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Aligning practice with policy to improve patient care

Volume 4, Issue 2

Mercy Ships
Surgical Pros Donate
Services for the Needy

OR Traffic

Are Your Scrubs

Spreading Infection?

to Foley



OR Connection
Aligning practice with policy to improve patient care

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and wonʼt miss out on our industry updates and Your name Medline’s Sahara® Super Absorbent OR table sheets are
articles addressing on-the-job issues and tips on Facility and position designed with your patients’ skin integrity in mind. The
caring for yourself! Mailing address Braden Scale tells us that moisture is one of the major
E-mail address risk factors for developing a pressure ulcer.1 We also
know that as many as 66 percent of all hospital-acquired
We also welcome any suggestions you might have on how we can continue to improve pressure ulcers come out of the operating room.2
The OR Connection! Love the content? Want to see something new? Just let us know!
That’s why we developed the Sahara Super Absorbent
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technology rapidly wicks moisture from the skin and
Content Key locks it away to help keep your patients dry.
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
Sahara OR table sheets are available on their own or
icons you'll know immediately that the subject matter on that page relates to one
as a component in our QuickSuite® OR Clean Up Kits,
or more of the following national initiatives:
• IHI's Improvement Map which were designed to help you dramatically improve To learn more about Sahara OR table sheets and
• Joint Commission 2009 National Patient Safety Goals your OR turnover time and help reduce cross contamina- Medline’s comprehensive product line, contact your
• Surgical Care Improvement Project (SCIP) tion risk through a combination of disposable products. Medline representative, call 1-800-MEDLINE or visit
us at
We've tried to include content that clarifies the initiatives or gives you ideas and References
1 Braden Scale for Predicting Pressure Sore Risk. Available at:
tools for implementing their recommendations. For a summary of each of the Accessed November 6, 2008.
initiatives, see pages 6 and 7. 2 Recommended practices for positioning the patient in the perioperative practice
setting. In: Perioperative Standards and Recommended Practices. Denver, CO:
AORN, Inc; 2008.
Sue MacInnes, RD, LD
6 Three Important National Initiatives for Improving Patient Care
20 Patient Safety Initiatives Across the United States
Clinical Editor
Alecia Cooper, RN, BS, MBA, CNOR 30 CAUTI Prevention: How Do You Rate?
Senior Writer 31 Back to Basics: Tell Me Again Why This Patient Needs
Carla Esser Lake
a Catheter?
Page 14
Art Director
51 Clean Up Your Act!
Mike Gotti

Clinical Team
Jayne Barkman, RN, BSN, CNOR

Rhonda J. Frick, RN, CNOR 8 Breaking News

Anita Gill, RN 22 The Silent Treatment
Megan Shramm, RN, CNOR, RNFA
Kimberly Haines, RN, Certified OR Nurse
42 Playing Traffic Control in the OR
Jeanne Jones, RNFA, LNC
Connie Sackett, RN, Nurse Consultant
Claudia Sanders, RN, CFA
10 Comparative Effectiveness Research
Angel Trichak, RN, BSN, CNOR 12 Prevention Above All Conference
Perioperative Advisory Board 13 Celebrating Nurses’ Accomplishments
Larry Creech, RN, MBA, CDT
Carilion Clinic, Virginia
14 OR Nurses Set Sail for Surgery
Sharon Danielewicz, RN, MSN, BSN, RNFA 40 A Cost-Effective Alternative to Urinary Catheterization
St. Lukeʼs The Woodlands, Texas 46 Legal Issues in the Care of Pressure Ulcer Patients
Barb Fahey RN, CNOR
Cleveland Clinic, Ohio
Page 31

Susan Garrett, RN
Hughston Hospital Inc., Georgia 56 How to Communicate Effectively
Zaida I. Jacoby, RN., M.A., M.Ed 65 Breast Cancer Awareness
NYU Medical Center, New York
Jackie Kraft, RN, CNOR
68 Recipe: 24-Hour Dill Pickles
Huntsville Hospital, Alabama
Audrey Kuntz, EdD, MSN, RN FORMS & TOOLS
Vanderbilt University Medical Center, Tennessee
71 SCIP Prophylactic Antibiotic Regimen Selection for Surgery
Tom McLaren, RN, BSN, MBA, CNOR
Florida Hospital
Page 42
73 VTE Prophylaxis Options for Surgery
Donna A. Pritchard, RN, BSN, MA, CNOR, NE-BC 75 What You Need to Know About Infections After
Kingsbrook Jewish Medical Center, New York
Surgery: English
Debbie Reeves, RN, CNOR, MS
Hutcheson Medical Center, Georgia 77 What You Need to Know About Infections After
Diane M. Strout, RN, BSN, CNOR Surgery: Spanish
Chesapeake Regional Medical Center, Virginia
Margery Woll, RN, MSN, CNOR
79 How to Handrub?
North Shore University Health System, Illinois 81 CATS Decrease Surgical Site Infections: English
Page 56
82 CATS Decrease Surgical Site Infections: Spanish

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About Medline

100,000 products to hospitals, extended care facilities, surgery centers, home FDA QSR compliant and ISO 13485 registered. Medline serves on major industry
care dealers and agencies and other markets. Medline has more than 800 dedi- quality committees to develop guidelines and standards for medical product use in-
cated sales representatives nationwide to support its broad product line and cost cluding the FDA Midwest Steering Committee, AAMI Sterilization and Packaging
management services. Committee and various ASTM committees. For more information on Medline, visit
our Web site,

©2009 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,

As the summer of 2009 comes to a close, my told her what was going on and the chief of surgery
youngest child, Molly will be going to college. She is told her she could shadow him any time. Molly said,
the youngest of three… so, my husband and I are now “Mom how many kids my age get a chance to actu-
officially empty nesters. I don’t usually discuss my ally go into surgery? I was right there. And, I was
work at home. By the time I get home, work is the last invited back to see a heart.”
thing I want to rehash, but Molly has had it in her head
for quite a while now that she wants to be a surgeon. Later Margery e-mailed me about the day. She said,
I haven’t said much to discourage or encourage her, “Dr. Velasco (Juan Velasco, MD, Vice Chairman of
but earlier in the summer, I thought to myself, does Surgery) was so impressed with Molly’s interest and
she have any idea what that means? And so, in typical discipline in watching the cases.” She continued, “It
motherly fashion, I asked her if she wanted to watch was a good day for Dr. Raab (David Raab, MD,

an actual surgery. My thinking was, if she is going to Orthopedic Surgeon), he taught both of us. He was so
commit the time and money into becoming a surgeon, honored …” I got to experience
she’d better make sure that is what she wants to do. vicariously the love
So, at a time that is so critical in health care, with you have for what you
I don’t know many eighteen-year-olds who are more healthcare reform, patient safety initiatives at the fore- do, the passion and
psyched about scrubbing in on a surgery than going front of every hospital’s agenda and new guidelines teamwork you express
to Six Flags … but Molly is one. I had promised to look and evidence directing our actions, I have to stop and at every opportunity.

into it; the summer was flying by and every day Molly say … you make a difference. I got to experience Thank you.
would ask me if I had made any arrangements. I really vicariously the love you have for what you do, the pas-
didn’t think she would hold me to this. I was wrong. sion and teamwork you express at every opportunity.
Thank you. You’ve just recruited another potential
My first dilemma was finding a mentor, someone who surgeon who is telling all of her friends that they
would embrace the curiosity and naiveté of youth and simply have to work in the OR (and this kid has a lot
allow Molly to watch a surgery. I contacted Margery of friends).
Woll, Director of Perioperative Services at North Shore
University Health System in Skokie, Ill., to ask her Here’s to you!
advice and to see if this was even possible. Margery
embraced the project and invited Molly to her OR.
And that was that. All I really knew before the event
Sue MacInnes, RD, LD
was that Molly had to get up much earlier than usual.
She had gotten directions to the hospital and was told
who to report to. I didn’t hear anything until she was
on her way home.

That afternoon I received a call at the office. Molly said

it was the greatest day of her life! She spoke so fast
and so full of excitement I couldn’t understand every-
thing she was saying. She said that surgery was a
“marriage between art and science,” and she felt she
could be good at both, so that is why this was meant
for her. She said the doctors told her she had great
hands. Celia (Celia Arrogante, RN, BSN, Clinical Nurse
Manager, Perioperative Services) and the nurses
treated her like she was one of them. She said it was
so cool because the surgeons were listening to music (Left to right): Scott Pittman, MD, Anesthesiologist; Margery Woll,
from their iPods. She stood 18 inches from the RN, MSN, CNOR, Director of Perioperative Services and Molly
surgery. Her favorite part was the first cut. She saw 3 MacInnes at North Shore University Health System in Skokie, Ill.
different surgeries starting with a breast biopsy, and Before observing three surgeries at the hospital, Molly said she
then proceeded to a total knee. She said that the total hadn’t realized what a major role nurses play in the OR. “The nurses
knee was messy, but really cool. And, finally she saw do so much. Nothing would happen without them,” she said.
a total hip. The surgery team was so nice to her, they

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

1 IHI Improvement Map

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

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

The IHI Improvement Map will cover the entire landscape of outstanding hospital care, keeping the 12 changes from
the 100,000 Lives and 5 Million Lives Campaigns and expanding the agenda with three new interventions.

2 Joint Commission 2009 National Patient Safety Goals

Origin: Developed by Joint Commission staff and the Patient Safety Advisory Group
(formerly the Sentinel Event Advisory Group)
Purpose: To promote specific improvements in patient safety, particularly in problematic areas

Joint Commission-accredited organizations are evaluated for compliance with these goals. The Joint Commission offers
guidance to help organizations meet goal requirements.

Over the next year, the current National Patient Safety Goals (NPSGs) will undergo an extensive review process. As a result,
no new NPSGs will be developed for 2010; however, revisions to the NPSGs will be effective in 2010.

Crucial to understanding the 2009 NPSGs is a new method of numbering the goals, for which the Joint Commission has
created a “crosswalk” available at

3 Surgical Care Improvement Project (SCIP)

Origin: 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
Purpose: To improve patient safety by reducing postoperative complications
Goal: 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

IHI Improvement Map: 12 Existing Interventions + Three New Ones

The Improvement Map is chartered with the following 15 interventions, and IHI will continue to add interventions
over time, clustering them by care setting and content area, and will help hospitals identify where they should
focus to maximize impact.
1. Prevent pressure ulcers 9. Deliver evidence-based care for acute myocardial infarction
2. Reduce methicillin-resistant staphylococcus aureus 10. Prevent surgical-site infections
(MRSA) infection 11. Prevent central-line infections
3. Prevent harm from high-alert medications 12. Prevent ventilator-associated pneumonia
4. Reduce surgical complications 13. WHO Surgical Safety Checklist
5. Deliver evidence-based care for congestive heart failure 14. Prevent catheter-associated urinary tract infections (CAUTI)
6. Get boards on board 15. Link quality and financial management – engage the chief
7. Deploy rapid response teams financial officer and provide value for patients
8. Prevent adverse drug events (ADEs)
To learn more, visit

Joint Commission 2009 National Patient Safety Goals

There are six new requirements for 2009:

• Elimination of transfusion errors that are related • When a patient leaves a facility, the patient and his
to misidentification of patients or her family receives a complete list of the patientʼs
• Prevention of healthcare-associated infections medications with an explanation of that list
resulting from multiple drug-resistant organisms • In settings in which medications are prescribed
(MDRO) using evidence-based practices minimally or for a short time, modified medication
(one-year phase-in period applies) reconciliation processes are carried out
• Prevention of central line-associated bloodstream
infections using evidence-based practices (one-year In addition to the new requirements, some of the NPSGs
phase-in period applies) already in place have been modified. Extensive changes
• Prevention of surgical site infections using best also have been made to the Universal Protocol (UP).
practices (one-year phase-in period applies)

To learn more about the 2009 National Patient Safety Goals, go to

Surgical Care Improvement Project (SCIP): Target Areas

1. Surgical-site infections
By the numbers:
• Antibiotics, blood sugar control, hair removal, normothermia
• 3,740 hospitals are submitting
2. Perioperative cardiac events data on SCIP measures, representing
• Use of perioperative beta-blockers 75 percent of all U.S. hospitals
3. Venous thromboembolism • Currently, SCIP has more than 36
• Use of appropriate prophylaxis association and business partners

SCIP is targeting two new measures for October 2009:

• Removal of urinary catheters within 48 hours post surgery
• A new, updated normothermia measure
Visit To learn more, turn to Page 8!

Aligning practice with policy to improve patient care 7

SCIP Adds Two New Measures AORN Revises Hand Hygiene
Effective October 1 Recommendations to Include
Use of Surgical Scrub Agent
Urinary catheter removal, normothermia
Revised terminology in “Recommended Practices for Hand
As part of its Surgical Care Improvement Project (SCIP), the Hygiene in the Perioperative Setting,” which was recently pub-
Centers for Medicare & Medicaid Services (CMS) will begin lished by the Association of periOperative Registered Nurses
requiring hospitals to report quality data on two new meas- (AORN), advises use of a surgical hand scrub before donning
ures effective October 1, 2009. The measures relate to gloves for a surgical procedure. AORN recommends using an
removal of urinary catheters and the documentation and reg- antimicrobial or alcohol-based surgical hand rub product.
ulation of patient body temperature.
The following terminology was submitted
SCIP Measure 9: Removal of urinary catheters and approved by AORN’s board of directors
This new measure states that urinary catheters are to be on July 17, 2009:
removed during the first or second day after surgery. The risk “A surgical hand scrub should be performed by health care
of urinary tract infection and bacteremia increase when a personnel before donning sterile gloves for surgical or other
catheter remains in place for more than two days. Although invasive procedures. Use of either an antimicrobial surgical
this measure pertains primarily to inpatient cases, surgery scrub agent intended for surgical hand antisepsis or an
departments will need to establish protocols for a physician alcohol-based antiseptic surgical hand rub with documented per-
order and a method of documenting catheter removals. sistent and cumulative activity that has met US Food and Drug
(FDA) regulatory requirements for surgical hand antisepsis is
SCIP Measure 10: Normothermia requirements acceptable.”
This new measure requires the recording and reporting of
patient temperatures, documenting whether temperatures These changes will be made to the “Recommended Practices
dropped below 96.8 degrees F from 30 minutes before surgery for Hand Hygiene in the Perioperative Setting,” which is cur-
to 15 minutes after anesthesia ends. It also must be noted rently available electronically. AORN’s electronic recom-
whether forced-air or warmed-water patient warming devices mended practices are available through AORN’s new
or garments were used. The measure applies to procedures eSubscription ( and through
that last 60 minutes or longer, and employ general anesthesia a pay-per-document platform (
or neuroaxial blocks. sourcees/AORNStandardsandRecommendedPractices/EDo
For more details on all of the SCIP measures,
visit Reference
AORN board revises hand hygiene recommended practice. News Release. July
22, 2009. Available at
81B585C4FB6DF06E/HandHygieneAnnct.pdf. Accessed July 29, 2009.

8 The OR Connection
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©2009 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
What’s Happening in Healthcare Reform

Patient-centered research
Therefore, the healthcare research conducted under this
initiative will be patient-centered and apply to the “real
world” in order to help patients, clinicians and other deci-
sion makers assess the relative benefits and harms of
strategies to prevent, diagnose, treat, manage or monitor
health conditions.1

In addition, the research should consider and include a

variety of patient populations (e.g., people with disabilities
and chronic illnesses, and different racial and ethnic back-
grounds) for the program to be effective.2

Federal Coordinating Council for Comparative

Effectiveness Research
The first step in the comparative effectiveness initiative was
to appoint a management council in March 2009. The Federal
Coordinating Council for Comparative Effectiveness
Research (the Council) is composed of 15 distinguished
leaders from key government healthcare-related agencies,
including the Veterans Health Administration (VHA), Centers
for Disease Control and Prevention (CDC), Centers for
Medicare & Medicaid Services (CMS) and the HHS, among
Comparative Effectiveness Research: others.2 The Council’s purpose is to coordinate compara-
What It Is and How tive effectiveness research and related health services
research across the federal government with the intent of
It Can Help You and reducing duplication and encouraging the complementary
use of resources.1
Your Patients The Council will oversee the $1.1 billion in funding, of which
$300 million is allocated to the Agency for Healthcare
Research and Quality (AHRQ), $400 million to the National
Legislators in the Senate and House have been busy
Institutes of Health (NIH) and $400 million to the Office of
this year preparing and debating their versions of a
the Secretary.1
healthcare reform bill. Perhaps one of the bills, or a
hybrid, will be passed by the end of 2009. In the interim,
Goals of Comparative Effectiveness Research
the launch of a new federally funded healthcare program on
• Reduce healthcare costs2
comparative effectiveness research is well underway.
• Build public interest2
• Improve patient care2
The American Recovery and Reinvestment Act of 2009
• Encourage development and use of clinical registries
allocated $1.1 billion to the U.S. Department of Health and
and data networks1
Human Services (HHS) for this initiative. What is compara-
• Increase consistency of treatment provided in different
tive effectiveness? The Institute of Medicine (IOM) defines it
geographic regions1
as “the extent to which a specific intervention, procedure,
• Greater ability to tailor interventions to treat patients’
regimen or service does what it is intended to do under real
specific needs1
world circumstances.”1 As HHS describes it, comparative
• Care based on evidence and best practices1
effectiveness research provides information on the relative
strengths and weaknesses of various medical interventions,
including drugs, devices and procedures.2

10 The OR Connection
High-Priority Topics for Federally Funded
Comparative Effectiveness Research3
The American Recovery and Reinvestment Act of 2009
called on the Institute of Medicine to recommend a list of
priority topics to be the initial focus of a new national
investment in comparative effectiveness research.

The complete list contains 100 topics, prioritized into four

groups of 25 each. The following is a sampling of topics that
relate to surgical professionals. They are listed in order from
highest to lowest priority, as indicated by the Institute of
Graduation Day – for Two!
• Compare the effectiveness of treatment strategies for
atrial fibrillation, including surgery, catheter ablation Brian Lee Morrison earned his registered nurse degree in
and pharmacologic treatment. May 2009 from St. Petersburg College School of Nursing
in St. Petersburg, Fla. He (and Medline nurse doll Alice)
• Compare the effectiveness of various screening, graduated with honors. Brian is continuing at St. Peters-
burg College to complete a bachelor’s degree in nursing.
prophylaxis, and treatment interventions in eradicating
methicillin-resistant Staphylococcus aureus
He currently works in the OR at St. Joseph’s Hospital in
(MRSA) in communities, institutions and hospitals. Tampa. Before earning his RN, he had been a surgical
technologist and certified first assistant.
• Compare the effectiveness of strategies (e.g.,
bio-patches, reducing central line entry, chlorhexidine
for all line entries, antibiotic-impregnated catheters,
treating all line entries via a sterile field) for reducing
healthcare-associated infections (HAI), including
catheter-associated bloodstream infection, ventilator-
Check out
associated pneumonia and surgical site infections in
adults and children.
All continuing education
• Compare the effectiveness of robotic assistance credits are now FREE!
surgery and conventional surgery for common
operations, such as prostatectomies. Easier navigation to find
what you need – faster.

Visit the redesigned www.

1. U.S. Department of Health and Human Services. Federal Coordinating Council today, and let us know
for Comparative Effectiveness Research: Report to the President and Congress, what you think!
June 30, 2009. Available at
alrpt.pdf. Accessed August 3, 2009.
2. Zigmond, J. Healthy choices: industry wonders how $1.1 billion for comparative-
effectiveness research will be applied. Modern Healthcare. March 30, 2009:
3. Institute of Medicine. 100 Initial Priority Topics for Comparative Effectiveness
Research. Available at Accessed August 3, 2009.

Aligning practice with policy to improve patient care 11


Also, two experts in wound care and healthcare law, who are
Prevention Above All Conference, also members of the International Expert Wound Care Advisory
Washington, DC, August 16-18, 2009 Panel, addressed the legal implications of caring for patients with
pressure ulcers, sharing ways healthcare professionals can pro-
Chief nursing officers, chief medical officers, directors of nursing tect themselves from litigation. Turn to page 46 for excerpts from
and other clinical executives from hospitals across the country their new white paper, “Legal Issues in the Care of Pressure
gathered in Washington, DC, August 16-18, 2009, for Medline’s Ulcer Patients: Key Concepts for Healthcare Providers.”
popular Prevention Above All Conference. They learned new
strategies for delivering cost-effective, high-quality health care SCIP. The Surgical Care Improvement Project continues to
and evidence-based solutions for improving patient care. evolve, with two new measures coming in October. Highly
regarded quality improvement specialist Dale Bratzler, DO, MPH,
An impressive agenda medical director of SCIP, discussed patient safety in the context
Tying in all that is top-of-mind on Capitol Hill these days, former of SCIP and expanded on new and revised SCIP measures.
senator Tom Daschle opened the conference by discussing his
book on healthcare reform and the delivery of cost-effective Prevention Above All Discoveries Grant recipients
health care. Following Daschle was Institute of Medicine President Dr. Andrew Kramer announced the names of Prevention Above
Dr. Harvey Fineberg, who addressed the impact of comparative All (PAA) Discoveries Grant award winners. Dr. Kramer, professor
effectiveness research on delivering cost-effective, evidence- of medicine at the University of Colorado, served as chair of the
based health care. (See article on page 10 to learn more about PAA Discoveries Grant Review Committee. The committee also
comparative effectiveness research.) included Dale Bratzler, DO, MPH, medical director of SCIP; Diane
Krasner, PhD, RN, CWCN, CWS, BCLNC, FAAN, wound & skin
Emphasis on patient safety care consultant; Michael Raymond, MD, chief medical officer,
As always, patient safety was a major focus, and world North Shore University Health System and Heidi Wald, MD,
renowned experts shared the latest innovations and evidence- MPH, professor of medicine, University of Colorado. All grant
based practices in the prevention of catheter-associated urinary applications and proposals were independently reviewed and
tract infections (CAUTI), hand hygiene and pressure ulcer approved by this committee. Watch for more information on the
prevention. recipients and their research topics in upcoming issues of The
OR Connection.
CAUTI. Medline introduced its new evidence-based system
to help prevent CAUTI. The ERASE CAUTI™ program combines Unable to attend the Prevention Above All Conference?
innovative design, education and awareness to tackle catheter- Visit for highlights from the meeting, including video
associated urinary tract infection – the number one hospital- clips from the presentations.
acquired infection.

Hand hygiene. Internationally renowned professor and

epidemiologist Didier Pittet, of Switzerland, shared the latest Critical: What We Can Do About the
hand hygiene improvement strategies. Dr. Pittet is lead of the Health-Care Crisis, authored by for-
World Health Organization (WHO) World Alliance for Patient mer senator Tom Daschle, outlines the
Safety and a member of the advisory board for the WHO’s healthcare reform strategies that are
First Global Patient Safety Challenge, “Clean Care Is Safe Care.” the foundation of President Obama’s
healthcare initiative. Evaluating where
In addition, German epidemiologist Gunter Kampf presented previous attempts at national
new discoveries and considerations in hand sanitizing tech- healthcare coverage have succeeded,
niques. He is the author of 119 scientific papers published and where they have gone wrong,
in national and international infection control journals. Daschle explains the complex social,
economic and medical issues involved in reform and sets
Pressure ulcers. Wound care expert Elizabeth Ayello provided forth his vision for change. The book is available for purchase
insight on CMS present on admission (POA) indicators as they at leading retail bookstores and online outlets.
relate to hospital administrators and clinicians.

12 The OR Connection
The OR Connection Celebrates
Nurses’ Accomplishments
OSF St. Joseph Medical Center
Achieves Magnet Recognition
OSF St. Joseph Medical Center in Bloomington, Ill., A magnet steering committee
recently achieved Magnet Recognition for excellence in was formed to create a docu-
nursing services by the American Nurses Credentialing ment proving that OSF St.
Center (ANCC). Joseph Medical Center met or
exceeded the 164 standards
The Magnet Recognition Program recognizes healthcare that are part of the Forces of
organizations that demonstrate excellence in nursing prac- Magnetism.
tice and adherence to national standards for the organi-
zation and delivery of nursing services. The ANCC’s Each committee member was responsible for finding
Commission on Magnet made a unanimous decision to sources of evidence to support the standards within one
make OSF St. Joseph Medical Center a Magnet hospital. force. Committee chair Sandra Scheidenhelm encouraged
all members to stay on task until the final documentation
Magnet applicants undergo a rigorous evaluation process, was turned in – all 15 volumes of it!
including written documentation of 14 specific areas of
nursing practice called Forces of Magnetism. Hospitals The committee’s hard work and dedication paid off.
also participate in extensive interviews and an on-site OSF St. Joseph was awarded Magnet Recognition in
review of nursing services. OSF St. Joseph began work- December 2008.
ing toward Magnet Recognition in 2004.

OSF St. Joseph Medical Center Magnet Steering Committee. OSF St. Joseph Medical Center CEO Ken Natzke presents
Back row (left to right): Marcia Laesch, Dixie Reynolds, the ANCC Magnet Recognition obelisk to Chief Nursing
Sue Herriott, Pat O’Dell, Barb Stevig. Front row (left to right): Officer Deb Smith.
Mark Dabbs, Deb Smith, Sandi Scheidenhelm, Phyllis McNeil.

Aligning practice with policy to improve patient care 13

14 The OR Connection
Special Feature


Excellent nursing care for the underprivileged

by Mila Hightower

Mercy Ships is a global charity additional average of 30 cataract

that has operated hospital ships removals and other eye-related
in developing nations since surgeries also take place daily. Tu-
1978. Mercy Ships brings hope mors are removed, burn contrac-
and healing to the forgotten poor tures are released, limbs are
by mobilizing people and re- straightened, deformities are cor-
sources worldwide and serving all rected, sight is restored and,
people without regard for race, above all, dignity and hope are
gender or religion. Recently, a given to thousands of previously
partnership was formed between suffering individuals.
AORN and Mercy Ships with the goal of increasing
awareness of the opportunities available to operating The work of highly skilled surgeons from around the
room nurses wanting to serve the suffering poor. world allows for such tremendous healing to take place.
However, without the help of the operating room (OR)
The Africa Mercy is the world’s largest non-governmental nursing staff, none of it would be possible.
hospital ship. An entire deck functions as a complete
hospital with five wards, an intensive care unit, medical There are currently 15 OR nurses serving onboard the
lab, CT scanner and six operating rooms. There are 450 Africa Mercy. Some have been onboard for more than
crew members, and 130 are healthcare staff. Each year, two years (long-term); others will serve short-term for two
Mercy Ships welcomes more than 1,200 long-term weeks or more. Both long-term and short-term commit-
volunteers from over 40 nations and 2,000 short-term ments are important and greatly appreciated. The dura-
volunteers. tion of commitment may vary, but the standard of work
and care provided by all of the nurses is impeccable.
Onboard the Africa Mercy, 12 surgeries, on average, are
completed each day, including maxillofacial, plastics, OR nurses from all walks of life serve with Mercy Ships –
general, orthopaedic, and vesicovaginal fistula (VVF). An even those with families of their own. Before Jenny Rol-

Aligning practice with policy to improve patient care 15


Melissa Brown of the USA is

currently serving with Mercy
Ships as an OR nurse for 3
months. An AORN member,
Brown has found the
management and efficiency
of the Africa Mercy’s onboard
hospital similar to that of a First
World hospital.

land, along with her husband and three children, joined Mercy Ships,
she worked as an OR nurse in the United States for 14 years, spe-
cializing in otolaryngology, ophthalmolics and plastics. She now
works as the assistant OR supervisor onboard the Africa Mercy. She
manages the daily surgery schedule, acts as a liaison between the
wards and the ORs, and provides orientation and assistance for new

Apart from the fact that it is located on a ship, the

Africa Mercy’s OR is almost identical to the OR of a
regular hospital.

“Remarkably, this hospital is very similar,” Rolland said. “It’s encour-

aging to have short-term nurses who know how an OR functions,
and all they really need to know is where the supplies are kept. Then
they can do what they know how to do. That’s the beauty of it.”

Every weekday morning, the OR staff meets at 7:30 a.m. for devo-
tions and a time of prayer. This is followed by a short briefing on the
day’s schedule. Thereafter, surgeries begin. Though it changes every
day, the OR usually doesn’t end surgeries until around 6:00 p.m.
During nights and weekends, the OR is closed, although a weekly
team of three is on call in case of an emergency.

16 The OR Connection
Of course, running a First World facility in a Third World Melissa Brown recently joined Mercy Ships as a short-term
environment has its challenges. As a not-for-profit organi- OR nurse. “My experience so far has been great! My first day
zation, Mercy Ships’ resources are sometimes limited. in the OR everyone was very welcoming, and they helped
Surgical instruments and equipment have to be used more me fit right in by explaining the procedures,” she said.
than once. Effective methods of sterilization and a subse-
quently low infection rate make this feasible. Brown is a registered nurse and a member of AORN with
CNOR and first assistant certifications. She worked as a
With an international staff represented by more than six travel nurse in the United States before joining the Africa
countries, language and communication can be problem- Mercy as an OR nurse for three months during the summer.
atic. “There’s a language that one has to get used to when
there are four different names for one instrument,” Rolland “I have never been able to combine missions with my OR
said. “Thankfully the OR is sort of a universal environment.” nursing career,” she said. “Here with Mercy Ships is my first
opportunity to be able to do that, and that is very special to
A broad spectrum of nationalities and cultures also has its me,” Brown said.
benefits. Rolland explained, “I think being able to work with
an international staff is very enlightening because there are Although the Africa Mercy is currently stationed in the West
ways that people from different parts of the world do African nation of Benin, the onboard hospital continues
things. It’s nice to have that added to what we do. to operate effectively. Its staff finds the conditions famil-
Sometimes there might be a way that is more efficient.” iar and comfortable.

Continued on Page 19

Aligning practice with policy to improve patient care 17

a new
in patient


Medline’s Gold Standard Safety Program is designed 3. AORN Checklist: Wrong site, wrong procedure,
to break down barriers to surgical safety compliance wrong patient surgery prevention.
by offering easy-to-use tools to help you reach your 4. Med-Pack™: Electronic pack audit and a review
safety goals. of safety components.

The program offers four levels of safety options: To learn more about the Gold Standard Safety
1. The Gold Standard Safety Bundle: Includes six Program, contact your Medline sales representative,
call us at 1-800-MEDLINE or visit
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.™) Flag and Drape remind OR
staff to take time to verify key information before
the first incision.

©2009 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

Taking time for a little fun. Jenny Rolland of the USA lives onboard the Africa Mercy with
her husband and three children. With 14 years of experience,
she now works as the Assistant OR Supervisor for Mercy Ships.

“I worked a day shift at home so the hours here are very ing and has already completed training in ophthalmolics,
similar,” explained Brown. “As far as how the OR is run and general and maxillofacial surgery.
the management and efficiency of things, I think it’s very
similar to a First World OR.” “In the United States I found surgeries were all about time
and getting things done, but here the surgeons are willing
Although she is currently assisting with eye surgeries, to teach you more so that you are able to take better care
Brown will get the opportunity to work in all the surgical of the patients. They are humble and willing,” she explained.
specialties performed onboard the Mercy Ship.
Green finds that a notable and positive difference is the
Alison Green is a long-term volunteer who joined Mercy opportunity to spend more time with patients. “I think that
Ships shortly after completing four years of nursing school here we get more connected with our patients. We have an
in Tyler, Texas. Although she has only been onboard the opportunity to pray with them, get to meet them face-to-
Africa Mercy for a few months, she has already gained a face before surgery, see them afterwards in the ward and
wealth of experience that will undoubtedly further her pro- watch how they heal,” she explained. “It’s great to see what
fessional career as an OR nurse. I was a part of and how I’ve made a difference in their lives.”

“It’s great to see what I was a part of and “Life here is very fast-paced and very busy, but at the same
time, it’s rewarding and life-changing. This work really
how I’ve made a difference in their lives.”
reminds me about why I became an OR nurse. I can see
the hope and healing brought to the patient firsthand. I think
“I’ve found that I’ve learned more here in five months than
if nurses are rundown and have forgotten why they are
I did in three years back home,” Green said. “Many of the
doing what they are doing, they will be inspired if they come
procedures and surgeries we do here are not normally done
here,” Green said.
back home because the cases are so unique. I have
learned so much as a scrub nurse. I get to be more
If you would like to be a part of bringing hope and healing
involved in assisting the surgeons, whereas back home I
to the world’s poor, please visit or
had to do more paperwork.”
contact the Mercy Ships human resources department at
(903) 939-7045. Mercy Ships headquarters is located in
Because Green has made a long-term commitment to
Lindale, Texas.
Mercy Ships, she is being trained in all the specialties. She
is currently undergoing six weeks of VVF scrub nurse train-

Aligning practice with policy to improve patient care 19

Patient Safety Initiatives Across the United States

Rhode Island adopts protocol to guardian all confirm the surgical site together before it is marked
prevent wrong site surgery with the surgeon’s initials.

Program implemented July 1, 2009 OR team briefing. All team members introduce themselves and
their roles. The surgeon then briefs the team, identifying the patient,
All 12 hospitals and 21 surgical centers in procedure and site, and explaining plans for the surgery, including
Rhode Island have agreed to adopt a sur- any medications, documentation and equipment needed.
gical safety protocol designed to reduce
the risk of wrong site surgeries. According to the Hospital Associ- Time out. Led by the surgeon, all team members verify the
ation of Rhode Island, the state is the first in the nation to have all patient, procedure and site and confirm that the site marking is
surgical providers voluntarily adopt the same safety protocol.1 visible after prepping and draping.

The term “wrong site surgery” applies if the wrong procedure is per- Post-op de-briefing. The surgeon leads a discussion of the post-
formed or if a procedure is performed on the wrong person or the operative plan of care and a review of how the surgery went and
wrong body part. what could have been done differently.

Rhode Island’s protocol was developed over a period of 18 months William Cioffi, MD, surgeon-in-chief at Rhode Island Hospital, said
by state hospital and healthcare leaders in cooperation with the that safety efforts must walk a fine line, requiring accountability with-
Joint Commission.2 It is similar to surgical safety checklists created out overemphasizing blame; each member of the surgical team has
by the World Health Organization and The Joint Commission. responsibilities to meet but also must feel free to acknowledge and
report errors.1
With an emphasis on clear communication among surgeons, staff
and patients, the protocol is designed to prevent errors but also to Cioffi added that the hospitals will train staff through lectures and a
avoid the confusion that sometimes occurs when practitioners split video and also will devise ways to make sure the protocol is prop-
their time between facilities with different policies. erly and uniformly adopted around the state. “This is a great first
step. It’s not the end of the process.”1
“They have steps built into their protocol that allow all team mem-
bers to be accountable and responsible for speaking up if they Providers began implementing the protocol July 1, but it could be
believe that something doesn’t look right,” said Mark Crafton, as long as one year before staff at all facilities have received train-
the Joint Commission’s executive director for state and external ing on the new rules.1
Earlier this year, the federal government took steps toward pre-
Four key features of the protocol include:2 venting wrong site surgery. As of January 15, 2009, the Centers
for Medicare and Medicaid Services (CMS) no longer reimburse
Three-way pre-op consult. The surgeon, one other licensed hospitals or surgery centers for wrong site surgery.3,4,5
practitioner (such as a registered nurse) and the patient or patient’s

20 The OR Connection
Patient Safety

Near zero incidence of HAIs at New Hampshire first state to

Monroe Hospital in Indiana adopt surgical safety checklist

How do they do it? NH hospitals, ASCs lead the nation

in infection control
Monroe Hospital in Bloomington, Ind. has
a near zero rate (0.06 percent) of hospital- New Hampshire hospitals and ambulatory
acquired infections among the more than surgery centers have voluntarily adopted
2,800 inpatients treated since the hospital opened in 2006.6 The a safety checklist for surgeries and all other invasive procedures.
national average of healthcare-acquired infections in U.S. hospitals The protocol is based on a checklist developed by the World Health
is assumed to be five percent.7 Organization (WHO), which identifies three phases of a procedure
for which medical team members confirm appropriate tasks have
So, how does Monroe Hospital stave off healthcare-acquired been completed. New Hampshire Gov. John Lynch applauded the
infections? The following is a list of infection control measures used statewide collaboration, noting that “reducing errors and infections
at the hospital:6 and improving quality all help in controlling the cost of health care.”8

1. Frequent handwashing with alternating products. Doctors New Hampshire hospitals perform better than the national average
and staff are encouraged to wash their hands frequently – particu- in each of the five Surgical Care Improvement Project (SCIP) meas-
larly after having contact with a patient and before and after eating ures related to surgical care.9
or using the restroom. They are instructed to use three different
products – soap and water, an alcohol-based hand foam and Surgical Care Improvement Project (SCIP)
an ammonia-based hand sanitizer – on an alternating basis; each NH Nat. Avg.
one third of the time. Prophylactic Antibiotic Received Within One 96% 94%
Hour Prior To Surgery
Hospital officials say this combination of products keeps the hands Prophylactic Antibiotic Selection 98% 97%
clean, but also soft and pliable. Individuals with dry, cracked skin on Prophylactic Antibiotic Discontinued Within 94% 90%
their hands tend to wash them less often. 24 Hours After Surgery
Recommended VTE Prophylaxis Ordered 94% 93%
2. A clean environment. Cleaning of all surfaces takes place Recommended VTE Prophylaxis Received 92% 90%
daily. Environmental services staff wipes down door handles, light Controlled 6 am Postop Serum Glucose 91% 90%
switches, patient beds, countertops and computer keyboards. Appropriate Hair Removal 99% 98%
Deep cleaning, which includes cleaning behind computers and
under keyboards, occurs every Friday.
3. Isolation procedures. Patients with a history of MRSA are iso- 1. Freyer FJ. R.I. hospitals agree on safety protocol for surgeries. The Providence Journal.
lated, and staff must wear gloves and protective gowns when they July 1, 2009. Available at
come in contact with these patients. The patients remain in isola-
09_QLETDSU_v10.3dce7cb.html. Accessed July 8, 2009.
tion their entire hospital stay, regardless of subsequent negative 2. Tsikitas I. R.I. adopts uniform surgery safety protocol. Outpatient Surgery Magazine.
MRSA cultures. Available at Accessed July 8, 2009.
3. Decision Memo for Wrong Surgery Performed on a Patient (CAG-00401N). Centers for
Medicare and Medicaid Services Web site.
4. Hospital-laundered scrubs. The hospital launders all doctors’ memo.asp?id=223. Accessed July 8, 2009.
and staff scrubs to make sure they are cleaned properly to remove 4. Decision Memo for Surgery on the Wrong Body Part (CAG-00402N). Centers for Medicare
bacteria. No staff member enters or leaves the hospital wearing and Medicaid Services Web site. Accessed July 8, 2009.
scrubs. 5. Surgery on the Wrong Patient (CAG-00403N). Centers for Medicare and Medicaid Services
Web site.
For further discussion on how scrubs may spread infection, turn to Accessed July 8, 2009.
6. Denny D. Monroe Hospital’s low infection rates draw national interest. Bloomington Herald
page 51. Times. January 19, 2009. Available at http://www.heraldtimeson- Accessed May 11, 2009.
7. Wenzel R, Edmond MB. The impact of hospital-acquired blood stream infections. Emerg Inf
Dis. 2001;7(2):174-177.
8. NH Health Care Quality Assurance Commission issues 4th annual report. News from the
Foundation for Healthy Communities. July 2009. Available at
fhc/about/newsletter/FHCNewsletterJul09.pdf. Accessed July 21, 2009.
9. NH Quality Care Reports. New Hampshire – Surgical Care Improvement Project (SCIP).
Available at Accessed July 22, 2009.

Aligning practice with policy to improve patient care 21


22 The OR Connection
OR Issues

by Kathleen Bartholomew, RN, RC, MN

and John J. Nance, JD

Recently, a highly accomplished orthopedic sur- thoughts couldn’t let it go: “Where’s the checklist for when
geon was scheduled to work on three consecutive things go wrong?” he thought sarcastically to himself,
cases with his OR team. The operating rooms were having seen system error after system error despite the
state of the art within the medical center’s newly con- apparent adaptation of techniques used by high reliability
structed orthopedic hospital, which had not yet cele- organizations. Sharply, he gave an order for Gentamycin
brated its first birthday. A system of time outs including for his first patient and turned his attention, as best he
use of the World Health Organization (WHO) surgical could, to his next case. He dreaded the moment when he
checklist had been in place at the medical center for al- would have to tell his patient – a man who trusted him
most three years now, with multiple checklists for patient implicitly for a second knee replacement. But things just
identification, pre-op procedures and instrumentation. got worse.

The surgeon was scrubbing in for his second case when the His second case was a lawyer who had a long history of
charge nurse approached him from behind and quietly surgeries due to rheumatoid arthritis. The physician had
said, “Doctor, I have something to tell you. The instru- literally spent hours selecting the best implants for this
ments that you used for the first case were not sterilized.” complicated revision, talking to vendors at great length to
With the second patient already under anesthesia, there ensure the compatibility of the various systems and care-
was no time for the surgeon to discuss the small bomb- fully relaying his recommendations to the patient, who
shell that had just been lobbed in his direction, but his was extremely involved after five surgeries.

Aligning practice with policy to improve patient care 23

Three powerful forces impede
communication in health care: time
pressures, knowledge and culture.

“Socket,” he said at the appropriate moment with hand never happen again. Despite the very best of intentions and
extended, eyes still fixated on the open wound. the adoption of standardized checklists and procedures,
this team has a long way to go. The level of trust and feel-
“Socket,” he said again, irritated after nothing had landed ings of personal safety in the group simply aren’t high
in his hand. enough for anyone to risk being vulnerable and actually
address a painful truth – that as a team they had systemi-
From his peripheral vision he picked up on commotion. He cally screwed up.
turned and looked up at the circulating nurse who quietly
said, “It’s not here doctor.” Fully focused on getting the Worse, violating every premise of regarding mistakes as
piece he needed STAT, the surgeon immediately got on important messages from the underlying system, they were
the phone to the vendor, trying to negotiate the use of willing to squander and discard the obvious opportunity to
another implant despite his careful planning. improve their own techniques, not to mention the opportu-
nity to share what had happened (and how to fix it) with
“She’s under a spinal … it will be wearing off. I can’t wait other surgical teams. Patient safety can only be enhanced
that long – why isn’t it here?” he said loudly over the phone. when bad experiences are shared, probed, understood,
Finally, after half an hour, the vendor arrived with the implant. and procedures changed. In fact, collegial interactive teams
Both relieved and frustrated, the surgeon closed and turned – groups of professionals dedicated to a common goal and
to his third case, which was uneventful – and painfully, as willing to care about each other and trust each other
silent as the second case. In fact, despite the two major enough to honestly report and evaluate any failure – never
mistakes of the day, not a single person in the operating hesitate to put a failure on the table for discussion. And
room had mentioned either event. never – never – does an effective collegial team care so lit-
tle for their own that they permit silence to shroud the
“The saddest thing was that no one said a word,” the sur- human pathways of interaction between them.2
geon said soberly. “I work with these people all the time and
you think someone could have at least said, ‘I’m sorry that Three powerful forces impede communication in health
happened,’ or something like that. But instead, there was care: time pressures, knowledge and culture. Understand-
nothing but this awkward silence. More than anything, I’m ing their impact is the first step to creating collegial and
still bothered by the silence.” effective teams in which relationships go deeper than the
mask of composure. Honest and meaningful relationships
As well he should have been. can only happen if we are free to speak our truth at all times.

As noted communication expert Susan Scott says, “The Culture – the undertow of health care
conversation isn’t about the relationship. It is the relation- There is no force more powerful in an organization than cul-
ship.”1 This orthopedic surgeon is an outstanding physician, ture. As all business experts counsel: “Culture kills the best
known and respected for his skill and compassion – the of strategies.” In fact, the phrase and the concept of “This
only surgeon who would actually drive to a patient’s house. is the way we’ve always done it!” is the mindless battle cry
Yet, he could not communicate his disappointment to his of culture-resisting change. Culture is never written down
team – and his team refused to reach out to him; or vocalize or spoken – but known by everyone.
any concerted team effort to make sure these errors would

24 The OR Connection
Instructors were often heard to say,
“If you want to work in the OR, you
better have thick skin.”

For decades, operating room nurses were raised to be

humble; to care not only for the patient, but also for the sur-
geon. They monitored his/her moods and wondered if
he/she had gotten enough sleep. If necessary, they stroked
egos or took the blame for mistakes – all for the sake of an
uneventful surgery. This is how many nurses were trained.
Instructors were often heard to say: “If you want to work in
the OR, you better have thick skin.” There were valid rea-
sons why a warning accompanied an invitation to work in
the OR.

Physicians were trained to lead in a hierarchical system and

taught to act and think as if their very education meant that
they were more important than any other member of the
team.3 Certainly they were, and are, more vulnerable. If the
patient died, the surgeon was faulted. And when all the
responsibility and liability is yours, then you had better have
total control over the situation.

In essence, this is the same drive for absolute physician

autonomy that according to healthcare governance expert
Jaime Orlikoff, originated about four thousand years ago
with the Code of Hammurabi, which decreed amputation of
a physician’s fingers if his patient died after surgery. The
physician response, even in ancient Babylonia, was very
understandable: “If I have total accountability, I demand total
autonomy in making decisions for my patients.”4 In all the
millennia since, we’ve simply reinforced autonomy in our
medical culture. And that drive alone is frankly one of the
principal stumbling blocks in creating true collegial teams
in the OR – rather than an iron-willed, all-knowing leader
and obedient followers (the old model).

Aligning practice with policy to improve patient care 25

Today, the massive profession-wide push for major improve- that they were just as upset as he was about the events of
ments in patient safety includes considerable pressure on the day, because nobody said anything. In the Silence Kills
doctors to step away from the old model and shoulder the study,5 fewer than 10 percent of physicians, registered
responsibility of being an effective leader in building mean- nurses and clinical staff could directly confront their col-
ingful, collegial relationships. But even the best leaders can’t leagues about their concerns. Why aren’t people talking?
lead if the members of the would-be team refuse to shoulder
their reciprocal responsibilities to be receptive and commu- A recent study of over 2,500 hospital nurses gives us some
nicative and trusting. That’s what happened to the unhappy answers.6 Nurses were asked to identify a conversation that
orthopod left wondering why he got the silent treatment. they needed to have in order to create a healthy
Whatever culpability he, as the surgeon, might have had for work environment.
not breaking the silence, his “team” also has a vital role.
The responsibility for a true team is a shared responsibility. When asked why they had avoided the crucial
conversation, they responded:
Start the conversation. What is the current culture of your • Fear of retribution
OR? Can you speak up at any time to ask a question or • Fear of retaliation (unfair assignment or schedule,
stop the line? The culture of the operating room in the pre- refusing to help, refusing a vacation)
vious case was to ‘lay low when things go wrong.’ No • Fear of being isolated or excluded from the group
member of the team ever acknowledged this, or said these • Fear of being gossiped or talked about
words out loud. As a team, they learned over the years to • Fear of being wrong
hibernate until the ‘storm’ passed. But until someone steps • No time
forth and starts acting differently, nothing will change. Only • Fear of upsetting the status quo; rocking the boat
the courage to act differently over a long period of time, • Why bother? Nothing will change; it’s no use
even without the support of the group, can move cultural
inertia. If you can do this, you are a true leader – regardless
of your position.

What is the single most important thing you can do

to impact culture on an individual level? Speak your
truth. But how?

Knowledge is power
Communication classes are noticeably absent from both
medical and nursing school curricula. Yet the number one
cause of adverse outcomes in a study of 2,400 sentinel
events by The Joint Commission was communica-
tion errors.

Communication omissions happen frequently. The operat-

ing room coordinator didn’t know the bowel resection was The primary denominator here is fear. As long as we live in
going to be lappy because “nobody told him.” The tech fear, nothing will change. Healthcare workers share a pas-
didn’t know that the surgeon switched systems for his sive-aggressive style of communication. They say why they
lumbar fusions because “nobody told her.” Likewise, the are upset – to everyone in the department except the
orthopedic surgeon didn’t know that his team cared, and person they are angry with. In addition, the most common

Continued on Page 28

26 The OR Connection
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way nurses deal with confrontation is avoidance. Nothing is STATE - When something happens that is not normal
worth upsetting the relationship. Noting this, it is imper- (unanticipated event or error), I would appreciate your
ative that leaders teach assertive communication and support or acknowledgement of what happened. I want to
confrontation skills in the workplace. create an atmosphere where every member feels sup-
ported, and today, I certainly did not.
One very simple model is called the D-E-S-C Communica- CONSEQUENCE - If we continue to ignore issues as a
tion Model. It provides a great framework for organizing your team, then we are not a team.
thoughts and feelings.7
D - Describe the behavior Time is money AND…
E - Explain the effect of the behavior For every good idea to improve patient safety and clinical
S - State the desired outcome quality there is a voice reminding us that time is money.
C - Say what happens if the behavior continues Money governs healthcare in America. No surgeon, OR
scheduler, or CEO can refuse to be concerned about how
For example, the physician could have efficiently an OR can be used. Pressures have become so
approached the team this way after intrusive on the surgical team that beepers and Blackber-
the surgeries: ries now provide a constant opportunity for interruption and
DESCRIBE - I want to talk to all of you about the silence in distraction that few patients on the table would appreciate
the operating room today. No one said a word all day. if awake. While only preliminary data is emerging to validate
EXPLAIN - The silence is what upset me the most. Having what we already intuitively know, the fact is, the higher the
to explain the unsterile instruments to my patient was pressure on time, and the higher the level of distraction in an
extremely upsetting; as was not having the right implant. OR, the less concentration on the procedure. To the extent
But the silence made me feel like I was alone, or surrounded that a surgical team is constantly disrupted by mid-proce-
by strangers. dure personnel substitutions, thoughtless intrusions, and

28 The OR Connection
highly distracting communications, patient safety is com- References
1. Scott, S. (2004). Fierce Conversations. New York: The Berkley Publishing
promised. Time pressures drive distractions that fragment Company.
and fracture teamwork and the ability of a surgical team to 2. Nance, J. (2008). Why hospitals should fly. Second River Healthcare Press,
Bozeman, MT.
stay focused and supportive of each other.
3. Bartholomew, K. (2007). Stressed Out About Communication Skills,
Marblehead, MA
How does the leader of a would-be collegial interactive 4. Orlikoff, J. (2008). IHI Conference: From the top: the role of the board in quality
and safety, November 6-7, Boston, MA.
team respond to such pressures? By taking the time to 5. “Silence Kills: The Seven Crucial Conversations for Healthcare” study by
discuss issues outside the OR, tracking outcomes and VitalSmarts available at
6. Bartholomew, K. Presentation for Sigma Theta Tau International: “Using a
reviewing all outliers. A team cannot coordinate their
communication model to identify barriers and increase self esteem” November
actions or responses if they don’t make the time to come 2, 2009, Indianapolis, IN
together before the fact and at least go over the basics of 7. Cox, S. (2007) Cox & Associates, Brentwood, TN.

what they’re about to do; as well as openly discuss unin-

Kathleen Bartholomew, RN, RC, MN, has
tended outcomes.2
been a national speaker for the nursing pro-
fession for the past seven years. Her back-
Example: During a bariatric surgery the surgeon asked the ground in sociology laid the foundation for
anesthesiologist, “Is the stomach clear?” and the anesthe- correctly identifying the norms particular to
siologist answered “Yes.” And so the surgeon stapled the health care – specifically physician and
stomach – to the tube. For when the surgeon asked if the nurse relationships. For her master’s thesis,
she authored Speak Your Truth: Proven
stomach was clear, the anesthesiologist thought he meant
Stategies for Effective Nurse-Physician
‘clear of fluids’ - and not the tube they had inserted for
Communication, which is the only book to date that addresses
decompression. After the event, the checklist was revised physician-nurse communication. Stressed Out About Communi-
to include teaching and now reads: “Before stapling, I will cation is a book designed for new nurses. Save 20 percent by
specifically ask, ‘Is the stomach clear of the tube’ because using source code MB84712A at
before I staple, I need the tube to be pulled. Respond ‘clear’ or call customer service at (800) 650-6787.
when the tube is pulled.”
John J. Nance, JD, author of the American
College of Healthcare Executive's 2009
SCOAP (Surgical Care and Outcomes Assessment Pro- Book of the Year, Why Hospitals Should Fly
gram) is the future of surgical quality improvement. It is a (2008, Second River Healthcare Press,
physician-led voluntary collaborative creating an aviation- Bozeman, MT), has been a dedicated mem-
like surveillance and response system for surgical quality. ber of the healthcare profession for the past
20 years and an acknowledged leader in
SCOAP's goal is to improve quality by reducing variation in
adapting the most effective methods of
process of care and outcomes at more than 40 hospitals in
transforming human systems to high relia-
the state of Washington. SCOAP is an engaged community bility status. One of the founding board members of the National
of clinicians working to build a safer, higher quality, Patient Safety Foundation, John is a licensed attorney, a 13-thou-
and more cost-effective surgical healthcare system. sand hour veteran airline captain, and an Air Force Reserve Lt. Colonel, as well as the author of 19 best-selling books. He also
serves as the aviation analyst for “ABC World News” and the avi-
ation editor for “Good Morning America.” Why Hospitals Should
Find your voice Fly can be purchased online at
In the opening case scenario, every team member failed to
communicate. The truth is that neither checklists, nor pro-
cedures, or process improvement will work in the absence
of meaningful, collegial relationships in which every member
of the team feels comfortable communicating what they
see, feel and know at all times. Silent cultures never change.
Find the courage. Find your voice.

Aligning practice with policy to improve patient care 29

CAUTI Prevention: How Do You Rate?
1. At my facility, we remove urinary catheters 4. At my facility, we keep track of how long
within 48 hours after surgery. catheters are kept in patients.
a. Always a. Always
b. Sometimes b. Sometimes
c. Never c. Never

2. I follow strict aseptic technique when 5. Before placing a catheter, I assess whether
inserting a catheter. the patient really needs it, and I document
a. Always the assessment in the chart.
b. Sometimes a. Always
c. Never b. Sometimes
c. Never
3. At my facility, we educate catheterized What’s your score?
patients about urinary tract infections.
a. Always a _____ x 5 = _______
b. Sometimes b _____ x 3 = _______
c. Never c _____ x 0 = _______
TOTAL _______

How do you rate?

25 Perfect score! Keep up the great work and educate others.
17 – 23 Great job. Read below for more helpful tips.
8 – 14 You’re doing OK. Turn to page 31 to find out more about CAUTI prevention AND earn a free CE!
0 – 5 Lots of opportunity to improve practices at your facility. Medline can help! Also review the strategies below.

We invite you to join the Race to ERASE CAUTI! With 100,000 nurses working together, we can do it!

CAUTI FACTS Evidence-Based Prevention Strategies

• The MOST effective way to prevent CAUTI is to AVOID inappropriate catheterization.1
• Greater attention is REQUIRED to avoid inserting catheters in patients unnecessarily.2
• Limiting urinary catheter use and, when a catheter is indicated, minimizing the duration the catheter remains
in place, are primary strategies for CAUTI prevention.3
• Alternatives to catheterization should be considered.3
• Documentation must include: indications for catheter insertion, date and time of catheter insertion,
individual who inserted catheter, date and time of catheter removal.3
• Insertion using aseptic techniques and sterile equipment.4
• Handwashing is the FIRST and most important preventive measure.5
• Education must include appropriate indications for catheter placement and the possible alternatives to
indwelling catheters.5
• Educating the patient can reduce readmissions6 and help to achieve higher patient satisfaction scores.
• SHEA/IDSA guidelines suggest that some common practices SHOULD NOT be used routinely to prevent
CAUTI including: Routine use of silver-coated or antibacterial urinary catheters.3, 4

1. Expert discusses strategies to prevent CAUTIs. Infection Control Today Web site. June 1, 2005. Available at
Accessed July 10, 2009.
2. Catheter-related UTIs: a disconnect in preventive strategies. Physician’s Weekly. 25(6), February 11, 2008.
3. Lo E, Nicolle L, Classen D, Arias A, Podgorny K, Anderson DJ, et al. SHEA/IDSA practice recommendation: strategies to prevent catheter-associated urinary tract infections in acute
care hospitals. Infect Control Hosp Epidemiol. 2008;29:S41–S50.
4. Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA, et al. Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2008. Draft. Centers for Disease Control
and Prevention. Available at Accessed July 10, 2009.
5. Gokula RM, Hickner JA, Smith MA. Inappropriate use of urinary catheters in elderly patients at a midwestern community teaching hospital. Am J Infect Control 2004;32:196-199.
6. Stokowski, LA. Preventing catheter-associated urinary tract infections. Medscape Nursing Perspectives. February 3, 2009. Available at Accessed July 6, 2009.

30 The OR Connection
Patient Safety
Back to Basics Tenth in a Series

Tell Me Again Why This Patient

Needs a Catheter?

by Alecia Cooper, RN, BS, MBA, CNOR

Insertion of an indwelling urinary catheter is a common

procedure within perioperative services. In fact, as many
as 86 percent of patients undergoing surgery have urinary
catheters.1 In addition, 50 percent of these catheters remain in
place for more than two days.1 Have you ever thought about or
questioned if the catheter you were inserting was really neces-
sary and clinically indicated for your surgical patient? It has
become critically important that we evaluate the need for
urinary catheterization and no longer insert catheters for con-
venience or because there is a preference card telling us to
insert a catheter. What’s more, did you know that requests from
nurses to place a urinary catheter for nursing convenience are
not uncommon?2

New guidelines and recommendations tell us that we should

determine if there is an approved medical indication for
catheterization. This means that we evaluate and reconsider a
common practice occurring pre-, intra-, or postoperatively —
insertion of an indwelling catheter prior to a certain surgical pro-
cedures. This evaluation may change how we have always
done things.

The Centers for Medicare & Medicaid Services (CMS),

as a result of the Medicare Modernization Act of 2003
and the Deficit Reduction Act of 2005, has identi-
fied catheter-associated urinary tract infec-
tion (CAUTI) as a healthcare-associated
infection (HAI) that can reasonably be
prevented through the application of

Aligning practice with policy to improve patient care 31

Too many indwelling urinary catheters are inserted
It has been estimated at up to 50 percent of the
indwelling urinary catheters are unnecessarily placed.7

evidence-based practice. CMS reported in the 2008 Fed- CAUTI incidence outside the
eral Register that in 2007 there were 12,185 CAUTIs, costing perioperative environment
$44,043 per hospital stay.2 CAUTI is one of 10 hospital- To help you further realize the magnitude and role of
acquired conditions (HACs) for which CMS will no longer perioperative services in preventing CAUTI, let’s look at
provide reimbursement if it occurs during hospitalization.3 additional statistics from outside the perioperative environ-
ment. Did you know that the emergency department (ED)
Brand-new CAUTI prevention guidelines has the highest percentage of catheter placements?7 In the
CAUTI is the number one healthcare-associated infection ED, as well as in perioperative services, documentation of
(HAI), accounting for 40 percent of all hospital-acquired the reason for catheter placement is poor and a written
infections.4 One in four patients receives an indwelling physician order is frequently lacking. Without a physician
urinary catheter at some point during their hospital stay.5 order, physicians are unaware that the patient has a
As a result of this data, leading industry experts, including catheter.5 When physicians do not know that a catheter has
the Association for Professionals in Infection Control and been inserted, it is no wonder that an order for timely
Epidemiology (APIC), the Society for Healthcare Epidemiol- removal is lacking, and catheters stay in longer than med-
ogy (SHEA), the Centers for Disease Control and Prevention ically necessary.
(CDC), the Joint Commission and many others have joined
together to outline strategies and guidelines to prevent Common catheter practices in perioperative services
catheter-associated urinary tract infections in acute care Adding to the problem, inappropriately placed catheters are
hospitals.6 The CDC’s Draft Guideline for Prevention of more often forgotten about.5 In 56 percent of hospitals there
Catheter-Associated Urinary Tract Infections 2008 (released is no system to keep track of which patients have catheters,
in June 2009) identifies new guidelines and recommenda- and 74 percent of hospitals do not keep track of how long
tions to prevent CAUTI. the catheter is in place.8 Shocking as this may be, let’s
assess common practice in perioperative services and see
Barriers to CAUTI prevention if any of these common occurrences occur at your facility.
Three distinct barriers to the prevention of CAUTI become 1. Do you have preference cards that tell you to insert
evident when analyzing the problem. In the perioperative an indwelling catheter for a specific procedures
environment it is hard to imagine that there are errors in performed by a particular surgeon?
aseptic technique because we are acutely aware of proper 2. Do you assess patients to determine if the standing
technique. But remember that most nurses outside of the order to insert an indwelling catheter is medically
perioperative environment do not routinely perform aseptic indicated?
technique and may not be aware when contamination 3. When a patient comes to the OR with an
occurs. In fact, during most observations of nurses outside indwelling urinary catheter or when you insert one
of the perioperative environment, we have seen inconsis- intraoperatively, do you evaluate the need to keep
tent practice in setting up a sterile field and inserting the catheter in place at the end of the surgical
indwelling catheters aseptically. It is perfectly clear that in procedure before transporting the patient to the
perioperative services, two of the three barriers occur rou- post anesthesia care unit (PACU)?
tinely – too many catheters are inserted and catheters stay 4. Do you date and time when the catheter was
in too long. inserted? This critical step helps the clinicians on
the patient care unit to remove the catheter within
48 hours or less following the surgical procedure.

32 The OR Connection
Perioperative nurses are positioned to significantly impact b. Appropriate urinary catheter use
the reduction and elimination of catheter-associated urinary Use indwelling catheters only when medically necessary.
tract infections by removing catheters when patients do not c. Aseptic insertion of urinary catheters
meet the approved indications. Take a peek at Table 1, which Use aseptic insertion technique with appropriate hand
lists when indwelling urinary catheters should and should not hygiene and gloves. Allow only trained healthcare
be used. providers to insert catheters.
d. Proper urinary catheter maintenance
What is a nurse to do? If your patient has no alternatives, - Properly secure catheters after insertion.
and you must insert a urinary catheter, is there anything you - Maintain a sterile closed drainage system.
can do to help prevent catheter-associated urinary tract - Maintain good hygiene at the catheter-urethral interface.
infections? Absolutely! - Maintain unobstructed urine flow.
- Maintain drainage bag below level of bladder at
CAUTI prevention methods all times.
a. Alternatives to urinary catheter use - Use portable ultrasound bladder scans to detect
Do not allow routine urinary catheter placement in the residual urine amounts.
OR. Remove as many urinary catheters as you can - Do not change indwelling catheters or urinary drainage
within 24 hours. Consider alternatives to indwelling bags at arbitrary fixed intervals.
urethral catheters, such as intermittent catheterization. e. Timely removal
- Remove catheters when
Table 1. Appropriate Indications for Indwelling Urethral Catheter Use 10,11 no longer needed.
Patient has acute urinary retention or obstruction - Document indication for
Need for accurate measurements of urinary output in critically ill patients urinary catheter on each
Perioperative use for selected surgical procedures: day of use.
• Patients undergoing urologic surgery or other surgery on contiguous structures - Use reminder systems
of the genitourinary tract to target opportunities
• Anticipated prolonged duration of surgery (catheters inserted for this reason to remove catheter.
should be removed in PACU)
The above list was combined from
• Patients anticipated to receive large-volume infusions or diuretics during surgery
recommendations in the CDC
• Operative patients with urinary incontinence guidelines and 2008 APIC CAUTI
• Need for intraoperative monitoring of urinary output Elimination Guidelines.
To assist in healing of open sacral or perineal wounds in incontinent patients
Patient requires prolonged immobilization (e.g., potentially unstable thoracic or Continued on Page 36
lumbar spine)
To improve comfort for end of life care if needed
Indwelling catheters should not be used:
• As a substitute for nursing care of the patient or resident with incontinence
• As a means of obtaining urine for culture or other diagnostic tests when the
patient can voluntarily void
• For prolonged postoperative duration without appropriate indications
• Routinely for patients receiving epidural anesthesia/analgesia

Note: These indications are based primarily on expert consensus.

Aligning practice with policy to improve patient care 33

Point and click to
The new ERASE CAUTI program combines design,
education and awareness to tackle catheter-associated
urinary tract infection – the number one hospital-acquired

The innovative one-layer tray design guides the clinician
through the process of placing a catheter to ensure
aseptic technique.

The acronym ERASE is easy to remember, reminding
the clinician to:

Evaluate indications – Does the patient really require

a catheter?

Read directions and tips – Follow evidence-based

insertion techniques
Aseptic techniques – Key design solutions support Open up the
innovative one-layer
aseptic technique
catheter tray and
see the intuitive
Secure catheter – A properly secured catheter will design for
reduce movement and urethral traction yourself.
Educate the patient – Printed materials tell the patient
how to reduce the likelihood of infection

Join the Race to ERASE CAUTI! The current state of health
care demands that nurses play a leading role in identifying
and implementing CAUTI risk reduction strategies. Help us
reach our goal to introduce 100,000 nurses to the ERASE
CAUTI system.

Ask your Medline representative about the new ERASE

CAUTI Program or call 1-800-MEDLINE (633-5463).
ww rem
w. ierin
m gA
ed u
lin gu
e. st 1
co 7
m , 20
/e 09

Click here for
details on nursing
education materials
that promote
practice. Awareness
Visit this section
to join 100,000
nurses in the
Race to ERASE

1. Catheter-related UTIs: a disconnect in preventive strategies.
Physicians Weekly. 25(6), February 11, 2008.
Contamination occurs during insertion
Most nurses are aware of the importance of aseptic technique but it can take extra time.
Heavier nursing workloads contribute to poor compliance with aseptic technique.7

Putting it all together to ERASE catheter-associated

urinary tract infections
Until recently, catheter-associated urinary tract infections
have received little attention compared to many of the
other types of HAIs. However, research and best practices
for the prevention of CAUTI are readily available. Despite
the link between urinary catheters and urinary tract infec-
tions in hospitals and other healthcare settings, a recent
survey of U.S. hospital practices identified that no strategy
is consistently or universally used in U.S. hospitals to pre-
vent these infections.11

Literature reports numerous organizations that have imple-

mented successful strategies to reduce CAUTI. These or-
ganizations have utilized multidisciplinary teams to implement
evidence-based changes in practice; have incorporated
practice changes into the routine standard of care; and
have performed ongoing or periodic review of progress to Questions to consider to help you get started
reinforce successful strategies.11 with your own CAUTI prevention program:
• Are there policies or guidelines that define criteria
Develop a CAUTI prevention program for your facility for insertion of a urinary catheter?
If your organization does not have a CAUTI elimination • Has the organization established criteria for when
program, or you are not getting the results you had hoped a catheter should be discontinued?
for, start by assessing whether an effective organizational • Is there a process to identify inappropriate usage
program exists. Work with your infection preventionist and or duration of urinary catheters?
other key multidisciplinary stakeholders to develop your • Is there a program or guidelines to identify and remove
campaign. catheters that are no longer necessary? (e.g., physician
reminders, automatic stop orders or nurse-driven
• Are there policies or guidelines for use of a bladder
scanner to detect urinary retention prior to insertion
of a catheter?
• Are there mechanisms to educate care providers
about use and care of urinary catheters?
• Overall Assessment: Is there an effective
organizational program in place?11

36 The OR Connection
Start the race to erase CAUTI in the operative arena by References
1. Wald HL, Ma A, Bratzler DW, Kramer AM. Indwelling urinary catheter use in the
educating your patients and staff about CAUTI. Ensure all postoperative period: analysis of the national surgical infection prevention project data.
staff practice aseptic technique and remove catheters in a Arch Surg. 2008;143:551-557
2. Ribby KJ. Decreasing urinary tract infections through staff development, outcomes,
timely manner. and nursing process. J Nurs Care Qual. 2006; 21:272-276.
3. CMS, Proposed Changes to the Hospital IPPS and FY2009 rates; Available at Accessed July 24, 2009
Join the Race to ERASE CAUTI! Talk about prevention, 4. Catheter-related UTIs: a disconnect in preventive strategies. Physician’s Weekly. 25(6),
February 11, 2008.
raise awareness, then implement solutions in your 5. Saint S, Kaufman SR, Thompson M, Rogers MA, Chenoweth CE. A reminder reduces
organization. urinary catheterization in hospitalized patients. Jt Comm J Qual Patient Saf. 2005;
6. Lo E, Nicolle L, Classen D, Arias A, Podgorny K, Anderson DJ, et al. SHEA/IDSA
practice recommendation: strategies to prevent catheter-associated urinary tract
infections in acute care hospitals. Infect Control Hosp Epidemiology. 2008; 29:S41–


7. Stokowski, LA. Preventing catheter-associated urinary tract infections. Medscape

GET SET ... Nursing Perspectives. February 3, 2009. Available at

viewarticle/587464_4. Accessed July 6, 2009.

8. Saint S, Kowalski CP, Kaufman SR, Hofer PH, Kauffman CA, Olmsted RN et al.
Preventing hospital–acquired urinary tract infection in the United States: a national study.
Clinical Infectious Diseases. 2008; 46(2):243-250.
9. Magnall, J. Waterson, L. “Principles of aseptic technique in urinary catheterization.”
Nursing Standards. 2006 November 1 – 7; 21(8) 49 – 56;quiz. Available at Accessed July 24, 2009
10. The CDC Guideline for Prevention of Catheter-Associated Urinary Tract Infections
2008, Draft
11. An APIC Guide to the Elimination of Catheter-Associated Urinary Tract Infections 2008
(CA-UTI) p. 22,35 -41 The Association of Professionals in Infection Control and

Aligning practice with policy to improve patient care 37

Check out

All-new look and upgraded content!

Easier navigation to find what you need – faster.

Interactive courses & competencies help you and your facility view and keep track
Continuing education courses are still available, of all completed courses.
and now you can earn all credits for FREE! In
addition, we are adding online competencies. And for facilities participating in the Pressure
Courses and competencies are more interactive Ulcer Prevention and Hand Hygiene programs,
with more graphics, sound and animation to all materials, pre- and post-tests are now conve-
make learning more fun. niently located online at

Facility-specific features Visit the redesigned

Now each facility has the option of creating a today, and let us know what you think!
group account on Medline University. This will

©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
CE Questions Back to Basics

Tell Me Again Why This Patient

Needs a Catheter?
True or False (circle one) 11. CMS reported in the 2008 Federal Register that in
1. As many as 95 percent of patients undergoing 2007 there were ______CAUTIs.
surgery have urinary catheters. T F a. 800,000
b. 56,296
2. The emergency department has the highest percentage c. 1,877
of catheter placements. T F d. 12,185

3. One in three patients receives an indwelling urinary 12. It has been estimated that up to ____ percent of
catheter at some point during their hospital stay. T F indwelling urinary catheters are unnecessarily placed.
a. 85
4. Assistance in pressure ulcer healing for incontinent b. 10
patients is an approved indication for urinary c. 50
catheterization. T F d. None of the above

5. Allowing only trained healthcare providers to insert 13. Which of the following is a successful strategy
catheters is one method for preventing catheter- implemented by healthcare organizations to
associated urinary tract infections (CAUTI). T F reduce CAUTI?
a. Redesign patient care areas
6. A recent survey of U.S. hospital practices identified b. Utilize multidisciplinary teams to put
that no strategy is consistently or universally used to evidence-based changes in practice
prevent CAUTI. T F c. Serve cranberry juice to patients
d. Deploy rapid response teams (RRTs)
7. CAUTI is one of 10 hospital-acquired conditions for
which the Centers for Medicare & Medicaid Services 14. Which of the following organizations did not
(CMS) will no longer provide reimbursement if it participate in outlining strategies and guidelines
occurs during hospitalization. T F to prevent CAUTI?
a. American Medical Association (AMA)
8. Nurses rarely request to place a urinary catheter for b. Centers for Disease Control and Prevention (CDC)
nursing convenience. T F c. Association for Professionals in Infection Control
and Epidemiology (APIC)
Multiple Choice d. The Joint Commission
9. Which of the following is not an approved indication
for urinary catheterization? 15. One way to help prevent CAUTI is to use
a. To improve comfort during end-of-life care. ___________ systems to target opportunities to
b. Management of acute urinary retention and remove catheters.
urinary obstruction. a. infection control
c. The patient requires prolonged immobilization. b. emergency
d. The patient is incontinent and requires two or c. aseptic
three linen changes per shift. d. reminder

10. Which of the following are techniques for proper

urinary catheter maintenance? Submit your answers at
a. Properly secure catheters after insertion.
b. Maintain unobstructed urine flow. and receive 1 FREE CE credit
c. Both a and b.
d. Change indwelling catheters or urinary drainage
bags at arbitrary fixed intervals.

Aligning practice with policy to improve patient care 39

A cost-effective alternative
to urinary catheterization
p ita l
rea s e s
ith Use
CAUTI w nence
of Incon s

Knowing catheter-related urinary tract infections (UTIs) According to Rothfeld’s findings, catheters are needed in only
are the most common of all hospital-acquired infec- about half the cases in which they are used.
tions, Alan F. Rothfeld, MD, was looking for alternatives to
catheterizing patients at Hollywood Presbyterian Medical Before beginning the study, Rothfeld developed the
Center (HPMC), a 434-bed hospital in Los Angeles. following indications for the use of urinary catheters:
1. Written orders for hourly urinary output
Rothfeld noted that new incontinence management products 2. Inability to void spontaneously (usually due
offer less costly and more effective alternatives to catheteri- to obstruction)
zation. Restore ultra-absorbent disposable briefs, manufac- 3. Active urinary tract infection with Stage 3 or 4
tured by Medline, stay dry and hold significantly more urine pressure ulcer
per day.
If a patient had none of these indications, no catheter was
In order to document whether using disposable briefs in place requested. If a patient had a catheter already, a request to the
of urinary catheters would decrease UTIs, Rothfeld led a six- physician for discontinuance was initiated.
month study, from January to October 2008, at HPMC’s ICU
step-down units. The study observed the use of Restore An anonymous questionnaire conducted at the end of the
briefs during two three-month periods in two separate units of study revealed the disposable briefs were a welcome alter-
the hospital with a total of 60 beds, averaging 83 percent native among physicians and nurses. “In fact, no patient
occupancy. reported decreased comfort and most of the staff was sup-
portive of this program, indicating it increased overall satis-
50 Percent Reduction in UTIs faction among nursing personnel,” Rothfeld said.
There were five hospital-acquired UTIs during the three-month
control period, indicating an infection rate of 3.2 per 1,000 References
catheter days. During the three-month intervention period, Ditch the foleys, adopt diapers to address UTIs. Infection Control Today Web
site. Posted March 10, 2009. Available at
there were only two hospital-acquired UTIs, with an infection Ac-
rate of 2.4 per 1,000 catheter days. cessed May 22, 2009.

Rothfeld AF & Stickley A. A Program to Reduce Nosocomial Urinary Catheter

Infections during the intervention period fell from an average of Infections at an Acute Care Hospital [manuscript]. Hollywood Presbyterian
Medical Center; 2009.
1.06 per 1,000 patient days to 0.45. “The reduction in
Restore is a registered trademark of Medline Industries, Inc.
infections was mainly due to the decrease in catheter use
rather than other changes in patient care,” Rothfeld
explained, noting that catheter use during the intervention
period fell from 330 to 190 per 1,000 patient days.

40 The OR Connection

& performance,
comfort without compromise.

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provides you with exceptional fit, feel • SensiCare® with Aloe – standard thickness,
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• SensiCare® LT with Aloe – standard thickness,
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latex allergies.
• SensiCare® Green with Aloe – 10% thinner for
enhanced tactile sensitivity
The American Latex Allergy Association estimates that
• SensiCare® Ortho – 40% thicker for extra protection
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Contact your local Medline representative
that the costs of healthcare workers’ disability compen-
for samples or e-mail us at glovedivision@
sation due to latex allergies justifies or significantly offsets Your staff will love you for it!
the cost of conversion to a latex-free environment.2

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In fact, it is softer, more elastic and more comfortable.

1. American Latex Allergy Association. Latex Allergy Statistics. Available at:
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.
©2009 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
by Lorri A. Downs RN, BSN, MS, CIC

OR nurses all over the United States work diligently

to decrease the foot traffic entering the operative
arena. This important step helps decrease the potential risk
of harmful bacteria contaminating the sterile environment.
Traffic must be controlled to maintain separation of clean
from dirty areas, to segregate clean and sterile supplies

Playing Traffic
Control in the OR
from contaminated materials, and to ensure that only
authorized personnel in appropriate attire enter the operat-
ing room.1

With increased surgical volumes in ambulatory and

same-day surgical settings, operative areas may become
congested with personnel and equipment. Operative
nurses monitor movement of patients and personnel and
work to maintain a standardized process.

42 The OR Connection
OR Issues

for controlling traffic in the OR2

1. Ensure the surgical suite is divided into three areas:

• Unrestricted: Locker rooms, control desk, offices,
pre-operative holding areas. Street clothes may be worn.
• Semi-restricted: PACU and storage areas for clean
and sterile supplies. Surgical scrub clothing, head
covering and identification badge are required.
Increased restrictions on traffic movement for patients
and personnel.
• Restricted: Sterile/clean core of OR area, operating
rooms and sub sterile rooms. Surgical scrub clothing,
head covering, identification badge, warm up jacket
(for circulator, anesthesia provider or observers), shoe
covers (if required) must be worn. The scrub team
must wear surgical gowns, gloves, masks and
AORN has published six recommended eye wear.
practices for traffic control:2 2. Ensure environmental and dress code controls increase
• Traffic patterns should be designed to facilitate movement as patients and staff move from unrestricted to
of patients and personnel through defined areas within restricted areas.
the surgical suite. 3. Post signage that clearly indicates traffic and
• Operating suites should be secure.
dress controls.
• Movement of personnel should be kept to a minimum
4. Keep operating room doors closed except when
while invasive and noninvasive procedures are in progress.
moving patients, personnel or equipment.
• The movement of clean and sterile supplies and equipment
should be separated from contaminated supplies, This helps to decrease the mixing of operating room air
equipment and waste by space, time, or traffic patterns. with the corridor air, which may have increased bacterial
• During construction and renovation, specific traffic patterns counts from dust or debris.
should be established and maintained in accordance 5. Keep talking to a minimum and limit movement within the
with applicable state regulations. OR during procedures.
• Policies and procedures for traffic patterns for patients, 6. Restrict the number of personnel in the OR to only those
personnel, supplies, and equipment should be developed,
involved in the case and document all personnel involved
reviewed periodically, revised as necessary, and kept
in the patient’s care.
readily available in the practice setting.
7. Use covered carts to protect clean and sterile supplies
Why all the fuss? during transportation.
Surgical site infections are believed to account for up to $10 8. Remove external shipping containers in
billion annually in healthcare expenditures.3 We know that unrestricted areas.
bacterial shedding occurs in the OR from personnel moving 9. Contaminated instruments should be covered and
about the room. Skin cells transport bacteria, and increased air moved to a decontamination area.
movement can circulate dust and bacteria, which can con- 10. Construction and renovation require specific traffic plans
taminate a sterile field. Movement of personnel in and out of
to minimize contamination.
the operative suite causes potential risks for contamination and
potential surgical site infections. These environmental issues
can be addressed with education, clear policies and proce-
dures to help increase awareness.

Aligning practice with policy to improve patient care 43

In June 2009 research published by The Association of
Professionals in Infection Control and Epidemiology (APIC)
found opportunities for improving surgical site infection (SSI)
prevention by examining clinical management and quality
improvement (QI) strategies used at seven teaching hospitals. A
post review of medical records revealed that compliance with
recommended practices was inconsistent. Interviews with 18 of
19 surgeons and managers, plus analysis of pertinent docu-
ments revealed that despite awareness of SSI prevention rec-
ommendations, most sites had not undertaken systematic or
comprehensive efforts to review their own practice and imple-
ment corrective stratgies.4

Operating room nurse leaders, surgeons, educators and infec-

tion preventionists will need to partner together to develop
infection prevention solutions – solutions that make it hard for
the healthcare professional to do the wrong thing.

1. Surgical Services. In: APIC Text of Infection Control and Epidemiology. Vol II. 3rd ed.
Washington, DC: Association for Professionals in Infection Control and Epidemiology,
Inc. (APIC); 2009
2. Recommended Practices for Traffic Patterns in the Perioperative Practice Setting. In:
2008 Perioperative Standards and Recommended Practices. Denver, CO: Association
of PeriOperative Registered Nurses; 2008.
3. Anderson DJ, Kaye KS, Classen D, Arias KM, Podgorny K, Burstin H, et al. Strategies
to prevent surgical site infections in acute care hospitals. Infection Control and Hospital
Epidemiology. 2008; 29:S51-S61.
4. Gagliardi A, Eskicioglu C, McKenzie M, Fenech D, Nathens A, McLeod R.
Identifying opportunities for quality improvement in surgical site infection prevention.
AJIC. 2009; 37(4):398-402.

Lorri Downs, RN, BSN, MS, CIC is a board

certified infection preventionist and vice
president of infection prevention for Medline
Industries, Inc. She has a diverse portfolio of
more than 25 years in the nursing profession.
Her expertise focuses on infection prevention
surveillance at large acute care organizations,
plus ambulatory and public health settings.
Lorri has developed hospital infection control
programs and local emergency preparedness plans, and she has
lectured on various infection prevention topics. She is a member
of the Alpha Delta Omega Delta Chapter National Honor Society
for Human Service Education, a member of The National Association
of Infection Prevention and Control Professionals (APIC) and a
member of the local APIC Chicago area chapter.

44 The OR Connection
S.T.O.P. for safety. ™

It could be the difference If you would like to receive a free sample

between life and death. of the S.T.O.P. Drape system to evaluate for
Wrong site surgery has recently moved into the yourself, ask your Medline representative or
number one position as the most frequently call us at 1-800-MEDLINE.
reported hospital error.1 STOP!!!
P erform “TIME
This is despite a conscientious effort to eliminate this Verify
Verify correct:
problem before it occurs. What is needed is another layer Person
of safety...something that will improve our chances of Site
Site & Side
S ide 
correcting the mistake before it happens. Date:
Date: ______
______ Time:
Time: _______
Surgeon’s IInitials:
nitials: _____
Enter S.T.O.P. Surgical Drapes* from Medline.
We just made a good idea even better. S.T.O.P. (Surgical
Time Out Procedure) drapes are available in a variety of
configurations, and include a “S.T.O.P.” strip across the
fenestration. As a result, you can’t forget to take a time
out to verify the correct patient, procedure, side and site.
Then all that is left is to hand the sticker off to the circulating
nurse to include in the medical record, documenting that
the verification process was completed. S.T.O.P. strip and sticker

1 The Joint Commission. The Statistics page. Available at: http://www.jointcommis-
Accessed March 13, 2008.

* Patent pending
©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
Legal Issues in the Care
of Pressure Ulcer Patients
The International Expert Wound Care Advisory References
1. Voss AC, Bender SA, Ferguson ML, et al. Long-term care liability for pressure
Panel released a 23-page white paper in June ulcers. J Am Geriatric Soc. 2005;53:1587-1592.
2. Ayello EA, Capitulo KL, Fife CE, Fowler E, Krasner DL, Mulder G, et al. Legal
2009 identifying key concepts to help healthcare is sues in the care of pressure ulcer patients: key concepts for healthcare
professionals with preventative legal care providers. White paper. June 2009.
3. Aronovitch SA. Intraoperatively acquired pressure ulcers: are there common
practices taking into consideration the current risk factors? Ostomy Wound Management. 2007;53(2):57-69. Available at
pressure ulcer regulatory and legal environment. Accessed July 29, 2009.

The paper is titled “Legal Issues in the Care of

Pressure Ulcer Patients: Key Concepts for
Healthcare Providers.”

Lawsuits over pressure ulcers are increasingly

common in both acute and long-term settings
with judgments as high as $312 million in a single
case.1 Quoting from the paper itself, “Like some
pressure ulcers, litigation over pressure ulcers
may be unavoidable. For this reason, knowing
how to react when it occurs is no less important
than knowing how to minimize the risk of pressure
ulcer lawsuits themselves.”2

And med-surg professionals are not the only

ones that could be affected by litigation concern-
ing pressure ulcers. How about these startling
statistics? Reports show that as many as 66
percent of surgical patients develop intraopera-
tively acquired pressure ulcers and nearly 42 per-
cent of all hospital-acquired pressure ulcers
occur in surgical patients.3

Read the following excerpt from “Legal Issues

in the Care of Pressure Ulcer Patients: Key
Concepts for Healthcare Providers” for a
nurse’s personal account of what happened
after she was handed a subpoena to report for
a deposition.

For more information and to receive a copy of

the entire white paper, visit Medline’s Web site

46 The OR Connection

Deposed: A Personal Perspective

By Evonne Fowler, MSN, RN, CWOCN

The unthinkable happened to me. of bruising or wounds. She developed sepsis, had
an altered mental status with bouts of confusion,
In my 46 years of nursing, I have always felt uncooperative behavior, lethargy, difficulty
that I was a patient advocate. In fact, I have told awakening and agitation; she was verbally abusive
many a patient, “If I were you, I would want me to the staff. Her hospitalization was fraught with
to take care of you.” I was shocked when I opened complications, including pneumonia with subsequent
the door one evening and was handed a subpoena need for intubation. Her behavior became combative.
to report for a deposition. She pulled out the nasogastric tube and intravenous
lines and had to be placed in restraints.
One of the patients I had cared for a few years
ago had brought a lawsuit against the hospital and Eight days after admission, two pressure ulcers
I was implicated as one of the wound care specialists (Stage I and Stage II) were noted in the sacral area.
who had rendered service. As per our protocol, photographs were taken. On post
op day 12, the orthopedic surgeon requested a wound
I was devastated. I have always done my best care consultation for recommendations regarding the
to keep patients in my charge clean, dry, comfortable management of the open fasciotomy incision. During
and safe. So how did this happen and what does it the skin assessment, the wound care nurse document-
mean for me? What would happen next? ed a 9 x 20 centimeter unstageable pressure ulcer
on the sacral area, 75% black, 20% yellow, 5% red.
I remembered the patient quite well. She was a The patient was on the bariatric air support surface.
very complex and difficult patient. Here’s what my
review of her medical record revealed. She was a The post-op leg wound continued to heal;
54-year-old morbidly obese (425 lbs.) female who however, the sacral pressure ulcer needed multiple
was admitted to the Emergency Department after surgical debridements. At the base of the pressure
three days of being febrile, unable to eat, experienc- ulcer, an abscessed area was found. Once the sacral
ing liquid stools and being lethargic. The paramed- area was clean, a negative pressure wound therapy
ics had been called to the home earlier, but she had closure device was applied over the wound.
refused to be taken to the hospital. Later that night,
her daughter was able to persuade her to go to the Upon discharge, she spent an additional six
Emergency Department. Her admitting diagnosis months in a skilled nursing facility for pressure ulcer
was right leg cellulitis. She had a history of multiple management. Eventually, she returned home with
co-morbidities including venous disease, diabe- a small open wound. Her lower leg cellulitis had
tes, morbid obesity, hypertension, chronic anemia, extended into an eight-month saga due to the com-
chronic kidney disease, asthma, and of non-adherent plication from the hospital-acquired pressure ulcer.
behavior. She had called the membership services
over 100 times during her years of coverage, Now what?
reporting various incidents regarding her care.
I was a fact witness (required to help relate the
A few hours after admission, she was taken specific facts of this one case) rather than expert
to the operating room, where she had a soft tissue witness (who is usually called in to offer an opinion).
incision and fasciotomy for compartment syndrome The hospital’s attorney represented me for the
of the right leg. On post-op admission to the inten- deposition. I was called by the defense and counseled
sive care unit, her initial skin assessment was clear not to give any opinions.

fact witness. A person testifying in court as to the facts or specifics of an individual case but not to offer opinions.

expert witness. A person, typically with expert credentials, testifying in court and offering an educated opinion on the case.

Legal Issues in the Care of Pressure Ulcers: Key Concepts for Healthcare Providers

Aligning practice with policy to improve patient care 47

My attorney sent a file box filled with medical records Lessons Learned
for me to review. I was frustrated as I reviewed these Some of the common complaints registered against
records. Notes were handwritten, difficult to read and nurses in a lawsuit are failure to follow a standard
fragmented with different disciplines writing in various of care, failure to communicate, failure to assess and
sections. Very few notes were made in the comment monitor appropriately, failure to report significant
section of the nursing notes. Flow sheets were not com- findings, failure to act as a patient advocate and
pleted. It was challenging to determine if the patient failure to document. That certainly applies in this
actually had been turned, cleansed and repositioned case. Documentation is essential! Here are the main
consistently. Although the patient was incontinent of lessons I learned from this experience:
stool, there were very few episodes of incontinence
noted. Even though I remembered that she was placed
care specialist to assess the patient’s skin and
on a special mattress for pressure redistribution, I was
wound and write a detailed, initial, focused
unable to determine this fact from the chart, despite
assessment. If a wound is present on admission,
the fact that a special bed was ordered on day eight.
document the wound profile.
The attorney for the plaintiff handed me the nurses’ patient is on or whenever a support system
notes for the first seven days of the patient’s change is ordered.
hospitalization and asked me to read the Braden
Score, the integumentary, neuromuscular section,
to your organization’s guidelines. For me, that
turning/repositioning section of the flow sheet and
would mean using a measurement label and a
the nurses’ comment section. There was very little
black marking pen to clearly identify the patient’s
charted in any of the sections. The Braden Score
name or initials, medical record number, date
showed the patient to be at high risk for pressure
and location of the wound on the photo.
ulcer development. I was unable to find a plan of
care in any of the files. Although the hospital had s 2EVIEWANDFOLLOWTHEGUIDELINESRELATED
just implemented a new pressure ulcer program, to skin and wound care.
none of the new forms or the pressure ulcer trending
were filled out. The attorney had me go through
standing orders and, if a wound is present,
the chart looking for documentation of instances
the wound and skin care treatment standing
of patient non-adherence. I was stunned at the lack
orders. Complete the required sections and sign.
of documentation by both physicians and nurses
about her behavior, the skin and the pressure ulcer s .OTIFYTHEPHYSICIANREGARDINGTHESKIN
throughout her hospitalization. wound condition. Based on your findings,
document if the wound is healable or
The opposing counsel had me read my own charting non-healable and document the interventions
for the times I had interacted with the patient and for prevention and treatment of the skin/wound.
asked if the doctor had been informed consistently
regarding the skin changes and wound management
of the pressure ulcer. I was embarrassed with my s 2ECORDINTHEDISCHARGENOTETHESKIN
own charting and lack of information charted. The and wound status.
photographs taken throughout her hospitalization
were not labeled properly and were out of sequence.
attention to “words not to use.”
There were no follow-up notes to indicate the patient
or family received education about pressure ulcer
prevention or treatment. There also was no discharge
note detailing the pressure ulcer other than the order
to continue negative therapy.

After a few months, the case was settled out of court in favor of the patient.
I hope by my sharing my own story of doing a deposition, you will gain from my pain!

Legal Issues in the Care of Pressure Ulcers: Key Concepts for Healthcare Providers

48 The OR Connection
Are Your
What to Do Physicians
If This Happens Making
to You 2
the Grade?
Although finding out you are being sued can be shocking and A recent survey graded physiciansʼ abilities to
upsetting, it is crucial to stay calm and take some simple recognize, assess and document Stage III and
steps to allow for the best possible results. IV pressure ulcers at a “D” level. Medlineʼs new
Pressure Ulcer Prevention Program MD Education
• Notify your institution and malpractice carrier CD contains everything physicians need to brush
immediately for the name of your attorney (counsel). up on their skills and comply with the new CMS
Inpatient Prospective Payment System (IPPS).
• DO NOT create notes on your own – separate and apart
from a meeting with your lawyer. These notes could “The new MD Education component of Medlineʼs
easily be discoverable in litigation. Pressure Ulcer Prevention Program is critical for
acute-care facilities to ensure that physicians
• Avoid the temptation to talk to anyone about the case understand their role in recognizing and accurately
until you have discussed it with your attorney. Your documenting POA pressure ulcers.”
attorney will likely advise you to avoid talking to Michael Raymond, MD, Associate Chief Medical
colleagues about the case; this is important advice. Quality Officer, NorthShore University HealthSystem,
Skokie Hospital, Skokie, IL
• Your attorneys or legal department are your resources,
so ask them about terminology or procedures that are
unfamiliar to you.

• As part of the litigation, you may be deposed. You can

be deposed even if the case is not about you. If you face
deposition, meet with your attorney first to go over the
procedure and talk about the sorts of questions the
other attorneys are expected to ask.

• While not all litigation goes to court, sometimes you will

find your self taking the witness stand. Talk to your legal
Contact your Medline sales representative for more
representatives before testifying in court. It is important
details. You can also learn more about Medlineʼs
that you understand the procedures and can go over Pressure Ulcer Prevention Programs for long-term
what you likely will be asked. care, acute care and perioperative services by visiting

Aligning practice with policy to improve patient care 49

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Patient Safety

Your Act!
MRSA, C. diff, other harmful bacteria
lurk in unexpected places

Busy, overburdened hospitals, ever-mutating

strains of bacteria and spotty handwashing
compliance – these are just a few of the
reasons behind increasing rates of healthcare-
acquired infection (HAI). But with multiple and
varied contributing factors, it’s difficult to get a
handle on this widespread, worldwide problem.
According to the Centers for Disease Control
and Prevention (CDC), HAIs account for an
estimated 1.7 million infections and 99,000 deaths
in U.S. hospitals each year.1

The so-called “bad bugs” behind many HAIs

are so insidious, they can be found lurking
practically anywhere within a healthcare facility.
Several new studies show that healthcare profes-
sionals’ scrubs, lab coats and stethoscopes are
carriers of deadly bacteria such as methicillin-
resistant Staphylococcus aureus (MRSA) and
Clostridium difficile (C. diff) that easily can be
transmitted to patients.

Aligning practice with policy to improve patient care 51

65 percent of medical personnel
admitted to changing their lab coat less
than once a week

Bacteria-laden stethoscopes ability of isopropyl alcohol, bleach, benzalkonium chloride

Ill patients are obvious carriers of bacteria, and any sur- swabs and soap and water, isopropyl alcohol was
face or piece of medical equipment is a potential vector proven to be most effective to rid the stethoscopes of
for that bacteria. For example, bacterial contamination S. aureus.4
of a stethoscope increases markedly after it is used to
examine more than five patients without cleaning.2 The same study also addressed whether bacteria could
Several studies, however, suggest that many healthcare be transferred to human skin from the stethoscope
professionals use bacteria-laden stethoscopes, poten- diaphragm. Micrococcus luteus was inoculated onto a
tially transferring bacteria from patient to patient. stethoscope diaphragm, and the study showed that it
did transfer to human skin. The authors concluded that
A recent study at one tertiary care center suggests the transfer of M. luteus to human skin made it likely that
roughly one third of stethoscopes carried by EMS other bacteria could be transferred as well.
professionals harbor MRSA. A microbiologic analysis of
50 stethoscopes provided by EMS professionals in an Stethoscopes are an extension of the hand in clinical set-
emergency department revealed that 16 had MRSA tings and should be cleaned with the same frequency;
colonization. Similarly, 16 of the EMS workers could not that is, after contact with each patient. Cleaning a stetho-
remember the last time they cleaned their stethoscope. scope takes little time and effort, requires no special
For those who did remember, the median time from the equipment – and it could avoid a deadly infection.
last stethoscope cleaning was one to seven days.
MRSA colonization rates fell considerably in the stetho- Dirty scrubs
scopes that were cleaned more recently. 3 How about your scrubs? Some medical personnel wear
the same uniform to work more than once before laun-
Another study cultured 99 stethoscopes on four medical dering, meaning they could be starting their shift with C.
floors of a 600-bed hospital. All were positive for bacteria diff, MRSA and who knows what other bacteria already
growth. Half of the stethoscopes were cleaned using on their scrubs. A study conducted at the University of
ethanol-based cleaner (hand-sanitizing gel) and the Maryland revealed that 65 percent of medical personnel
other half were cleaned using isopropyl alcohol pads. admitted to changing their lab coat less than once a
Cleaning with the ethanol gel and isopropyl alcohol pads week; 15 percent changed once a month.5 Healthcare
significantly reduced the bacteria counts (by 92.8 workers often touch their own uniforms, potentially
percent and 92.5 percent, respectively).2 transferring bacteria from the fabric to their patients.
Studies confirm that the more bacteria found on sur-
A similar study at a large academic medical center took faces touched often by doctors and nurses, the higher
cultures from 40 randomly selected clinicians’ stetho- the risk for the bacteria to be carried to the patient and
scopes. Staphylococcus aureus was found on 38 per- cause infection.5
cent of them. When comparing the bacteria-removing

52 The OR Connection
In one study, 65 percent of nurses who cared for St. Mary’s Health Center in St. Louis, Mo., reduced
patients with MRSA contaminated their uniforms with infections after cesarean births by more than 50 percent
MRSA.6 Staphylococci and Enterococci were found to by providing staff with hospital-laundered scrubs.5
survive for days to months after drying on commonly Similarly, Monroe Hospital in Bloomington, Ind., which
used hospital fabrics, such as scrubs made from 100 has a near-zero rate of hospital-acquired infections,
percent cotton or 60 percent cotton and 40 percent requires all staff to wear hospital-laundered scrubs and
polyester, as shown in a study conducted by the bans them from wearing scrubs outside the hospital
Shriners Hospital for Children and the Department of building.5
Surgery at the University of Cincinnati.

Surgical staff are exposed to possible

bacteria-containing debris and fluid much more
often than staff in other areas of a hospital

Home laundering or hospital laundering?

There is ongoing debate whether hospitals should laun-
der staff uniforms or allow staff to wash their own
uniforms at home. The Association of PeriOperative
Registered Nurses (AORN) recommends that all
reusable surgical attire, including scrubs, be laundered
in a facility-approved and monitored laundry.7

AORN recommendations further state, “Surgical attire On the other side of the debate, a 1997 state-of-the-art
should be changed daily or whenever it becomes visibly report (SOAR) compiled by the Association for Profes-
soiled, contaminated, or wet. Worn surgical attire should sionals in Infection Control and Epidemiology (APIC)
be placed in an appropriately designed container for states, “There is no scientific evidence to suggest that
washing or disposal and should not be hung or placed home laundering versus institutional laundering poses
in a locker for wearing at another time. This promotes any increased risk of infection transmission.” 9
high-level cleanliness and hygiene within the practice
setting. It has been reported that bacterial colony counts Yet the report also says, “OSHA holds employers
are higher when scrub clothing is removed, stored in a responsible for laundering any clothing, including scrubs
locker, and used again.” worn by health care workers, that becomes contami-
nated with blood or other potentially infectious body
Surgical staff are exposed to possible bacteria-contain- fluids, regardless of who owns the scrubs.”9
ing debris and fluid much more often than staff in other
areas of a hospital, however, microbial contamination The CDC supports home laundering of scrub uniforms
still can occur outside the surgical suite, in patient rooms in its Guideline for Isolation Precautions (2007), which
where patients have MRSA or VRE.8 states, “In the home, textiles and laundry from patients

Aligning practice with policy to improve patient care 53

with potentially transmissible infectious pathogens do home- or hospital-laundered fabrics. 14 It could be
not require special handling or separate laundering, and argued, however, that the front shoulder of a scrub
may be washed with warm water and detergent.” Con- uniform is one of the least likely areas to be touched
versely, the state health departments in Pennsylvania or contaminated.
and Massachusetts, among others, recommend that
patients infected with MRSA launder their clothing Fewer bacteria = fewer HAIs
at home in hot water and laundry detergent. They also When it comes to preventing HAIs, it’s better to be safe
suggest drying clothes in a hot dryer to help kill than sorry. If there’s even a small chance you could be
the bacteria. 11,12 transferring bacteria to patients, why not take a little
extra time and a small amount of effort to clean up your
The CDC’s laundering recommendation is based on the act? Hand rub dispensers are conveniently located
outcome of two small, limited studies. One of the stud- throughout most facilities, so go ahead and disinfect
ies examined the scrub clothing of 68 labor and delivery your stethoscope between patients. When you wash
employees. The scrubs were laundered at home in your scrubs, turn those dials to hot, and of course –
warm water and detergent and also dried in a clothes keep washing your hands. Pass the word along to
dryer on the hot setting. The authors concluded that colleagues, and you may be surprised to see your
home-laundered scrub clothing can be worn safely in facility’s HAI rates go down.
labor and delivery units. What about other areas of
a hospital? 1 Estimates of Healthcare-Associated Infections. Centers for Disease Control
and Prevention Web site. Available at Accessed May 13, 2009.
2 Lecat P, Cropp E, McCord G, et al. Ethanol-based cleanser versus isopropyl
The other study tested the left front shoulders only of 30 alcohol to decontaminate stethoscopes. American Journal of Infection
home-laundered scrubs and 20 hospital-laundered Control. 2009;37(3):241-243.
3 Merlin MA, Wong ML, Pryor PW, et al. Prevalence of methicillin-resistant
scrubs. No pathogenic growth was found on either the Staphylococcus aureus on the stethoscopes of emergency medical
services providers. Prehosp Emerg Care. 2009;13(1):71-74.
4 Marinella MA, Pierson C, Chenoweth C. The stethoscope. A potential
source of nosocomial infection? Archives of Internal Medicine.
Change your habits for infection prevention 5 McCaughey, B. Hospital scrubs are a germy, deadly mess. The Wall Street
• Keep isopropyl alcohol wipes or ethanol-based Journal. January 8, 2009:A13.
6 LeTexier, R. Coming clean on home laundered scrubs. Infection Control
hand cleaner available and wipe down your Today Web site. Posted October 1, 2001. Available at http://www.infection- Accessed May 11, 2009.
stethoscope after each patient encounter. 7 Recommended Practices for Surgical Attire in: 2008 Perioperative
• Wear street clothes to work, and then change Standards and Recommended Practices. Association of PeriOperative
Registered Nurses: Denver, CO.
into clean scrubs every day. Keep an extra set 8 Dix K. Apparel in the hospital: what to wear, where? Infection Control Today
on hand and change mid shift if your scrubs Web site. Posted March 1, 2005. Available at http://www.infectioncontrolto- Accessed May 11, 2009.
get visibly dirty or notably splattered with any 9 Belkin NL. Use of scrubs and related apparel in health care facilities.
American Journal of Infection Control. 1997;25(5):401-404.
substance possibly containing bacteria. Change
10 Siegel JD, Rhinehart E, Jackson M, et al. Centers for Disease Control and
back into street clothes before leaving the facility Infection. 2007 Guideline for Isolation Precautions: Preventing Transmission
of Infectious Agents in Healthcare Settings. Available at
to avoid carrying bacteria into your car, public Accessed May
places and your home. If you wear a lab coat, 11, 2009.
11 Recommendations on Children with Methicillin-Resistant Staphylococcus
keep a clean supply at your facility and change aureus (MRSA) in School Settings. Pennsylvania Department of Health Web
into a new one each day. site. Available at Accessed
May 11, 2009.
• If your facility allows you to launder your own 12 Helpful Reminders About MRSA Infection. Massachusetts Department of
Public Health Web site. Available at:
uniforms at home, be sure to use hot water (110
to 125 degrees F or 43.33 to 51.67 degrees C)7 minders.pdf. Accessed May 11, 2009.
13 Kiehl E, Wallace R, Warren C. Tracking perinatal infection: is it safe to launder
with 50 to 150 parts per million of chlorine your scrubs at home? MCN Am J Matern Child Nurs. 1997;22(4):195-197.
bleach.6 (Note: Bleach is the only known cleaner 14 Jurkovich P. Home- versus hospital-laundered scrubs: a pilot study.
MCN Am J Matern Child Nurs. 2004;29(2):106-110.
proven to kill C. diff.)15 Above all, drying laundered
linen in a hot clothes dryer plays the most
significant role in eliminating bacteria.6

54 The OR Connection
Perioperative Pressure Ulcer Education

More important than ever before

Medlineʼs Pressure Ulcer Prevention Program
now has a component designed specifically for the
perioperative services. The easy-to-use interactive
CD addresses the following:
• Hospital-acquired conditions
“I have seen an increase in the number of legal
• CMS reimbursement changes
issues linking facility-acquired pressure ulcers to
• Best practices for pressure ulcer prevention
post-surgical patients. A pressure ulcer program
• Perioperative assessment tools
for the OR is more critical than ever.”
• Critical patient and equipment risk factors
Diane Krasner, PhD, RN, CWCN,
Contact your Medline sales representative
for more details. You can also learn more about
Medlineʼs Pressure Ulcer Prevention Programs
for long-term care, acute care and perioperative
services by visiting
ulcerprevention, where you can sign up for a
free informational Webinar.
©2009 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
The AORN Seal of Recognition has been awarded to Pressure Ulcer Prevention for Perioperative Services in June 2009 and does not
imply that AORN approves or endorses any product or service mentioned in any presentation, format or content. The AORN Recogni-
tion program is separate from the AORN, ANCC Accredited Provider Unit and therefore does not include any CE credit for programs.

The AORN Seal of Recognition is a trademark of AORN, Inc., All rights reserved.
By Wolf J. Rinke, PhD, RD, CSP 1. Reality Test
Most of us assume words have meaning. They do not! The
Do you have problems with communication in fact is all of us speak a different “language” because we all
have different values, beliefs and life experiences that impact
your facility and at home? Whenever I ask that
how we interpret everything. For example, what does the
question of my audiences virtually all hands go up. word “fast” mean to you? If you’ve been dieting, it probably
Why? Because we are all terrible communicators. means “to not eat.” If you are an amateur photographer, you
Here are 12 specific strategies that will help you might be thinking of the speed of film. If you do a lot of laun-
dry, you might be thinking of how stable a color is. If you like
communicate more effectively and get more of to race, you might think of the speed of a vehicle. And the list
what you want. goes on.

56 The OR Connection
Caring for Yourself

How to Communicate More Effectively and Get More of What You Want

To get around this, do a reality test, especially when a shared 2. Get Really Good at Asking Questions
understanding is critical. Here are several examples. When As an executive coach, I’ve learned the benefits of asking
your spouse tells you how much you irritate him, summarize questions. Here is what questions can do:
your conversation: “Sweetheart, let me just make sure that • Put you in control of the conversation. Questions elicit
you and I are on the same page. What I heard you say was . an almost Pavlovian response in the listener to find
. .” At the end of a complicated instruction to one of your pa- an answer.
tients: “Now Miss Eager, we went over a lot of technical in- • Establish rapport. Questions demonstrate interest, which
formation. To make sure you will be able to follow my causes others to like you. And people who like you
instructions, please repeat what you heard me say.” are more likely to comply with your wishes and requests.
• Build trust. Eliciting ideas from others causes them to
feel that you care about them, which helps build trust.

Continued on Page 59
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• Protective eyewear

For more information on Medline

facemasks, please contact your
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call 1-800-MEDLINE.

©2009 Medline Industries, Inc.

Medline is a registered trademark of Medline Industries, Inc.
I see this all the time in my coaching practice.
A manager tells me, “My boss does not care about me.”
I ask, “How do you know?”
“Well, he never tells me anything.”
I ask, “How do you mean?”
“Well, most of the time I find out stuff through the grapevine
instead of from my boss.”
I ask, “Have you ever asked him to keep you in the loop?”
“No, but you know, that is a very good idea.
I should really do that.”

• Achieve deeper understanding. When you ask questions, My consistent advice is deceptively simply but extremely
you will help the other party focus on what you want powerful: If in doubt, check it out.
them to focus on.
• Provide for greater buy-in, higher motivation and 4. Utilize Adult Language
compliance. Questions allow individuals to come up According to Eric Berne and Thomas Harris, of the transac-
with their “solution,” and invariably their level of tional analysis (TA) fame, all of us utilize three different internal
commitment will increase. “recordings” that represent our “ego states”: child, parent
and adult.
3. Avoid Fundamental Attribution Errors
Someone is late for an appointment, and we perceive that The child ego state refers to the behavior pattern, thoughts
they don’t care or they are sloppy, when in fact they may and feelings we learned as children. They include helpless-
have had an accident. In psychology this is referred to as ness, blaming and emotional expressions such as “I can’t
making a fundamental attribution error. I refer to it as “we help it,” “Don’t blame me,” “It’s your fault,” etc. Nonverbal
are very good at running our own movies,” meaning that we cues of the child ego state include whining, whistling, laughing,
attach all kinds of meanings to behavior we observe that has teasing, expressing dejection, pouting, nail biting, moving
nothing whatsoever to do with the person’s actions. restlessly and looking rebellious, nervous or sad.

I see this all the time in my coaching practice. Our parent ego state was developed by observing parents
A manager tells me, “My boss does not care about me.” and other authority figures. When we are in a parent role we
I ask, “How do you know?” tend to be very judgmental, critical, controlling, comforting or
“Well, he never tells me anything.” nurturing, and use such phrases as “You can’t do that,” “You
I ask, “How do you mean?” have to,” “Always,” “Never,” etc. Nonverbal cues include
“Well, most of the time I find out stuff through finger pointing, looking at your watch while communicating,
the grapevine instead of from my boss.” finger tapping, pressing lips tight, grinding teeth, checking
I ask, “Have you ever asked him to keep you in the loop?” up on others, scowling, sneering, patronizing or expressing
“No, but you know, that is a very good idea. sympathy.
I should really do that.”
The third internal recording is that of the adult. An adult is a
fact finder, information seeker, analyzer and logical problem

Aligning practice with policy to improve patient care 59

It is better to remain quiet and be thought a fool
than to speak and remove all doubt,”
— Anonymous

solver. When you use your adult recording, you ask why? 6. Listen Actively
what? when? where? who? how? and say such things as “I Even though it’s been said by the prolific author Anonymous,
made a mistake,” “I changed my mind,” “I don’t know,” “It is better to remain quiet and be thought a fool than to
“I don’t understand,” “It’s my opinion,” “Let me check on speak and remove all doubt,” most of us are very good at re-
that,” and “What can we learn from this?” When you are in moving all doubt. One reason is that most of us are very
this ego state, you tend to be clear, calm and non-judg- good at “talking and telling” instead of “listening and learn-
mental. Your nonverbal expressions include straight but ing.” To become an active listener, remind yourself that there
relaxed posture, comfortable eye contact and a friendly face must be a reason that we were born with only one mouth
that says, “I’m interested in what you have to say. I’m alert, and two ears.
thoughtful and attentive.”
The better you get at listening, the more you’ll find out what
Communication effectiveness is dramatically enhanced the other party really wants. Once you know that, you are
when you express yourself in an adult ego state, especially communicating from a position of strength. Your husband
when both you and the other party are playing the same says: “For our next vacation I want to go to Phoenix.” Un-
recording. Since it is difficult to change other people, fortunately you are tired of Phoenix. Instead of telling him
I strongly urge you to get in the driver’s seat of your trans- why Phoenix is a bad idea, ask questions to find out what he
actions by using adult language whenever you are commu- really wants. “Please tell me what you would like to do in
nicating. If you would like more help with this, read my How Phoenix?” He might say, “I want to play golf where the air is
to Maximize Professional Potential CPE program available warm and dry.” Now you can put your thinking caps on to
from identify lots of places that will meet both of your needs. Here
are several related strategies:
5. Accept 111 Percent Responsibility • When someone asks a question, keep your mouth shut
for the Entire Communication Process until the other person has finished speaking. Do this even
Most of us are experts at playing the blame game. Have you though you know the answer when the other person
noticed that when there is a breakdown in communication, begins to speak. Remember, when the mouth is
it’s almost always the fault of someone or something else, engaged, the ears are out of gear.
but seldom the person who is making the excuses! To make • Show the person speaking that you are listening actively
this point, ask someone who arrives late for a meeting, by totally focusing all of your mental energy on what the
“Would you have been on time if $1,000 were riding on it?” other person is saying, not only with her words but also
The typical answer is “Of course!” her body. You can achieve that by making strong eye
contact, leaning slightly forward and using your body
To achieve dramatic improvements in your communication language to acknowledge the message and
effectiveness, I strongly recommend that you buy 111 per- the messenger.
cent into the following axiom: If it is to be, it is up to me. (This
one works for all aspects of your life, so do try this at home.)

60 The OR Connection
• Listen to the “music” as well as the words. In order to would cause you to react negatively, PIN it. For example, your
really understand what’s being communicated, it’s team member says, “Boss, you know how morale has gone
important that you hear more than the words, which down the tube? Let’s close the hospital and go on a cruise.”
you can achieve by tuning into the mood, atmosphere
and emotional tone that put the words into context. Instead of NIPing anything “weird,” focus your mental energy
• Demonstrate empathy by getting inside the other first on the:
person’s thoughts and feelings. This can be expressed P - Positive. Ask yourself what could be positive about your
by saying “I see,” “I understand,” “I follow you,” “I’m with employee’s suggestion: “Well at least she seems interested in
you,” and so on. making things better.” After you’ve done that in your mind’s
• Take off your mask and be yourself. This engenders eye, next evaluate the …
trust, and trust is essential to effective communication. I - Interesting or Innovative. Ask what could be interesting
• Before ending your communication, summarize and do or innovative about your team member’s suggestion. “Maybe
a reality test, as previously discussed. there is a need for more celebration around here.” Once
you’ve evaluated that, and only after you’ve exhausted all the
7. Express Yourself in Positive Terms Ps and Is, then ask yourself: “What is the downside, or the
When we speak, we can say things negatively or positively. …”
For example, you can say, “I don’t have an answer for that,” N - Negative. Because in communication, just like in life,
or “I can answer that the next time we get together.” Which do nothing ever goes one way, there is yin and yang, health and
you think is easier to understand? Research has demon- sickness, life and death, high stock market and low stock
strated that positively worded statements are one-third eas- market and the list goes on. PINing it will enable you to eval-
ier to comprehend than their negative counterparts. The uate both the upside and downside of every conversation.
reason is that human beings are unable to move away However, if you NIP comments, ideas or suggestions in the
from the reverse of an idea. Instead, we move toward that bud, it’s like closing the proverbial shade, which prevents you
which we visualize in our minds. Don’t believe it? Let me ask from seeing opportunities.
you not to think of a green snake. What did you just think of?
A green snake, right? You see, none of us can move away 9. Convey Integrity at All Times
from the reverse of an idea. Take advantage of this phenom- People prefer to deal with communicators they can trust,
enon by expressing yourself in positive terms. rather than those they have to second-guess. The fact is that
without trust, relationships die and your ability to communi-
8. Master the PIN Technique cate is severely compromised. So be sure to be congruent,
The PIN technique is a powerful way to reframe your percep- which means that your body language, vocal patterns and
tions and turn the negatives into positives. Here is how it pitch support what you’re saying. And the way to achieve that
works. When you are confronted with anyone or anything that is to “tell it like it is,” even though it shows that you are not
omnipotent. Also be aware of self-defeating phrases some

Continued on Page 63

To turbo-charge your communication

effectiveness, pretend that all people you
communicate with have printed across
their forehead a big bold sign that reads

Aligning practice with policy to improve patient care 61

results with far less resistance. (For other powerful techniques
read my Win-Win Negotiation CPE program, available at

people use habitually without being aware of their implica- 12. Make Them Glad They Communicated
tions. For example, avoid saying, “Let me be absolutely with You
honest with you.” If you say that to me, I’m thinking: “What are To turbo-charge your communication effectiveness, pretend
you normally?” that all people you communicate with have printed across
their forehead a big bold sign that reads MAKE ME FEEL
10. Strive For Win-Win IMPORTANT! This phrase will remind you to always focus on
When you are communicating be on the lookout for things their needs first, because once they get the feeling you want
that will be beneficial to the other party. For example, if you are to help them, most people will do whatever they can to
talking with a team member, instead of saying “You have to reciprocate, which in the long run will help you get more of
yada, yada, yada,” use: “How can I help you with . . .?” When what you want.
you are talking to patients, instead of saying, “According to
hospital policy you have to . . .,” use, “What options can we
think of that will . . .” This attitude shows that you are inter-
ested in helping the other person get what he wants, which
in turn will make him more receptive to helping you get what
you want.

11. Always Strive to Make the Other Person

Right—Never Wrong
Whatever you do, avoid arguing. People who argue will lose Dr. Wolf J. Rinke, RD, CSP is a keynote speaker, seminar leader,
management consultant, executive coach and editor of the free
the “battle” because it causes the other person to become
electronic newsletters Make It a Winning Life and The Winning
defensive. So what’s a better approach? Make the other per- Manager. To subscribe go to He is the
son right. My Superwoman and I have taken this to another author of numerous books, CDs and DVDs including Winning
level. Anytime we find ourselves getting into conflict, one of Management: 6 Fail-Safe Strategies for Building High-Performance
us will raise his/her hand with all five fingers extended, which Organizations and Don’t Oil the Squeaky Wheel and 19 Other
stands for: “You are right about that.” (One finger for each Contrarian Ways to Improve Your Leadership Effectiveness available
at His company also produces a wide variety
word.) So you don’t sound like a parakeet, use other phrases
of quality pre-approved continuing professional education (CPE)
that make the other person right, such as: “That is a very self-study courses including his latest The Power of Communication:
interesting idea;” “I’ve never thought of it that way;” “This How to Increase Your Personal and Professional Effectiveness
seems very important to you,” etc. So make it a habit to agree on which this article was based. It is available at www.easyCPE-
with people and you will find that you will get much better Reach him at

Aligning practice with policy to improve patient care 63

A world without breast cancer is in our hands.

Medline’s Generation Pink latex-free, third-generation

vinyl exam gloves have the comfort, barrier protection
and price you love. Even better, when you choose
Generation Pink gloves, you’re helping Medline
support the National Breast Cancer Foundation.

For more information on Medline’s exam gloves,

please contact your Medline sales representative
or call 1-800-MEDLINE.
Caring for Yourself

Breast Cancer
Month October 2009

Medline Breast Cancer Awareness Campaign
Celebrates Five Years

“Together We Can Save Lives”

Five years ago, Medline began a mission to promote breast
cancer awareness beyond the standard 31 days of public
awareness each October. We launched a year-round breast
cancer campaign called “Together We Can Save Lives
Through Early Detection,” which supports breast cancer
education and early detection. Since the launch of the cam-
paign, Medline has donated more than $450,000 to the
National Breast Cancer Foundation (NBCF). For more infor-
mation on the NBCF, visit

In partnership with NBCF, Medline

has helped fund grants to hospitals
and other healthcare organizations
that offer free mammograms to The Web page contains background on the breast cancer
women in need. Through this part- campaign, AORN breakfast forum special event details with
nership, Medline continues its mis- photo galleries and keynote speaker bios. Visit today at
sion to give back to customers and
their communities, help promote the
early detection of breast cancer and Pink Ribbon Products
ultimately save lives. We hope this Medline Industries, Inc. also promotes breast cancer
campaign will help spread the word – awareness by displaying the pink ribbon logo on products.
early detection and mammograms save lives! By purchasing a pink ribbon product from Medline, you are
helping to support Medline’s $100,000 annual contribution
New Breast Cancer Awareness Web Page to the NBCF.
Medline has just launched a new Web page dedicated to breast
cancer awareness and the “Together We Can Save Lives” Some of the products include pink exam gloves, the pink rib-
campaign. Raising breast cancer awareness among nurses is bon rollator, pink ribbon bouffant caps and breast cancer
one of our key goals, as it is the leading cause of death for awareness scrubs and other apparel. Ask your Medline
women ages 40-55. The average age of a nurse is 46. rep for details or visit

Aligning practice with policy to improve patient care 65

Medline’s Annual Breast Cancer Awareness
Breakfast at AORN Congress

Each year since 2006, Medline has been hosting a compli-

mentary breast cancer awareness breakfast at the Association
of periOperative Registered Nurses (AORN) Congress. In
addition to a hot buffet breakfast, the program includes
inspiring stories from famous breast cancer survivors.
In 2009 Medline was proud to host TV journalist Linda Ellerbee.
Past speakers have included Dr. Marla Shapiro, Rue
McClanahan and Ann Jillian. More than 1,000 guests attend Medline’s annual Breast Cancer
Awareness Breakfast during the AORN Congress.
If you attended our Breast Cancer Awareness Breakfast at the
Famous breast
AORN Conference this past spring, and signed up for our cancer survivors
breast cancer awareness mailing list, you will be receiving sev- Ann Jillian (left)
eral education and awareness mailings, including information and Dr. Marla
on our campaign, breast cancer news and events and Shapiro.
special gifts.

Not on the list? Go to

awareness and sign up today!

Guests at the 2009 Medline Breast Cancer Awareness Breakfast.

Save the Date!

Medline’s Breast Cancer
Awareness Breakfast
AORN Congress, Denver, CO
March 3-8, 2010

66 The OR Connection
Breast Self-Examination
1. In the Shower
Fingers flat – move gently over
every part of each breast.

Use your right hand to examine

left breast, left hand to examine
right breast. Check for any lump,
hard knot or thickening. Carefully
observe any changes in your

Breast breast.

2. Before a Mirror
Cancer Inspect your breasts with your
arms raised high overhead. Next,

Facts place your arms at your sides.

Look for any changes in contour
of each breast; a swelling, a
dimpling of skin, or changes
in the nipple.

Then rest palms on hips and

press firmly to flex your chest
muscles. Left and right breasts
• Each year, more than 211,000 American women learn will not match exactly. Few
they have breast cancer. women’s breasts do match.
• The chance of a woman having invasive breast cancer
3. Lying Down
sometime during her life is about 1 in 8. The chance Place pillow under right shoulder,
of dying from breast cancer is about 1 in 35. right arm behind your head.
• About 192,370 estimated cases of breast cancer for With fingers of left hand flat,
press right breast gently in small
women and about 1,910 estimated cases of
circular motions, moving vertically
breast cancer for men will be diagnosed in 2009. or in a circular pattern covering
Of these, 40,170 cases for women and 440 cases the entire breast.
for men will result in death.
Use light, medium and firm pressure. Squeeze nipple,
• Nearly 90 percent of women diagnosed with breast check for discharge and lumps. Repeat these steps on
cancer will survive their disease at least five years. your left breast.
• The chance of getting breast cancer goes up as a
Recommendations for Routine
woman gets older. Most cases occur in women Mammography Screening
over 60. Age 40: A baseline mammogram as a standard for future
• Women 40 and older should have a mammogram comparison
every one to two years. Mammograms are the most
40-49: a mammorgram every one or two years, depending
effective way to detect breast cancer. on previous findings
• Breast cancer death rates are falling, probably as a
result of early detection and improved treatment. 50 and older: a mammogram every year

American Cancer Society,
National Cancer Institute,

Compliments of Medline’s “Together We Can Save Lives

Through Early Detection” campaign. To learn more go to
Healthy Eating

24-Hour Dill Pickles

(24 servings)

•1 cup white vinegar

•5 cups water
•1/2 cup sugar
•1/3 cup kosher salt

•5 to 6 cucumbers (10 to 12 inches long,

cut in half lengthwise and then cut Nutritional
into spears) Servings: 24
•1 bulb garlic, separated, peeled and
Amount per serving
sliced thin Calories: 25
•5 to 6 heads fresh dill Total fat: 0 g
Sodium: 1,571 mg
Fiber: 0.3 g
Put first four ingredients in a large pot and bring
to a rolling boil. Set aside and cool completely.

As Operations Manager for Medline’s Information Services

Place cucumbers in a half gallon jar, along with the garlic
Department, Vicki said she tested her pickle recipe with
and dill. If you like spicy, add a little crushed pepper as
the department’s 130 employees before the cookoff,
well. Next, pour the cooled liquid mixture into the jar.
and it was a big hit. “I still have people calling me and
Attach a lid and store in the refrigerator. (It must be kept
asking when they can get their next jar! They don’t just like
refrigerated.) After 24 hours, they are ready, but if you leave
the pickles – they crave them. If you eat one, you just want
them for 48 hours, they taste even better. The pickles will
keep three to six months in the refrigerator.

She added, “Vegetable gardening was part of my life

This recipe, which was created by
growing up, and we did a lot of canning. I’ve gotten back
Medline employee Vicki Brown,
into gardening as an adult, using only organic materials for
was a Gold Medal Winner at Med-
growing and fertilizing.” She said she would never even
line’s International Cookoff dur-
dream of using anything other than home grown cucum-
ing Employee Appreciation Week
bers to make her pickles.
2008. Vicki chose the recipe
because it was quick and easy, plus
This year she will be entering the Employee Cookoff again,
she could use home grown vegeta-
possibly in the entrée category, again making a recipe
bles to make it.
using her home grown veggies.

68 The OR Connection
Forms & Tools

The following pages contain practical tools for implementing

patient-focused care practices at your facility.

Prophylactic Antibiotic Regimen Selection for Surgery . . . . . . . . .71

Surgical Care Improvement Project (SCIP)

VTE Prophylaxis Options for Surgery . . . . . . . . . . . . . . . . . . . . . .73

CATS Decrease Surgical Site Infections – English . . . . . . . . . . .81
CATS Decrease Surgical Site Infections – Spanish . . . . . . . . . . .82

What You Need to Know About Infections After Surgery:

Institute for Healthcare Improvement (IHI)

A Fact Sheet for Patients – English . . . . . . . . . . . . . . . . . . . . . . . .75

What You Need to Know About Infections After Surgery:
A Fact Sheet for Patients – Spanish . . . . . . . . . . . . . . . . . . . . . . .77

How to Handrub? (Non-surgical) . . . . . . . . . . . . . . . . . . . . . . . . . .79

World Health Organization (WHO)

Aligning practice with policy to improve patient care 69

Halt Hypothermia with Medline Warmers

Medline’s double-door and tabletop warming All of our blanket and fluid warmers have
cabinets are the perfect way to ensure that conveniently located keypads and digital
the warm blankets and fluids your patients controls for easy operation. The uniform
need before, during and after surgery are heating and open shelf design provide
right at your fingertips. greater temperature accuracy, and the
simplified control panel is a snap to use!
Studies have shown that hypothermia may To learn more about Medline
delay healing, predispose patients to wound Best of all, Medline blanket and fluid blanket and fluid warmers, contact
infections and increase the length of hospital warmers are so affordable that you can your Medline representative,
stays.1 Clearly, taking measures to prevent cover your needs on every floor! call 1-800-MEDLINE or visit us
hypothermia in the perioperative setting at
is crucial.

1 Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the incidence of
surgical-wound infection and shorten hospitalization. The New England Journal of Medicine.

©2009 Medline is a registered trademark of Medline Industries, Inc.

SCIP Forms & Tools

Prophylactic Antibiotic Regimen Selection for Surgery

Procedure Approved Antibiotics
CABG, Other Cefazolin, Cefuroxime or Vancomycin** If -lactam allergy:
Cardiac or Vancomycin* or Clindamycin*

Hysterectomy Cefotetan, Cefazolin, Cefoxitin, Cefuroxime, or

Ampicillin/Sulbactam If -lactam allergy: Clindamycin +
Aminoglycoside, or Clindamycin + Quinolone, or Clindamycin
+ Aztreonam OR Metronizadole+Aminoglycoside
Metronidazole+Quinolone OR Clindamycin monotherapy OR
Metronidazole monotherapy

Special *For cardiac, orthopedic, and vascular surgery, if the patient

Considerations is allergic to -lactam antibiotics, Vancomycin or Clindamycin
are acceptable substitutes. **Vancomycin is acceptable with a
physician/APN/PA /pharmacist documented justification for its
use (see data element Vancomycin) . A single dose of
Ertapenem is recommended for colon

The antibiotic regimens described in this table reflect the combined, published recommendations of
the Specifications Manual for discharges from 04-01-09 to 09-30-09.

Aligning practice with policy to improve patient care 71

Forms & Tools SCIP

Prophylactic Antibiotic Regimen Selection for Surgery

Procedure Approved Antibiotics
Hip/Knee Cefazolin or Cefuroxime or Vancomycin** If -lactam allergy:
Arthroplasty Vancomycin* or Clindamycin*

Colon Cefotetan, Cefoxitin, Ampicillin/Sulbactam or Ertapenem OR

Cefazolin or Cefuroxime + Metronidazole If -lactam allergy:
Clindamycin + Aminoglycoside, or Clindamycin + Quinolone,
or Clindamycin + Aztreonam OR Metronidazole with
Aminoglycoside, or Metronidazole + Quinolone

Special *For cardiac, orthopedic, and vascular surgery, if the patient

Considerations is allergic to -lactam antibiotics, Vancomycin or Clindamycin
are acceptable substitutes. **Vancomycin is acceptable with a
physician/APN/PA/pharmacist documented justification for its
use (see data element Vancomycin). A single dose of
Ertapenem is recommended for colon

The antibiotic regimens described in this table reflect the combined, published recommendations of
the Specifications Manual for discharges from 04-01-09 to 09-30-09.

72 The OR Connection
VTE Forms & Tools

VTE Prophylaxis Options for Surgery

Surgery Type Recommended Prophylaxis Options*
Intracranial Any of the following:
• Intermittent pneumatic compression devices (IPC) with or without graduated
compression stockings (GCS)
• Low-dose unfractionated heparin (LDUH).
• Low molecular weight heparin (LMWH)**
• LDUH or LMWH** combined with IPC or GCS
**Current guidelines recommend postoperative low molecular weight heparin for Intracranial

General Surgery Any of the following:

• Low-dose unfractionated heparin (LDUH)
• Low molecular weight heparin (LMWH)
• Factor Xa Inhibitor (Fondaparinux)
• LDUH or LMWH or Factor Xa Inhibitor (Fondaparinux) combined with IPC
or GCS.

General Surgery with Any of the following:

a reason for not • Graduated compression stockings (GCS)
administering • Intermittent pneumatic compression devices (IPC)

Gynecologic Surgery Any of the following:

• Low-dose unfractionated heparin (LDUH)
• Low molecular weight heparin (LMWH)
• Factor Xa Inhibitor (Fondaparinux)
• Intermittent pneumatic compression devices (IPC)
• LDUH or LMWH or Factor Xa Inhibitor (Fondaparinux) combined with IPC
or GCS

Elective Total Hip Any of the following started within 24 hours of surgery:
Replacement • Low molecular weight heparin (LMWH)
*Patients who receive • Factor Xa Inhibitor (Fondaparinux)
• Warfarinnesthesia or have a documented reason for not the performance
measure if either appropriate pharmacological is ordered. Manual for
National Hospital Inpatient Quality Measures Discharges 4-01-09 (2Q09)
* Patients who receive neuraxial anesthesia or have a documented reason for administering pharmacological prophylaxis
may pass the performance measure if either appropriate pharmacological or mechanical prophylaxis is ordered.

Discharges 04-01-09 to 09-30-09.

Aligning practice with policy to improve patient care 73

Forms & Tools VTE

VTE Prophylaxis Options for Surgery

Surgery Type Recommended Prophylaxis Options*
Elective Total Hip Any of the following:
Replacement with a • Venous foot pump (VFP)
reason for not • Intermittent pneumatic compression devices (IPC)

Hip Fracture Surgery Any of the following:

with a reason for not • Graduated Compression Stockings (GCS)
administering • Intermittent pneumatic compression devices (IPC)
• Venous foot pump (VFP)

Hip Fracture Surgery Any of the following:

• Low-dose unfractionated heparin ( LDUH)
• Low molecular weight heparin (LMWH)
• Factor Xa Inhibitor (Fondaparinux)
• Warfarin

Elective Total Knee Any of the following:

Replacement • Low molecular weight heparin (LMWH)
• Factor Xa Inhibitor (Fondaparinux)
• Warfarin
• Intermittent pneumatic compression devices (IPC)
• Venous foot pump (VFP)

Urologic Surgery This Any of the following:

material was prepared by • Low-dose unfractionated heparin (LDUH)
• Low molecular weight heparin (LMWH)
• Factor Xa Inhibitor (Fondaparinux)
• Intermittent pneumatic compression devices (IPC)
• Graduated compression stockings (GCS)
• LDUH or LMWH or Factor Xa Inhibitor (Fondaparinux)
combined with IPC or GCSealth and the Oklahoma Foundation for Medical Quality, the Quality
Center for Patient Safety, under contract with the Centers for Medicare & cy of the U.S. Department of Health and Human
Services. CMS policy. 9SOW-QIOSC-6.2-09-31

* Patients who receive neuraxial anesthesia or have a documented reason for administering pharmacological prophylaxis
may pass the performance measure if either appropriate pharmacological or mechanical prophylaxis is ordered.

Discharges 04-01-09 to 09-30-09.

74 The OR Connection
Surgical Infections Forms & Tools

What You Need to Know about Infections after Surgery:

A Fact Sheet for Patients and Their Family Members

Most patients who have surgery do well. But sometimes patients get infections.
This happens to about 3 out of 100 patients who have surgery. Infections after
surgery can lead to other problems. Sometimes, patients have to stay longer in
the hospital. Rarely, patients die from infections. Patients and their family
members can help lower the risk of infection after surgery. Here are some ways:

Days or weeks before surgery:

Meet with your surgeon.
• Bring an up-to-date list of all the medications you take. Talk with your surgeon
about why you take each medication and how it helps.
• Let the surgeon know if you are allergic to any medication and what happens
when you take it.
• Tell the surgeon if you have diabetes or high blood sugar.
• Talk about ways to lower your risk of getting an infection. This may include
taking antibiotic medicines.

The day or night before surgery:

Take extra good care of your body.
• Do not shave near where you will have surgery. Shaving can irritate your skin
which may lead to infection. If you are a man who shaves your face every
day, ask your surgeon if it is okay to do so.
• Keep warm. This means wearing warm clothes or wrapping up in blankets
when you go to the hospital. In cold weather, it also means heating up the car
before you get in. Keeping warm before surgery lowers your chance of getting
an infection.

This document is in the public domain and may be used and reprinted without permission provided
appropriate reference is made to the Institute for Healthcare Improvement.

Aligning practice with policy to improve patient care 75

Forms & Tools Surgical Infections

At the time of surgery:

• Tell the anesthesiologist (doctor or nurse who puts you to sleep for surgery)
about all the medications you take. A good way to do this is with an up-to-
date medication list.
• Let the anesthesiologist know if you have diabetes or high blood sugar.
People with high blood sugar have a greater chance of getting infections after
• Speak up if someone tries to shave you before surgery. Ask why you need to
be shaved and talk with your surgeon if you have any concerns.
• Ask for blankets or other ways to stay warm while you wait for surgery. Find
out how you will be kept warm during and after surgery. Ask for extra blankets
if you feel cold.
• Ask if you will get antibiotic medicine. If so, find out how much medicine you
will get. Most people are on antibiotics for just one day as taking too much
can lead to other problems.

Information provided in this Fact Sheet is intended to help patients and their families in obtaining effective
treatment and assisting medical professionals in the delivery of care. The IHI does not provide medical
advice or medical services of any kind, however, and does not practice medicine or assist in the diagnosis,
treatment, care, or prognosis of any patient. Because of rapid changes in medicine and information, the
information in this Fact Sheet is not necessarily comprehensive or definitive, and all persons intending to
rely on the information contained in this Fact Sheet are urged to discuss such information with their health
care provider. Use of this information is at the reader's own risk.

This document is in the public domain and may be used and reprinted without permission provided
appropriate reference is made to the Institute for Healthcare Improvement.

76 The OR Connection
Surgical Infections Español Forms & Tools

Lo Que Usted Debe Saber sobre las Infecciones después de las Cirugías:
Pagína de Informe para Pacientes y Sus Familiares:

La mayor parte de los pacientes que se operan, salen bien. Pero a veces al
paciente le da una infección. Esto ocurre en alrededor de 3 de cada 100
pacientes que se operan. Una infección después de una cirugía puede resultar
en otras complicaciones. A veces, el paciente debe permanecer más tiempo en
el hospital. Son raros los casos en que muere el paciente de una infección. El
paciente y sus familiares pueden ayudar a reducir el riesgo de una infección
después de una cirugía. Vea cómo, a continuación:

Los días o semanas antes de la operación:

Haga un turno con su cirujano.
• Traiga una lista, que esté al día, con todos los medicamentos que usted
toma. Hable con su cirujano y dígale porque toma cada medicamento y
cómo le ayuda.
• Avise al cirujano si es alérgico o alérgica a cualquier medicamento y que le
ocurre cuando lo toma.
• Diga al cirujano si es diabético o si tiene el azúcar de la sangre elevado
• Hable de cómo puede reducir el riesgo de una infección. Puede que le
recomiende algún medicamento antibiótico.

El día o la noche antes de la operación:

Cuídese mucho mejor.
• No se afeite cerca del área donde va a operarse. El afeitarse puede irritar su
piel y puede hacerlo/hacerla más propensa a una infección. Si usted se
rasura la cara todos los días, pregunte a su cirujano si le recomienda
• Manténgase caliente. Use ropa de frío o cobíjese bien cuando vaya al
hospital. Cuando hace frío, esto también significa calentar el carro antes de
entrar en el mismo. El mantenerse caliente antes de una cirugía reduce el
riesgo de una infección.

Aligning practice with policy to improve patient care 77

Forms & Tools Surgical Infections Español

A la hora de la cirugía:
• Comunique al anestesiólogo (el médico o enfermera que lo duerme durante
la cirugía) cuales medicamentos usted toma. Una buena manera de hacer
esto es por medio de una lista de medicamentos, que esté al día.
• Diga al anestesiólogo si es diabético o si tiene el azúcar de la sangre
elevado. Las personas con el azúcar de la sangre alto tienen una mayor
probabilidad de adquirir una infección después de una cirugía.

• Diga algo si alguien intenta afeitarlo antes de la cirugía. Pregunte porque

necesita ser afeitado y hable con su cirujano si tiene alguna duda.
• Pida cobijas u otras formas de mantenerse caliente mientras espera.
Pregunte como van a mantenerlo/la caliente durante y después de la cirugía.
Pida más cobijas si tiene frío.
• Pregunte si va a recibir algún medicamento antibiótico. Si le dicen que sí,
pida cuanto le van a dar. La mayor parte de la gente toma antibióticos solo
por un día ya que tomar demasiado puede resultar en otras complicaciones.

La información que aparece en esta hoja se provee con la intención de ayudar a pacientes y a sus
familiares a recibir buen cuidado médico y para asistir a los profesionales médicos a prestar cuidado
médico. El Instituto para el Mejoramiento de la Salud no da consejos médicos ni presta servicios médicos
de ninguna clase, y no práctica medicina ni asiste en el diagnóstico, tratamiento, cuidado, o prognosis de
ningún paciente. A causa de los rápidos cambios en la medicina y la información, la información en esta
hoja no pretende estar completa ni tampoco es definitiva. Toda persona con la intención de usar la
información contenida en esta hoja, debe consultar con su proveedor médico. El uso de esta información
es a su propio riesgo.

Este documento es parte del dominio público y se puede usar y reproducir sin permiso con tal de que se
mencione apropiadamente al Instituto para el Mejoramiento de la Salud (Institute for Healthcare

78 The OR Connection
Handrub (Non-surgical) Forms & Tools

How to Handrub?
Duration of the entire procedure: 20-30 seconds

1a 1b 2

Apply a palmful of the product in a cupped hand, covering all surfaces; Rub hands palm to palm;

3 4 5

Right palm over left dorsum with Palm to palm with fingers interlaced; Backs of fingers to opposing palms
interlaced fingers and vice versa; with fingers interlocked;

6 7 8

Rotational rubbing of left thumb Rotational rubbing, backwards and Once dry, your hands are safe.
clasped in right palm and vice versa; forwards with clasped fingers of right
hand in left palm and vice versa;

All reasonable precautions have been taken by the World Health Organization to verify the information contained in this document. However, the published material is being distributed without warranty of any kind,
either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use.
WHO acknowledges the Hôpitaux Universitaires de Genève (HUG), in particular the members of the Infection Control Programme, for their active participation in developing this material.

May 2009

Aligning practice with policy to improve patient care 79

And now ...
Introducing the first
disposable sterile

surgical clipper !
Contact your Medline
sales representative for
your evaluation today!

FREE MediClip® Trial!

Why choose MediClip?
Clippers can help you avoid nicking or cutting the pa-
tient's skin during preoperative hair removal, helping to
reduce the patient’s risk for surgical site infections.
MediClip is designed to be held at a 30-degree angle to
prevent the cutting blades from ever coming in contact
with the patient’s skin. Sign up now at to conduct your own extensive test of
MediClip! Get up to 10 clippers and five cases of blades
Other reasons to try MediClip
• User instructions are right on the handle for
ease of use Sign up online at
• Ergonomic handle design provides a
comfortable grip
• Hands-free blade disposal protects the user
• Clean-up is easy with the sealed, * This offer is good through 6/30/2010. It applies to new cus-
tomers only and is good for up to 10 MediClip Clippers and up
waterproof handle to five cases of MediClip blades.
• Smooth surface has no screws, crevices
† Patent pending
or engraving to trap dirt and debris
CATS - SSI Forms & Tools

CATS Decrease
Surgical Site Infections

Hair Removal:
If hair must be removed from the
surgical site, clippers are the best
option. Never use a razor.

Prophylactic Antibiotics:
Antibiotics consistent with national
guidelines should be administered
within 1 hour of incision time and
discontinued within 24 hours (48
hours for cardiac surgeries) of surgery
end time.

Surgery patients should be normo-
thermic (≥ 96.8º F /36º C) within the
first 15 minutes after leaving the
operating room.

Glucose Control:
Cardiac surgery patients should have
controlled 6 a.m. serum glucose
(d 200 mg/dL) on postoperative Day 1
and Day 2.

Additional information about reducing surgical site infections is available at

This material was prepared by Health Services Advisory Group, Inc. (HSAG), the Medicare Quality Improvement
Organization for Arizona, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of
the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.
Publication No: AZ-9SOW-6.2.3-071909-01

Aligning practice with policy to improve patient care 81

Forms & Tools CATS - SSI Español

‘GATO’ Disminuye
Infecciones en el Sitio de Cirugía

Control de glucosa:
Pacientes de cirugía cardiaca deben
tener suero de glucosa controlado
(<200 mg/dL) por las seis de la mañana
en el Día 1 y el Día 2 después de la operación.
Antibióticos profilácticos:
Antibióticos consecuentes con directrices
nacionales deben ser administrados
dentro de una hora del tiempo de
incisión y discontinuados dentro de 24
horas (48 horas para cirugías cardiacas)
del fin de cirugía.
Pacientes de cirugía deben tener una
temperatura llamada normothermia
( >96.8°F, 36°C) dentro los primeros 15
minutos después de salir del consultorio
de cirugía.
Removimiento de pelo:
Si el pelo debe ser removido del sitio de
cirugía, use crema depilatoria o una
maquinilla para cortar pelo—o no lo corte
si no es necesario. Nunca use navaja de
Opciones para
remover pelo

Más información sobre la diminución de infecciones en el sitio de cirugía es disponible a

Este materiál fue preparado por Health Services Advisory Group (HSAG) bajo contrato con CMS (Centers for Medicare & Medicaid Services),
una agencia del departamento federal Health and Human Services. Esta información no viene de parte de CMS. HSAG es una organización
para mejorar la calidad de servicios de Medicare en Arizona. Número de Publicación AZ-9SOW-6.2.3-071909-02

82 The OR Connection

OR Connection
Aligning practice with policy to improve patient care

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Subscribing to The OR Connection guarantees that To subscribe, simply go to
Keep your surgical patients desert dry.
youʼll continue to receive this info-packed magazine orconnection. You will need to provide:
and wonʼt miss out on our industry updates and Your name Medline’s Sahara® Super Absorbent OR table sheets are
articles addressing on-the-job issues and tips on Facility and position designed with your patients’ skin integrity in mind. The
caring for yourself! Mailing address Braden Scale tells us that moisture is one of the major
E-mail address risk factors for developing a pressure ulcer.1 We also
know that as many as 66 percent of all hospital-acquired
We also welcome any suggestions you might have on how we can continue to improve pressure ulcers come out of the operating room.2
The OR Connection! Love the content? Want to see something new? Just let us know!
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
Content Key locks it away to help keep your patients dry.
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
Sahara OR table sheets are available on their own or
icons you'll know immediately that the subject matter on that page relates to one
as a component in our QuickSuite® OR Clean Up Kits,
or more of the following national initiatives:
• IHI's Improvement Map which were designed to help you dramatically improve To learn more about Sahara OR table sheets and
• Joint Commission 2009 National Patient Safety Goals your OR turnover time and help reduce cross contamina- Medline’s comprehensive product line, contact your
• Surgical Care Improvement Project (SCIP) tion risk through a combination of disposable products. Medline representative, call 1-800-MEDLINE or visit
us at
We've tried to include content that clarifies the initiatives or gives you ideas and References
1 Braden Scale for Predicting Pressure Sore Risk. Available at:
tools for implementing their recommendations. For a summary of each of the Accessed November 6, 2008.
initiatives, see pages 6 and 7. 2 Recommended practices for positioning the patient in the perioperative practice
setting. In: Perioperative Standards and Recommended Practices. Denver, CO:
AORN, Inc; 2008.
Aligning practice with policy to improve patient care

Volume 4, Issue 2

Mercy Ships
Surgical Pros Donate

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Join the Race to ERASE CAUTI™
The current state of health care demands nurses play
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• Video podcast series hosted by John Nance
• Hospital press release announcing
OR Traffic
educating and supporting nurses to help them rise to Awareness Campaign
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has set a goal to introduce 100,000 nurses to its
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awareness to ERASE CAUTI
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