culture of targeting zero healthcare-associated infections and zero tolerance for unsafe practices is characterized by the following: • Setting the theoretical goal of elimination of HAIs; • An expectation that infection prevention and control (IPC) measures will be applied consistently by all healthcare workers, 100 percent of the time; • A safe environment for healthcare workers to pursue 100 percent adherence, where they are empowered to hold each other accountable for infection prevention; • Systems and administrative support that provide the foundation to successfully perform IPC measures; • Transparency and continuous learning where mistakes and/or poor systems and processes can be openly discussed without fear of penalty;

1 Association for Professionals in Infection Control and Epidemiology, Inc. APIC Vision 2012. Available at: http://www.apic.org/AM/Template.cfm?Section=About_APIC&Template=/CM/ContentDisplay.cfm&ContentFileID=4688. Accessed October 31, 2008.

About the author

Kathy Warye is the executive director of the Association for Professionals in Infection Control and Epidemiology, Inc., (APIC), a worldwide membership association providing 11,500 infection prevention professionals legislative and/or public relations strategies on issues impacting the infection prevention and control profession. APIC advances its mission through education, research, collaboration, practice guidance, public policy and credentialing.

16 The OR Connection

More than an ounce of prevention.
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Maintain closed system

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Reference 1 Wald HL, Ma A, Bratzler DW, Kramer AM. Indwelling urinary catheter use in the postoperative period. Archives of Surgery. 2008;143(6):551-557.

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Back to Basics

Ninth in a Series

Applying Evidence-Based Information to Improve Hand-Off Communication in Perioperative Services
By Alecia Cooper, RN, BS, MBA, CNOR

There are three very significant hand-offs that occur in perioperative services for each patient who undergoes a surgical procedure. The first one is from the pre-operative patient care area to the holding room staff. The second one is from the OR team to OR team members. The third one is from the OR team to the post-anesthesia care team.

There are also additional hand-offs that result for data gathered within each unit or area, depending upon information gathered during assessment periods. There can be hand-offs from holding room staff to anesthesia and the assigned circulator as well as from circulator to circulator when being relieved for breaks, lunch and at shift change. The last hand-off occurs when the PACU nurse hands off to the post-op caregiver.

Adverse events during surgery

Obviously, there are many opportunities to gather and communicate critical information that can affect and improve patient care, prevent injuries and medical errors and ensure that your patient has the safest and highest-quality surgical outcomes.

The list of what can go wrong during a surgical experience is long and intimidating. Foreign bodies, mislabeled pathology specimens, operative fires, transfusion and medication errors and wrong site, wrong procedure, wrong person surgery are just some of the preventable hazards associated with surgery.1 Adverse events occur more often in surgery than in any other specialty, and disproportionately greater harm results from surgical errors.2 In the surgical setting, a premium is placed on efficiency. There are strict schedules that must be kept despite constant

18 The OR Connection

Patient Safety

interruptions from emergencies, add-ons, delays and complications. Time becomes a barrier to communication.2 Rushing the hand-off can lead to small, yet critical mistakes that can ultimately harm patients.2

Example: A patient who has been in an accident and requires surgery also has a severe shoulder sprain. However, the staff members who transfer the patient to preoperative holding forget to mention this, so no one else – including the OR, anesthesia, PACU or the floor – is aware of the shoulder sprain. Throughout the care, nurses repeatedly manipulate the patientʼs arm during repositioning, causing distress to the patient and worsening the patientʼs injury.2

National Patient Safety Goal 2E

1. Interactive communication that allows for the opportunity for questioning between the giver and receiver of patient information. 2. Up-to-date information regarding the patientʼs condition, care, treatment, medications, services and any recent or anticipated changes. 3. A method to verify the received information, including repeat-back or read-back techniques. 4. An opportunity for the receiver of the hand-off information to review relevant patient historical data, which may include previous care, treatment or services. 5. Interruptions during hand-offs are limited to minimize the possibility that information fails to be conveyed or is forgotten. The goal further states that an organization should implement a standardized approach to hand-off communication. Is your process standardized? Hand-off communication is defined as the “transfer of information (along with authority and responsibility) during transitions in care across the continuum for the purpose of ensuring the continuity and safety of the patientʼs care.”4 It is the interactive delivery of accurate and current information about a patient exchanged from one provider/caregiver to another. To improve the reliability of workflows accomplishing their desired goals, and to reduce the risk to patient safety, researchers

According to the Joint Commission, communication issues are the leading factor in root causes of sentinel events.3 For this reason, the National Patient Safety Goal 2E (NPSG.02.05.01) was added in 2006. This goal reads as follows: “The [organization] implements a standardized approach to hand-off communications, including an opportunity to ask and respond to questions.”3 The elements of performance that are measured by the Joint Commission in an organizationʼs hand-off process include3:

Standardizing hand-off communication

Aligning practice with policy to improve patient care 19

A clear barrier to hand-off communication is the sheer number of individuals involved in the care of surgical patients. In a recent study, it was revealed that the typical surgical patient sees an average of 26.6 health professionals during their hospital stay, compared with the mean of 17.8 health professionals seen by medical patients.2 Therefore a standardized process for hand-off communication becomes critical in perioperative services to ensure that communication is thorough and complete among all of the perioperative team members. Healthcare providers have looked at other high-risk, highstakes industries such as aviation, aerospace, nuclear power and the military for new approaches that can be applied to healthcare hand-offs.2 Organizations have also used the Six Sigma methodology framework to try and better understand the process for hand-off communication.6 The development of a standardized hand-off communications tool is a dynamic process that allows continued opportunities for improving the delivery of patient care.4 AORN has developed a Perioperative

recommend structured communications and clear agreements about roles and responsibilities in a hand-off.5

Patient “Hand-Off” Tool Kit that includes nine recommendations for standardized hand-off policy development.4

Popular hand-off communication systems

Here are four widely used hand-off communication systems:

Choosing a standardized hand-off method and tool

• “I PASS the BATON” (Introduction, Patient, Assessment, Situation, Safety Concerns, Background, Actions, Timing, Ownership, Next) • “I-SBAR” (Introduction, Situation, Background, Assessment, Recommendation) • “PACE” (Patient/Problem, Assessment/Actions, Continuing [treatments]/Changes, Evaluation) • “Five Ps” (Patient, Plan, Purpose, Problem, Precautions, Physician [assigned to coordinate])
All four systems are effective as long as there is adherence to the following rules4:

AORNʼs nine recommendations for standardized hand-off policy development4
Recommendation One Leadership should respond to the Joint Commission mandate to improve hand-offs by initiating a program within each facility, setting the priority and identifying the timeline.

1. Conduct the hand-off face-to-face. 2. Be certain that the hand-off is two-way, with both participants taking joint responsibility for ensuring accurate communication. 3. Use verbal and written means of communication. 4. Give as much time as necessary to ensure accurate communication.

Recommendation Two Consider using structured tools that can facilitate consistency in communication exchanges. Examples include, but are not limited to, the “I PASS THE BATON,” “I-SBAR,” “PACE” or the “Five Ps.” Each mnemonic is developed to guide medical hand-offs and optimize information transfer. Recommendation Three When implementing training and process changes, use a broad definition for hand-offs to include most care transitions and information handling across the continuum of care. Recommendation Four Use a system, checklist, template or mnemonic that includes updated information, recent changes in condition or circumstances and any anticipated changes or aspects of care that need to be observed or watched closely. Recommendation Five Redesign the hand-off and shift change processes to protect against unnecessary interruptions, and allocate sufficient time to the process.

Recommendation Six Design methods that facilitate instruction on and implementation of effective communication and teamwork skills, as provided in TeamSTEPPS, which verify information transfer with closed-loop communication tools (including check-back, read-back, call-out, etc.) for transferring important information, such as critical actions, medication doses and urgent actions. Recommendation Seven To meet this requirement, charts, written information and reports/results should be available for review (as appropriate) by the oncoming provider(s). Recommendation Eight While developing hand-off policies and protocols, include a clear statement of how and when responsibility is transferred during healthcare transitions.

Recommendation Nine Teach and practice communication using established clear, common language among care providers during hand-offs.

20 The OR Connection

10 barriers to effective hand-offs

1. Lack of education at nursing and medical schools 2. Healthcare system that historically has supported individual autonomy and performance 3. Lack of engagement of patients and families in the care process 4. Resistance to change among staff 5. Lack of time for providers to devote to handoffs 6. Problems in the physical setting, including background noise and interruptions 7. Language barriers between clinicians and between the clinician and the patient. Itʼs also important for clinicians to avoid abbreviations and ambiguous terminology 8. Failures in mode of communication, such as fax machine or email or the inability to locate the patient record 9. Lack of definitive scientific research and data to identify accepted hand-off best practices 10. Lack of financial resources to implement standardized hand-off processes

10 tips for effective hand-offs

1. Allow for face-to-face hand-offs whenever possible. 2. Ensure two-way communication during the hand-off process. 3. Allow as much time as necessary for hand-offs. 4. Use both verbal and written means of communication. 5. Conduct hand-offs at the patient bedside whenever possible. Involve patients and families in the hand-off process. Provide clear information at discharge. 6. Involve staff in the development of hand-off standards. 7. Incorporate communication techniques, such as SBAR, in the handoff process Require a verification process to ensure that information is both received and understood. 8. In addition to information exchange, hand-offs should clearly outline the transfer of patient responsibility from one provider to another. 9. Use available technology, such as the electronic medical record, to streamline the exchange of timely, accurate information. 10. Monitor use and effectiveness of the hand-off. Seek feedback from staff.

TeamSTEPPS

The DoD Patient Safety Program extended permission to AORN to customize its existing materials with a focus on perioperative settings. This is what was used in the development of AORNʼs tool kit. The TeamSTEPPS program is an opportunity for the surgical team to diminish the risk of error and improve patient outcomes by creating a structure to support standardized hand-offs and improve communications during care transistions.4 Within this kit are numerous tools, mnemonics and strategies to be used as templates. The AORN tool kit is available for free and can be downloaded from www.aorn.org. One healthcare organization utilizing the TeamSTEPPS curriculum developed a team hand-off model. To minimize interruptions and distractions during the hand-off process, this organization modified a concept championed by the aviation industry – the “sterile cockpit.” In response to the increasing number of commercial airline accidents involving the cockpit

TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety) is an evidence-based teamtraining curriculum used by the Department of Defense (DoD). It was developed by the Agency for Healthcare Research and Quality (AHRQ).

crewʼs attention being diverted from more critical tasks, the Federal Aviation Administration enacted regulations to prohibit crew members from performing nonessential duties or activities (including conversation) while the aircraft is involved in the phases of flight most commonly associated with error: taxi, takeoff and landing.6 This healthcare organization interpreted the sterile cockpit concept for the clinical setting during the verbal transfer of patient information. Specifically, only patient-specific conversation or urgent clinical interruptions were permitted to occur during the hand-off process. They measured their performance improvement after implementing the system and found they were able to reduce hand-off turnaround time from 15.3 minutes to 9.6 minutes.

Formula 1 hand-offs

Another healthcare organization has initiated a new hand-off process modeled after routine pit stops in racing, which typically take less than 10 seconds. Each crew member has a specific job that they know very well. The crew is prepared down to the smallest detail. Safety is the number one concern because the consequences of errors can be life-threatening for both driver and crew. In contrast to pit stops, hand-offs can be chaotic events involving multiple simultaneous conversations.

Aligning practice with policy to improve patient care 21

Continued on Page 23

Searching for that one last sponge?

The RF Surgical® Detection System™
Perioperative nurses spend 15 to 30 stressful minutes manually counting surgical sponges and instruments before, during and after each operation. Even with such protocols, studies suggest that given the 28.4 million inpatient operations performed nationwide, more than 1,500 cases of a retained foreign body occur annually in the United States.1 According to Harvard University researchers, 88 percent of retained sponge cases falsely recorded a “correct” manual count of sponges at the end of the procedure, leading staffs to unknowingly leave behind sponges in patients. Prevent Retained Surgical Objects RF Detect® is the first easy-to-use scanning system to accurately detect and prevent retained sponges, gauze and towels in patients. No larger than a grain of rice, RF Detect brings major improvements in patient safety to the OR.
Reference 1. Popovic JR, Hall MJ. 1999 National Hospital Discharge Survey. Advance data from vital and health statistics. No. 319. Hyattsville, Md.: National Center for Health Statistics, 2001. (DHHS publication no. (PHS) 2001-1250 1-0287.).

Are You Covered? As of October 1, 2008 Medicare will stop paying for objects retained during surgery. Several major insurers are following suit. By helping prevent the occurrence and risk of retained surgical objects, the RF Surgical Detection System sets a new standard of patient care and safety in the operating room and helps you avoid the cost of diagnosis, treatment, re-operation, legal settlement and the time tracking OR disposables. Developed and Manufactured by RF Surgical Systems, Inc. The RF Surgical Detection System is exclusively distributed by Medline® Industries, Inc.

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©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc. RF Detect® is a registered trademark of RF Surgical Systems, Inc. RF Surgical® is a registered trademark of RF Surgical Systems, Inc. RF Surgical Detection System™ is a trademark of RF Surgical Systems, Inc.

This organization utilized a human factors expert along with members of the medical staff to study the unique maneuvers of Formula 1 pit crews. They witnessed many behaviors that they then applied to patient hand-offs following surgery. Before the hand-off, the surgical team notifies the receiving caregivers of any specific equipment that the patient will need so that there is no scrambling to get it set up. The equipment can be ready and waiting upon arrival. When the patient arrives, there is a routine process that is standardized and takes place in the same order every time. First, all lines and tubes are untangled and reconnected quietly and efficiently. Then, the team ensures that the patientʼs condition is stable before the report begins. The final phase is the report, which utilizes a handover checklist and surgeonʼs summary. This occurs without distraction from transfer activities or competing conversations because the receiving team is able to give their full attention to the transferring team as the report is given. The hand-off is smooth, efficient and – most important – safe.2

the recipient is prepared to mentally process. Because of this, many organizations have developed structured communication techniques such as checklists and read-back techniques.6 The use of a checklist serves two purposes. It ensures that critical information necessary for patient care is not overlooked and it provides a consistent order in which information is communicated. These tools serve to address those unique issues or critical pieces of information related to continuity of patient care between specialty areas.4 The hand-off checklist or documentation tool will help ensure a standardized method for everyone to use. Although checklists can enhance memory, longer lists might not be as effective. A checklistʼs content and design must be prudent and strategic to gain its desired results. When providing the hand-off communication, remember these important communication techniques to ensure that there is two-way interaction: • Get the personʼs attention • Make eye contact • Face the person • Use the personʼs name • Express concern • Use a standardized communication technique • Use a standardized communication tool/checklist • Re-assert as necessary • Escalate if necessary

Battling lost data in nursing hand-offs

In a study done by Pothier, Monteiro et al, the hand-off of 12 simulated patients was observed over five consecutive handoff cycles. Three hand-off styles were used and the amount of data loss was recorded for each style. The purely verbal handoff style resulted in the loss of all data after three cycles. A note-taking style resulted in only 31 percent of data being transferred correctly after five cycles. When a printed form was included with the verbal hand-off, data loss was minimal. The authors recommend that nursing and medical staff include a printed data sheet as part of the hand-off process.4 AORN describes the preoperative brief as a powerful tool to “bring the entire OR team onto the same page”; remove incorrect assumptions; clarify the intended plan and contingency plans; obtain key information from surgeons, anesthesia providers, circulating nurses and surgical technologists or scrub nurses that enhances patient care safety and quality and develop counter-strategies for avoiding common pitfalls, errors and complications.4 AORN recommends using four different hand-off briefs, the Pre-Op Brief, HandOff Briefs for Continuity, Post-Op Brief and Discharge Brief. The diagram to the right displays the operating room briefs from the OR to discharge home. Pre-Operative Pre-Op Brief

Transitions in care are prime targets for improved patient safety efforts. There are several strategies that have been developed in high-reliability organizations that can be applied to health care and have been successfully implemented with positive results. For a sample hand-off policy and procedure as well as checklists and other tools from Trinity Medical Center in Rock Island, IL, please refer to Pages 82-83 and 85-86 in the Forms & Tools section. Trinity has been recognized by the Joint Commission as a model for hand-off communication.

Forms and checklists

To facilitate an individualʼs comprehension of what is communicated, information must be organized in a format that

“Bring the OR Nurse-nurse team onto the Anesth-anesth same page” by Tech-tech stating the plan

Intra-Operative Hand-Off Briefs for Continuity

Anesth to PACU nurse to inpatient provider

Post-Operative Post-Op Brief

Discharge Brief/Home Discharge Brief To the patient and family for home care or home health nurse with clear diagnosis and post-op plan

Aligning practice with policy to improve patient care 23

Topics for hand-off checklists

Anesthesia provider may report: • Patient name, gender, age, procedure, physician • History of present illness • History of chronic illness • Relevant pre-op lab tests • Type of anesthesia administered • Patient response to anesthesia agents • Duration of anesthesia • Reversal agents • Narcotics • Antibiotics • Fluid replacement and type (I & O) • Invasive monitoring line • Vital signs • Allergies • Other conditions • Medications given • Complications related to the procedure • Orders Surgeon may report: • Immediate orders • Diagnostic tests for PACU • Interventions needed in PACU

Perioperative nurse may report: • Baseline patient assessment • Positioning during procedure • Skin prep • ESU pad placement and removal assessment • Use of special equipment (laser, endoscope) • Intraoperative irrigation fluids • Administration of medications or dyes from surgical field • Implants, transplants, explants • Dressing • Drains, stents, catheters • Sensory or motor limitations • Prosthesis presence • Pressure ulcer risk assessment • Other pertinent patient information • Information about the family or others waiting for the patient

Be sure to complete the CE credit crossword puzzle on Page 26!

References 1 Makary M, Sexton J, Freischlag J. et al. Patient safety in surgery. Ann Surg. 2006;243: 628-635. 2 Stokowski L. Perioperative Nurses: Dedicated to Safe Surgical Care. Available at: http://www.medscape.com/viewarticle/562998. Accessed November 4, 2008. 3 The Joint Commission. National Patient Safety Goals: History Tracking Report 20092008. Available at: http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/09_hap_npsgs.htm. Accessed November 4, 2008. 4 AORN. Perioperative Patient “Hand-Off” Tool Kit. AORN. Available at: http://www.aorn.org/PracticeResources/ToolKits/PatientHandOffToolKit/. Accessed November 4, 2008. 5 Agency for Healthcare Research and Quality. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. AHRQ Publication No. 08-0043. April 2008. 6 Mistry K, Jaggers J, Lodge A et al. Using Six Sigma® Methodology to Improve Handoff Communication in High-Risk Patients. Available at: http://www.ahrq.gov/downloads/pub/advances2/vol3/advances-mistry_114.pdf. Accessed November 4, 2008

24 The OR Connection

Care Bundle for Surgical Site Preparation

Following these steps for best practice can help reduce the incidences of surgical site infections.1 • • • • • • • • Glucose control Preoperative CHG shower Appropriate hair removal Hand hygiene No razors Skin antisepsis Antimicrobial prophylaxis Normothermia

Reference 1. Mangram AJ, et al. The hospital control practices advisory committee. Guidelines for prevention of surgical site infection. Infect Control Hosp Epidemiol. 1999;20(4): 250-278. Information contained on this site pertains only to the United States of America.

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Back to Basics

Crossword Puzzle

Applying Evidence-Based Information to Improve Hand-Off Communication in Perioperative Services
1 2 3 4 5 6 7 10 8 11 12 13 9

14 15 16 17

18

19 22

20

21

23 24 26 30 31 27 28 25 29

32 33

34

26 The OR Connection

www.medlineuniversity.com 1. Register (free) or log in 2. Click Free Courses tab 3. Locate the puzzle and click Learn More, then Begin Course 4. Certificates are available online after puzzle completion

Across 1 Consider using structured _____ that can facilitate consistency in communication exchanges. 5 When providing the hand-off communication, express _____. 7 Teach and practice communication using established clear, common _____ among care providers during hand-offs. 9 According to the Joint Commission, communication issues are the _____ factor in root causes of sentinel events. 12 _____ the hand-off can lead to small, yet critical mistakes that can ultimately harm patients. 13 A clear _____ to hand-off communication is the sheer number of individuals involved in the care of surgical patients. 16 The National Patient Safety Goal 2E states that an organization should implement a _____ approach to hand-off communication. 18 Redesign the hand-off and shift change processes to protect against unnecessary interruptions, and allocate sufficient time to the process. 21 Give as much _____ as necessary for the hand-off to ensure accurate communication. 22 Time becomes a barrier to _____. 23 In the surgical setting, a premium is placed on _____. 24 A healthcare organization initiated the sterile _____ concept for the clinical setting during the verbal transfer of patient information. 2 7 _____ must be organized in a format that the recipient is prepared to mentally process. 31 _____ should respond to the Joint Commission mandate to improve hand-offs by initiating a program within each facility. 32 When providing the hand-off communication, make _____ contact. 33 Adverse events occur more often in _____ than in any other specialty, and disproportionately greater harm results from surgical errors. 34 A checklistʼs content and design must be prudent and strategic to gain its desired _____.

Down 1 A standardized process for hand-off communication becomes critical in perioperative services to assure that communication is _____. 2 Be certain that the hand-off is two-way, with both participants taking _____ responsibility for ensuring accurate communication. 3 When providing the hand-off communication, _____ the person. 4 _____ in care are prime targets for improved patient safety efforts. 6 When providing the hand-off communication, use a standardized communication _____. 8 Healthcare providers have looked at other high-risk, high-stakes industries such as _____ for new approaches that can be applied to hand-offs. 10 The use of a checklist ensures that critical information necessary for patient care is not _____. 11 The _____ brief brings the OR team on to the same page by stating the plan. 14 When providing the hand-off communication, get the other personʼs _____. 15 “I-SBAR” stands for introduction, _____, background, assessment, recommendation. 17 While developing hand-off policies and protocols, include a clear statement of how and when _____ is transferred during healthcare transitions. 19 TeamSTEPPS is an evidence-based team-training _____ used by the Department of Defense. 20 Another healthcare organization has initiated a new hand-off process modeled after routine _____ stops in racing. 25 Researchers recommend _____ communications and clear agreements about roles and responsibilities in a hand-off. 26 There are _____ very significant hand-offs that occur in perioperative services for each patient who undergoes a surgical procedure. 28 The use of a checklist ensures a consistent _____ for information. 29 When providing the hand-off communication, use the personʼs _____. 30 _____ communication is defined as the “transfer of information during transitions in care across the continuum.”

To receive one hour of CE credit, enter your answers online at www.medlineuniversity.com
Aligning practice with policy to improve patient care 27

Measuring What You Manage

We have all heard the old adage “If you canʼt measure it, you canʼt manage it.” Most folks in health care strongly believe in this concept. So it will come as no surprise to you that when I speak to healthcare executives about the work of LifeWings, I am always asked, “How do you measure this?”

So, the goal of the facility is great patient satisfaction. The measurement tool is the satisfaction survey.

I think what they are really asking is, “What are the results we can expect to see?” and “How can you document that?” Consequently, we spend quite a bit of time and effort helping hospital executive teams create realistic data collection and analysis plans to help them paint the “before” and “after” pictures for their teamwork-based patient safety initiatives. Of course, by gathering and analyzing data that builds the “after” picture, the client can see in their measurement tool if the steps they are taking are actually changing anything – are they hitting their goal(s)? If not, they can take management action and change or adjust the methodology to reach their goal(s).

Based upon recent research from a large hospital in the mid-South, if your goal is to improve patient satisfaction, the management action should be to improve the teamwork of the healthcare team.

Teamwork: the key to patient satisfaction

One common goal of most hospitals today is getting great HCAHPS scores. CMS now publishes the results of these patient satisfaction survey scores on their Web site. What patients think about the care they received in your hospital is now available for the whole world to see on the Internet.

What management action should an institution take if the satisfaction score is not where theyʼd like it to be? By adding a question to their satisfaction survey asking the patient to rate the level of teamwork they experienced during their stay, the hospital mentioned above was able to analyze the results of almost 30,000 surveys to discover a .97 correlation between the “teamwork” rating and the patientʼs willingness to give a “Would Recommend” and an “Overall Excellent” rating on their survey responses.

Whether your goal is reduced mortality, to eliminate bloodstream infections or to improve patient satisfaction, providing your caregivers with excellent teamwork skills should play an important part in your improvement equation.

28 The OR Connection

Special Feature

Patients may not be expertly trained teamwork assessors, but they seem to know good teamwork when they see it. When your caregiversʼ teamwork is first rate, your patients are going to give you an “Overall Excellent” rating and “Recommend” your facility to their friends and family.

Using teamwork to improve your mortality rate

This same research also showed a correlation between a patientʼs “teamwork” rating and the mortality rate of the hospital. The teamwork of the facilityʼs caregivers, as rated by the patient, controls approximately one third of the variation in mortality in that institution. If your goal is to provide better care and one of the measurement tools for that goal is your mortality rate, then one of the management actions you should take to help reach that goal is to improve your providersʼ teamwork skills.

Based upon recent research from a large hospital in the mid-South, if your goal is to improve patient satisfaction, the management action should be to improve the teamwork of the healthcare team.

Hereʼs one more example of these principles. The state of Michigan began a state-wide initiative called the Keystone Project to reduce or eliminate bloodstream infections in patients in their hospitalʼs ICUs. To achieve this, one of the tactics the facilities adopted was the use of a standard protocol, accomplished with the aid of a checklist, to insert a central line. The checklist and the training process on how to use it were pretty near identical for every institution. Yet despite the similarity in protocol, process and training, ICUs saw variability in their results. What causes the variability? Further analysis revealed the most successful ICUs were those with a better safety culture as evidenced by a greater willingness to cross check one another and to speak up to hold one another accountable to abide by the protocol. In short, better teamwork. If your goal is fewer bloodstream infections, and your measurement tools are the level of compliance with the protocol and the number of infections, the management action you should take to help reach your goal is to improve the teamwork of the folks in the ICU. One of my favorite quotes about measurement is from the author Robert Heinlein. He says, “If it canʼt be expressed in figures, it is not science; it is opinion.” One thing we know about teamwork is there is a “science” to it. Teamwork has been clearly shown, by expression in “figures” (or numbers), to improve outcomes in health care.

Whether your goal is reduced mortality, to eliminate bloodstream infections or to improve patient satisfaction, providing your caregivers with excellent teamwork skills should play an important part in your improvement equation.

About the author

Stephen W. Harden is President of LifeWings Partners LLC and co-founder of Crew Training International, Inc. (CTI), the parent company of LifeWings. Prior to his position at LifeWings, he was the principal courseware designer of CTIʼs Crew Resource Management (CRM) training for the U.S. Air Combat Command, Air National Guard, Air Force Reserve Command, Italian Air Force, Swiss Air Force, Belgian Air Force, domestic and commercial airlines, construction crews and hospital surgical teams.

Aligning practice with policy to improve patient care 29

Patient Safety in Surgery
Learning from aviation safety: a call for formal "readbacks" in surgery
By Philip F. Stahel

The first fatal airplane crash in history occurred exactly 100 years ago, on September 17, 1908, when Army lieutenant Thomas Selfridge died in a failed flight attempt with the aviation pioneer Orville Wright. Since that time, aviation safety standards have significantly improved. Currently, the risk for an American dying in an airplane crash is about 1:500,000, compared to a 1:20,000 chance of dying in a car accident. In the field of medicine, it was not until the shocking report by the Institute of Medicine in 1999 revealed that 100,000's of pa-

tients die in the United States every year as a consequence of medical errors [1], when we began to realize that there is something "wrong with the system". While this unacceptably high number has been chronically underrated in public recognition, an extrapolation of these statistics to professional aviation equals to about 200 jumbo jet crashes per year, or one 747 crash every other day. This dramatic insight led to the design of the "100,000 lives campaign" by the Institute for Healthcare Improvement in

30 The OR Connection

Patient Safety
2004 [2]. By 2006, the campaign had surpassed its initial goal by saving more than 120,000 lives through the implementation of increased patient safety standards and algorithms [2]. These include the recent implementation of a standardized surgical "time-out" to ensure the correct patient identity and correct procedure performed at the correct surgical site [3]. In addition, the implementation of formal, structured perioperative briefings in the operating room have been shown to significantly reduce the incidence of wrong site surgeries [4]. Despite those recent improvements, the analysis of the American College of Surgeons' closed claims study revealed that a breakdown in communication before, during, or after surgery still represents a significant source of errors which lead to patient complications [5]. Of these, 85% of adverse events related to communication breakdown occurred by verbal communication, while only 4% were attributed to communication in written form [5]. This notion provides the basis for a call for written checklists and formal verbal "readback" orders among healthcare professionals who care for surgical patients, in order to avoid or reduce the high incidence of perioperative complications related to a breakdown in communication. Interestingly, pilot readbacks represent a hallmark safety concept in professional aviation. While the current debate in aviation safety is related to optimizing and correcting the modality of readbacks [6,7], this crucial form of communication is still virtually nonexistent among surgeons. Dr. Eddie Hoover has characterized the issue to the point, in a recent editorial: "Getting surgeons to readback orders and instructions will age you 10 years, yet the Navies of the world have demonstrated for eons that it improves efficiency, promotes safety, and saves lives." [8].

Aligning practice with policy to improve patient care 31

I wish to emphasize that the implementation of verbal readback orders represents the 2nd National Patient Safety Goal (NPSG) for 2009, as defined by the Joint Commission [9]. The NPSG #02.01.01, aimed at improving the effectiveness of communication among caregivers, is defined as such: "For verbal or telephone orders or for telephone reporting of critical test results, the individual giving the order or test result verifies the complete order or test result by having the person receiving the information record and 'read back' the complete order or test result." [9]. In conclusion, I urge all healthcare professionals involved in the care of surgical patients to contribute to improved patient safety and reduced complications and sentinel events in 2009 by addressing the most frequent root cause for adverse outcome in surgery: Ineffective communication. The implementation of formal standardized "readbacks" is a promising start. Competing interests The author declares that he has no competing interests.

A Spotlight on “Never Events”
As you know, as of October 1, 2008, CMS is no longer reimbursing at a higher DRG for 11 conditions deemed “never events.” Those conditions are listed below, along with articles in this magazine that relate to them. We hope they help you enhance your facilityʼs prevention measures!
2. Air embolism

1. Retained foreign object after surgery “A Focus on Prevention” ..............................................Page 9 3. Blood incompatibility “Organ Donation”........................................................Page 36

Acknowledgements I would like to thank Ms. Jan Minifie, Dr. Ted Clarke, and Dr. Kagan Ozer for helpful discussions related to this editorial.

References 1. Institute of Medicine: To Err is Human: Building a Safer Health System. National Academy Press, Washington D.C.; 1999. 2. Wachter RM, Pronovost PJ: The 100,000 lives campaign: a scientific and policy review. Jt Comm J Qual Patient Saf 2006, 32(11):621-627. 3. Michaels RK, Makary MA, Dahab Y, Frassica FJ, Heitmiller E, Rowen LC, Crotreau R, Brem H, Pronovost PJ: Achieving the National Quality Forum's "never events": prevention of wrong site, wrong procedure, and wrong patient operations. Ann Surg 2007, 245:526-32. 4. Makary MA, Mukherjee A, Sexton JB, Syin D, Goodrich E, Hartmann E, Rowen L, Behrens DC, Marohn M, Pronovost PJ: Operating room briefings and wrong site surgery. J Am Coll Surg 2007, 204:236-43. 5. Greenberg CC, Regenbogen SE, Studdert DM, Lipsitz SR, Rogers SO, Zinner MJ, Gawande AA: Patterns of communication breakdowns resulting in injury to surgical patients. J Am Coll Surg 2007, 204:533-40. 6. Anderson DZ: Correcting readbacks. Aviation Safety 2008, 28(3):3. 7. Correcting readbacks – letters to the editor. Aviation Safety 2008, 28(4):. 8. Hoover EL: Patient safety and surgeons – why the resistance? Arch Surg 2007, 142:1127-8. 9. [http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/]. Published: 17 September 2008

4. Stage III and IV pressure ulcers “A Focus on Prevention” ..............................................Page 9 “Why Is Pressure Ulcer Risk Assessment So Important?” ..................................................................Page 50 “Fluid Flow Disruption?” ....................................................Page 58 “Pressure Ulcer Prevention Checklist” ......................Page 89 5. Falls and trauma (fractures, dislocations, intracranial injuries, crushing injuries, burns) 6. Catheter-associated urinary tract infections “A Focus on Prevention” ..............................................Page 9 “Targeting Zero” ..........................................................Page 15 7. Vascular catheter-associated infections “Targeting Zero” ..........................................................Page 15 “Care Bundle for Surgical Site Preparation” ...............Page 26 8. Surgical site infection – mediastinitis after coronary artery bypass graft (CABG) “Targeting Zero” ..........................................................Page 15 “Care Bundle for Surgical Site Preparation” ...............Page 26 “SCIP Fact Sheet” ......................................................Page 80 9. Surgical site infections following certain elective procedures, including certain orthopedic surgeries, and bariatric surgery for obesity “Targeting Zero” ..........................................................Page 15 “Care Bundle for Surgical Site Preparation” ...............Page 26 “SCIP Fact Sheet” ......................................................Page 80 10. Certain manifestations of poor control of blood sugar levels

Patient Safety in Surgery 2008, 2:21 doi:10.1186/1754-9493-2-21

This article is available from: http://www.pssjournal.com/content/2/1/21

© 2008 Stahel; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Address: Department of Orthopaedic Surgery, Denver Health Medical Center, University of Colorado School of Medicine, 777 Bannock Street, Denver, CO 80204, USA Email: Philip F Stahel - philip.stahel@dhha.org

11. Deep vein thrombosis or pulmonary embolism following total knee replacement and hip replacement procedures “SCIP Fact Sheet” ......................................................Page 80

32 The OR Connection

OR Issues

A Latex-Free Victory!
An interview with members of the River Oaks Hospital OR Team

One OR’s success

Kim Gordon, RN, BSN, CNOR, is the products nurse at River Oaks Hospital, a 14-room OR in Jackson, Mississippi. In her role, Kim was constantly ordering replacement gloves for all of the services and special needs of the medical and surgical staffs. She was responsible for the inventory of approximately 12 different types of gloves in sizes 5 ½ to 9. At best, it was a difficult task. Kim knew that her facility needed to standardize glove types and reduce their inventory. At the same time, she saw an opportunity for the hospital to address a rising concern in the OR community – latex allergies.

When facilities contemplate where to start combating latex intolerance, one of their most frequently ordered commodities pops into mind: gloves. Latex gloves have the highest concentration levels of allergenic proteins and therefore are the greatest threat to staff members and patients who are intolerant to latex.3

What worked at River Oaks

The American Latex Allergy Association estimates that between 8 and 17 percent of all healthcare workers are sensitized to natural rubber latex.1 Studies have suggested that the costs of healthcare workersʼ disability compensation due to latex allergies justifies or significantly offsets the cost of conversion to a latex-free environment.2

Latex allergies among healthcare workers

To help consolidate gloves and convert River Oaksʼ OR to a latex-free environment, Kim asked product representatives to initiate a glove trial. When selecting new gloves, it is important to establish criteria for the decision. Examples include product availability, viral penetration test results, color, texture, finish, length, primary material, pinhole levels and elongation levels.4

Kimʼs product representative set up a station in a high-traffic area and asked the medical and surgical staff to try on latex-free polyisoprene gloves with and without an interior aloe vera coating.

Aligning practice with policy to improve patient care 33

These gloves were made readily available to the staff for procedures while the likes and dislikes were addressed by the representative.

The evaluations were tallied and the majority of the surgical staff approved the conversion and 100 percent are now using latex-free gloves. Through the conversion, Kim reduced her massive inventory to four types of gloves – two types of latexfree gloves and two gloves that a handful of surgeons require.

Addressing cost concerns

Facilities have a tendency to believe that synthetic gloves are not cost effective. However, conversion and simplification can lead to cost savings through inventory management. Kim was able to demonstrate this by minimizing her glove stock from 12 to four different types of gloves. Although Kimʼs glove usage did not decrease, she was able to minimize waste and increase efficiency.

Left to right: Doug Morrison, Sharon Grisham, Kim Gordon and Dwayne Braxton – members of the Surgical Services Team at River Oaks Hospital who assisted with the latex-free conversion.

Kim summarizes the overall impact of converting to latex free gloves to be:

1. “We improved our patient care by providing a safer, latex-free environment without increasing costs.” 2. “The conversion has created new, much needed space for us. Eliminating so many different kinds of gloves freed up three storage system carts in our central supply area.” 3. “The majority of our staff has been pleased with the conversion. It has certainly cut down on confusion. There is a comfort in knowing that there are two types of gloves to choose from in our OR and both will provide safe care for our patients.”

It is estimated that more than three million people in the United States suffer from a latex allergy.5 The Mayo Clinic defines “latex allergy” as “a reaction to certain proteins found in natural rubber latex, a product manufactured from a milky fluid derived from the rubber tree (Hevea brasiliensis) found in Africa and Southeast Asia.”6 When people have latex allergies, their bodies mistake latex for a harmful substance.6
Milder reactions to latex include skin redness, rash, itching and hives. More serious reactions include sneezing, itchy eyes, scratchy throat and asthma. In severe cases, sinusitis, rhinoconjunctivitis, anaphylaxis and gastrointestinal problems can also occur.7

What is a latex allergy?

Other latex-free options

Gloves are not the only items purchased by medical facilities that contain latex. Some hospitals are beginning to purchase latex-free surgical packs. Other facilities have created a latexsafe unit or latex-safe rooms. This does not mean, however, that these rooms are 100 percent latex-free because there are still some products on the market without a latex-free option. The “latex-safe” designation simply means that there is a severely limited or small amount of latex that is kept or allowed to enter into the room. At River Oaks, Kim also focused on converting to latex-free Foley trays, tubing and arthroscopic cannulas.

Another option for assisting patients with latex sensitivity is creating a latex-free cart. This cart could be easily transported to patients with latex allergies without having to convert and entire room or unit to a latex-free environment. Medical staff will then only be permitted use the latex-free supplies on the cart while working with the patient.

References 1 American Latex Allergy Association. Latex Allergy Statistics. Available at: http://www.latexallergyresources.org/topics/LatexAllergyStatistics.cfm. Accessed November 5, 2008. 2 Phillips VL, Goodrich MA, Sullivan TJ. Health care worker disability due to latex allergy and asthma: a cost analysis. American Journal of Public Health. 1999;89(7):1024-28. 3 Lenehan GP. Latex allergy: separating fact from fiction. Nursing. 2004 Feb;Suppl:12-7; quiz 17-8. 4 Lillis K. Hospitalʼs latex-free program fits like a glove – what works. Healthcare Purchasing News. 2002 Sept. 5 Dyck RJ. Historical development of latex allergy. AORN Journal. 2000 Jul;72(1):27-9, 32-3, 35-40. 6 MayoClinic.com. Latex allergy. Available at: http://www.mayoclinic.com/health/latexallergy/DS00621. Accessed November 5, 2008. 7 Stout G. Creating a latex-safe environment. Infection Control Today Magazine. Available at: http://www.infectioncontroltoday.com/articles/051feat2.html. Accessed November 5, 2008.

34 The OR Connection

You have too much on your hands...
to worry about bacteria.
Sterillium® Rub’s high alcohol content delivers a devastating blow to microorganisms — not your skin. Sterillium® Rub’s balanced emollient blend leaves hands feeling soft and smooth, never greasy or sticky, and makes gloving a breeze. But that doesn’t mean that Sterillium® Rub makes any sacrifices in efficacy. In fact, it meets FDA requirements for efficacy specifications. It’s also CHG, latex and non-latex glove compatible. We know that comfort drives compliance. When you choose Sterillium® Rub, you have an ally that’s tough on bacteria but a real softie on your skin.
Sterillium® Rub with touchless dispenser pictured.

For more information on Sterillium® Rub, contact your Medline sales representative, call 1-800-MEDLINE or visit www.medline.com/sterilliumrub. Also be sure to ask about our Hand Hygiene Compliance Program!

Increased efficacy. Incredible comfort. Improved compliance. Sterillium Rub.

www.medline.com
©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

36 The OR Connection

Special Feature

Organ Donation
Overcoming obstacles and objections

By Jeanne M. Jones, RN

As nurses, we know firsthand that when you are in the emergency room and a massive injury comes through those doors, a multitude of decisions are being made very quickly. One of the important decisions is often organ donation and unfortunately, many of our patients have not made their wishes known beforehand. Organ donation is important for obvious reasons, and millions of people believe in its value. However, problems can crop up when itʼs actually time for the donation. Victims of trauma were not planning on dying – and they might have very strong feelings on whether they want to participate in this final act. But, unless they inform their family members of their wishes, the decision-making quest can be terrible.

A personal experience

My niece, Diane, lost her husband, Joe, two years ago after battling the waiting list. For patients to receive a transplant, they must be “sick enough” but not “too sick” to receive a healthy organ. Every time Joe was on the list, we prayed for a match. Every time he was too sick, we prayed that modern medicine could buy us more time. Joe and Dianeʼs children always said things like, “When Daddy gets his transplant, we can go to Disney” or “When Daddy gets his transplant, we can do the things we used to do.” Joe never got that organ and their lives have changed more than any of us could imagine. Diane and her two children have joined forces with Joeʼs parents and siblings to educate everyone they can on the value of this potentially life-saving decision.
Continued on Page 39

Aligning practice with policy to improve patient care 37

S.T.O.P. for safety.

It could be the difference between life and death.
Wrong site surgery has recently moved into the number one position as the most frequently reported hospital error.1 This is despite a conscientious effort to eliminate this problem before it occurs. What is needed is another layer of safety...something that will improve our chances of correcting the mistake before it happens. Enter S.T.O.P. Surgical Drapes* from Medline. We just made a good idea even better. S.T.O.P. (Surgical Time Out Procedure) drapes are available in a variety of configurations, and include a “S.T.O.P.” strip across the fenestration. As a result, you can’t forget to take a time out to verify the correct patient, procedure, side and site. Then all that is left is to hand the sticker off to the circulating nurse to include in the medical record, documenting that the verification process was completed.
References 1 The Joint Commission. The Statistics page. Available at: http://www.jointcommission.org/NR/rdonlyres/D7836542-A372-4F93-8BD7-DDD11D43E484/0/SE_Stats_12_07.pdf. Accessed March 13, 2008. * Patent pending

If you would like to receive a free sample of the S.T.O.P. Drape system to evaluate for yourself, ask your Medline representative or call us at 1-800-MEDLINE.
STOP!!! STOP!!!
Perform “TIME OUT” Perform “TIME O UT” Verify correct: Verify correct: Person Person Procedure Procedure Site S ide Site & Side Date: ______ Time: ______ Date: ______ Time: ______ Surgeon’s Initials: _____ Surgeon’s Initials: _____

S.T.O.P. strip and sticker

©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

www.medline.com

senate in New Jersey, local citizen groups and other supporters throughout the state to spread the word.

They have worked with insurance companies, the

In July of 2008, Bill S755/A2083, known as the New Jersey Hero Act, was signed by Acting Governor Richard Codey. New Jersey is the first state to require organ donation decisions before applying for a driverʼs license and mandatory high school education regarding organ donation.1 It is hoped that other states will follow the example of this first-in-the-nation initiative. You can learn about your stateʼs policies on organ donation by visiting http://www.donatelife.net/CommitToDonation/.

Organ donation myths “I canʼt donate because Iʼm too old/young/sick.” According to the DHHS, there are no strict upper or lower age limits when it comes to organ donation.5 There are very few illnesses that completely exclude people from donating. The exceptions are HIV, active cancer and systemic infections.5
“My religion prohibits it.”

Who is on the transplant waiting list?

According to information from the Department of Health and Human Services (DHHS), there were 100,238 waiting list candidates as of October 20, 2008.2 Kidneys are the organs needed by the largest number of waiting list candidates, accounting for 76 percent of all organ needs.3 Other commonly needed organs include lungs, hearts, intestines, livers and the pancreas.3 Doctors can currently perform transplants of the kidneys, heart, lungs, liver, pancreas and intestines.4 Corneas, the middle ear, skin, heart valves, bone, veins, cartilage, tendons and ligament can be used to restore sight, cover burns, repair hearts, replace veins and mend damaged connective tissue and cartilage.4 Stem cells, blood and platelets are also needed.4

Most religions encourage organ donation or leave the decision to be made by the individual. To view a listing of the official stances taken by churches, please visit http://organdonor.gov/donation/ religious_views.htm. The DHHS details four different types of donation. They are6: • Organ and tissue donation from living donors • Donation after brain death • Donation after cardiac death (DCD) • Whole body donation
“I have to donate my whole body.”

What can be donated?

How to encourage donation at your own facility

In 2003, the DHHS created the Organ Donation Breakthrough Collaborative with the goal of “saving or enhancing thousands of lives a year by spreading known best practices to the nationʼs largest hospitals, to achieve donation rates of 75 percent or higher in these hospitals.”7 The Collaborativeʼs members represent all members of the organ donation and transplant community – critical care nurses, organ procurement and transplant coordinators, hospital administrators, physicians, clergy, social workers, family members of organ donors and transplant recipients.7

Aligning practice with policy to improve patient care 39

Victims of trauma were not planning on dying – and they might have very strong feelings on whether they want to participate in this final act.
Critical care nurses are an integral part of the donation process. In this spirit, the Collaborative made the following recommendations to critical care nurses to aid them in turning best practices into common practice in their intensive care units7: • Refer all potential donors: Identify potential donors in your unit, familiarize yourself with your facilityʼs criteria for clinical triggers and promptly get in touch with your organ procurement organization (OPO). • Partner with your OPO: Introduce yourself to OPO coordinators and help them become part of your team. • Become a donor “champion”: Talk to your fellow nurses and colleagues about the importance of organ and tissue donation. • Advocate for your patients and their families: Honor your patientsʼ last wishes, including those related to organ donation. Be sure that families are aware of the donation option. • Educate yourself and your colleagues: One option for education is to invite your OPO to conduct in-service training sessions in your unit. • Be a change agent: Focus on system issues, examine what your facility is doing right and determine what needs to change to better your organ donor policies. • Understand the data: Compare your hospitalʼs data on organ donation to national benchmarks.
About the author

References 1 The State of New Jersey Office of the Governor. Acting Governor Codey Signs New Jersey Hero Act. Available at: http://www.nj.gov/governor/news/news/2008/ approved/20080722a.html. Accessed October 20, 2008. 2 OrganDonor.Gov. Waiting list candidates. Available at: www.organdonor.gov. Accessed October 20, 2008. 3 Transplant Living: Organ Donation and Transplantation Information for Patients. Organ Facts. Available at: http://transplantliving.org/beforethetransplant/organfacts/default.aspx. Accessed October 20, 2008. 4 OrganDonor.Gov. What Can Be Donated. Available at: http://organdonor.gov/donation/what_donate.htm. Accessed October 20, 2008. 5 OrganDonor.Gov. Who Can Donate. Available at: http://organdonor.gov/donation/who_donate.htm. Accessed October 20, 2008. 6 OrganDonor.Gov. Types of Donation. Available at: http://organdonor.gov/donation/typesofdonation.htm. Accessed October 20, 2008. 7 Tamburri LM. The role of critical care nurses in the Organ Donation Breakthrough Collaborative. Critical Care Nurse. 2006;26(2).

Jeanne M. Jones, RN has 40 years of perioperative experience. She is currently a clinical nurse product specialist.

40 The OR Connection

Customized solutions.

Anesthesia Supply Management Solutions
Does your anesthesia storage need help? When you partner with Medline, your anesthesia supply management world will be revolutionized. With Anesthesia Complete Delivery System (ACDS*), all anesthesia supplies will be par level packaged in a standardized drawer insert, which is then used to restock the anesthesia case carts. This decreases the time it takes staff to order, receive and stock shelf supplies. Taking care of your needs every step of the way Each program is custom designed based on your facility’s anesthesia supply requirements. Medline’s® ACDS will … • Increase staff productivity and satisfaction • Improve inventory control • Increase space utilization • Improve charge/cost capture • Eliminate outdated product • Enhance supply standardization • Enhance compliance with the Joint Commission, AORN and SCIP
* Patent pending

For your free cost-savings analysis, contact your sales representative or call 1-800-MEDLINE.

www.medline.com
©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

OR Issues

Supply Management for Perioperative Services
How to get your inventory under control

42 The OR Connection

While talking about supply management for perioperative services doesnʼt sound very clinical, perioperative leaders also know that supply management is a significant portion of their budget and their world. In fact, 50 percent of a typical OR budget is consumed by supply acquisition costs.1 When you begin to factor in inventory, systems support and staff handling of product, that figure can climb even higher. Letʼs take a look at one of the biggest obstacles to successful supply management – inventory.

When perioperative leaders think about their world, they think about patient care. And Iʼm sure all of us agree that if we or our loved ones need to undergo surgery, thatʼs exactly where we want the clinical staff to be focused!

By Ned Turner

Getting your inventory under control

When hospital CFOs mentions the word “inventory” to key hospital directors, theyʼre often talking about inventory reduction. While many ORs doubtless have the capability to reduce inventory, itʼs still crucial that the right products are in the right place, at the right time. Simply cutting back on inventory might not make your OR more cost effective and might even create a situation that could affect patient care, patient and staff safety and surgeon and staff satisfaction. So what can you do to get your inventory under control without making any sacrifices in safety or satisfaction? Here are five suggestions. 1. Organization Orderly and organized supplies are often more effectively managed.

2. Systems An effective OR materials management system and accurate reporting tools are critical for effective inventory management.

3. Staff Staff members who are focused and well-trained on supplies can allow clinical staff to remain focused on patient care.

5. Annual inventory counts Although annual inventory counts can be time-consuming and a task that volunteers rarely line up to help with, these counts are vital to managing inventory and identifying obsolete supplies. Look for more supply management stratagies in future issue of The OR Connection.
References 1 Davis E. Educating perioperative managers about materials and financial management. AORN Journal. 2005;81(4):798-812.

4. Consignment Consignment can be a great tool for high-cost supplies such as implants, grafts and custom packs.

About the author

Ned Turner has spent the past 29 years working in surgical supply manufacturing and supply management consulting. Ned joined Medline in 2003 after a lengthy career at Cardinal Health that included serving as Area Manager of the Western U.S. He is currently the vice president of Medlineʼs Sterile Procedure Tray Division – Sales and Supply Management Consulting Services.

Aligning practice with policy to improve patient care 43

44 The OR Connection

OR Issues

A New Way to “Pack” It All In
An interview with members of St. Vincentʼs perioperative team

Think about the last time you put a surgical pack together. You probably had a lot to think about. Could you lower costs? Increase productivity? Are all of the products youʼre ordering latex-free? Is there any way to standardize it all?

On average, operating room supplies account for more than 50 percent of a hospitalʼs budget.1 It makes sense that youʼd want to get as much bang for your buck as possible! In the spring of 2008, Medline launched a program to reduce the headaches typically associated with pack management. Med-Pack is a Web-based, real-time pack management tool that was created following intense input from focus groups and advisory boards. Med-Pack, which is available to any Medline pack customer, operates through a series of iViews, which are essentially microsites supplying specific information to users. Examples of iView topics include Safety, Analysis Tools, Alerts, Savings, Standardization and Supply Management, plus many more.

Each Med-Pack user also has an online “eBook” created for them. This eBook contains: • Component lists • Pack history • Documents • Pack images • Pack changes • Eco-friendly components

As you can see, the eBook is a great way to keep critical documents together – without creating a mountain of paper. Since its launch, hospitals throughout the country have adopted Med-Pack at their facilities. We wanted to share one facilityʼs success story with you.

St. Vincentʼs story

The goal of each of these iViews is to quickly provide critical information in a hassle-free format. Users simply click on an iView icon to get the material they need, eliminating the need to jump from Web site to Web site to track down information on latex-free options, St. Vincent Carmel Hospital industry initiatives, etc.

St. Vincent Health is the largest healthcare employer in the state of Indiana, with 17 health ministries serving 45 counties in the central portion of the state. It is also a member of the Catholic Healthcare System and Ascension Health, the nationʼs largest not-for-profit.

St. Vincent Indianapolis Hospital is ranked nationally for cardiac, stroke, orthopedic and gastrointestinal care. It is also Indianaʼs only hospital to be recognized for excellence in four specialty areas by HealthGrades, the leading provider of independent hospital ratings in the U.S.2

Aligning practice with policy to improve patient care 45

Easy to use

The goal was to make Med-Pack so intuitive that users would be up and running in minutes. The program is made up of a series of icons called iViews. Each iView is a microsite, supplying data specific to your account. Here are some of the most popular iViews.

Left to right; Vicky Smith, Gussie B. Johnson, Barb Weimer, Karen Fox, Sondra Jones and Francie Dolder

eBook

OR Corner

Safety

Becky Hodson is the OR Materials Team Leader at St. Vincent and estimates that the facilityʼs 10 operating rooms perform around 150 bariatric surgeries a month in addition to other types of procedures. With the hospitalʼs high volume of surgeries, Becky has found Med-Packʼs time-saving features especially beneficial. Simplifying pack changes Before using Med-Pack, Becky recalls that surgical packs would have to be built by arranging to have a sales rep visit the facility and complete paperwork. Making pack changes required more back-and-forth with paperwork. Now, Becky can view her packs online and request changes with a few clicks of her computer mouse. This comes in handy because team leaders at St. Vincent meet once a month to discuss any changes they would like to make with packs, which could create more time-draining paperwork with another system. All pack changes are approved by the management team.

Analysis Tools

Alerts

Savings

Spend and Trend

Standardization

Supply Management

This gives her time to alert staff that a change is coming and prevent potential frustration. Itʼs also easy to identify the most recent pack versions on St. Vincentʼs shelves because Med-Pack automatically changes the last letter in the packʼs product number each time a pack is altered. Standardization Becky has also used Med-Pack to help make strides toward St. Vincentʼs goal of pack standardization across its multiple facilities. “When you can have one pack, why have three out there?” she said.

Vicky Smith

Vicky Smith, CST, Spine Team Lead at St. Vincent Indianapolis, appreciates how Med-Pack enables her to see when a pack change is about to occur.

In one instance, Becky was able to use Med-Pack to view the pack used at a sister facility by one of St. Vincentʼs top-volume orthopedic doctors. Since that surgeon was also practicing at the Carmel location, Becky was able to standardize using his pack at both locations.

46 The OR Connection

Continued on Page 48

Everything you need to know about your packs at your fingertips.

Introducing Med-Pack, an interactive, real-time data management tool for surgical procedure pack management.
Whether you’re an OR director, materials manager or GPO administrator, Med-Pack has many different “iViews” that provide specific information to help you manage your surgical packs and your OR. • View photographs of your packs and components • View inventory in real time • Get alerts for pack changes • Run safety and latex analyses on your packs • Run reports by component, pack or discipline

Talk to your sales representative to obtain a Med-Pack login and experience Med-Pack for yourself.

Featuring OR Corner, where you can find the latest industry news, hot topics and industry calendar of events.

www.medline.com
©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

Cost savings Both Vicky and Becky praised Med-Pack for its ability to call attention to cost savings options. “I like that I can see item costs and have the option of checking to see if there are savings available,” said Vicky. To learn more about how Med-Pack could benefit your own facility, please contact your Medline sales representative.
References 1 Davis E. Educating perioperative managers about materials and financial management. AORN Journal. 2005;81(4):798-812. 2 St. Vincent Health. St. Vincent Indianapolis Hospital. Available at: http://www.stvincent.org/ourlocations/hospitals/indianapolis/default.htm. Accessed November 13, 2008.

Clinical

Logistical

Financial

eBook
Pack Detail Pack Image

Safety Center
Safety Analysis

Lu McKee and Becky Hodson

Latex Analysis Safety Articles

Supply Management
Alerts Inventory

Savings Analysis Tools
Standardization Component Utilization

OR Corner
Hot Topics Link to Industry Experts

Note: iViews can host clinical, operational or financial information. Which iViews would be most helpful to you?

48 The OR Connection

We’re setting a new standard in patient safety.

G O L D S TA N D A R D S A F E T Y P R O G R A M
Medline is proud to introduce our Gold Standard Safety Program, designed to break down barriers in surgical safety compliance by offering products, analysis tools and checklists to help you reach your safety goals. The program offers four levels of safety options: 1. The Gold Standard Safety Bundle: Includes six products to serve as visual safety reminders to reduce needle sticks and wrong site surgery. 2: Innovative safety products: Surgical Time Out Procedure (S.T.O.P.™) Drapes (patent pending), RF Surgical® Detection System and Universal Electrosurgical Pads. 3. AORN Checklist: Wrong site, wrong procedure, wrong patient surgery prevention. 4. Med-Pack™: Electronic pack audit and a review of safety components.

To learn more about the Gold Standard Safety Program, contact your Medline sales representative, call us at 1-800-MEDLINE or visit www.medline.com.

www.medline.com
©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

Why is Pressure Ulcer Risk Assessment So Important?
By Alecia Cooper, RN, BS, MBA, CNOR

Letʼs examine what a patient and nursing student have to say!
ago this past September, I have lived all pressure ulcers alone and got along pretty well caring occur in people 70 for myself. But as of late, I have been years and older.1 getting “blue” more often than not. I donʼt have much of an appetite and I canʼt get around as well as before. I become dizzy in the early mornings and I have taken a fall several times. Most of my friends are either too sick to get out much or they have passed on.

My name is Euretha and I have a story to tell you. I think it could help folks like you who work in hospitals and nursing homes alike. My granddaughter is studying to become a nurse and she thinks what she and I have learned about my experience can help everyone. So I agreed to help. I am 79 years old and have been in pretty good health all of my life until I started getting feeble these last few months. Since the passing of Theodore, my beloved husband, three years

About 70 percent of

50 The OR Connection

Patient Safety
On November 1, I went to stay at Happy Valley Nursing Home for what I thought was only temporary, no more than a couple of months. Today is Christmas Day and I hope the kids get here soon as I just cannot bear the thought of being away from home on my favorite holiday. As hard as I tried to persuade him otherwise, Dr. Hill said I am not ready to leave yet. You see, what I have not told you yet is that I had one of those dizzy spells 14 days after I came to Happy Valley.

It was early that morning when I got out of bed to go to the bathroom. I lost my footing, slipped and fell hard on my right hip and it broke. We were not sure it was broken at first, but once I got to the hospital, they were sure. I had surgery and a stay in the hospital and then came back Why is pressure ulcer risk to Happy Valley with this doggone bedsore on my assessment so important? other hip. It is not healing too Because it helps identify which well. In fact, it just keeps get- patients or residents may benefit ting worse. Those “blue” most from preventable measures.2 days have just been getting worse. I thought I would cry The best way to prevent pressure all day when Dr. Hill let me ulcers may be through the use of know that he now thinks that evidence based of pressure ulcer this bedsore could be risk assessment tools.3 infected. This whole situation worried my poor granddaughter, so she talked to one of her nursing instructors who gave her an idea for a school research project. She said she needed my Confinement to a bed or chair help. Imagine that. I get to for a week has been found to help her figure out what could increase the prevalence of preshave prevented my bedsore sure ulceration by 28 percent.4 from developing after I broke my hip. I asked her how could I possibly help, and she told me that we needed to go through every event from the time my injury occurred until the bedsore developed. She explained that she would take every part of the story and research the prevention measures that, if they had been done, might have prevented that bedsore from developing. To prove her point, she brought me an article to read that she found in one of her nursing journals. That article said that the experts say bedsores can be prevented in most cases. If all this is true, then I think we need to all work together to prevent them from happening. Oh, I know that mistakes can happen unintentionally. People can forget when they are working so hard, under stressful situations, Lord knows I have nothing better to do to occupy my time these days. Hereʼs a look back at what was going on when that bedsore developed.

Then things got worse. I tripped walking back from the mailbox a few months back and skinned my arm, my nose and bruised my left hip. My whole body was bruised up pretty bad. My daughter June insisted that I go see my doctor, Dr. Hill. I have been cared for by Dr. Hill for more than 30 years and pretty much think he is one of the smartest doctors I know of, so when he told me that he thought it was time for me to go live in a nursing home, only for a while, so I could get stronger, eat better and find out what was causing all these dizzy spells, I didnʼt much argue with him.

November 15, 2007 5:47 a.m.

Aligning practice with policy to improve patient care 51

I remember that I had tossed and turned all night, and even though I was still so tired, I just could not fall back to sleep no

Continued on Page 53

No pressure, just support.
Recent studies have shown that pressure ulcers can start to form in as little as 20 minutes in the operating room.1 When every second counts, the surfaces used for positioning and transporting patients need to be chosen carefully. Medline’s gel positioners are designed to help reduce pressure while providing exceptional support during surgical procedures. They’re latex- and silicone-free, antimicrobial, antibacterial and radiolucent. They’re also reusable and can easily be cleaned and disinfected with standard hospital disinfectants.

Our gel positioners are available in a wide variety of shapes and sizes to meet your needs. To learn more about Medline’s comprehensive Pressure Ulcer Prevention Program, contact your sales representative or visit www.medline.com/pressureulcerprevention.

References 1 Pressure ulcers hit a sore spot in the operating room. Healthcare Purchasing News. Available at: http://www.hpnonline.com/inside/2007-08/0708-OR-pressure.html. Accessed November 17, 2008.

©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

www.medline.com

matter how hard I tried. So I One pressure ulcer can cost got up to use the bathroom an average of $43,180. CMS and fix my dentures so I and other providers could go to breakfast. Maybe will not reimburse for the I got up too fast, or I was additional costs associated dizzy for some reason, but as with hospital-acquired soon as my feet hit the floor, pressure ulcers.5 I slipped and fell hard on my right hip. I think I remember hearing something snap, but Iʼm not certain. I yelled for help and that nice girl Sheila ran in and found me lying on the floor. She told me not to move if possible and she quickly ran to get some help. The head nurse came in and they got me stretched out as best they could and said they called my doctor and an ambulance was on the way to come get me and take me to Mercy Medical Center so I could be checked out.

7:46 a.m.

The ambulance came to take me to the hospital (1 hr and 59 minutes after the incident occurred). I looked at the very small stretcher with that tiny mattress – I donʼt think it could have been more than one or two inches thick – and worried how they were ever going to get me on and off that safely, but they did. And trust me, it was one of the most uncomfortable beds that I have ever laid on. They strapped me in and got me Pressure ulcer incidence is into the ambulance. I was in over 60 percent for high-risk so much pain, but the emer- patients with femoral fractures gency medical personnel told and/or hip fractures.1 me they could not give me anything to dull it until I was checked out at the hospital. I could not even have anything to drink. I think that was the worst part, but they said if I needed to have surgery it could hurt me.

Nurses need more education in: 8
• • • •

9:57 a.m. I am rolled down the hallway to the X-ray department for the Xrays that Dr. Hill ordered. The boys moved me from my stretcher to a very hard and very cold table in a darkened room. A very nice lady came in and explained what was going to 70 percent of nurses consider happen. Pictures were taken their basic wound education of my chest and hip and then to be insufficient.7 those sweet boys came back and moved me off that hard table and back to that uncomfortable stretcher and I was rolled back to the emergency room. When I got back, Dr. Hill was waiting on me and the first thing I asked for was a drink of water as I was so parched. I remembered that I had not had anything to drink since before 8 p.m. the night before and nothing at all to eat since dinner. He said he knew that I was dry, but it was unsafe to give me anything to drink until we knew whether I needed surgery. I asked if they could please hurry and find out. Risk assessment (interpretation of Braden Scale) Pressure ulcer staging Proper positioning Effects of moisture on the skin (including incontinence, humidity and maceration) • Pressure relieving products • Proper application and usage of prevention products

2. Was an admission pressure ulcer risk and skin assessment performed, documented and compared to the assessment performed at the nursing home?

8:37 a.m.

I am rolled off the ambulance and rolled into the hospitalʼs emergency room. Finally, after some confusion, I am moved from that tiny stretcher to a bigger bed that was a little wider, but that mattress was not much better than the one before. They nurses and doctors told me that I had to lie still while they checked me out, otherwise I might further injure my hip. For what seemed like forever, they checked me out. Then they told me they had Pressure ulcers are defined called Dr. Hill and that he was as areas of localized damage on his way, but had given to the skin and underlying them orders over the phone tissue caused by pressure, for me to have an EKG, a shear, or friction.6 chest X-ray and an X-ray of my hip. Also, June and the kids had arrived by now and they let June come back to sit with me for a while until it was time for me to go to the X-ray department.

11:02 a.m. The nurse comes in to tell me that the X-rays show that my right hip was indeed broken and that the surgeon, a Dr. Cloud, or one of his assistants would be here soon to discuss the plan for sur- The incidence of pressure gery with me. I was getting so ulcers occurring as a result tired of just laying in one spot for of surgery may be as high so many hours, but she explained as 66 percent.8 to me that they had to keep my body straight so I did not injure my hip more. I asked her what time it was, and when she said 11:02, I realized that it had been over six hours since I fell and that I had been in one position for as many hours. No wonder I was getting so stiff. If I could have only turned over and had a glass of water.

For consideration:

For consideration:

1. Was a pressure ulcer risk and skin assessment performed and documented on admission to the nursing home?

1. Did the stretcher pads used in the ambulance and in the emergency room have pressure redistribution capability? 2. Were pressure-relieving devices used to frequently reposition the patient?

Aligning practice with policy to improve patient care 53

11:35 a.m. Dr. Cloud comes in, intro- Key causes of OR-related duces himself and explains pressure ulcers8: that I need to have surgery. • Immobility during the He was dressed in what procedure looked like pajamas with a • Pressure on bones close white coat and a blue cap. to the skin He told me that he had been in surgery all morning and • Diminished tissue tolerance that he had one more proce- • Excessive moisture dure to finish and then he would be able to get me all fixed up. I told him how sore I The most frequent predictors was and how much pain that of perioperative pressure hip was giving me, so he told ulcers have been found to be8: the nurse to give me a shot • Increasing age of the for pain and that he would go patient ahead and have me moved • A patient diagnosed with to the surgery holding area, diabetes or vascular where they could get me disease ready for surgery. About 20 minutes later, a boy who was • Vascular procedures dressed like Dr. Cloud came in and told me he was there to roll me up stairs to where the Surgery Department was located. I said my goodbyes to June and the kids and they told me not to worry, that I was going to be fine. I told them I knew that, I just wanted to get this over with. 1:08 p.m. I am finally being rolled According to AORN, surfaces back to the operating room in the OR for both positioning to get this old hip fixed. and transporting patients They started an IV in the should be smooth and intact holding area and gave me because surfaces that hold some medicine that was moisture or wrinkle contribute making me very drowsy. I to skin breakdown.8 now had on one of those blue hats, too. They moved me over to a table that looked just as uncomfortable as that gurney I had been lying on for the past five or six hours. After that, I donʼt remember much, so I have to turn the story over to my granddaughter to explain what happened in surgery.

an immobilizer was positioned between her legs to keep her in proper body alignment, she was rolled onto her bed and taken to the recovery room, where she remained for two hours until she was stable enough to be taken back to her own room. Iʼll let Granny tell you how she was feeling when she got out of surgery.

Pressure ulcers can develop within two to six hours of the onset of pressure.1

For consideration:

While AORN guidelines recommend pressure relief surfaces for surgeries lasting longer than 2 hours, pressure ulcers can start to form in as few as 20 minutes.9

6:00 p.m.

1. Was the OR table pad a pressure redistribution pad? 2. Were all bony prominences and pressure points padded appropriately to minimize pressure that might occur during a surgical procedure?

June and the kids were all waiting for me when I got to my room. There was a pitcher of water waiting and that was the first thing I wanted – a cold drink. My nurse for the evening came in and introduced herself and checked me out. They gave me some broth to eat a little later. My hip was beginning to hurt again, so they gave me some more pain medicine and I drifted back to sleep. I guess I was really tired because I slept more that evening than I had in weeks. I woke up a few times during the night and needed some more pain medicine, but then I went right back to sleep.

For consideration:

For consideration:

Granny was positioned on her left hip, prepped and draped with a full-body drape and only her right hip exposed to the operative field. The procedure started at 1:45 p.m. and was completed at 3:30 pm., lasting one hour and forty-five minutes. During the surgery, Granny has some reasonable blood loss and the hip was irrigated with antibiotic fluid. At 3:45 p.m., after

1. Each time the patient was moved from stretcher to stretcher and table to table, were the staff well trained in transfer and positioning techniques that reduce friction and shear?

November 16, 2007 7:00 a.m. Breakfast arrives and I am The greatest incidence of awake and ready to eat. new-onset postoperative Soon afterward, the day shift pressure ulcers for elderly nurse comes in and says she patients with hip fractures has to check me out head to occur within the first two toe. In doing so, she finds a postoperative days.4 big red mark on my left hip and asked me if it had been there before I arrived at the hospital. I told her it hadnʼt been as far as I knew, but that I had been falling easily and bumping into things so it was possible that I was there and I didnʼt know it. There was still some paint from surgery and a few blood spots on my skin, so she got some soap and water and cleaned me up real good. My granddaughter can tell you what came out of all of this.
Continued on Page 56

1. Was the patientʼs skin thoroughly cleansed and inspected after surgery before leaving the operating room to ensure that there was no pooled blood or prep solutions under bony prominences?

54 The OR Connection

The program you need ...

right when you need it most.
Pressure Ulcer Prevention Program For the OR
“In many of the recent legal cases I have reviewed following facility acquired pressure ulcers, I have seen that an increasing number are occurring in post surgical patients. A pressure ulcer prevention program for perioperative services that addresses risk assessment as well as comprehensive prevention measures is more critical than ever.”
– Diane Krasner, PhD, RN, CWCN, CWS, BCLNC, FAAN, Wound and Skin Care Consultant

Topics addressed in the program include: I. Implications of the New CMS Payment Provision II. Incidence of Perioperative Pressure Ulcers III. Perioperative Risk Factors IV. Perioperative Assessment V. Perioperative Prevention Measures To learn more about Medline’s Perioperative Pressure Ulcer Prevention Program, contact your Medline representative, call 1-800-MEDLINE or visit us at www.medline.com.

Studies suggest that the incidence of pressure ulcers occurring as a result of surgery may be as high as 66 percent.1 With that in mind, Medline has developed a companion program to its highly successful Pressure Ulcer Prevention Program especially for perioperative services.

Reference 1 Recommended practices for positioning the patient in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2008.

www.medline.com
©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

For consideration:

By now, you must know the rest of the story. Granny was in the hospital for five days after surgery and then returned to Happy Valley Nursing Home. The reddened area eventually developed into a Stage III pressure ulcer that is now infected. When a Stage I pressure From my research, we have ulcer develops, the risk for developed a protocol for additional ulcers on the the prevention of pressure same individual is reported ulcers that includes a com- to increase tenfold.4 munity effort between the nursing home and acute-care facility to prevent facility-acquired pressure ulcers. In Grannyʼs case, the ulcer could have developed due to pressure, moisture, friction, shear, poor nutrition, tissue injury or tearing, but most likely from a combination of all of these factors. Not all pressure ulcers are avoidable, but many are. I encourage you to work closely within your medical community to make sure your pressure ulcer prevention measures and protocols are up to date and that everyone is fully trained to execute them appropriately. Critical steps Critical steps in pressure ulcer prevention and healing include8: • Identifying the individual resident at risk for developing pressure ulcers • Identifying and evaluating the risk factors and changes in the patientʼs condition • Identifying and evaluating factors that can be removed or modified • Implementing individualized interventions to attempt to stabilize, reduce or remove underlying risk factors • Monitoring the impact of the interventions • Modifying the interventions as appropriate Risk factors Risk factors for pressure ulcer development include8: • Impaired/decreased mobility • Decreased functional ability • Co-morbid conditions • Drugs that may affect wound healing • Impaired diffuse or localized blood flow • Resident refusal of some aspect of care and treatment • Cognitive impairment • Exposure of skin to urinary or fecal incontinence • Under-nutrition, malnutrition and hydration deficits • History of a healed ulcer

1. Should soap and water be used to cleanse patients at high risk for development of pressure ulcers?

higher acuity, requiring more All members of the healthcare resources and services to be team need to know their provided and at a higher cost responsibilities and how their burden for both the payer tasks relate to each other in and the provider. Added on the prevention and managetop of this is the at-risk con- ment of pressure ulcers. dition for the development of additional complications, such as additional pressure ulcers, deep vein thrombosis, pulmonary embolism and additional infections.

Prevention is paramount. It begins with proper risk and skin assessment, combined with proper prevention measures (including the appropriate prevention products). The cement that holds it all together is proper education and training of personnel across the complete continuum of health care, including the community of hospitals, nursing homes and emergency medical professionals. Refer to the Forms & Tools section to learn more about how you can prevent pressure ulcers at your facility.

This story is a fictional account based on the real-life experiences of the author.
References 1 Medical News Today. Clinical Trial Shows 96% Improvement In Pressure Ulcer Healing Among Nursing Home Residents. Available at: http://www.medicalnewstoday.com/articles/39327.php. Accessed September 3, 2008. 2 Ayello E, Braden B. Why is pressure ulcer risk assessment so important? Nursing. 2001;31(11):74-80. 3 Walsh K, Bennett G. Pressure ulcers as indicators of neglect. Nursing & Residential Care. 2000;2(11):536-539. 4 Maklebust J. Pressure ulcers: The great insult. Nursing Clinics of North America. 2005;40(2):365-389. 5 CMS, Proposed Changes to the Hospital IPPS and FY2009 rates; http://edocket.access.gpo.gov/2008/pdf/08-1135.pdf accessed October 24, 2008. 6 Lepisto M, Eriksson E, Hietanen H, Lepisto J, Lauri, S. Developing a pressure ulcer risk assessment scale for patients in long-term care. Ostomy/Wound Management. 2007;53(10):34-38. 7 Zulkowski K, Ayello E, Wexler S. Certification and education: Do they affect pressure ulcer knowledge in nursing? Advances in Skin & Wound Care. 2007;20(1):34-38. 8 AORN 2008 Perioperative Standards and Recommended Practices, “Recommended Practices for Positioning the Patient in the Perioperative Practice Setting.” 9 Akridge J. Pressure ulcers hit a sore spot in the OR. Healthcare Purchasing News. August, 2007.

For Happy Valley Nursing Home, they not only had to provide care for Eurethaʼs mending hip, they also had to deal with her facility-acquired pressure ulcer, which had become infected. Euretha was now a much more complex resident with a much

56 The OR Connection

It all adds up. The Pressure Reducing OR Table P

Pressure Free is treated with Ultra-Fresh, making it antimicrobial throughout. It is also antifungal, fluid proof, stain, fungal and fire resistant—making it reusable and easy to clean.

Pressure Free, Medline’s new OR table pad features 3 layers of foam covered in our exclusive Nirvana “Memory” Foam which not only completely conforms to the patient’s body contours and gently cradles delicate bony prominences but keeps its shape throughout even the longest procedure. All of this is encased in our state-of-the-art Proknit ticking to eliminate the “hamocking effect” seen in other vinyl pads.

To learn more about our pressure reducing table pads, contact your Medline representative, call 1-800-MEDLINE or visit www.medline.com.

Pressure Free OR table pad

www.medline.co

Keep your surgical patient desert dry

Fluid Flow

Disruption?
By Jayne Barkman RN, BSN, CNOR

As Joe and Sandy walked down the hall to the lounge, they almost collided with paramedics running down the hall and pushing a stretcher carrying an intubated young man. Joe and Sandy exchanged glances, turned around and scurried after the paramedics into OR 3.

58 The OR Connection

They assisted the paramedics and anesthesiologist in lifting the patient from the stretcher onto the operating room bed. Joe then grabbed a gown and a pair of gloves from the room stock supply to scrub in and help Tom, the scrub nurse, finish setting up. Sandy secured the patient to the bed with the safety strap and began cutting off the young

manʼs clothing. The attending poked his head into the room. “Letʼs go!” he barked. Sandy inserted a temperaturesensing Foley and Laura, the room circulator, poured betadine over the patientʼs chest and abdomen. Sandy tied up the attending and two surgical residents as Joe and

OR Issues

Tom draped the patient. Within in a minute, the young manʼs abdomen was opened. Blood immediately began pouring out.

“Get me another cell saver. Come on, I need more suction!” the surgeon yelled. Sandy delivered another cell saver tubing to the field and Joe handed it off to the perfusionist as the whirl of the second cell saver machine filled the room. Sandy and the anesthesiologist checked five units of emergency release blood as a CRNA squeezed the packed cells into the patient. Sandy and Joe then counted the additional packs of lap sponges that Sandy had tossed onto the field and began placing the soiled sponges from the kick bucket into the sponge counter bags. Next, Sandy carefully wiped up the blood that had pooled around the surgeonʼs feet and showed the anesthesiologist the blood-soaked bath towels so that he could incorporate the blood on the towels into the blood loss estimate. Soon, the attending had the bleeding under control.

fluid light was blinking on the machine. Sandy grabbed a bottle of sterile water and added the fluid to the machine. The low fluid light continued to blink an amber warning. Sandy called the control desk and requested an additional hypo/hyperthermia machine. When the machine arrived, she disconnected the faulty machine, inserted the warming blanket tubing into the new machine, plugged it into the wall and turned the machine on. The low fluid light began blinking on the new machine. Sandy went to the anesthesiologist and explained what was happening. Mike, the anesthesiologist, asked for some warm blankets that he then wrapped around the patientʼs head.

According to a report from the ECRI Institute, an evidence-based practice center, injuries related to the use of a warming/cooling blanket tend to occur in lengthy procedures in which the aorta is cross clamped.

“Clamps on,” the surgeon said as the anesthesiologist noted the time. The attending asked for an 18 woven graft. Before opening the graft to the field, Sandy and Joe verified the graft size. Jim, the senior resident, and the attending surgeon changed sides of the table. Jim asked for some 3-0 prolene suture and began sewing the graft into the patientʼs ruptured aorta. The anesthesiologist motioned for Sandy to come to the head of the bed. He asked her to check the warming blanket, as both the bladder and esophageal temperatures registered at 35 degrees. Sandy checked the hypo/hyperthermia machine. The low

When things slowed down, Sandy read the accident details provided by the paramedics. The patient had suffered an aortic injury due to deceleration when he slammed into another vehicle while running a red light. When Joe asked to do the initial counts, Sandy was surprised at how quickly the past three hours had gone. At the end of the case, Laura brought the ICU bed into the operating room. Sandy stood by the OR bed with warm blankets to cover the patient as Joe removed the drapes and Lisa secured the dressing. As she was placing the blankets on the patient, Sandy realized the draw sheet and the linen on the OR bed were saturated with fluid. She asked Laura to get a couple of bath towels to dry off the patient. A dry draw sheet was placed under the patient, who was
Continued on Page 61

Aligning practice with policy to improve patient care 59

Keep your surgical patients desert dry.
Medline’s Sahara® Super Absorbent OR table sheets are designed with your patients’ skin integrity in mind. The Braden Scale tells us that moisture is one of the major risk factors for developing a pressure ulcer.1 We also know that as many as 66 percent of all hospital-acquired pressure come out of the operating room.2 That’s why we developed the Sahara Super Absorbent OR table sheet. The Sahara’s super-absorbent polymer technology rapidly wicks moisture from the skin and locks it away to help keep your patients dry. Sahara OR table sheets are available on their own or as a component in our QuickSuite® OR Clean Up Kits, which were designed to help you dramatically improve your OR turnover time and help reduce cross contamination risk through a combination of disposable products.
References 1 Braden Scale for Predicting Pressure Sore Risk. Available at: www.bradenscale.com/braden.PDF. Accessed November 6, 2008. 2 Recommended practices for positioning the patient in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2008.

To learn more about Sahara OR table sheets and Medline’s comprehensive product line, contact your Medline representative, call 1-800-MEDLINE or visit us at www.medline.com.

www.medline.com

then lifted onto the ICU bed. The patient was gently turned so Sandy and Laura could assess the patientʼs skin, which was intact with no redness noted. As the patient was being transported out of the OR, Sandy pulled the fluid-saturated sheets off the OR bed and placed them in the laundry hamper. She examined the reusable warming/cooling blanket and realized there was no fluid left in the blanket. She could not see a hole in the blanket, but nonetheless disconnected the blanket from the machine and placed it in the trash. A couple of days later, after she had transported a patient to the CVICU, Sandy decided to check on the young man with the ruptured aorta. She poked her head into the CVICU room. The patient was lying on his side, asleep. His nurse, Jennifer, was in the room doing her charting. Sandy asked how the patient was doing. Jennifer replied that he was progressing remarkably well, and his main complaint was pain on his back where it appeared pressure ulcers were developing. Jennifer and Sandy gently lifted the blankets off the patientʼs back. There were reddened areas on both scapulae as well as a four-inch long red area on his thoracic spine. They covered the patient.

As with any surgical complication, prevention is the key.
related to the use of a warming/cooling blanket tend to occur in lengthy procedures in which the aorta is cross clamped. ECRI recommends the following when using a hypo/hyperthermia blanket in the operating room1: • The blanket should be covered with a sheet. • The circulating water temperature as well as the patient temperature should be monitored. • The thermostat on the unit should be set at a maximum temperature of 42 degrees Celsius. • The machine should be used and maintained according to the manufacturerʼs recommendations.

Back in the OR, Sandy found Joe. She gave him an update on the patientʼs condition and the pressure ulcers developing on the patientʼs back 48 hours postoperatively, quite possibly related to lying on the fluid-saturated operating room bed linens.

Preventing pooling fluids and pressure ulcers

Great care is taken by preoperative nurses to avoid the formation of pressure ulcers in surgical patients. Bony prominences are padded and towels are placed to avoid pooling of solutions under the patient. The use of waterbased hypo/hyperthermia systems in the operating room should not be overlooked as a potential cause of pressure ulcer formation in operative patients. Minute holes in water-based hypo/hyperthermia blankets might not be evident until the pressure from the weight of a patient is placed onto the blanket, causing the fluid in the coils to leak out. According to a report from the ECRI Institute, an evidence-based practice center, injuries

Additional recommendations from the ECRI Institute to avoid skin injuries in the operating room include1: • Check the OR bed mattress for sufficient padding and thickness. • Verify that the patient safety strap is not placed too tightly, restricting circulation or placed over a grounding pad or ECG electrode. • Lift anesthetized patients rather then rolling or tugging them. • Avoid pooling of solutions under the patient.

Todayʼs technology offers impervious disposable fabrics to cover the operating room bed. Some of these fabrics trap fluid, wicking moisture away from the patient. This helps to reduce the possibility of the patient lying on wet bed linens during the operative procedure, potentially resulting in the formation of a pressure ulcer. Keep your patient desert dry. As with any surgical complication, prevention is the key.

Reference 1 ECRI Institute. Skin Injury in the OR and Elsewhere. Available at: http://www.mdsr.ecri.org/summary/detail. aspx? doc_id=8185. Accessed November 4, 2008.

Aligning practice with policy to improve patient care 61

Two out of three employees feel that the flow of communication between the departments of their facility is poor.

All information is important, but different disciplines value and prioritize it in different ways.

62 The OR Connection

Special Feature

Why Can’t We All Just Get Along?
Improving relationships within healthcare facilities
By Dayna Lowe, Clinical Instructor

Does your facility have a failure to communicate?

If it does, youʼre not alone. Surveys show that two out of three employees feel that the flow of communication between the departments of their facility is poor.2

First and foremost, healthcare providers, no matter what their discipline, want to give their patients the best possible care. If this is true, why are there so many problems? It all comes down to communication.

Hospitals claim that nursing homes never seem to send the right paperwork with their patients. Certainly it is not always this bad, but we are all guilty of similar thoughts from time to time.2 Nursing homes often say that hospitals transfer all of their complex problems to them. Although important, communication takes time – time that many people simply do not feel they have.

So what can you do? There is no one simple solution for breaking down the barriers of communication between healthcare providers of different organizations. Improvements need to be tailored to the needs of each facility. However, there are some basic guidelines that we can all follow. First of all, the information that is truly important and necessary needs to be identified. So often, time is wasted sifting through documents and repeating the same piece of information over and over. All information is important, but different disciplines value and prioritize it in different ways. Communi-

How can you help your own facility?

Healthcare facilities are only getting bigger. Many hospitals are part of a larger system that not only includes acute care facilities but outpatient services, doctorsʼ offices, rehabilitation centers and long-term care facilities. Departments that need to communicate many be a floor away from each other or miles apart in different buildings. Even with email and phones so readily available, important information still gets forgotten.2

Aligning practice with policy to improve patient care 63

Continued on Page 65

We take

blood pressure cuffs

personally.

A study found that 77 percent of blood pressure cuffs wheeled from room to room in a hospital were contaminated.1 Choosing Medline disposable blood pressure cuffs is great way to battle those bugs. Medline’s Blood Pressure Cuff Standardization Program, which helps ensure that virtually all blood pressure monitors accept the same cuff connector, allows the cuff to follow the patient throughout their stay and then be discarded. This helps to reduce the likelihood of cross contamination and also frees up caregivers to

focus on their primary concern – the patient – instead of hunting down connectors. To learn more about Medline disposable blood pressure cuffs and our Blood Pressure Cuff Standardization Program, please contact your Medline representative, call us at 1-800-MEDLINE or visit www.medline.com.
1 De Gialluly C, Morange V, de Gialluly E, Loulergue J, van der Mee N, Quentin R. Blood pressure cuff as a potential vector of pathogenic microorganisms: a prospective study in a teaching hospital. Infect Control Hosp Epidemiol. 2006 Sept;27(9):940-3.

©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

www.medline.com

cation checklists for different departments could be developed so that only necessary information is shared and nothing is missed. They would ensure the sharing of “need to know” rather then “nice to know” information.2 Properly conducted team-building exercises can dramatically improve how well department heads and staff members work with each other. Typically, this requires the use of an outside professional with experience getting fellow employees to unite as a team. Part of these exercises could also include staff rotating to other facilities to see “how the other half lives.” Not only does this give everyone a better understanding of what other facilities do, it also gives employees a more rounded perspective of how the work of the organization is conducted and the importance of sharing information between departments. It is also a great way for different organizations to get to know one another.2 Facilities need to look into available communication technology and train their staff how to use communication tools properly. Without adequate education, these tools can be used incorrectly, causing more problems then they solve.

Communication checklists for different departments could be developed so that only necessary information is shared and nothing is missed.

another. They must communicate in an efficient and proper manner. Last but not least, they need to ensure that the best possible communication tools are available and that their staff has adequate training on their use. Staff must learn to work with new technology and with each other. They must remember that this is all done for the good of the patient.
References 1 Plsek P. Interdepartmental communication in a large hospital. Available at: http://www.plexusinstitute.org/ edgeware/archive/think/main_tales9.html. Accessed September 2, 2008. 2 Katcher BL. How to improve interdepartmental communication. Available at: www.discoverysurveys.com/articles/itw-017.html. Accessed September 2, 2008. 3 Spring Valley Hospital Medical Center. High marks for prompt ER care. Available at: http://valleyhealth. uhspublications. com/winter2007/story2.html. Accessed September 2, 2008.

About the author

Dayna Lowe has been a surgical technologist for six years. She currently works at a hospital in Florida and as an Instructor of Surgical Technology at Central Florida Institute.

As we plunge headlong into the 21st century, health care will only continue to get bigger and more complex. Staff will be expected to provide skilled services faster then ever before. Administrators and managers of these organizations must set good examples for their staff. They must be able to put aside any personal differences and work with one

Aligning practice with policy to improve patient care 65

How to Set Priorities and Get the Job Done

When you donʼt set priorities, you tend to follow the path of least resistance. Youʼll pick and sort through the things you need to do and work on the easiest ones, leaving the more difficult and less fun tasks for a “later” that, in many cases, never comes. Or, worse, the “later” may come just before the action needs to be finished, throwing you into a whirlwind of activity, stress and regret. There are three basic approaches to setting priorities, each of which probably suits different kinds of personalities.

Popularized in Brian Tracyʼs book Eat That Frog!, the idea here is that you tackle the biggest, hardest and l e a s t appealing task first thing every day. Just knuckle down and do it, and the rest of the day will be a breeze. The second approach is for people who thrive on accomplishment, who need a stream of small victories to get through the day.

The first is for procrastinators, people who put off unpleasant tasks.

If you thrive on accomplishments – move big rocks

If you are a procrastinator – eat a frog!

Thereʼs an old saying that if you wake up in the morning and eat a live frog, you can go through the day knowing that the worst thing that can possibly happen to you that day has already passed. The day can only get better!

Maybe youʼre someone who fills your time fussing over little tasks. Youʼre busy all the time, but somehow, nothing important ever seems to get done. You need the wisdom of the pickle jar. Take a pickle jar and fill it up with sand. Now try to put a handful of rocks in there. You canʼt, because thereʼs no room.

66 The OR Connection

If itʼs important to put the rocks in the jar, youʼve got to put the rocks in first. The pickle jar is all the time you have in a

Special Feature

If you thrive on accomplishments – move big rocks

day. You can fill it up with meaningless little busy-work tasks, leaving no room for the big stuff, or you can do the big stuff

To put it into practice, sit down tonight before you go to bed and write down the three most important tasks you have to get done tomorrow. In the morning, take out your list and attack the first “big rock.” Work on it until itʼs done or you canʼt make any further progress. Then move on to the second, and then the third. Once youʼve finished them all, you can start in with the little stuff.

I. II. III. IV.

The third approach is for the more analytic types, who need to know that theyʼre working on the objectively most important thing possible at this moment.

If youʼre really on top of your time management, you can minimize Q1 tasks, but you can never eliminate them – a car accident, someone getting ill, a natural disaster. These things all demand immediate action and are rarely planned for.

Important and Urgent Important and Not Urgent Not Important but Urgent Not Important and Not Urgent

If you are analytical – use the Covey quadrants

If you just canʼt relax unless you absolutely know youʼre working on the most important thing you could be working on at every instant, Stephen Coveyʼs quadrant system might be for you. Covey suggests you divide a piece of paper into four sections, drawing a line across and a line from top to bottom. Into each of those quadrants, you put your tasks according to whether they are:

After youʼve plotted out your tasks on the Covey quadrant grid, according to your own sense of whatʼs important and what isnʼt, work as much as possible on items in quadrant II (and quadrant I tasks when they arise). Spend some time trying each of these approaches on for size. Itʼs hard to say what might work best for any given person. In the end, setting priorities is an exercise in self-knowledge.

Reprinted with permission from www.mercola.com.

Aligning practice with policy to improve patient care 67

Conquer Stress During Tough Economic Times
By Wolf J. Rinke, PhD, RD, CSP

68 The OR Connection

Caring for Yourself
Housing market imploding? Your 401(k) down the tubes? Uncle Sam bailing out everyone except you? No wonder stress is at an all-time high, to the point that many stress-related diseases are increasing logarithmically. (Things are so bad that the Occupational Safety and Health Administration has classified stress as a workplace hazard.) Even though some stress is good for us – for example, the excitement (stress) you experience when you are getting ready to go on vacation or start a new project – most other forms of stress, especially the type that you experience when you feel out of control, are bad for us (dysfunctional stress). It turns on your fight or flight response and causes your body to produce more adrenaline and hormones such as cortisol, norepinephrine, epinephrine and DHEA-S, which increase your blood pressure and pulse, tense your muscles and diminish the effectiveness of your immune system. Dysfunctional stress will lead to fatigue, frequent headaches and upset stomach. Long-term dysfunctional stress contributes to chronic health problems such as high blood pressure, heart disease, depression and memory loss. It may also lead to family breakdowns and injuries, especially on the job. To manage stress during tough economic times, I recommend you master the most powerful stress reduction technique of all time. It consists of just three steps:

Three steps to stress reduction

1. Change the changeable Donʼt like something? Change it! Your stocks driving you nuts? Sell them! Is the media giving you acid indigestion with their incessant stream of bad news? Turn off the TV! Donʼt fret, complain or whine … just do it! Remember, you donʼt have to do anything you donʼt want to do. All right, you caught me. There is one thing you have to do – die. Everything else is a choice. So what can you do? Get rid of the words “I have to.” Using these three little words generates “victim” behavior patterns. And victims experience dysfunctional stress, which will make you sick. 2. Remove yourself from the unacceptable Find something unacceptable? Get out of the way! Your credit card debt interfering with your sleep?

Aligning practice with policy to improve patient care 69

1. Hang out with positive people Negative people drain your battery. Positive people charge your battery. So minimize the time you are together with “stinking thinking” people.

2. Recognize that you are not your job Although we define much of who we are by what we do, you are a lot more than your job. You get paid what you are worth in the marketplace based on supply and demand, not based on who you are. Getting little pay does not mean that you are not a worthy person. In fact, you may be the most worthy human being on this planet.

Start paying them off now and cut up all your credit cards except one for true emergencies. Being followed by someone who is overdosing on road rage? Move out of her way and let her have a “coronary” without your help. Working for a toxic boss? Start shopping for a new one. Whatever you do, just do it without fretting, whining … I know youʼre catching on!

3. Get your life in balance If youʼre experiencing problems at home and at work, youʼll accelerate the burnout process. So think creatively, and develop a strategy for balancing personal and professional demands. For example, if you know youʼll be working late all week, arrange to meet your family for dinner one of those evenings at a nearby restaurant or plan a weekend outing. Recognize that the most important things in life are relationships – not stuff! So make time for the real important things in your life: your spouse, your children, your parents and your friends.

15 stress-reduction strategies

3. Accept the unchangeable There are lots of things beyond your control – for example, the crashing global economy. Regardless of how much you stress yourself, you will likely not be able to change it. So let it go. And then there are your parents. No matter how much you would like them to be different, they wonʼt be. So love them the way they are, not the way they ought to be. (By the way, that is a great prescription for getting along with all people!) Getting older – accept it. You are beautiful just the way you are! Donʼt sweat your chronological age – something that you canʼt change. Instead, take care of your body. Thatʼs something you can have a positive impact on right now.

4. Cut the electronic umbilical cord Too many of us simply no longer know how to relax. When we leave work to go home or on a vacation, we not only take work with us, we are still tied into the office via pager, email, cell phone or our “crackberries.” Discipline yourself to turn those things off. (Heads up: you are not nearly as important as you think you are.) Better yet, donʼt even give out your cell phone number. I use mine only for bona-fide emergencies. Also, leave work at work so that you can set aside time to relax and recharge – recreate yourself. 5. Reduce your commuting time If you are commuting more than one hour a day, itʼs time to move. One hour a day means that you are wasting about 30 working days per year. Plus, you are already stressed by the time you get to work. If you must commute, get in the habit of listening to motivational and educational CDs – it will reduce your perceived commuting time dramatically. (If you donʼt know where to start, go to www.WolfRinke.com. We have several powerful CDs to choose from.)
Continued on Page 73

Once you have mastered the basic three, here are 15 additional stress-reduction strategies to help you kiss stress good-bye once and for all.

70 The OR Connection

Small in size. Big on safety.

Sometimes smaller is better!
At just 15 square inches, the Medline Universal Pad with proprietary Safety Ring meets the same thermal performance standard as traditional electrosurgical pads up to 33% larger in conductive surface area. Despite its smaller size, this pad is big on safety. The proprietary Safety Ring allows the pad to be oriented in any direction and also reduces corner and edge effect by more uniformly dispersing electrosurgical current over the entire conductive surface of the pad.

The transthermal backing on 9100 Series electrosurgical pads provides a barrier of moisture; it is waterproof and fluid resistant. The backing allows heat to escape 25% faster than the foam traditionally used on grounding pads, reducing the risk of excessive heat buildup.

For more information on the impact the Universal Pad 9100 Series can have in your OR, contact your Medline sales representative or call 1-800-MEDLINE.

Electrosurgical Pad 9100 Series

Manufactured by 3M Medical Division

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©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

Jeepers, creepers...
Where'd ya get them peepers?
With Medline EyeShields, you get the protection your eyes need in a lightweight and stylish design. Distortion-free, opticalgrade disposable lenses are paired with reusable frames available in 10 designer colors. The wraparound design provides both front and side eye protection. From the operating room to the lab, Medline EyeShields are a great way to protect yourself–and you’ll love their surprisingly affordable price tag.

To learn more, contact your Medline representative, call 1-800-MEDLINE or visit www.medline.com.

Disposable clear lenses with reusable wraparound frames shown in blue

Frames available in 10 designer colors

©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

www.medline.com

10. Get eight hours of sleep a day If you find you donʼt have eight hours, reduce TV viewing by one hour per day. (Good advice even if you do get enough sleep.) That will give you – are you ready for this? – 15 extra days per year. Just think how much fun stuff you could do if you had 15 extra days! 11. Manage priorities You canʼt manage time. We all get the same 24 hours every day. But you can manage your energy and your priorities. (Have you ever noticed that all of us make time for all the important things in our lives?) Each day, figure out what your high pay-off items are and do them when you are at your best. For most of us, thatʼs in the morning. And donʼt forget to make vacation and play time a priority.

6. Find a boss who knows how to MBA – manage by association If you report to a toxic boss, someone who constantly “builds you down,” or who practices seagull management, itʼs time to look for a new boss, or at least stay away from your current boss as much as you can. (Seagull management is when the boss flies in, makes a lot of noise, eats your lunch, craps on you and flies back out.) If you are a manager and the shoe fits, you owe it to yourself to read – no, wait, devour – my book Winning Management: 6 FailSafe Strategies for Building High-Performance Organizations. 7. Move your body Weʼve made our lives too simple. Make yours more difficult by conducting your next meeting while walking (walk and talk), use a stand-up desk, park in the farthest spot from the door, take the stairs, walk into the bank instead of using a drive up window, mow your lawn with a push mower, and so on.

12. Get rid of conflict If youʼre having problems with a family member or someone at work, arrange to meet and discuss the situation. By opening the lines of communication, youʼll set the stage for a fair resolution. You might even find out that what seemed like a major and stressful conflict was actually a minor misunderstanding. And donʼt forget to master the most powerful conflict and stress reduction phrase in the world: “You are right about that.” Try it any time conflict rears its ugly head and conflict will vaporize. 13. Celebrate more often than you think is wise Set attainable and measurable goals for each of your projects, whether they are at home or at work. Then celebrate each baby-step accomplishment with small rewards, such as taking time to go out to lunch with your spouse or colleagues. It will keep you motivated and increase your productivity.

8. Exercise Do approximately 30 minutes of aerobic exercise every other day, such as jogging, biking or fast walking. Alternate that with resistance exercise like lifting weights or using a “gym” machine. And be sure to start every exercise session with light warm-up exercises and end with a comprehensive stretch routine.

9. Take breaks Youʼll be surprised how refreshed you feel just by taking brief stretch breaks throughout the day. Simple actions such as taking three very deep breath and exhaling slowly, going for a short walk or just standing up and stretching at your desk are a powerful way to alleviate stress and boost productivity.

Aligning practice with policy to improve patient care 73

14. Reduce information Most of us suffer from TMI – too much information. So when you need to make a decision, avoid whatʼs referred to as “decision optimization” in systems language. (A friend of mine refers to it as contemplating your navel.) Instead, go for decisions that are minimally acceptable. Itʼs faster and leads to better decision outcomes in the long term. I truly believe that most of us need lots more reminding and less information. In other words, I believe most of us know how to do the right thing – we just forget what we already know. If youʼd like help with this, I have just the right tool for you. It is my Make It a Winning Life: Success Strategies for Life, Love and Business perpetual calendar, available at

www.WolfRinke.com. Every day, it provides you with an inspirational message – a reminder of what you probably already know. However, then it takes you to the next level by providing you a specific action step that helps you implement what you already know in a dramatically new and different way. When you get to the end of the year, you can start the calendar all over again.

15. Ask for help If you still have dysfunctional stress after all this, itʼs time to ask for help. (Remember that asking for help is a sign of strength, not weakness.) While sometimes it might seem like itʼs you against the world, keep in mind that this is rarely the case. Often the help you need is available simply by asking for it. Reach out to family members, colleagues or your boss by letting them know of your challenges. You can avoid being perceived as a complainer by objectively outlining how others can help. If that still does not do the trick, talk with your mentor or coach (you do have one, donʼt you?) or a professional counselor. Because they are removed from a situation, they are more likely to provide you with a fresh perspective that will enable you to develop new strategies for conquering stress once and for all.

About the author

Dr. Wolf J. Rinke, RD, CSP is a keynote speaker, seminar leader, management consultant, executive coach and editor of the free electronic newsletters Make It a Winning Life and The Winning Manager. To subscribe, go to www.WolfRinke.com. He is the author of numerous books, CDs and DVDs, including Make it a Winning Life: Success Strategies for Life, Love and Business; Winning Management: 6 Fail-Safe Strategies for Building High-Performance Organizations and Donʼt Oil the Squeaky Wheel and 19 Other Contrarian Ways to Improve Your Leadership Effectiveness, available at www.WolfRinke.com. His company also produces a wide variety of quality pre-approved continuing professional education (CPE) self-study courses available at www.easyCPEcredits.com. Reach him at WolfRinke@aol.com.

74 The OR Connection

The choice is yours.
Medline’s comprehensive line of facemasks was designed to meet a variety of needs and preferences, but all of our masks are united by a common trait— quality. Every mask we manufacture—from our fluidresistant masks to our spearmint-scented masks—is backed by Medline’s quality guarantee and designed to exceed expectations for comfort and protection. • Fluid resistant • Fog free • Spearmint scented • Chamber style • Isolation • Procedure • Face shield • Protective eyewear

For more information on Medline facemasks, please contact your Medline sales representative or call 1-800-MEDLINE.

©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

www.medline.com

Here’s a tip for you.
Medline’s exclusive Blue Silk™ electrodes are coated with PTFE, the same non-stick compound used in Teflon®, enabling them to be wiped clean with a wet piece of gauze or sponge instead of an abrasive scratch pad. Blue Silk electrodes also have rounded edges to prevent RF current from concentrating too much energy in one area. All tips shorter than 3 inches in length features ribbed insulation to make swapping out tips easy–even with a slippery pencil or when wearing gloves!

Ribbed insulation

Rounded blade

Vega Series electrosurgical pencils are the perfect match for our Blue Silk electrodes!

ESPB3002

ESRK3002

To learn more about Blue Silk electrodes and Vega Series electrosurgical pencils, contact your Medline representative, call 1-800-MEDLINE or visit www.medline.com.

©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

www.medline.com

Special Feature
Medline Industries, Inc. will be hosting its annual AORN Breast Cancer Awareness Breakfast, by invitation only, at the 2009 AORN Congress. The event will take place at the Hyatt Regency McCormick Place in Chicago on Monday, March 16, 2009. We are honored to announce that this yearʼs speaker will be Linda Ellerbee, an outspoken journalist, award-winning television producer, bestselling author, breast cancer survivor, mother and grandmother. About Linda Ellerbee Ellerbee began her career at CBS, and then moved to NBC News where, after years covering national politics, she pioneered the late-night news program NBC News Overnight, which she wrote and anchored. Overnight was cited by the duPont Columbia Awards as "the best written and most intelligent news program ever." In 1986, Ellerbee moved to ABC News to anchor and write Our World, a weekly primetime historical series. Her work on Our World won her an Emmy. In 1987, Ellerbee and Rolfe Tessem, her partner, quit network news to start Lucky Duck Productions, first producing documentaries for PBS. In 1991, Lucky Duck began producing Nick News for Nickelodeon with Ellerbee writing and hosting. Seventeen years later, Nick News is watched by more children than watch all other television news shows put together— and has earned honors traditionally associated with adult programming. Known for the respectful and direct way it speaks to children about the important issues of our time, Nick News has collected three Peabody Awards (including one personal Peabody given to Ellerbee for her coverage of the Clinton investigation), a duPont Columbia Award and six Emmys. These days, Ellerbee and her work can be seen all over the television universe. Lucky Duck has and continues to produce primetime specials for ABC, CBS, HBO, PBS, Lifetime, MTV, Logo, A&E, MSNBC, SOAPnet, Trio, Animal Planet and TV Land, among others. Ellerbee was honored with an Emmy for her series, When I Was a Girl, which aired on WE: Womenʼs Entertainment network.

Mark Your Calendar

Ellerbeeʼs first foray into books for kids, an eight-part fiction series titled Get Real, published in 2000, won her raves among middle school readers. Both of Ellerbeeʼs previous adult books—And So It Goes, a humorous look at television news, and Move On, stories about being a working single mother, a child of the ʻ60s and a woman trying to find some balance in her life—have been national best sellers. Ellerbeeʼs recent book, also a best seller, Take Big Bites: Adventures Around the World and Across the Table, a tribute to her love of travel, talking to (and eating with) strangers, and, according to Ellerbee, “oh, just making trouble in general.”

As a breast cancer survivor, Ellerbee travels thousands of miles each year giving inspirational speeches to others. She is as direct with women as she is with kids; they understand that she understands their lives.

Although Ellerbee has won all of television's highest honors, she says itʼs her two children whoʼve brought her the richest rewards. Ellerbee spends her personal time in New York City and Massachusetts with Rolfe, her partner in work and life and their dogs, Daisy and Dolly.

Aligning practice with policy to improve patient care 77

Healthy Eating

Bruschetta Delizioso
A delicious and easy appetizer!
Ingredients 5 tomatoes (chopped) 1/2 cup extra-virgin olive oil 2 tablespoons balsamic vinegar 5 fresh basil leaves (julienne cut) 1 bulb of garlic 1 loaf of French bread Salt and pepper to taste Directions Preheat oven to broil. Combine the tomatoes, extra-virgin olive oil, balsamic vinegar, basil, salt and pepper in a medium bowl. Set the bowl aside. Slice the loaf of French bread so that each slice is about one-half inch thick. Place the bread on a cookie sheet and toast on the top rack of the oven. Once the bread has turned a golden-brown color, flip each piece in order to toast the other side. Remove the bread from the oven once both sides have been toasted. Peel the garlic cloves and rub directly on each side of the toast. Spoon the tomato mixture on top of the bread and serve.

Note: This recipe, created by Emily MacInnes, won an award at Medlineʼs Employee Appreciation Week International Cook-Off!

78 The OR Connection

Forms & Tools

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

SCIP Fact Sheet ..................................................80 Hand-Off Communication Policy and Procedure ..................................82 Perioperative SBAR ....................................85 Endoscopy SBAR........................................86 Pressure Ulcer Prevention

Checklist ................................................89

Aligning practice with policy to improve patient care 79

FACT SHEET Summary of SCIP Measure Changes for 10/1/08+ Discharges
All Measures:
For the exclusion data element Clinical Trial, notes were added that the patient must be enrolled in the trial during this hospital stay. There must be a signed consent in the medical record and the trial must be studying patients with the same condition as the measure set being abstracted.

VTE-1 and VTE-2:
Patients whose surgeries lasted < 60 minutes or whose hospital stays were < 3 calendar days will be excluded from SCIP-VTE-1 and 2. The algorithms were revised to reflect this. With this change, the data element Discharge Time is no longer necessary and was removed from the data dictionary.

Data Element and Table Changes Data Element or Table
Beta-Blocker Perioperative

New Clarification

Change
Documentation of a time associated with the last dose of the beta-blocker is necessary to verify that it was taken within the perioperative time frame. If the patient arrives on the day of surgery and there is documentation that the beta-blocker was taken on that same day prior to admission, the abstractor can select “Yes.” The data element Sex will be used in the algorithm to exclude male patients. Physician documentation of a bleeding risk associated with surgery, such as the normal risk described in the operative permit, will not be considered a contraindication to pharmacological prophylaxis. Because cases with a hospital stay 3 days are excluded from the VTE measures, the data element Discharge Time is no longer necessary. Implanted or pocketed cardiac devices that are performed without general anesthesia will be abstracted as “Yes” for Other Surgeries because the antibiotic prophylaxis given for these procedures could interfere with the prophylaxis for the principal procedure.

Beta-Blocker During Pregnancy Contraindication to VTE Prophylaxis

Discharge Time

Other Surgeries

80 The OR Connection

Summary of 10/1/08 SCIP Manual Revisions Hospital Interventions QIOSC/Hospital Quality Measures Special Study September 2008

Page 1 of 2

Data Element or Table
Preoperative Hair Removal

New Clarification

Change
Documentation that does not reflect actual hair removal, such as surgeon documentation in the operative report that the patient was “shaved and prepped,” should not be considered when answering this data element. Hair removal that is documented as performed with scissors will be collected with Value 3 – Clippers. Exclusions were added for non-surgical site hair removal and hair removal performed during the patient’s daily hygiene routine.

Surgery End Time

The inclusion terms are now prioritized as 1st, 2nd and 3rd. The data sources are no longer prioritized. Priority order applies to items in the inclusion table, not to source document. Also, the synonyms in the lists are alphabetized, not prioritized. The Notes for Abstraction were modified to be consistent with the instructions for Surgical Incision Time.

Surgical Incision Time

The priority lists were changed to more accurately reflect the wording commonly found in operating room documentation. Priority order applies to items in the inclusion table, not to source document. Also, the synonyms in the lists are alphabetized, not prioritized. The Notes for Abstraction were modified to be consistent with the instructions for Surgery End Time.

Vancomycin

Allowable Value 2 was revised to include MRSA colonization or infection. Allowable Values 1, 3, 4, 7 and 9 can be documented by persons other than physician/APN/PA or pharmacist. Allowable Values 2, 5, 6, 8 and 10 must still be physician/APN/PA or pharmacist documentation.

Table 1.3 BetaBlockers Table 2.1 Antimicrobial Medications

5 medications were added to the table of beta-blockers. Doripenem was added to the antibiotic table.

For a complete list of changes please see the “Release Notes,” located in the Specifications Manual for National Hospital Quality Measures for discharges 10/1/2008. The manual can be found at http://www.qualitynet.org/dcs/ContentServer?cid=1192804535739&pagename=QnetPublic%2FPage%2FQnetTier3 &c=Page
This material was prepared by Oklahoma Foundation for Medical Quality, the Medicare Quality Improvement Organization for Oklahoma, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 4-728-OK-0908
Summary of 10/1/08 SCIP Manual Revisions Hospital Interventions QIOSC/Hospital Quality Measures Special Study Aligning September 2008

practice with policy to improve patient care 81
Page 2 of 2

Forms & Tools

Hand-Off Communication

Hand-Off Communication in the Perioperative Setting
Policy
• “Hand-offs” are interactive communications that allow the opportunity for questioning between the giver and receiver of patient information. • Hand-off communication includes: • Accurate patient information regarding care, treatment and services • Patientʼs current condition and diagnosis • Recent or anticipated changes in the patientʼs condition • What to watch for in the next interval of care • Holding area RN reports to anesthesia, the surgeon and the circulating RN • Circulating RNs report to the PACU RN and/or the patient care unit RN • Anesthesiologists report to the PACU RN and/or to the patient care unit RN • Surgical team (surgeon, nurse, surgical technologist) transfer of on-call responsibility • Surgeon hand-off from the perioperative area to inpatient units • Critical laboratory and radiology results disseminated to the surgical team

• Specific examples of times when the transfer of responsibility for the surgical patient, i.e., hand-offs, occur include, but are not limited to, the following: • Shift change or break relief • Physician to surgeon/nurse to nurse/surgical technician to surgical technician transfer of patient responsibility • When surgeons and nurses are transferring the patient to another level of care within or outside of the organization • Patient care unit RN/ambulatory care RN report to the holding area RN

Procedure:

• Healthcare professionals shall find a quiet area to give a verbal report (hand-off communication) to ensure accurate, clear and concise information is given with a minimum of interruptions.

• Healthcare professionals shall be allotted the time for hand-off patient communication and to ask and answer questions with minimal interruption. It is hoped that this will lessen the amount of information that might be forgotten or simply not conveyed.

I-SBAR: An example of hand-off communication
Introduction State name and unit State patient name, age, gender Situation Pre-op diagnosis NPO status (# of hours) Procedure Background History/past hospitalization

Assessment Vital signs Isolation required Pain assessment Medications Risk factors Activity/mobility/ falls risk Other issues

Recommendations Pain control IV pump EKG

Mental status Allergies

Infection control/ isolation

Patient stable/ unstable

Primary language

Family communication Treatments Radiology

Sensory impairment

82 The OR Connection

Advance Directive Religious needs: refuses blood Code status transfusion Family (location, Disposition of patient contact person/ belongings number)

Special needs: spiritual, cultural, learning, communication

Hand-Off Communication

Forms & Tools

• Hand-off communication shall be conducted face-to-face.

• Healthcare professionals shall give each other the opportunity to ask questions, answer questions and read-back or repeat-back information, as needed. • The following is an example of a generic hand-off communication that may be used.

Perioperative hand-off communication:

• At specific points within the perioperative continuum, specific communications shall occur and shall include, but are not limited to: Patient care unit/holding area to operating room: • Patient identification • Planned surgical procedure • Site marking • Planned anesthesia type • Allergies • Antibiotics to be given • Significant medical history • Family contact information • Other issues (i.e., NPO, blood products available) • Last voided • Equipment needs • Pre-operative medications

Operating room team to post anesthesia care unit: • Surgical procedure (completed vs. planned) • Anesthesia • Estimated blood loss • Input and output (i.e., straight catheter, Foley) • Allergies • Medications (received intra-op) • Significant medical history (i.e., contact precautions) • Family contact information • Equipment needs (i.e., sequential compression devices) • Other issues (i.e., blood products, anesthesia concerns)
References Joint Commission. Improving Hand-off Communications: Meeting National Patient Safety Goal 2E. Joint Perspectives on Patient Safety. 2006;6(8):9-15. http://www.jcipatientsafety.org/15427/. Accessed May 8, 2007. AORN. “Perioperative Patient 'Hand-Off' Tool Kit, http://www.aorn.org/ PracticeResources/ToolKits/PatientHandOffToolKit/. Last Accessed September 28, 2007. Reprinted with permission from Medical Consultants Network, Inc.

Change of shift/breaks/lunch relief: • Procedure • Surgeon plan and preferences (where we are in the case) • Anesthesia • Allergies • Significant medical history • Counts • Irrigation • Medications • Instrumentation on and off field • Specimens on and off field • Tubes, lines, equipment

Aligning practice with policy to improve patient care 83

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©2008 Medline Industries, Inc. 84 TheisOR Connection of Medline Industries, Inc. Medline a registered trademark

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SBAR Hand-Off Communication
TMC Perioperative Hand-Off Communication
Family MD: DNR: Yes No Modified
Isolation/Infection:
MRSA VRE Other C Diff

Forms & Tools
Label

Date:
Method of transfer:
Wheelchair Cart Ambulatory Mobility: Bedrest Assist Ambulatory

IV Fluids: IV Access: PICC
Saline Lock Central Line Peripheral

S B

Surgeon: Anesthesia: Admitting Diagnosis: NKA Allergies: Core Measures SCIP/SIP CHF

NPO:

Yes

No

Fall Risk:
Low High

Mental Status:
Alert Restless Confused Combative Unresponsive

O2 Needs:
Vision Impairment:
Contacts Glasses

Communication:
HOH R L Speech Clear: Yes Non-English speaking No

Past Medical History:
Diabetes HTN CVA Arthritis COPD Asthma Pacer/AICD CAD PVD Renal disease Seizure

Initial vitals: TPR _____________ B/P_________02 Sat_____________ Height________Weight__________ Admission Blood Glucose___________

Pre-op Antibiotic: Time: Med Given:____________Time______ Med Given:____________Time______

ASA Score __________ Other: ETOH Smoker H&P Yes Dentures/Partials/Loose teeth *No B/P ______ arm* Pre-procedure verification: Yes No Site Marking: Yes No N/A Foley: Straight Cath: Yes Yes No No Last pain med: Pain Control: (circle one) PCA Epidural Intermittent IV PO N/A Medication: Duramorph: Yes No No Med Given:____________Time______

Anesthesia: MAC Local
General Spinal Block Epidural

Procedure/Operation:

OR Intake: Blood/Blood Products: OR Output: EBL: Pertinent Assessment Findings:

A

__________________________
Dressings:

PACU discharge pain score_______ Med Reconciliation completed Operation End Time:____________

Penrose: Yes No Packing: Yes No Drains: JP Hemovac NG gravity suction G-tube Stryker Reinfusion start time: Chest Tube: Suction Water Seal Heimlich

PACU Vitals:

PACU Intake: Cardiac Rhythm________________

IV #____IV credit on Transfer_________ ASA________ PACU Output: Treatments: TEDS SCD’s CPM Foot Pumps Polar Care Binder

Misc. Information:

Family Notified:

Yes

No

Pre-op RN Sig: __________________ Intraop RN Sig:___________________________

R

Postop RN Sig:___________________________

Call______________for any questions @ ext.___________.

This document is not a part of the permanent medical record

Aligning practice with policy to improve patient care 85

Forms & Tools

SBAR Hand-Off Communication
Label

TMC Endoscopy Hand-Off Communication
Room/location:
DNR: Admitting MD: Yes No Modified

Date:
Method of transfer:
Wheelchair Cart Ambulatory

IV Fluids: IV Access:
PICC Saline Lock Central Line Peripheral

S

Surgeon:

Isolation/Infection:
MRSA C Diff VRE Other

Mobility:
Bedrest Assist Ambulatory

Fall Risk:
Low High

Admitting Diagnosis: NPO since: _________ NKA O2 Needs: Allergies:
Vision Impairment:
Contacts Glasses

Communication:
HOH R L Yes No Speech Clear:

Non-English speaking

Mental Status: Alert Restless Confused Combative Unresponsive

Past Medical History:

B

Diabetes HTN CVA Arthritis COPD Asthma Pacer/AICD Other:

CAD PVD Renal disease Seizure

Initial vitals: TPR _____________ B/P_________02 Sat_____________ Height________Weight__________ ASA Score __________ H&P Yes No

Do home meds include: B/P ____ Cardiac_____ Diabetes: oral____ insulin_____ MAO inhibitor_____ Pain Status:____________________

ETOH

Smoker Pre-procedure verification: Yes No Site Marking: Yes Medications given: Demerol __________ No N/A

*no B/P ______ arm*

Anesthesia: MAC
Procedural Sedation

Procedure/Operation:

Aldrete Score:__________________ Fentanyl __________ Versed ____________ Cardiac Rhythm:________________________

A

EGD ERCP Peg Tube Bronchoscopy Colonoscopy Polypectomy: Yes No __________________________
Misc. Information:

Cetacaine Spray: Time____________ Endo discharge pain score_________ Other Med:______________________ Reversal agent: Yes No ________________________________ Med Reconciliation Completed

Family Notified:

Yes

No

Pre-op RN : ___________________ Procedural RN :___________________________

R
86 The OR Connection

Postop RN: ______________________________

Call______________for any Questions @ ext.___________.

This document is not a part of the permanent medical record

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Pressure Ulcer Prevention Policy and Procedure

Forms & Tools

Pressure Ulcer Prevention Checklist: Perioperative Services
Yes No

Do you have a policy and procedure for skin and risk assessment that addresses: a. How and when a patient is considered at risk for development of a pressure ulcer and in need of prevention intervention(s)? b. Who is responsible for developing, implementing and monitoring the prevention care plan? Do you have prevention protocols for staff to implement when specific pressure ulcer risk factors are identified? Do you have a policy and procedure for positioning patients at risk for pressure ulcer that addresses: a. Pressure redistribution OR table pads for procedures lasting longer than two hours? b. The use of gel table pads when indicated? Do you warm your patients 30 minutes prior to the surgical procedure to maintain core body temperature intraoperatively? Does the individualized care plan for each patient at risk for pressure ulcers address the following prevention interventions: a. Pressure, friction and shear reduction 1. Pressure redistribution OR table pads or overlays (foam, gel)? 2. Positioning/repositioning techniques? 3. Positioning devices (foam, gel, wedges, etc.) to prevent pressure on bony prominences? 4. Mechanical aids (lifts, slide boards, sliding sheets) for lifting, moving and positioning/repositioning? 5. Protection for head, elbows and heels? 6. OR tables of sufficient sizes to fit your patient population? b. Skin care 1. Does skin inspection occur prior to and immediately following the surgical procedure? 2. Is skin is kept dry during the surgical procedure with minimal exposure to moisture, perspiration and drainage? 3. Is it ensured that warming blankets are not placed between the pressure redistribution table pad and the patient in high-risk patients?

Position Responsible

Comments/Notes

Aligning practice with policy to improve patient care 89

Forms & Tools

Pressure Ulcer Prevention Policy and Procedure
Yes No Position Responsible Comments/Notes

4. Is skin cleansed with a skin-cleansing agent and thoroughly dried as soon as the surgical procedure is complete (before moving to the holding room)? 5. Do you minimize skin-drying factors? Do your protocols address repositioning patients whenever possible (head, heels, arms etc.) in long surgical procedures at least every two hours? Are there adequate supplies and equipment for staff to provide prevention interventions to all patients who require them? Does the care plan include routine monitoring of the effectiveness of the prevention interventions? Is there a protocol for when the prevention care plan should be evaluated and revised?

90 The OR Connection

•••••••••••••••••••••••••••••••••

Ami Lends a Hand
By Laura Kuhn The OR Connection staff writer

When Ami arrived at work and obtained her assignments for the day, she learned that the patient in Room 210 had contracted Clostridium difficile. She proceeded to the isolation cart to obtain her personal protective equipment before entering the room. The patientʼs name was Jeffrey, and he was three days post inguinal hernia repair.

“I agree,” Ami said. “But maybe using lotion would help moisturize your hands so sanitizing them wouldnʼt hurt. You know, itʼs a myth that the alcohol in those sanitizers makes them sting. It only stings if your skin is already compromised. And you could always find a little bottle of it to carry around with you so itʼs always available.” Dr. Payton sighed. “Look, Ami, I know. Iʼll talk to you later, okay?” With that, he was off to his next patient.

“How are you feeling today, Jeffrey?” Ami asked him. “Iʼm so sorry to hear about the infection. Weʼre going to do everything we can to make sure that you donʼt pick up any other infections. Iʼm sure Dr. Payton will be by soon to check in on you.”

Ami had no more than said his name when Dr. Payton walked into the room. He had been a surgeon at the hospital for as long as anybody could remember and was beloved by his patients for his gentle bedside manner. “Hello there, Jeffrey,” Dr. Payton said. “You should be able to get back to skiing in six to eight weeks, if you take care of yourself. Now, letʼs get a look at my handiwork.” He peeled Jeffreyʼs bandage back to inspect his wound. Then, satisfied, he placed the bandage back over the wound.

A few days later, Dr. Payton entered his office to find sample-sized bottles of hand lotion and the same hand sanitizer that the hospital used. He laughed to himself and tucked the bottles inside his coat pocket.
••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••

Ami stood in the hallway for a moment, deciding what to do. Then she smiled to herself and walked to the nursesʼ lounge. She picked up the phone and dialed the facilityʼs hand hygiene product vendor.

“Everything looks good,” Dr. Payton told Jeffrey. “We need to get this nasty infection cleared up so that we can get you home. Iʼll stop by later and check in on you again.” He stood to leave, and Ami followed him from Jeffreyʼs room.

The next day, Ami saw Dr. Payton in the hallway. He caught her attention, took the bottle of hand sanitizer out of his pocket, applied it to his hands and waved at her before entering a patientʼs room. Ami smiled and gave him a thumbs-up.
•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••

“Dr. Payton, I noticed you didnʼt sanitize your hands before touching Jeffrey,” she said to him quietly once they were in the hallway. Dr. Payton sighed. “I know, Ami, but this cold weather is really wreaking havoc on my skin. If I sanitized my hands all the times weʼre supposed to, they would be unbearably sore. And letʼs face it, this is a job where I need my hands to be in good condition!”

Stay tuned for the continued adventures of Medline’s family of nurse dolls, Ami, Angel, Alice Aurora and Anastasia!

Aligning practice with policy to improve patient care 91

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