The

Aligning practice with policy to improve patient care
Volume 4, Issue 2
Alternatives
to Foley
Catheterization
Traffic
Control OR
Are Your Scrubs
Spreading Infection?
Race to ERASE CAUTI
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Aligning practice with policy to improve patient care
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Content Key
We've coded the articles and information in this magazine to indicate which patient
care initiatives they pertain to. Throughout the publication, when you see these
icons you'll know immediately that the subject matter on that page relates to one
or more of the following national initiatives:
• IHI's Improvement Map
• Joint Commission 2009 National Patient Safety Goals
• Surgical Care Improvement Project (SCIP)
We've tried to include content that clarifies the initiatives or gives you ideas and
tools for implementing their recommendations. For a summary of each of the
initiatives, see pages 6 and 7.
Medline’s Sahara
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Braden Scale tells us that moisture is one of the major
risk factors for developing a pressure ulcer.
1
We also
know that as many as 66 percent of all hospital-acquired
pressure ulcers come out of the operating room.
2
That’s why we developed the Sahara Super Absorbent
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References
1 Braden Scale for Predicting Pressure Sore Risk. Available at:
www.bradenscale.com/braden.PDF. Accessed November 6, 2008.
2 Recommended practices for positioning the patient in the perioperative practice
setting. In: Perioperative Standards and Recommended Practices. Denver, CO:
AORN, Inc; 2008.
www.medline.com
Keep your surgical patients desert dry.
To learn more about Sahara OR table sheets and
Medline’s comprehensive product line, contact your
Medline representative, call 1-800-MEDLINE or visit
us at www.medline.com.
44453_cvr.indd 2 8/12/09 12:44:04 PM
Aligning practice with policy to improve patient care 3
PATIENT SAFETY
6 Three Important National Initiatives for Improving Patient Care
20 Patient Safety Initiatives Across the United States
30 CAUTI Prevention: How Do You Rate?
31 Back to Basics: Tell Me Again Why This Patient Needs
a Catheter?
51 Clean Up Your Act!
OR ISSUES
8 Breaking News
22 The Silent Treatment
42 Playing Traffic Control in the OR
SPECIAL FEATURES
10 Comparative Effectiveness Research
12 Prevention Above All Conference
13 Celebrating Nurses’ Accomplishments
14 OR Nurses Set Sail for Surgery
40 A Cost-Effective Alternative to Urinary Catheterization
46 Legal Issues in the Care of Pressure Ulcer Patients
CARING FOR YOURSELF
56 How to Communicate Effectively
65 Breast Cancer Awareness
68 Recipe: 24-Hour Dill Pickles
FORMS & TOOLS
71 SCIP Prophylactic Antibiotic Regimen Selection for Surgery
73 VTE Prophylaxis Options for Surgery
75 What You Need to Know About Infections After
Surgery: English
77 What You Need to Know About Infections After
Surgery: Spanish
79 How to Handrub?
81 CATS Decrease Surgical Site Infections: English
82 CATS Decrease Surgical Site Infections: Spanish
Editor
Sue MacInnes, RD, LD
Clinical Editor
Alecia Cooper, RN, BS, MBA, CNOR
Senior Writer
Carla Esser Lake
Art Director
Mike Gotti
Clinical Team
Jayne Barkman, RN, BSN, CNOR
Rhonda J. Frick, RN, CNOR
Anita Gill, RN
Megan Shramm, RN, CNOR, RNFA
Kimberly Haines, RN, Certified OR Nurse
Jeanne Jones, RNFA, LNC
Carla Nitz, RN, BSN
Connie Sackett, RN, Nurse Consultant
Claudia Sanders, RN, CFA
Angel Trichak, RN, BSN, CNOR
Perioperative Advisory Board
Larry Creech, RN, MBA, CDT
Carilion Clinic, Virginia
Sharon Danielewicz, RN, MSN, BSN, RNFA
St. Lukeʼs The Woodlands, Texas
Barb Fahey RN, CNOR
Cleveland Clinic, Ohio
Susan Garrett, RN
Hughston Hospital Inc., Georgia
Zaida I. Jacoby, RN., M.A., M.Ed
NYU Medical Center, New York
Jackie Kraft, RN, CNOR
Huntsville Hospital, Alabama
Audrey Kuntz, EdD, MSN, RN
Vanderbilt University Medical Center, Tennessee
Tom McLaren, RN, BSN, MBA, CNOR
Florida Hospital
Donna A. Pritchard, RN, BSN, MA, CNOR, NE-BC
Kingsbrook Jewish Medical Center, New York
Debbie Reeves, RN, CNOR, MS
Hutcheson Medical Center, Georgia
Diane M. Strout, RN, BSN, CNOR
Chesapeake Regional Medical Center, Virginia
Margery Woll, RN, MSN, CNOR
North Shore University Health System, Illinois
About Medline
Medline, headquartered in Mundelein, IL, manufactures and distributes more than
100,000 products to hospitals, extended care facilities, surgery centers, home
care dealers and agencies and other markets. Medline has more than 800 dedi-
cated sales representatives nationwide to support its broad product line and cost
management services.
Meeting the highest level of national and international quality standards, Medline is
FDA QSR compliant and ISO 13485 registered. Medline serves on major industry
quality committees to develop guidelines and standards for medical product use in-
cluding the FDA Midwest Steering Committee, AAMI Sterilization and Packaging
Committee and various ASTM committees. For more information on Medline, visit
our Web site, www.medline.com.
Page 14
Page 31
Page 56
Page 42
Page 22
©2009 Medline Industries, Inc. The OR Connection is published by Medline Industries, Inc. One Medline Place, Mundelein, IL 60060. 1-800-MEDLINE.
Dear Reader,
As the summer of 2009 comes to a close, my
youngest child, Molly will be going to college. She is
the youngest of three… so, my husband and I are now
officially empty nesters. I don’t usually discuss my
work at home. By the time I get home, work is the last
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.
I haven’t said much to discourage or encourage her,
but earlier in the summer, I thought to myself, does
she have any idea what that means? And so, in typical
motherly fashion, I asked her if she wanted to watch
an actual surgery. My thinking was, if she is going to
commit the time and money into becoming a surgeon,
she’d better make sure that is what she wants to do.
I don’t know many eighteen-year-olds who are more
psyched about scrubbing in on a surgery than going
to Six Flags … but Molly is one. I had promised to look
into it; the summer was flying by and every day Molly
would ask me if I had made any arrangements. I really
didn’t think she would hold me to this. I was wrong.
My first dilemma was finding a mentor, someone who
would embrace the curiosity and naiveté of youth and
allow Molly to watch a surgery. I contacted Margery
Woll, Director of Perioperative Services at North Shore
University Health System in Skokie, Ill., to ask her
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
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
from their iPods. She stood 18 inches from the
surgery. Her favorite part was the first cut. She saw 3
different surgeries starting with a breast biopsy, and
then proceeded to a total knee. She said that the total
knee was messy, but really cool. And, finally she saw
a total hip. The surgery team was so nice to her, they
told her what was going on and the chief of surgery
told her she could shadow him any time. Molly said,
“Mom how many kids my age get a chance to actu-
ally go into surgery? I was right there. And, I was
invited back to see a heart.”
Later Margery e-mailed me about the day. She said,
“Dr. Velasco (Juan Velasco, MD, Vice Chairman of
Surgery) was so impressed with Molly’s interest and
discipline in watching the cases.” She continued, “It
was a good day for Dr. Raab (David Raab, MD,
Orthopedic Surgeon), he taught both of us. He was so
honored …”
So, at a time that is so critical in health care, with
healthcare reform, patient safety initiatives at the fore-
front of every hospital’s agenda and new guidelines
and evidence directing our actions, I have to stop and
say … you make a difference. I got to experience
vicariously the love you have for what you do, the pas-
sion and teamwork you express at every opportunity.
Thank you. You’ve just recruited another potential
surgeon who is telling all of her friends that they
simply have to work in the OR (and this kid has a lot
of friends).
Here’s to you!
Sue MacInnes, RD, LD
Editor


4 The OR Connection
THE OR CONNECTION I Letter from the Editor
I got to experience
vicariously the love
you have for what you
do, the passion and
teamwork you express
at every opportunity.
Thank you.
(Left to right): Scott Pittman, MD, Anesthesiologist; Margery Woll,
RN, MSN, CNOR, Director of Perioperative Services and Molly
MacInnes at North Shore University Health System in Skokie, Ill.
Before observing three surgeries at the hospital, Molly said she
hadn’t realized what a major role nurses play in the OR. “The nurses
do so much. Nothing would happen without them,” she said.
OR11.2.qxp:Layout 1 8/12/09 7:54 AM Page 4
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OR11. 2. qxp: La yout 1 8/ 12/ 09 7: 55 AM Pa ge 5
6 The OR Connection
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.
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.
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 www.jointcommission.org.
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.
IHI Improvement Map
1
Joint Commission 2009 National Patient Safety Goals
2
Surgical Care Improvement Project (SCIP)
3
OR11. 2. qxp: La yout 1 8/ 12/ 09 7: 55 AM Pa ge 6
IHI Improvement Map: 12 Existing Interventions + Three New Ones
Surgical Care Improvement Project (SCIP): Target Areas
Joint Commission 2009 National Patient Safety Goals
Aligning practice with policy to improve patient care 7
Patient Safety
By the numbers:
• 3,740 hospitals are submitting
data on SCIP measures, representing
75 percent of all U.S. hospitals
• Currently, SCIP has more than 36
association and business partners
There are six new requirements for 2009:
• Elimination of transfusion errors that are related
to misidentification of patients
• Prevention of healthcare-associated infections
resulting from multiple drug-resistant organisms
(MDRO) using evidence-based practices
(one-year phase-in period applies)
• Prevention of central line-associated bloodstream
infections using evidence-based practices (one-year
phase-in period applies)
• Prevention of surgical site infections using best
practices (one-year phase-in period applies)
• When a patient leaves a facility, the patient and his
or her family receives a complete list of the patientʼs
medications with an explanation of that list
• In settings in which medications are prescribed
minimally or for a short time, modified medication
reconciliation processes are carried out
In addition to the new requirements, some of the NPSGs
already in place have been modified. Extensive changes
also have been made to the Universal Protocol (UP).
To learn more about the 2009 National Patient Safety Goals, go to www.jointcommission.org.
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.
To learn more, turn to Page 8!
1. Surgical-site infections
• Antibiotics, blood sugar control, hair removal, normothermia
2. Perioperative cardiac events
• Use of perioperative beta-blockers
3. Venous thromboembolism
• Use of appropriate prophylaxis
SCIP is targeting two new measures for October 2009:
• Removal of urinary catheters within 48 hours post surgery
• A new, updated normothermia measure
Visit www.qualitynet.org
1. Prevent pressure ulcers
2. Reduce methicillin-resistant staphylococcus aureus
(MRSA) infection
3. Prevent harm from high-alert medications
4. Reduce surgical complications
5. Deliver evidence-based care for congestive heart failure
6. Get boards on board
7. Deploy rapid response teams
8. Prevent adverse drug events (ADEs)
9. Deliver evidence-based care for acute myocardial infarction
10. Prevent surgical-site infections
11. Prevent central-line infections
12. Prevent ventilator-associated pneumonia
13. WHO Surgical Safety Checklist
14. Prevent catheter-associated urinary tract infections (CAUTI)
15. Link quality and financial management – engage the chief
financial officer and provide value for patients
To learn more, visit www.ihi.org
OR11. 2. qxp: La yout 1 8/ 12/ 09 7: 55 AM Pa ge 7
8 The OR Connection
SCIP Adds Two New Measures
Effective October 1
Urinary catheter removal, normothermia
As part of its Surgical Care Improvement Project (SCIP), the
Centers for Medicare & Medicaid Services (CMS) will begin
requiring hospitals to report quality data on two new meas-
ures effective October 1, 2009. The measures relate to
removal of urinary catheters and the documentation and reg-
ulation of patient body temperature.
SCIP Measure 9: Removal of urinary catheters
This new measure states that urinary catheters are to be
removed during the first or second day after surgery. The risk
of urinary tract infection and bacteremia increase when a
catheter remains in place for more than two days. Although
this measure pertains primarily to inpatient cases, surgery
departments will need to establish protocols for a physician
order and a method of documenting catheter removals.
SCIP Measure 10: Normothermia requirements
This new measure requires the recording and reporting of
patient temperatures, documenting whether temperatures
dropped below 96.8 degrees F from 30 minutes before surgery
to 15 minutes after anesthesia ends. It also must be noted
whether forced-air or warmed-water patient warming devices
or garments were used. The measure applies to procedures
that last 60 minutes or longer, and employ general anesthesia
or neuroaxial blocks.
For more details on all of the SCIP measures,
visit www.qualitynet.org.
AORN Revises Hand Hygiene
Recommendations to Include
Use of Surgical Scrub Agent
Revised terminology in “Recommended Practices for Hand
Hygiene in the Perioperative Setting,” which was recently pub-
lished by the Association of periOperative Registered Nurses
(AORN), advises use of a surgical hand scrub before donning
gloves for a surgical procedure. AORN recommends using an
antimicrobial or alcohol-based surgical hand rub product.
The following terminology was submitted
and approved by AORN’s board of directors
on July 17, 2009:
“A surgical hand scrub should be performed by health care
personnel before donning sterile gloves for surgical or other
invasive procedures. Use of either an antimicrobial surgical
scrub agent intended for surgical hand antisepsis or an
alcohol-based antiseptic surgical hand rub with documented per-
sistent and cumulative activity that has met US Food and Drug
(FDA) regulatory requirements for surgical hand antisepsis is
acceptable.”
These changes will be made to the “Recommended Practices
for Hand Hygiene in the Perioperative Setting,” which is cur-
rently available electronically. AORN’s electronic recom-
mended practices are available through AORN’s new
eSubscription (www.aorn.org/eSubscription) and through
a pay-per-document platform (www.aorn.org/PracticeRe-
sourcees/AORNStandardsandRecommendedPractices/EDo
cuments/).
Reference
AORN board revises hand hygiene recommended practice. News Release. July
22, 2009. Available at http://www.aorn.org/docs/assets/A36FA8F4-046B-197F-
81B585C4FB6DF06E/HandHygieneAnnct.pdf. Accessed July 29, 2009.
OR11. 2. qxp: La yout 1 8/ 12/ 09 7: 55 AM Pa ge 8
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We know that comfort drives compliance. When you choose Sterillium Rub,
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10 The OR Connection
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
others.
2
The Council’s purpose is to coordinate compara-
tive effectiveness research and related health services
research across the federal government with the intent of
reducing duplication and encouraging the complementary
use of resources.
1
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
Institutes of Health (NIH) and $400 million to the Office of
the Secretary.
1
Goals of Comparative Effectiveness Research
• Reduce healthcare costs
2
• Build public interest
2
• Improve patient care
2
• Encourage development and use of clinical registries
and data networks
1
• Increase consistency of treatment provided in different
geographic regions
1
• Greater ability to tailor interventions to treat patients’
specific needs
1
• Care based on evidence and best practices
1
Legislators in the Senate and House have been busy
this year preparing and debating their versions of a
healthcare reform bill. Perhaps one of the bills, or a
hybrid, will be passed by the end of 2009. In the interim,
the launch of a new federally funded healthcare program on
comparative effectiveness research is well underway.
The American Recovery and Reinvestment Act of 2009
allocated $1.1 billion to the U.S. Department of Health and
Human Services (HHS) for this initiative. What is compara-
tive effectiveness? The Institute of Medicine (IOM) defines it
as “the extent to which a specific intervention, procedure,
regimen or service does what it is intended to do under real
world circumstances.”
1
As HHS describes it, comparative
effectiveness research provides information on the relative
strengths and weaknesses of various medical interventions,
including drugs, devices and procedures.
2
Comparative Effectiveness Research:
What It Is and How
It Can Help You and
Your Patients
What’s Happening in Healthcare Reform
OR11. 2. qxp: La yout 1 8/ 12/ 09 7: 55 AM Pa ge 10
Aligning practice with policy to improve patient care 11
High-Priority Topics for Federally Funded
Comparative Effectiveness Research
3
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
Medicine:
• Compare the effectiveness of treatment strategies for
atrial fibrillation, including surgery, catheter ablation
and pharmacologic treatment.
• Compare the effectiveness of various screening,
prophylaxis, and treatment interventions in eradicating
methicillin-resistant Staphylococcus aureus
(MRSA) in communities, institutions and hospitals.
• 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-
associated pneumonia and surgical site infections in
adults and children.
• Compare the effectiveness of robotic assistance
surgery and conventional surgery for common
operations, such as prostatectomies.
References
1. U.S. Department of Health and Human Services. Federal Coordinating Council
for Comparative Effectiveness Research: Report to the President and Congress,
June 30, 2009. Available at http://www.hhs.gov/recovery/programs/cer/cerannu-
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:
6-7,16.
3. Institute of Medicine. 100 Initial Priority Topics for Comparative Effectiveness
Research. Available at http://www.iom.edu/?id=71032. Accessed August 3, 2009.
Brian Lee Morrison earned his registered nurse degree in
May 2009 from St. Petersburg College School of Nursing
in St. Petersburg, Fla. He (and Medline nurse doll Alice)
graduated with honors. Brian is continuing at St. Peters-
burg College to complete a bachelor’s degree in nursing.
He currently works in the OR at St. Joseph’s Hospital in
Tampa. Before earning his RN, he had been a surgical
technologist and certified first assistant.
Graduation Day – for Two!
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12 The OR Connection
Prevention Above All Conference,
Washington, DC, August 16-18, 2009
Chief nursing officers, chief medical officers, directors of nursing
and other clinical executives from hospitals across the country
gathered in Washington, DC, August 16-18, 2009, for Medline’s
popular Prevention Above All Conference. They learned new
strategies for delivering cost-effective, high-quality health care
and evidence-based solutions for improving patient care.
An impressive agenda
Tying in all that is top-of-mind on Capitol Hill these days, former
senator Tom Daschle opened the conference by discussing his
book on healthcare reform and the delivery of cost-effective
health care. Following Daschle was Institute of Medicine President
Dr. Harvey Fineberg, who addressed the impact of comparative
effectiveness research on delivering cost-effective, evidence-
based health care. (See article on page 10 to learn more about
comparative effectiveness research.)
Emphasis on patient safety
As always, patient safety was a major focus, and world
renowned experts shared the latest innovations and evidence-
based practices in the prevention of catheter-associated urinary
tract infections (CAUTI), hand hygiene and pressure ulcer
prevention.
CAUTI. Medline introduced its new evidence-based system
to help prevent CAUTI. The ERASE CAUTI™ program combines
innovative design, education and awareness to tackle catheter-
associated urinary tract infection – the number one hospital-
acquired infection.
Hand hygiene. Internationally renowned professor and
epidemiologist Didier Pittet, of Switzerland, shared the latest
hand hygiene improvement strategies. Dr. Pittet is lead of the
World Health Organization (WHO) World Alliance for Patient
Safety and a member of the advisory board for the WHO’s
First Global Patient Safety Challenge, “Clean Care Is Safe Care.”
In addition, German epidemiologist Gunter Kampf presented
new discoveries and considerations in hand sanitizing tech-
niques. He is the author of 119 scientific papers published
in national and international infection control journals.
Pressure ulcers. Wound care expert Elizabeth Ayello provided
insight on CMS present on admission (POA) indicators as they
relate to hospital administrators and clinicians.
PREVENTION
ABOVE ALL
TARTGETED INTERVENTIONS • PRACTICAL SOLUTIONS
Also, two experts in wound care and healthcare law, who are
also members of the International Expert Wound Care Advisory
Panel, addressed the legal implications of caring for patients with
pressure ulcers, sharing ways healthcare professionals can pro-
tect themselves from litigation. Turn to page 46 for excerpts from
their new white paper, “Legal Issues in the Care of Pressure
Ulcer Patients: Key Concepts for Healthcare Providers.”
SCIP. The Surgical Care Improvement Project continues to
evolve, with two new measures coming in October. Highly
regarded quality improvement specialist Dale Bratzler, DO, MPH,
medical director of SCIP, discussed patient safety in the context
of SCIP and expanded on new and revised SCIP measures.
Prevention Above All Discoveries Grant recipients
Dr. Andrew Kramer announced the names of Prevention Above
All (PAA) Discoveries Grant award winners. Dr. Kramer, professor
of medicine at the University of Colorado, served as chair of the
PAA Discoveries Grant Review Committee. The committee also
included Dale Bratzler, DO, MPH, medical director of SCIP; Diane
Krasner, PhD, RN, CWCN, CWS, BCLNC, FAAN, wound & skin
care consultant; Michael Raymond, MD, chief medical officer,
North Shore University Health System and Heidi Wald, MD,
MPH, professor of medicine, University of Colorado. All grant
applications and proposals were independently reviewed and
approved by this committee. Watch for more information on the
recipients and their research topics in upcoming issues of The
OR Connection.
Unable to attend the Prevention Above All Conference?
Visit medline.comfor highlights fromthe meeting, including video
clips from the presentations.
Critical: What We Can Do About the
Health-Care Crisis, authored by for-
mer senator Tom Daschle, outlines the
healthcare reform strategies that are
the foundation of President Obama’s
healthcare initiative. Evaluating where
previ ous attempts at national
healthcare coverage have succeeded,
and where they have gone wrong,
Daschle explains the complex social,
economic and medical issues involved in reform and sets
forth his vision for change. The book is available for purchase
at leading retail bookstores and online outlets.
Aligning practice with policy to improve patient care 13
OSF St. Joseph Medical Center
Achieves Magnet Recognition
OSF St. Joseph Medical Center in Bloomington, Ill.,
recently achieved Magnet Recognition for excellence in
nursing services by the American Nurses Credentialing
Center (ANCC).
The Magnet Recognition Program recognizes healthcare
organizations that demonstrate excellence in nursing prac-
tice and adherence to national standards for the organi-
zation and delivery of nursing services. The ANCC’s
Commission on Magnet made a unanimous decision to
make OSF St. Joseph Medical Center a Magnet hospital.
Magnet applicants undergo a rigorous evaluation process,
including written documentation of 14 specific areas of
nursing practice called Forces of Magnetism. Hospitals
also participate in extensive interviews and an on-site
review of nursing services. OSF St. Joseph began work-
ing toward Magnet Recognition in 2004.
A magnet steering committee
was formed to create a docu-
ment proving that OSF St.
Joseph Medical Center met or
exceeded the 164 standards
that are part of the Forces of
Magnetism.
Each committee member was responsible for finding
sources of evidence to support the standards within one
force. Committee chair Sandra Scheidenhelm encouraged
all members to stay on task until the final documentation
was turned in – all 15 volumes of it!
The committee’s hard work and dedication paid off.
OSF St. Joseph was awarded Magnet Recognition in
December 2008.
The OR Connection Celebrates
Nurses’ Accomplishments
OSF St. Joseph Medical Center CEO Ken Natzke presents
the ANCC Magnet Recognition obelisk to Chief Nursing
Officer Deb Smith.
OSF St. Joseph Medical Center Magnet Steering Committee.
Back row (left to right): Marcia Laesch, Dixie Reynolds,
Sue Herriott, Pat O’Dell, Barb Stevig. Front row (left to right):
Mark Dabbs, Deb Smith, Sandi Scheidenhelm, Phyllis McNeil.
OR11. 2. qxp: La yout 1 8/ 12/ 09 7: 56 AM Pa ge 13
14 The OR Connection
OR11. 2. qxp: La yout 1 8/ 12/ 09 7: 56 AM Pa ge 14
OR NURSES SET SAIL
FOR SURGERY ONBOARD
MERCYSHIPS
Aligning practice with policy to improve patient care 15
Excellent nursing care for the underprivileged
Mercy Ships is a global charity
that has operated hospital ships
in developing nations since
1978. Mercy Ships brings hope
and healing to the forgotten poor
by mobilizing people and re-
sources worldwide and serving all
people without regard for race,
gender or religion. Recently, a
partnership was formed between
AORN and Mercy Ships with the goal of increasing
awareness of the opportunities available to operating
room nurses wanting to serve the suffering poor.
The Africa Mercy is the world’s largest non-governmental
hospital ship. An entire deck functions as a complete
hospital with five wards, an intensive care unit, medical
lab, CT scanner and six operating rooms. There are 450
crew members, and 130 are healthcare staff. Each year,
Mercy Ships welcomes more than 1,200 long-term
volunteers from over 40 nations and 2,000 short-term
volunteers.
Onboard the Africa Mercy, 12 surgeries, on average, are
completed each day, including maxillofacial, plastics,
general, orthopaedic, and vesicovaginal fistula (VVF). An
additional average of 30 cataract
removals and other eye-related
surgeries also take place daily. Tu-
mors are removed, burn contrac-
tures are released, limbs are
straightened, deformities are cor-
rected, sight is restored and,
above all, dignity and hope are
given to thousands of previously
suffering individuals.
The work of highly skilled surgeons from around the
world allows for such tremendous healing to take place.
However, without the help of the operating room (OR)
nursing staff, none of it would be possible.
There are currently 15 OR nurses serving onboard the
Africa Mercy. Some have been onboard for more than
two years (long-term); others will serve short-term for two
weeks or more. Both long-term and short-term commit-
ments are important and greatly appreciated. The dura-
tion of commitment may vary, but the standard of work
and care provided by all of the nurses is impeccable.
OR nurses from all walks of life serve with Mercy Ships –
even those with families of their own. Before Jenny Rol-
Special Feature
by Mila Hightower
OR11. 2. qxp: La yout 1 8/ 12/ 09 7: 56 AM Pa ge 15
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
nurses.
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
MERCYSHIPS
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.
OR11. 2. qxp: La yout 1 8/ 12/ 09 7: 56 AM Pa ge 16
Of course, running a First World facility in a Third World
environment has its challenges. As a not-for-profit organi-
zation, Mercy Ships’ resources are sometimes limited.
Surgical instruments and equipment have to be used more
than once. Effective methods of sterilization and a subse-
quently low infection rate make this feasible.
With an international staff represented by more than six
countries, language and communication can be problem-
atic. “There’s a language that one has to get used to when
there are four different names for one instrument,” Rolland
said. “Thankfully the OR is sort of a universal environment.”
A broad spectrum of nationalities and cultures also has its
benefits. Rolland explained, “I think being able to work with
an international staff is very enlightening because there are
ways that people from different parts of the world do
things. It’s nice to have that added to what we do.
Sometimes there might be a way that is more efficient.”
Melissa Brown recently joined Mercy Ships as a short-term
OR nurse. “My experience so far has been great! My first day
in the OR everyone was very welcoming, and they helped
me fit right in by explaining the procedures,” she said.
Brown is a registered nurse and a member of AORN with
CNOR and first assistant certifications. She worked as a
travel nurse in the United States before joining the Africa
Mercy as an OR nurse for three months during the summer.
“I have never been able to combine missions with my OR
nursing career,” she said. “Here with Mercy Ships is my first
opportunity to be able to do that, and that is very special to
me,” Brown said.
Although the Africa Mercy is currently stationed in the West
African nation of Benin, the onboard hospital continues
to operate effectively. Its staff finds the conditions famil-
iar and comfortable.
Aligning practice with policy to improve patient care 17
Continued on Page 19
OR11. 2. qxp: La yout 1 8/ 12/ 09 7: 56 AM Pa ge 17
©2009 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
Medline’s Gold Standard Safety Program is designed
to break down barriers to surgical safety compliance
by offering easy-to-use tools to help you reach your
safety goals.
The program offers four levels of safety options:
1. The Gold Standard Safety Bundle: Includes six
products to serve as visual safety reminders to reduce
needle sticks and wrong site surgery.
2. Innovative safety products: Surgical Time Out
Procedure (S.T.O.P.

) Flag and Drape remind OR
staff to take time to verify key information before
the first incision.
3. AORN Checklist: Wrong site, wrong procedure,
wrong patient surgery prevention.
4. Med-Pack

: Electronic pack audit and a review
of safety components.
To learn more about the Gold Standard Safety
Program, contact your Medline sales representative,
call us at 1-800-MEDLINE or visit www.medline.com.
www.medline.com
We’re
setting
a new
standard
in patient
safety.
G O L D S TA N D A R D S A F E T Y P R O G R A M
Aligning practice with policy to improve patient care 19
“I worked a day shift at home so the hours here are very
similar,” explained Brown. “As far as how the OR is run and
the management and efficiency of things, I think it’s very
similar to a First World OR.”
Although she is currently assisting with eye surgeries,
Brown will get the opportunity to work in all the surgical
specialties performed onboard the Mercy Ship.
Alison Green is a long-term volunteer who joined Mercy
Ships shortly after completing four years of nursing school
in Tyler, Texas. Although she has only been onboard the
Africa Mercy for a few months, she has already gained a
wealth of experience that will undoubtedly further her pro-
fessional career as an OR nurse.
“It’s great to see what I was a part of and
how I’ve made a difference in their lives.”
“I’ve found that I’ve learned more here in five months than
I did in three years back home,” Green said. “Many of the
procedures and surgeries we do here are not normally done
back home because the cases are so unique. I have
learned so much as a scrub nurse. I get to be more
involved in assisting the surgeons, whereas back home I
had to do more paperwork.”
Because Green has made a long-term commitment to
Mercy Ships, she is being trained in all the specialties. She
is currently undergoing six weeks of VVF scrub nurse train-
ing and has already completed training in ophthalmolics,
general and maxillofacial surgery.
“In the United States I found surgeries were all about time
and getting things done, but here the surgeons are willing
to teach you more so that you are able to take better care
of the patients. They are humble and willing,” she explained.
Green finds that a notable and positive difference is the
opportunity to spend more time with patients. “I think that
here we get more connected with our patients. We have an
opportunity to pray with them, get to meet them face-to-
face before surgery, see them afterwards in the ward and
watch how they heal,” she explained. “It’s great to see what
I was a part of and how I’ve made a difference in their lives.”
“Life here is very fast-paced and very busy, but at the same
time, it’s rewarding and life-changing. This work really
reminds me about why I became an OR nurse. I can see
the hope and healing brought to the patient firsthand. I think
if nurses are rundown and have forgotten why they are
doing what they are doing, they will be inspired if they come
here,” Green said.
If you would like to be a part of bringing hope and healing
to the world’s poor, please visit www.mercyships.org or
contact the Mercy Ships human resources department at
(903) 939-7045. Mercy Ships headquarters is located in
Lindale, Texas.
MERCYSHIPS
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.
Taking time for a little fun.
OR11. 2. qxp: La yout 1 8/ 12/ 09 7: 56 AM Pa ge 19
20 The OR Connection
Rhode Island adopts protocol to
prevent wrong site surgery
Program implemented July 1, 2009
All 12 hospitals and 21 surgical centers in
Rhode Island have agreed to adopt a sur-
gical safety protocol designed to reduce
the risk of wrong site surgeries. According to the Hospital Associ-
ation of Rhode Island, the state is the first in the nation to have all
surgical providers voluntarily adopt the same safety protocol.
1
The term “wrong site surgery” applies if the wrong procedure is per-
formed or if a procedure is performed on the wrong person or the
wrong body part.
Rhode Island’s protocol was developed over a period of 18 months
by state hospital and healthcare leaders in cooperation with the
Joint Commission.
2
It is similar to surgical safety checklists created
by the World Health Organization and The Joint Commission.
With an emphasis on clear communication among surgeons, staff
and patients, the protocol is designed to prevent errors but also to
avoid the confusion that sometimes occurs when practitioners split
their time between facilities with different policies.
“They have steps built into their protocol that allow all team mem-
bers to be accountable and responsible for speaking up if they
believe that something doesn’t look right,” said Mark Crafton,
the Joint Commission’s executive director for state and external
relations.
1
Four key features of the protocol include:
2
Three-way pre-op consult. The surgeon, one other licensed
practitioner (such as a registered nurse) and the patient or patient’s
guardian all confirm the surgical site together before it is marked
with the surgeon’s initials.
OR team briefing. All team members introduce themselves and
their roles. The surgeon then briefs the team, identifying the patient,
procedure and site, and explaining plans for the surgery, including
any medications, documentation and equipment needed.
Time out. Led by the surgeon, all team members verify the
patient, procedure and site and confirm that the site marking is
visible after prepping and draping.
Post-op de-briefing. The surgeon leads a discussion of the post-
operative plan of care and a review of how the surgery went and
what could have been done differently.
William Cioffi, MD, surgeon-in-chief at Rhode Island Hospital, said
that safety efforts must walk a fine line, requiring accountability with-
out overemphasizing blame; each member of the surgical team has
responsibilities to meet but also must feel free to acknowledge and
report errors.
1
Cioffi added that the hospitals will train staff through lectures and a
video and also will devise ways to make sure the protocol is prop-
erly and uniformly adopted around the state. “This is a great first
step. It’s not the end of the process.”
1
Providers began implementing the protocol July 1, but it could be
as long as one year before staff at all facilities have received train-
ing on the new rules.
1
Earlier this year, the federal government took steps toward pre-
venting wrong site surgery. As of January 15, 2009, the Centers
for Medicare and Medicaid Services (CMS) no longer reimburse
hospitals or surgery centers for wrong site surgery.
3,4,5
Patient Safety Initiatives Across the United States
OR11. 2. qxp: La yout 1 8/ 12/ 09 7: 56 AM Pa ge 20
Aligning practice with policy to improve patient care 21
Near zero incidence of HAIs at
Monroe Hospital in Indiana
How do they do it?
Monroe Hospital in Bloomington, Ind. has
a near zero rate (0.06 percent) of hospital-
acquired infections among the more than
2,800 inpatients treated since the hospital opened in 2006.
6
The
national average of healthcare-acquired infections in U.S. hospitals
is assumed to be five percent.
7
So, how does Monroe Hospital stave off healthcare-acquired
infections? The following is a list of infection control measures used
at the hospital:
6
1. Frequent handwashing with alternating products. Doctors
and staff are encouraged to wash their hands frequently – particu-
larly after having contact with a patient and before and after eating
or using the restroom. They are instructed to use three different
products – soap and water, an alcohol-based hand foam and
an ammonia-based hand sanitizer – on an alternating basis; each
one third of the time.
Hospital officials say this combination of products keeps the hands
clean, but also soft and pliable. Individuals with dry, cracked skin on
their hands tend to wash them less often.
2. A clean environment. Cleaning of all surfaces takes place
daily. Environmental services staff wipes down door handles, light
switches, patient beds, countertops and computer keyboards.
Deep cleaning, which includes cleaning behind computers and
under keyboards, occurs every Friday.
3. Isolation procedures. Patients with a history of MRSA are iso-
lated, and staff must wear gloves and protective gowns when they
come in contact with these patients. The patients remain in isola-
tion their entire hospital stay, regardless of subsequent negative
MRSA cultures.
4. Hospital-laundered scrubs. The hospital launders all doctors’
and staff scrubs to make sure they are cleaned properly to remove
bacteria. No staff member enters or leaves the hospital wearing
scrubs.
For further discussion on how scrubs may spread infection, turn to
page 51.
New Hampshire first state to
adopt surgical safety checklist
NH hospitals, ASCs lead the nation
in infection control
New Hampshire hospitals and ambulatory
surgery centers have voluntarily adopted
a safety checklist for surgeries and all other invasive procedures.
The protocol is based on a checklist developed by the World Health
Organization (WHO), which identifies three phases of a procedure
for which medical team members confirm appropriate tasks have
been completed. New Hampshire Gov. John Lynch applauded the
statewide collaboration, noting that “reducing errors and infections
and improving quality all help in controlling the cost of health care.”
8
New Hampshire hospitals perform better than the national average
in each of the five Surgical Care Improvement Project (SCIP) meas-
ures related to surgical care.
9
Surgical Care Improvement Project (SCIP)
NH Nat. Avg.
Prophylactic Antibiotic Received Within One 96% 94%
Hour Prior To Surgery
Prophylactic Antibiotic Selection 98% 97%
Prophylactic Antibiotic Discontinued Within 94% 90%
24 Hours After Surgery
Recommended VTE Prophylaxis Ordered 94% 93%
Recommended VTE Prophylaxis Received 92% 90%
Controlled 6 am Postop Serum Glucose 91% 90%
Appropriate Hair Removal 99% 98%
References
1. Freyer FJ. R.I. hospitals agree on safety protocol for surgeries. The Providence Journal.
July 1, 2009. Available at
http://www.projo.com/health/conteent/SURGICAL_SAFETY_PROTOCOL_07-01-
09_QLETDSU_v10.3dce7cb.html. Accessed July 8, 2009.
2. Tsikitas I. R.I. adopts uniform surgery safety protocol. Outpatient Surgery Magazine.
Available at http://www.outpatientsurgery.net/news/2009/07/2.php. Accessed July 8, 2009.
3. Decision Memo for Wrong Surgery Performed on a Patient (CAG-00401N). Centers for
Medicare and Medicaid Services Web site. http://www.cms.hhs.gov/mcd/viewdecision-
memo.asp?id=223. Accessed July 8, 2009.
4. Decision Memo for Surgery on the Wrong Body Part (CAG-00402N). Centers for Medicare
and Medicaid Services Web site.
http://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=222. Accessed July 8, 2009.
5. Surgery on the Wrong Patient (CAG-00403N). Centers for Medicare and Medicaid Services
Web site.
http://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=221. Accessed July 8, 2009.
6. Denny D. Monroe Hospital’s low infection rates draw national interest. Bloomington Herald
Times. January 19, 2009. Available at http://www.heraldtimeson-
line.com/stories/2009/01/19/news.qp-7992582.sto?1242057521. 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 http://www.healthynh.com/
fhc/about/newsletter/FHCNewsletterJul09.pdf. Accessed July 21, 2009.
9. NH Quality Care Reports. New Hampshire – Surgical Care Improvement Project (SCIP).
Available at http://nhqualitycare.org/reports.php?id=sip. Accessed July 22, 2009.
Patient Safety
OR11. 2. qxp: La yout 1 8/ 12/ 09 7: 56 AM Pa ge 21
22 The OR Connection
THE
SILENT
TREATMENT
OR11. 2. qxp: La yout 1 8/ 12/ 09 7: 56 AM Pa ge 22
Aligning practice with policy to improve patient care 23
Recently, a highly accomplished orthopedic sur-
geon was scheduled to work on three consecutive
cases with his OR team. The operating rooms were
state of the art within the medical center’s newly con-
structed orthopedic hospital, which had not yet cele-
brated its first birthday. A system of time outs including
use of the World Health Organization (WHO) surgical
checklist had been in place at the medical center for al-
most three years now, with multiple checklists for patient
identification, pre-op procedures and instrumentation.
The surgeon was scrubbing in for his second case when the
charge nurse approached him from behind and quietly
said, “Doctor, I have something to tell you. The instru-
ments that you used for the first case were not sterilized.”
With the second patient already under anesthesia, there
was no time for the surgeon to discuss the small bomb-
shell that had just been lobbed in his direction, but his
thoughts couldn’t let it go: “Where’s the checklist for when
things go wrong?” he thought sarcastically to himself,
having seen system error after system error despite the
apparent adaptation of techniques used by high reliability
organizations. Sharply, he gave an order for Gentamycin
for his first patient and turned his attention, as best he
could, to his next case. He dreaded the moment when he
would have to tell his patient – a man who trusted him
implicitly for a second knee replacement. But things just
got worse.
His second case was a lawyer who had a long history of
surgeries due to rheumatoid arthritis. The physician had
literally spent hours selecting the best implants for this
complicated revision, talking to vendors at great length to
ensure the compatibility of the various systems and care-
fully relaying his recommendations to the patient, who
was extremely involved after five surgeries.
by Kathleen Bartholomew, RN, RC, MN
and John J. Nance, JD
OR Issues
OR11. 2. qxp: La yout 1 8/ 12/ 09 7: 56 AM Pa ge 23
24 The OR Connection
“Socket,” he said at the appropriate moment with hand
extended, eyes still fixated on the open wound.
“Socket,” he said again, irritated after nothing had landed
in his hand.
From his peripheral vision he picked up on commotion. He
turned and looked up at the circulating nurse who quietly
said, “It’s not here doctor.” Fully focused on getting the
piece he needed STAT, the surgeon immediately got on
the phone to the vendor, trying to negotiate the use of
another implant despite his careful planning.
“She’s under a spinal … it will be wearing off. I can’t wait
that long – why isn’t it here?” he said loudly over the phone.
Finally, after half an hour, the vendor arrived with the implant.
Both relieved and frustrated, the surgeon closed and turned
to his third case, which was uneventful – and painfully, as
silent as the second case. In fact, despite the two major
mistakes of the day, not a single person in the operating
room had mentioned either event.
“The saddest thing was that no one said a word,” the sur-
geon said soberly. “I work with these people all the time and
you think someone could have at least said, ‘I’m sorry that
happened,’ or something like that. But instead, there was
nothing but this awkward silence. More than anything, I’m
still bothered by the silence.”
As well he should have been.
As noted communication expert Susan Scott says, “The
conversation isn’t about the relationship. It is the relation-
ship.”
1
This orthopedic surgeon is an outstanding physician,
known and respected for his skill and compassion – the
only surgeon who would actually drive to a patient’s house.
Yet, he could not communicate his disappointment to his
team – and his team refused to reach out to him; or vocalize
any concerted team effort to make sure these errors would
never happen again. Despite the very best of intentions and
the adoption of standardized checklists and procedures,
this team has a long way to go. The level of trust and feel-
ings of personal safety in the group simply aren’t high
enough for anyone to risk being vulnerable and actually
address a painful truth – that as a team they had systemi-
cally screwed up.
Worse, violating every premise of regarding mistakes as
important messages from the underlying system, they were
willing to squander and discard the obvious opportunity to
improve their own techniques, not to mention the opportu-
nity to share what had happened (and how to fix it) with
other surgical teams. Patient safety can only be enhanced
when bad experiences are shared, probed, understood,
and procedures changed. In fact, collegial interactive teams
– groups of professionals dedicated to a common goal and
willing to care about each other and trust each other
enough to honestly report and evaluate any failure – never
hesitate to put a failure on the table for discussion. And
never – never – does an effective collegial team care so lit-
tle for their own that they permit silence to shroud the
human pathways of interaction between them.
2
Three powerful forces impede communication in health
care: time pressures, knowledge and culture. Understand-
ing their impact is the first step to creating collegial and
effective teams in which relationships go deeper than the
mask of composure. Honest and meaningful relationships
can only happen if we are free to speak our truth at all times.
Culture – the undertow of health care
There is no force more powerful in an organization than cul-
ture. As all business experts counsel: “Culture kills the best
of strategies.” In fact, the phrase and the concept of “This
is the way we’ve always done it!” is the mindless battle cry
of culture-resisting change. Culture is never written down
or spoken – but known by everyone.
Three powerful forces impede
communication in health care: time
pressures, knowledge and culture.
OR11. 2. qxp: La yout 1 8/ 12/ 09 7: 57 AM Pa ge 24
Aligning practice with policy to improve patient care 25
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).
Instructors were often heard to say,
“If you want to work in the OR, you
better have thick skin.”
OR11. 2. qxp: La yout 1 8/ 12/ 09 7: 57 AM Pa ge 25
26 The OR Connection
Today, the massive profession-wide push for major improve-
ments in patient safety includes considerable pressure on
doctors to step away from the old model and shoulder the
responsibility of being an effective leader in building mean-
ingful, collegial relationships. But even the best leaders can’t
lead if the members of the would-be team refuse to shoulder
their reciprocal responsibilities to be receptive and commu-
nicative and trusting. That’s what happened to the unhappy
orthopod left wondering why he got the silent treatment.
Whatever culpability he, as the surgeon, might have had for
not breaking the silence, his “team” also has a vital role.
The responsibility for a true team is a shared responsibility.
Start the conversation. What is the current culture of your
OR? Can you speak up at any time to ask a question or
stop the line? The culture of the operating room in the pre-
vious case was to ‘lay low when things go wrong.’ No
member of the team ever acknowledged this, or said these
words out loud. As a team, they learned over the years to
hibernate until the ‘storm’ passed. But until someone steps
forth and starts acting differently, nothing will change. Only
the courage to act differently over a long period of time,
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
going to be lappy because “nobody told him.” The tech
didn’t know that the surgeon switched systems for his
lumbar fusions because “nobody told her.” Likewise, the
orthopedic surgeon didn’t know that his team cared, and
that they were just as upset as he was about the events of
the day, because nobody said anything. In the Silence Kills
study,
5
fewer than 10 percent of physicians, registered
nurses and clinical staff could directly confront their col-
leagues about their concerns. Why aren’t people talking?
A recent study of over 2,500 hospital nurses gives us some
answers.
6
Nurses were asked to identify a conversation that
they needed to have in order to create a healthy
work environment.
When asked why they had avoided the crucial
conversation, they responded:
• Fear of retribution
• Fear of retaliation (unfair assignment or schedule,
refusing to help, refusing a vacation)
• Fear of being isolated or excluded from the group
• Fear of being gossiped or talked about
• Fear of being wrong
• No time
• Fear of upsetting the status quo; rocking the boat
• Why bother? Nothing will change; it’s no use
The primary denominator here is fear. As long as we live in
fear, nothing will change. Healthcare workers share a pas-
sive-aggressive style of communication. They say why they
are upset – to everyone in the department except the
person they are angry with. In addition, the most common
Continued on Page 28
OR11. 2. qxp: La yout 1 8/ 12/ 09 7: 57 AM Pa ge 26
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28 The OR Connection
way nurses deal with confrontation is avoidance. Nothing is
worth upsetting the relationship. Noting this, it is imper-
ative that leaders teach assertive communication and
confrontation skills in the workplace.
One very simple model is called the D-E-S-C Communica-
tion Model. It provides a great framework for organizing your
thoughts and feelings.
7
D - Describe the behavior
E - Explain the effect of the behavior
S - State the desired outcome
C - Say what happens if the behavior continues
For example, the physician could have
approached the team this way after
the surgeries:
DESCRIBE - I want to talk to all of you about the silence in
the operating room today. No one said a word all day.
EXPLAIN- The silence is what upset me the most. Having
to explain the unsterile instruments to my patient was
extremely upsetting; as was not having the right implant.
But the silence made me feel like I was alone, or surrounded
by strangers.
STATE - When something happens that is not normal
(unanticipated event or error), I would appreciate your
support or acknowledgement of what happened. I want to
create an atmosphere where every member feels sup-
ported, and today, I certainly did not.
CONSEQUENCE - If we continue to ignore issues as a
team, then we are not a team.
Time is money AND…
For every good idea to improve patient safety and clinical
quality there is a voice reminding us that time is money.
Money governs healthcare in America. No surgeon, OR
scheduler, or CEO can refuse to be concerned about how
efficiently an OR can be used. Pressures have become so
intrusive on the surgical team that beepers and Blackber-
ries now provide a constant opportunity for interruption and
distraction that few patients on the table would appreciate
if awake. While only preliminary data is emerging to validate
what we already intuitively know, the fact is, the higher the
pressure on time, and the higher the level of distraction in an
OR, the less concentration on the procedure. To the extent
that a surgical team is constantly disrupted by mid-proce-
dure personnel substitutions, thoughtless intrusions, and
OR11. 2. qxp: La yout 1 8/ 12/ 09 7: 57 AM Pa ge 28
Aligning practice with policy to improve patient care 29
highly distracting communications, patient safety is com-
promised. Time pressures drive distractions that fragment
and fracture teamwork and the ability of a surgical team to
stay focused and supportive of each other.
How does the leader of a would-be collegial interactive
team respond to such pressures? By taking the time to
discuss issues outside the OR, tracking outcomes and
reviewing all outliers. A team cannot coordinate their
actions or responses if they don’t make the time to come
together before the fact and at least go over the basics of
what they’re about to do; as well as openly discuss unin-
tended outcomes.
2
Example: During a bariatric surgery the surgeon asked the
anesthesiologist, “Is the stomach clear?” and the anesthe-
siologist answered “Yes.” And so the surgeon stapled the
stomach – to the tube. For when the surgeon asked if the
stomach was clear, the anesthesiologist thought he meant
‘clear of fluids’ - and not the tube they had inserted for
decompression. After the event, the checklist was revised
to include teaching and now reads: “Before stapling, I will
specifically ask, ‘Is the stomach clear of the tube’ because
before I staple, I need the tube to be pulled. Respond ‘clear’
when the tube is pulled.”
SCOAP (Surgical Care and Outcomes Assessment Pro-
gram) is the future of surgical quality improvement. It is a
physician-led voluntary collaborative creating an aviation-
like surveillance and response system for surgical quality.
SCOAP's goal is to improve quality by reducing variation in
process of care and outcomes at more than 40 hospitals in
the state of Washington. SCOAP is an engaged community
of clinicians working to build a safer, higher quality,
and more cost-effective surgical healthcare system.
http://www.scoap.org/index.html.
Find your voice
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 knowat all times. Silent cultures never change.
Find the courage. Find your voice.
References
1. Scott, S. (2004). Fierce Conversations. New York: The Berkley Publishing
Company.
2. Nance, J. (2008). Why hospitals should fly. Second River Healthcare Press,
Bozeman, MT.
3. Bartholomew, K. (2007). Stressed Out About Communication Skills,
Marblehead, MA
4. Orlikoff, J. (2008). IHI Conference: From the top: the role of the board in quality
and safety, November 6-7, Boston, MA.
5. “Silence Kills: The Seven Crucial Conversations for Healthcare” study by
VitalSmarts available at www.silencekills.com.
6. Bartholomew, K. Presentation for Sigma Theta Tau International: “Using a
communication model to identify barriers and increase self esteem” November
2, 2009, Indianapolis, IN
7. Cox, S. (2007) Cox & Associates, Brentwood, TN.
Kathleen Bartholomew, RN, RC, MN, has
been a national speaker for the nursing pro-
fession for the past seven years. Her back-
ground in sociology laid the foundation for
correctly identifying the norms particular to
health care – specifically physician and
nurse relationships. For her master’s thesis,
she authored Speak Your Truth: Proven
Stategies for Effective Nurse-Physician
Communication, which is the only book to date that addresses
physician-nurse communication. Stressed Out About Communi-
cation is a book designed for new nurses. Save 20 percent by
using source code MB84712A at www.HCMarketplace.com
or call customer service at (800) 650-6787.
John J. Nance, JD, author of the American
College of Healthcare Executive's 2009
Book of the Year, Why Hospitals Should Fly
(2008, Second River Healthcare Press,
Bozeman, MT), has been a dedicated mem-
ber of the healthcare profession for the past
20 years and an acknowledged leader in
adapting the most effective methods of
transforming human systems to high relia-
bility status. One of the founding board members of the National
Patient Safety Foundation, John is a licensed attorney, a 13-thou-
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
Fly can be purchased online at www.whyhospitalsshouldfly.com.
QUIZ YOURSELF!
CAUTI Prevention: How Do You Rate?
1. At my facility, we remove urinary catheters
within 48 hours after surgery.
a. Always
b. Sometimes
c. Never
2. I follow strict aseptic technique when
inserting a catheter.
a. Always
b. Sometimes
c. Never
3. At my facility, we educate catheterized
patients about urinary tract infections.
a. Always
b. Sometimes
c. Never
4. At my facility, we keep track of how long
catheters are kept in patients.
a. Always
b. Sometimes
c. Never
5. Before placing a catheter, I assess whether
the patient really needs it, and I document
the assessment in the chart.
a. Always
b. Sometimes
c. Never
30 The OR Connection
What’s your score?
a _____ x 5 = _______
b _____ x 3 = _______
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 readmissions
6
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
References
1. Expert discusses strategies to prevent CAUTIs. Infection Control Today Web site. June 1, 2005. Available at http://www.infectionacontroltoday.com/articles/402/402_561feat2.html.
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 http://www.cdc.gov/ncidod/dhqp/pdf/pc/cauti_GuidelineApx_June09.pdf. 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
http://www.medscape.com/viewarticle/587464_4. Accessed July 6, 2009.
Aligning practice with policy to improve patient care 31
Back to Basics Tenth i n a Seri es
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
Tell Me Again Why This Patient
Needs a Catheter?
Patient Safety
OR11. 2. qxp: La yout 1 8/ 12/ 09 7: 57 AM Pa ge 31
32 The OR Connection
evidence-based practice. CMS reported in the 2008 Fed-
eral Register that in 2007 there were 12,185 CAUTIs, costing
$44,043 per hospital stay.
2
CAUTI is one of 10 hospital-
acquired conditions (HACs) for which CMS will no longer
provide reimbursement if it occurs during hospitalization.
3
Brand-new CAUTI prevention guidelines
CAUTI is the number one healthcare-associated infection
(HAI), accounting for 40 percent of all hospital-acquired
infections.
4
One in four patients receives an indwelling
urinary catheter at some point during their hospital stay.
5
As a result of this data, leading industry experts, including
the Association for Professionals in Infection Control and
Epidemiology (APIC), the Society for Healthcare Epidemiol-
ogy (SHEA), the Centers for Disease Control and Prevention
(CDC), the Joint Commission and many others have joined
together to outline strategies and guidelines to prevent
catheter-associated urinary tract infections in acute care
hospitals.
6
The CDC’s Draft Guideline for Prevention of
Catheter-Associated Urinary Tract Infections 2008 (released
in June 2009) identifies new guidelines and recommenda-
tions to prevent CAUTI.
Barriers to CAUTI prevention
Three distinct barriers to the prevention of CAUTI become
evident when analyzing the problem. In the perioperative
environment it is hard to imagine that there are errors in
aseptic technique because we are acutely aware of proper
technique. But remember that most nurses outside of the
perioperative environment do not routinely perform aseptic
technique and may not be aware when contamination
occurs. In fact, during most observations of nurses outside
of the perioperative environment, we have seen inconsis-
tent practice in setting up a sterile field and inserting
indwelling catheters aseptically. It is perfectly clear that in
perioperative services, two of the three barriers occur rou-
tinely – too many catheters are inserted and catheters stay
in too long.
CAUTI incidence outside the
perioperative environment
To help you further realize the magnitude and role of
perioperative services in preventing CAUTI, let’s look at
additional statistics from outside the perioperative environ-
ment. Did you know that the emergency department (ED)
has the highest percentage of catheter placements?
7
In the
ED, as well as in perioperative services, documentation of
the reason for catheter placement is poor and a written
physician order is frequently lacking. Without a physician
order, physicians are unaware that the patient has a
catheter.
5
When physicians do not know that a catheter has
been inserted, it is no wonder that an order for timely
removal is lacking, and catheters stay in longer than med-
ically necessary.
Common catheter practices in perioperative services
Adding to the problem, inappropriately placed catheters are
more often forgotten about.
5
In 56 percent of hospitals there
is no system to keep track of which patients have catheters,
and 74 percent of hospitals do not keep track of how long
the catheter is in place.
8
Shocking as this may be, let’s
assess common practice in perioperative services and see
if any of these common occurrences occur at your facility.
1. Do you have preference cards that tell you to insert
an indwelling catheter for a specific procedures
performed by a particular surgeon?
2. Do you assess patients to determine if the standing
order to insert an indwelling catheter is medically
indicated?
3. When a patient comes to the OR with an
indwelling urinary catheter or when you insert one
intraoperatively, do you evaluate the need to keep
the catheter in place at the end of the surgical
procedure before transporting the patient to the
post anesthesia care unit (PACU)?
4. Do you date and time when the catheter was
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.
MAJOR BARRIERS TO CAUTI PREVENTION
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
OR11. 2. qxp: La yout 1 8/ 12/ 09 7: 57 AM Pa ge 32
Aligning practice with policy to improve patient care 33
Perioperative nurses are positioned to significantly impact
the reduction and elimination of catheter-associated urinary
tract infections by removing catheters when patients do not
meet the approved indications. Take a peek at Table 1, which
lists when indwelling urinary catheters should and should not
be used.
What is a nurse to do? If your patient has no alternatives,
and you must insert a urinary catheter, is there anything you
can do to help prevent catheter-associated urinary tract
infections? Absolutely!
CAUTI prevention methods
a. Alternatives to urinary catheter use
Do not allow routine urinary catheter placement in the
OR. Remove as many urinary catheters as you can
within 24 hours. Consider alternatives to indwelling
urethral catheters, such as intermittent catheterization.
b. Appropriate urinary catheter use
Use indwelling catheters only when medically necessary.
c. Aseptic insertion of urinary catheters
Use aseptic insertion technique with appropriate hand
hygiene and gloves. Allow only trained healthcare
providers to insert catheters.
d. Proper urinary catheter maintenance
- Properly secure catheters after insertion.
- Maintain a sterile closed drainage system.
- Maintain good hygiene at the catheter-urethral interface.
- Maintain unobstructed urine flow.
- Maintain drainage bag below level of bladder at
all times.
- Use portable ultrasound bladder scans to detect
residual urine amounts.
- Do not change indwelling catheters or urinary drainage
bags at arbitrary fixed intervals.
e. Timely removal
- Remove catheters when
no longer needed.
- Document indication for
urinary catheter on each
day of use.
- Use reminder systems
to target opportunities
to remove catheter.
The above list was combined from
recommendations in the CDC
guidelines and 2008 APIC CAUTI
Elimination Guidelines.
Table 1. Appropriate Indications for Indwelling Urethral Catheter Use
10,11
Patient has acute urinary retention or obstruction
Need for accurate measurements of urinary output in critically ill patients
Perioperative use for selected surgical procedures:
• Patients undergoing urologic surgery or other surgery on contiguous structures
of the genitourinary tract
• Anticipated prolonged duration of surgery (catheters inserted for this reason
should be removed in PACU)
• Patients anticipated to receive large-volume infusions or diuretics during surgery
• Operative patients with urinary incontinence
• Need for intraoperative monitoring of urinary output
To assist in healing of open sacral or perineal wounds in incontinent patients
Patient requires prolonged immobilization (e.g., potentially unstable thoracic or
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.
Continued on Page 36
OR11. 2. qxp: La yout 1 8/ 12/ 09 7: 57 AM Pa ge 33
Point and click to
ERASE CAUTI
The new ERASE CAUTI program combines design,
education and awareness to tackle catheter-associated
urinary tract infection – the number one hospital-acquired
infection.
1
Design
The innovative one-layer tray design guides the clinician
through the process of placing a catheter to ensure
aseptic technique.
Education
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
aseptic technique
Secure catheter – A properly secured catheter will
reduce movement and urethral traction
Educate the patient – Printed materials tell the patient
how to reduce the likelihood of infection
Awareness
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).
www.medline.com
Design
Open up the
innovative one-layer
catheter tray and
see the intuitive
design for
yourself.
OR11. 2. qxp: La yout 1 8/ 12/ 09 7: 57 AM Pa ge 34
P
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Education
Click here for
details on nursing
education materials
that promote
evidence-based
practice.
Awareness
Visit this section
to join 100,000
nurses in the
Race to ERASE
CAUTI.
Reference
1. Catheter-related UTIs: a disconnect in preventive strategies.
Physicians Weekly. 25(6), February 11, 2008.
OR11. 2. qxp: La yout 1 8/ 12/ 09 7: 57 AM Pa ge 35
36 The OR Connection
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
reinforce successful strategies.
11
Develop a CAUTI prevention program for your facility
If your organization does not have a CAUTI elimination
program, or you are not getting the results you had hoped
for, start by assessing whether an effective organizational
program exists. Work with your infection preventionist and
other key multidisciplinary stakeholders to develop your
campaign.
Questions to consider to help you get started
with your own CAUTI prevention program:
• Are there policies or guidelines that define criteria
for insertion of a urinary catheter?
• Has the organization established criteria for when
a catheter should be discontinued?
• Is there a process to identify inappropriate usage
or duration of urinary catheters?
• Is there a program or guidelines to identify and remove
catheters that are no longer necessary? (e.g., physician
reminders, automatic stop orders or nurse-driven
protocols)
• 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
MAJOR BARRIERS TO CAUTI PREVENTION
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
OR11. 2. qxp: La yout 1 8/ 12/ 09 7: 57 AM Pa ge 36
Aligning practice with policy to improve patient care 37
GO!
Start the race to erase CAUTI in the operative arena by
educating your patients and staff about CAUTI. Ensure all
staff practice aseptic technique and remove catheters in a
timely manner.
Join the Race to ERASE CAUTI! Talk about prevention,
rai se awareness, then i mpl ement sol uti ons i n your
organi zation.
ON YOUR MARK ...
GET SET ...
References
1. Wald HL, Ma A, Bratzler DW, Kramer AM. Indwelling urinary catheter use in the
postoperative period: analysis of the national surgical infection prevention project data.
Arch Surg. 2008;143:551-557
2. Ribby KJ. Decreasing urinary tract infections through staff development, outcomes,
and nursing process. J Nurs Care Qual. 2006; 21:272-276.
3. CMS, Proposed Changes to the Hospital IPPS and FY2009 rates; Available at
http://edocket.access.gpo.gov/2008/pdf/08-1135.pdf. Accessed July 24, 2009
4. Catheter-related UTIs: a disconnect in preventive strategies. Physician’s Weekly. 25(6),
February 11, 2008.
5. Saint S, Kaufman SR, Thompson M, Rogers MA, Chenoweth CE. A reminder reduces
urinary catheterization in hospitalized patients. Jt Comm J Qual Patient Saf. 2005;
31(8):455-462.
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–
S50.
7. Stokowski, LA. Preventing catheter-associated urinary tract infections. Medscape
Nursing Perspectives. February 3, 2009. Available at http://www.medscape.com/
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
http://www.ncbi.nlm.nih.gov/pubmed/17111954. 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
Epidemiology.
OR11.2.qxp:Layout 1 8/13/09 10:28 AM Page 37
©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
Interactive courses & competencies
Continuing education courses are still available,
and now you can earn all credits for FREE! In
addition, we are adding online competencies.
Courses and competencies are more interactive
with more graphics, sound and animation to
make learning more fun.
Facility-specific features
Now each facility has the option of creating a
group account on Medline University. This will
help you and your facility view and keep track
of all completed courses.
And for facilities participating in the Pressure
Ulcer Prevention and Hand Hygiene programs,
all materials, pre- and post-tests are now conve-
niently located online at medlineuniversity.com.
Visit the redesigned www.medlineuniversity.com
today, and let us know what you think!
www.medline.com
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All-new look and upgraded content!
Easier navigation to find what you need – faster.
OR11. 2. qxp: La yout 1 8/ 12/ 09 7: 58 AM Pa ge 38
Aligning practice with policy to improve patient care 39
True or False (circle one)
1. As many as 95 percent of patients undergoing
surgery have urinary catheters. T F
2. The emergency department has the highest percentage
of catheter placement . T F
3. One in three patients receives an indwelling urinary
catheter at some point during their hospital stay. T F
4. Assistance in pressure ulcer healing for incontinent
patients is an approved indication for urinary
catheterization. T F
5. Allowing only trained healthcare providers to insert
catheters is one method for preventing catheter-
associated urinary tract infections (CAUTI). T F
6. A recent survey of U.S. hospital practices identified
that no strategy is consistently or universally used to
prevent CAUTI. T F
7. CAUTI is one of 10 hospital-acquired conditions for
which the Centers for Medicare & Medicaid Services
(CMS) will no longer provide reimbursement if it
occurs during hospitalization. T F
8. Nurses rarely request to place a urinary catheter for
nursing convenience. T F
Multiple Choice
9. Which of the following is not an approved indication
for urinary catheterization?
a. To improve comfort during end-of-life care.
b. Management of acute urinary retention and
urinary obstruction.
c. The patient requires prolonged immobilization.
d. The patient is incontinent and requires two or
three linen changes per shift.
10. Which of the following are techniques for proper
urinary catheter maintenance?
a. Properly secure catheters after insertion.
b. Maintain unobstructed urine flow.
c. Both a and b.
d. Change indwelling catheters or urinary drainage
bags at arbitrary fixed intervals.
11. CMS reported in the 2008 Federal Register that in
2007 there were ______CAUTIs.
a. 800,000
b. 56,296
c. 1,877
d. 12,185
12. It has been estimated that up to ____ percent of
indwelling urinary catheters are unnecessarily placed.
a. 85
b. 10
c. 50
d. None of the above
13. Which of the following is a successful strategy
implemented by healthcare organizations to
reduce CAUTI?
a. Redesign patient care areas
b. Utilize multidisciplinary teams to put
evidence-based changes in practice
c. Serve cranberry juice to patients
d. Deploy rapid response teams (RRTs)
14. Which of the following organizations did not
participate in outlining strategies and guidelines
to prevent CAUTI?
a. American Medical Association (AMA)
b. Centers for Disease Control and Prevention (CDC)
c. Association for Professionals in Infection Control
and Epidemiology (APIC)
d. The Joint Commission
15. One way to help prevent CAUTI is to use
___________ systems to target opportunities to
remove catheters.
a. infection control
b. emergency
c. aseptic
d. reminder
CE Questi ons Back to Basics
Tell Me Again Why This Patient
Needs a Catheter?
Submit your answers at
www.medlineuniversity.com
and receive 1 FREE CE credit
OR11. 2. qxp: La yout 1 8/ 12/ 09 7: 58 AM Pa ge 39
s
40 The OR Connection
A cost-effective alternative
to urinary catheterization
Knowing catheter-related urinary tract infections (UTIs)
are the most common of all hospital-acquired infec-
tions, Alan F. Rothfeld, MD, was looking for alternatives to
catheterizing patients at Hollywood Presbyterian Medical
Center (HPMC), a 434-bed hospital in Los Angeles.
Rothfeld noted that newincontinence management products
offer less costly and more effective alternatives to catheteri-
zation. Restore ultra-absorbent disposable briefs, manufac-
tured by Medline, stay dry and hold significantly more urine
per day.
In order to document whether using disposable briefs in place
of urinary catheters would decrease UTIs, Rothfeld led a six-
month study, from January to October 2008, at HPMC’s ICU
step-down units. The study observed the use of Restore
briefs during two three-month periods in two separate units of
the hospital with a total of 60 beds, averaging 83 percent
occupancy.
50 Percent Reduction in UTIs
There were five hospital-acquired UTIs during the three-month
control period, indicating an infection rate of 3.2 per 1,000
catheter days. During the three-month intervention period,
there were only two hospital-acquired UTIs, with an infection
rate of 2.4 per 1,000 catheter days.
Infections during the intervention period fell from an average of
1.06 per 1,000 patient days to 0.45. “The reduction in
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.
According to Rothfeld’s findings, catheters are needed in only
about half the cases in which they are used.
Before beginning the study, Rothfeld developed the
following indications for the use of urinary catheters:
1. Written orders for hourly urinary output
2. Inability to void spontaneously (usually due
to obstruction)
3. Active urinary tract infection with Stage 3 or 4
pressure ulcer
If a patient had none of these indications, no catheter was
requested. If a patient had a catheter already, a request to the
physician for discontinuance was initiated.
An anonymous questionnaire conducted at the end of the
study revealed the disposable briefs were a welcome alter-
native among physicians and nurses. “In fact, no patient
reported decreased comfort and most of the staff was sup-
portive of this program, indicating it increased overall satis-
faction among nursing personnel,” Rothfeld said.
References
Ditch the foleys, adopt diapers to address UTIs. Infection Control Today Web
site. Posted March 10, 2009. Available at
http://www.vpico.com/articlemanager/printerfriendly.aspx?article=23711. Ac-
cessed May 22, 2009.
Rothfeld AF & Stickley A. A Program to Reduce Nosocomial Urinary Catheter
Infections at an Acute Care Hospital [manuscript]. Hollywood Presbyterian
Medical Center; 2009.
Restore is a registered trademark of Medline Industries, Inc.
California
H
ospital
Decreases
CA
U
TI w
ith
U
se
of Incontinence
Briefs
OR11.2.qxp:Layout 1 8/13/09 10:29 AM Page 40
©2009 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
Medline's comprehensive line of SensiCare
®
latex-free polyisoprene surgical gloves
provides you with exceptional fit, feel
and protection so that you can address
a rising concern in the OR community –
latex allergies.
The American Latex Allergy Association estimates that
between 8 and 17 percent of all healthcare workers are
sensitized to natural rubber latex.
1
Studies have suggested
that the costs of healthcare workers’ disability compen-
sation due to latex allergies justifies or significantly offsets
the cost of conversion to a latex-free environment.
2
Medline’s Sensicare
®
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structure that is virtually identical to natural rubber latex.
In fact, it is softer, more elastic and more comfortable.
So never compromise again. Choose the
SensiCare glove that best fts your needs.
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References:
1. American Latex Allergy Association. Latex Allergy Statistics. Available at:
www.latexallergyresources.org/topics/LatexAllergyStatistics.cfm.
Accessed November 5, 2008
2. Phillips VL, Goodrich MA, Sullivan TJ. Health care worker disability due to latex
allergy and asthma: a cost analysis. American Journal of Public Health.
1999:89(7):1024-28.
&
Protection,
performance,
comfort without compromise.
OR11. 2. qxp: La yout 1 8/ 12/ 09 7: 58 AM Pa ge 41
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
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.
Playing Traffic
Control in the OR
42 The OR Connection
OR11. 2. qxp: La yout 1 8/ 12/ 09 7: 58 AM Pa ge 42
OR Issues
Aligning practice with policy to improve patient care 43
AORN has published six recommended
practices for traffic control:
2
• Traffic patterns should be designed to facilitate movement
of patients and personnel through defined areas within
the surgical suite.
• Operating suites should be secure.
• Movement of personnel should be kept to a minimum
while invasive and noninvasive procedures are in progress.
• The movement of clean and sterile supplies and equipment
should be separated from contaminated supplies,
equipment and waste by space, time, or traffic patterns.
• During construction and renovation, specific traffic patterns
should be established and maintained in accordance
with applicable state regulations.
• Policies and procedures for traffic patterns for patients,
personnel, supplies, and equipment should be developed,
reviewed periodically, revised as necessary, and kept
readily available in the practice setting.
Why all the fuss?
Surgical site infections are believed to account for up to $10
billion annually in healthcare expenditures.
3
We know that
bacterial shedding occurs in the OR from personnel moving
about the room. Skin cells transport bacteria, and increased air
movement can circulate dust and bacteria, which can con-
taminate a sterile field. Movement of personnel in and out of
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.
10QUICK TIPS
for controlling traffic in the OR
2
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
eye wear.
2. Ensure environmental and dress code controls increase
as patients and staff move from unrestricted to
restricted areas.
3. Post signage that clearly indicates traffic and
dress controls.
4. Keep operating room doors closed except when
moving patients, personnel or equipment.
This helps to decrease the mixing of operating room air
with the corridor air, which may have increased bacterial
counts from dust or debris.
5. Keep talking to a minimum and limit movement within the
OR during procedures.
6. Restrict the number of personnel in the OR to only those
involved in the case and document all personnel involved
in the patient’s care.
7. Use covered carts to protect clean and sterile supplies
during transportation.
8. Remove external shipping containers in
unrestricted areas.
9. Contaminated instruments should be covered and
moved to a decontamination area.
10. Construction and renovation require specific traffic plans
to minimize contamination.
OR11. 2. qxp: La yout 1 8/ 12/ 09 7: 58 AM Pa ge 43
44 The OR Connection
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.
References
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.
OR11. 2. qxp: La yout 1 8/ 12/ 09 7: 58 AM Pa ge 44
©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
It could be the difference
between life and death.
Wrong site surgery has recently moved into the
number one position as the most frequently
reported hospital error.
1
This is despite a conscientious effort to eliminate this
problem before it occurs. What is needed is another layer
of safety...something that will improve our chances of
correcting the mistake before it happens.
Enter S.T.O.P. Surgical Drapes* from Medline.
We just made a good idea even better. S.T.O.P. (Surgical
Time Out Procedure) drapes are available in a variety of
configurations, and include a “S.T.O.P.” strip across the
fenestration. As a result, you can’t forget to take a time
out to verify the correct patient, procedure, side and site.
Then all that is left is to hand the sticker off to the circulating
nurse to include in the medical record, documenting that
the verification process was completed.
If you would like to receive a free sample
of the S.T.O.P. Drape system to evaluate for
yourself, ask your Medline representative or
call us at 1-800-MEDLINE.
www.medline.com
STOP!!!
Perform “TIME OUT”
Verify correct:
Person
Procedure
Site & Side
Date: ______ Time: ______
Surgeon’s Initials: _____
































S
m r o f rrf e P
r e V
o s r e P
e c o r P
& e t i S
_ _ _ _ : e t a D _
’ n o e g r u S








!!! P O T S
” T U O E M I T “ m
: t c e r r o c y ffy i r
n o
e r u d e
e d i S &
_ _ _ _ _ _ : e m i T _ _
_ _ _ _ _ : s l a i t i n I s ’
















































































































































































S.T.O.P. strip and sticker
S.T.O.P.

for safety.
References
1
The Joint Commission. The Statistics page. Available at: http://www.jointcommis-
sion.org/NR/rdonlyres/D7836542-A372-4F93-8BD7-DDD11D43E484/0/SE_Stats_12_07.pdf.
Accessed March 13, 2008.
* Patent pending
OR11. 2. qxp: La yout 1 8/ 12/ 09 7: 58 AM Pa ge 45
46 The OR Connection
The International Expert Wound Care Advisory
Panel released a 23-page white paper in June
2009 identifying key concepts to help healthcare
professionals with preventative legal care
practices taking into consideration the current
pressure ulcer regulatory and legal environment.
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
at www.medline.com.
References
1. Voss AC, Bender SA, Ferguson ML, et al. Long-term care liability for pressure
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
is sues in the care of pressure ulcer patients: key concepts for healthcare
providers. White paper. June 2009.
3. Aronovitch SA. Intraoperatively acquired pressure ulcers: are there common
risk factors? Ostomy Wound Management. 2007;53(2):57-69. Available at
http://www.o-wm.com/article/6776. Accessed July 29, 2009.
Legal Issues in the Care
of Pressure Ulcer Patients
OR11. 2. qxp: La yout 1 8/ 12/ 09 7: 58 AM Pa ge 46
IJJJJJJJJJJJJI
IJJJJJJJJJJJJI
Legal Issues in the Care of Pressure Ulcers: Key Concepts for Healthcare Providers
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.
Deposed: A Personal Perspective
By Evonne Fowler, MSN, RN, CWOCN
The unthinkable happened to me.
In my 46 years of nursing, I have always felt
that I was a patient advocate. In fact, I have told
many a patient, “If I were you, I would want me
to take care of you.” I was shocked when I opened
the door one evening and was handed a subpoena
to report for a deposition.
One of the patients I had cared for a few years
ago had brought a lawsuit against the hospital and
I was implicated as one of the wound care specialists
who had rendered service.
I was devastated. I have always done my best
to keep patients in my charge clean, dry, comfortable
and safe. So how did this happen and what does it
mean for me? What would happen next?
I remembered the patient quite well. She was a
very complex and difficult patient. Here’s what my
review of her medical record revealed. She was a
54-year-old morbidly obese (425 lbs.) female who
was admitted to the Emergency Department after
three days of being febrile, unable to eat, experienc-
ing liquid stools and being lethargic. The paramed-
ics had been called to the home earlier, but she had
refused to be taken to the hospital. Later that night,
her daughter was able to persuade her to go to the
Emergency Department. Her admitting diagnosis
was right leg cellulitis. She had a history of multiple
co-morbidities including venous disease, diabe-
tes, morbid obesity, hypertension, chronic anemia,
chronic kidney disease, asthma, and of non-adherent
behavior. She had called the membership services
over 100 times during her years of coverage,
reporting various incidents regarding her care.
A few hours after admission, she was taken
to the operating room, where she had a soft tissue
incision and fasciotomy for compartment syndrome
of the right leg. On post-op admission to the inten-
sive care unit, her initial skin assessment was clear
of bruising or wounds. She developed sepsis, had
an altered mental status with bouts of confusion,
uncooperative behavior, lethargy, difficulty
awakening and agitation; she was verbally abusive
to the staff. Her hospitalization was fraught with
complications, including pneumonia with subsequent
need for intubation. Her behavior became combative.
She pulled out the nasogastric tube and intravenous
lines and had to be placed in restraints.
Eight days after admission, two pressure ulcers
(Stage I and Stage II) were noted in the sacral area.
As per our protocol, photographs were taken. On post
op day 12, the orthopedic surgeon requested a wound
care consultation for recommendations regarding the
management of the open fasciotomy incision. During
the skin assessment, the wound care nurse document-
ed a 9 x 20 centimeter unstageable pressure ulcer
on the sacral area, 75% black, 20% yellow, 5% red.
The patient was on the bariatric air support surface.
The post-op leg wound continued to heal;
however, the sacral pressure ulcer needed multiple
surgical debridements. At the base of the pressure
ulcer, an abscessed area was found. Once the sacral
area was clean, a negative pressure wound therapy
closure device was applied over the wound.
Upon discharge, she spent an additional six
months in a skilled nursing facility for pressure ulcer
management. Eventually, she returned home with
a small open wound. Her lower leg cellulitis had
extended into an eight-month saga due to the com-
plication from the hospital-acquired pressure ulcer.
Now what?
I was a fact witness (required to help relate the
specific facts of this one case) rather than expert
witness (who is usually called in to offer an opinion).
The hospital’s attorney represented me for the
deposition. I was called by the defense and counseled
not to give any opinions.
Aligning practice with policy to improve patient care 47
Special Feature
OR11. 2. qxp: La yout 1 8/ 12/ 09 7: 58 AM Pa ge 47
IJJJJJJJJJJJJI
IJJJJJJJJJJJJI
Legal Issues in the Care of Pressure Ulcers: Key Concepts for Healthcare Providers
My attorney sent a file box filled with medical records
for me to review. I was frustrated as I reviewed these
records. Notes were handwritten, difficult to read and
fragmented with different disciplines writing in various
sections. Very few notes were made in the comment
section of the nursing notes. Flow sheets were not com-
pleted. It was challenging to determine if the patient
actually had been turned, cleansed and repositioned
consistently. Although the patient was incontinent of
stool, there were very few episodes of incontinence
noted. Even though I remembered that she was placed
on a special mattress for pressure redistribution, I was
unable to determine this fact from the chart, despite
the fact that a special bed was ordered on day eight.
The Deposition
The attorney for the plaintiff handed me the nurses’
notes for the first seven days of the patient’s
hospitalization and asked me to read the Braden
Score, the integumentary, neuromuscular section,
turning/repositioning section of the flow sheet and
the nurses’ comment section. There was very little
charted in any of the sections. The Braden Score
showed the patient to be at high risk for pressure
ulcer development. I was unable to find a plan of
care in any of the files. Although the hospital had
just implemented a new pressure ulcer program,
none of the new forms or the pressure ulcer trending
were filled out. The attorney had me go through
the chart looking for documentation of instances
of patient non-adherence. I was stunned at the lack
of documentation by both physicians and nurses
about her behavior, the skin and the pressure ulcer
throughout her hospitalization.
The opposing counsel had me read my own charting
for the times I had interacted with the patient and
asked if the doctor had been informed consistently
regarding the skin changes and wound management
of the pressure ulcer. I was embarrassed with my
own charting and lack of information charted. The
photographs taken throughout her hospitalization
were not labeled properly and were out of sequence.
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.
Lessons Learned
Some of the common complaints registered against
nurses in a lawsuit are failure to follow a standard
of care, failure to communicate, failure to assess and
monitor appropriately, failure to report significant
findings, failure to act as a patient advocate and
failure to document. That certainly applies in this
case. Documentation is essential! Here are the main
lessons I learned from this experience:
- 0n admission, il is impoilanl foi llc wound
care specialist to assess the patient’s skin and
wound and write a detailed, initial, focused
assessment. If a wound is present on admission,
document the wound profile.
- Pocumcnl llc lypc of suppoil suifacc the
patient is on or whenever a support system
change is ordered.
- 1akc a clcai plologiapl of llc wound according
to your organization’s guidelines. For me, that
would mean using a measurement label and a
black marking pen to clearly identify the patient’s
name or initials, medical record number, date
and location of the wound on the photo.
- Rcvicw and follow llc guidclincs iclalcd
to skin and wound care.
- Labcl and placc llc picvcnlion piolocol
standing orders and, if a wound is present,
the wound and skin care treatment standing
orders. Complete the required sections and sign.
- Nolify llc plysician icgaiding llc skin|
wound condition. Based on your findings,
document if the wound is healable or
non-healable and document the interventions
for prevention and treatment of the skin/wound.
- Makc suic you do a follow-up nolc.
- Rccoid in llc disclaigc nolc llc skin
and wound status.
- Rcmcmbci llc powci of woids. Pay
attention to “words not to use.”
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!
48 The OR Connection
OR11. 2. qxp: La yout 1 8/ 12/ 09 7: 58 AM Pa ge 48
Aligning practice with policy to improve patient care 49
What to Do
If This Happens
to You
2
Although finding out you are being sued can be shocking and
upsetting, it is crucial to stay calm and take some simple
steps to allow for the best possible results.
•Notify your institution and malpractice carrier
immediately for the name of your attorney (counsel).
•DO NOT create notes on your own – separate and apart
from a meeting with your lawyer. These notes could
easily be discoverable in litigation.
•Avoid the temptation to talk to anyone about the case
until you have discussed it with your attorney. Your
attorney will likely advise you to avoid talking to
colleagues about the case; this is important advice.
•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
representatives before testifying in court. It is important
that you understand the procedures and can go over
what you likely will be asked.
Are Your
Physicians
Making
the Grade?
A recent survey graded physiciansʼ abilities to
recognize, assess and document Stage III and
IV pressure ulcers at a “D” level. Medlineʼs new
Pressure Ulcer Prevention Program MD Education
CD contains everything physicians need to brush
up on their skills and comply with the new CMS
Inpatient Prospective Payment System (IPPS).
“The new MD Education component of Medlineʼs
Pressure Ulcer Prevention Program is critical for
acute-care facilities to ensure that physicians
understand their role in recognizing and accurately
documenting POA pressure ulcers.”
Michael Raymond, MD, Associate Chief Medical
Quality Officer, NorthShore University HealthSystem,
Skokie Hospital, Skokie, IL
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
www.medline.com/pressureulcerprevention.
OR11. 2. qxp: La yout 1 8/ 12/ 09 7: 58 AM Pa ge 49
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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 Preventi on (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 i nsidious, 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.
Your Act!
MRSA, C. diff, other harmful bacteria
lurk in unexpected places
Aligning practice with policy to improve patient care 51
Patient Safety
OR11. 2. qxp: La yout 1 8/ 12/ 09 8: 00 AM Pa ge 51
52 The OR Connection
Bacteria-laden stethoscopes
Ill patients are obvious carriers of bacteria, and any sur-
face or piece of medical equipment is a potential vector
for that bacteria. For example, bacterial contamination
of a stethoscope increases markedly after it is used to
examine more than five patients without cleaning.
2
Several studies, however, suggest that many healthcare
professionals use bacteria-laden stethoscopes, poten-
tially transferring bacteria from patient to patient.
A recent study at one tertiary care center suggests
roughly one third of stethoscopes carried by EMS
professionals harbor MRSA. A microbiologic analysis of
50 stethoscopes provided by EMS professionals in an
emergency department revealed that 16 had MRSA
colonization. Similarly, 16 of the EMS workers could not
remember the last time they cleaned their stethoscope.
For those who did remember, the median time from the
last stethoscope cleaning was one to seven days.
MRSA colonization rates fell considerably in the stetho-
scopes that were cleaned more recently.
3
Another study cultured 99 stethoscopes on four medical
floors of a 600-bed hospital. All were positive for bacteria
growth. Half of the stethoscopes were cleaned using
ethanol-based cleaner (hand-sanitizing gel) and the
other half were cleaned using isopropyl alcohol pads.
Cleaning with the ethanol gel and isopropyl alcohol pads
significantly reduced the bacteria counts (by 92.8
percent and 92.5 percent, respectively).
2
A similar study at a large academic medical center took
cultures from 40 randomly selected clinicians’ stetho-
scopes. Staphylococcus aureus was found on 38 per-
cent of them. When comparing the bacteria-removing
ability of isopropyl alcohol, bleach, benzalkonium chloride
swabs and soap and water, isopropyl alcohol was
proven to be most effective to rid the stethoscopes of
S. aureus.
4
The same study also addressed whether bacteria could
be transferred to human skin from the stethoscope
diaphragm. Micrococcus luteus was inoculated onto a
stethoscope diaphragm, and the study showed that it
did transfer to human skin. The authors concluded that
the transfer of M. luteus to human skin made it likely that
other bacteria could be transferred as well.
Stethoscopes are an extension of the hand in clinical set-
tings and should be cleaned with the same frequency;
that is, after contact with each patient. Cleaning a stetho-
scope takes little time and effort, requires no special
equipment – and it could avoid a deadly infection.
Dirty scrubs
How about your scrubs? Some medical personnel wear
the same uniform to work more than once before laun-
dering, meaning they could be starting their shift with C.
diff, MRSA and who knows what other bacteria already
on their scrubs. A study conducted at the University of
Maryland revealed that 65 percent of medical personnel
admitted to changing their lab coat less than once a
week; 15 percent changed once a month.
5
Healthcare
workers often touch their own uniforms, potentially
transferring bacteria from the fabric to their patients.
Studies confirm that the more bacteria found on sur-
faces touched often by doctors and nurses, the higher
the risk for the bacteria to be carried to the patient and
cause infection.
5
65 percent of medical personnel
admitted to changing their lab coat less
than once a week
OR11. 2. qxp: La yout 1 8/ 12/ 09 8: 00 AM Pa ge 52
In one study, 65 percent of nurses who cared for
patients with MRSA contaminated their uniforms with
MRSA.
6
Staphylococci and Enterococci were found to
survive for days to months after drying on commonly
used hospital fabrics, such as scrubs made from 100
percent cotton or 60 percent cotton and 40 percent
polyester, as shown in a study conducted by the
Shriners Hospital for Children and the Department of
Surgery at the University of Cincinnati.
6
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
should be changed daily or whenever it becomes visibly
soiled, contaminated, or wet. Worn surgical attire should
be placed in an appropriately designed container for
washing or disposal and should not be hung or placed
in a locker for wearing at another time. This promotes
high-level cleanliness and hygiene within the practice
setting. It has been reported that bacterial colony counts
are higher when scrub clothing is removed, stored in a
locker, and used again.”
Surgical staff are exposed to possible bacteria-contain-
ing debris and fluid much more often than staff in other
areas of a hospital, however, microbial contamination
still can occur outside the surgical suite, in patient rooms
where patients have MRSA or VRE.
8
St. Mary’s Health Center in St. Louis, Mo., reduced
infections after cesarean births by more than 50 percent
by providing staff with hospital-laundered scrubs.
5
Similarly, Monroe Hospital in Bloomington, Ind., which
has a near-zero rate of hospital-acquired infections,
requires all staff to wear hospital-laundered scrubs and
bans them from wearing scrubs outside the hospital
building.
5
On the other side of the debate, a 1997 state-of-the-art
report (SOAR) compiled by the Association for Profes-
sionals in Infection Control and Epidemiology (APIC)
states, “There is no scientific evidence to suggest that
home laundering versus institutional laundering poses
any increased risk of infection transmission.”
9
Yet the report also says, “OSHA holds employers
responsible for laundering any clothing, including scrubs
worn by health care workers, that becomes contami-
nated with blood or other potentially infectious body
fluids, regardless of who owns the scrubs.”
9
The CDC supports home laundering of scrub uniforms
in its Guideline for Isolation Precautions (2007), which
states, “In the home, textiles and laundry from patients
Aligning practice with policy to improve patient care 53
Surgical staff are exposed to possible
bacteria-containing debris and fluid much more
often than staff in other areas of a hospital
OR11. 2. qxp: La yout 1 8/ 12/ 09 8: 00 AM Pa ge 53
with potentially transmissible infectious pathogens do
not require special handling or separate laundering, and
may be washed with warm water and detergent.”
10
Con-
versely, the state health departments in Pennsylvania
and Massachusetts, among others, recommend that
patients infected with MRSA launder their clothing
at home in hot water and laundry detergent. They also
suggest dryi ng cl othes i n a hot dryer to hel p ki l l
the bacteria.
11,12
The CDC’s laundering recommendation is based on the
outcome of two small, limited studies. One of the stud-
ies examined the scrub clothing of 68 labor and delivery
employees. The scrubs were laundered at home in
warm water and detergent and also dried in a clothes
dryer on the hot setting. The authors concluded that
home-laundered scrub clothing can be worn safely in
labor and delivery units.
13
What about other areas of
a hospital?
The other study tested the left front shoulders only of 30
home-laundered scrubs and 20 hospital-laundered
scrubs. No pathogenic growth was found on either the
home- or hospital-laundered fabrics.
14
It could be
argued, however, that the front shoulder of a scrub
uniform is one of the least likely areas to be touched
or contaminated.
Fewer bacteria = fewer HAIs
When it comes to preventing HAIs, it’s better to be safe
than sorry. If there’s even a small chance you could be
transferring bacteria to patients, why not take a little
extra time and a small amount of effort to clean up your
act? Hand rub dispensers are conveniently located
throughout most facilities, so go ahead and disinfect
your stethoscope between patients. When you wash
your scrubs, turn those dials to hot, and of course –
keep washing your hands. Pass the word along to
col leagues, and you may be surprised to see your
facility’s HAI rates go down.
References
1 Estimates of Healthcare-Associated Infections. Centers for Disease Control
and Prevention Web site. Available at
http://www.cdc.gov/ncidod/dhqp/hai.html. Accessed May 13, 2009.
2 Lecat P, Cropp E, McCord G, et al. Ethanol-based cleanser versus isopropyl
alcohol to decontaminate stethoscopes. American Journal of Infection
Control. 2009;37(3):241-243.
3 Merlin MA, Wong ML, Pryor PW, et al. Prevalence of methicillin-resistant
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.
1997;157(7):786-790.
5 McCaughey, B. Hospital scrubs are a germy, deadly mess. The Wall Street
Journal. January 8, 2009:A13.
6 LeTexier, R. Coming clean on home laundered scrubs. Infection Control
Today Web site. Posted October 1, 2001. Available at http://www.infection-
controltoday.com/articles/407/407_1a1feat4.html. Accessed May 11, 2009.
7 Recommended Practices for Surgical Attire in: 2008 Perioperative
Standards and Recommended Practices. Association of PeriOperative
Registered Nurses: Denver, CO.
8 Dix K. Apparel in the hospital: what to wear, where? Infection Control Today
Web site. Posted March 1, 2005. Available at http://www.infectioncontrolto-
day.com/articles/407/407_531inside.html. Accessed May 11, 2009.
9 Belkin NL. Use of scrubs and related apparel in health care facilities.
American Journal of Infection Control. 1997;25(5):401-404.
10 Siegel JD, Rhinehart E, Jackson M, et al. Centers for Disease Control and
Infection. 2007 Guideline for Isolation Precautions: Preventing Transmission
of Infectious Agents in Healthcare Settings. Available at
http://www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf. Accessed May
11, 2009.
11 Recommendations on Children with Methicillin-Resistant Staphylococcus
aureus (MRSA) in School Settings. Pennsylvania Department of Health Web
site. Available at http://www.stlouisco.com/doh/CDC/MRSA.pdf. Accessed
May 11, 2009.
12 Helpful Reminders About MRSA Infection. Massachusetts Department of
Public Health Web site. Available at:
http://www.mass.gov/Eeohhs2/docs/dph/cdc/antibiotic/mrsa_helpful_re-
minders.pdf. Accessed May 11, 2009.
13 Kiehl E, Wallace R, Warren C. Tracking perinatal infection: is it safe to launder
your scrubs at home? MCN Am J Matern Child Nurs. 1997;22(4):195-197.
14 Jurkovich P. Home- versus hospital-laundered scrubs: a pilot study.
MCN Am J Matern Child Nurs. 2004;29(2):106-110.
54 The OR Connection
Change your habits for infection prevention
• Keep isopropyl alcohol wipes or ethanol-based
hand cleaner available and wipe down your
stethoscope after each patient encounter.
• Wear street clothes to work, and then change
into clean scrubs every day. Keep an extra set
on hand and change mid shift if your scrubs
get visibly dirty or notably splattered with any
substance possibly containing bacteria. Change
back into street clothes before leaving the facility
to avoid carrying bacteria into your car, public
places and your home. If you wear a lab coat,
keep a clean supply at your facility and change
into a new one each day.
• If your facility allows you to launder your own
uniforms at home, be sure to use hot water (110
to 125 degrees F or 43.33 to 51.67 degrees C)
7
with 50 to 150 parts per million of chlorine
bleach.
6
(Note: Bleach is the only known cleaner
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
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
• CMS reimbursement changes
• Best practices for pressure ulcer prevention
• Perioperative assessment tools
• Critical patient and equipment risk factors
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 www.medline.com/pressure-
ulcerprevention, where you can sign up for a
free informational Webinar.
“I have seen an increase in the number of legal
issues linking facility-acquired pressure ulcers to
post-surgical patients. A pressure ulcer program
for the OR is more critical than ever.”
Diane Krasner, PhD, RN, CWCN,
CWS, BCLNC, FAAN
©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.
www.medline.com
Perioperative Pressure Ulcer Education
More important than ever before
OR11. 2. qxp: La yout 1 8/ 12/ 09 8: 00 AM Pa ge 55
56 The OR Connection
By Wolf J. Rinke, PhD, RD, CSP
Do you have problems with communication in
your facility and at home? Whenever I ask that
question of my audiences virtually all hands go up.
Why? Because we are all terrible communicators.
Here are 12 specific strategies that will help you
communicate more effectively and get more of
what you want.
1. Reality Test
Most of us assume words have meaning. They do not! The
fact is all of us speak a different “language” because we all
have different values, beliefs and life experiences that impact
how we interpret everything. For example, what does the
word “fast” mean to you? If you’ve been dieting, it probably
means “to not eat.” If you are an amateur photographer, 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
to race, you might think of the speed of a vehicle. And the list
goes on.
OR11. 2. qxp: La yout 1 8/ 12/ 09 8: 00 AM Pa ge 56
To get around this, do a reality test, especially when a shared
understanding is critical. Here are several examples. When
your spouse tells you how much you irritate him, summarize
your conversation: “Sweetheart, let me just make sure that
you and I are on the same page. What I heard you say was .
. .” At the end of a complicated instruction to one of your pa-
tients: “Now Miss Eager, we went over a lot of technical in-
formation. To make sure you will be able to follow my
instructions, please repeat what you heard me say.”
2. Get Really Good at Asking Questions
As an executive coach, I’ve learned the benefits of asking
questions. Here is what questions can do:
• Put you in control of the conversation. Questions elicit
an almost Pavlovian response in the listener to find
an answer.
• Establish rapport. Questions demonstrate interest, which
causes others to like you. And people who like you
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.
How to Communicate More Effectively and Get More of What You Want
Caring for Yourself
Continued on Page 59
OR11. 2. qxp: La yout 1 8/ 12/ 09 8: 00 AM Pa ge 57
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OR11. 2. qxp: La yout 1 8/ 12/ 09 8: 01 AM Pa ge 58
Aligning practice with policy to improve patient care 59
• Achieve deeper understanding. When you ask questions,
you will help the other party focus on what you want
them to focus on.
• Provide for greater buy-in, higher motivation and
compliance. Questions allow individuals to come up
with their “solution,” and invariably their level of
commitment will increase.
3. Avoid Fundamental Attribution Errors
Someone is late for an appointment, and we perceive that
they don’t care or they are sloppy, when in fact they may
have had an accident. In psychology this is referred to as
making a fundamental attribution error. I refer to it as “we
are very good at running our own movies,” meaning that we
attach all kinds of meanings to behavior we observe that has
nothing whatsoever to do with the person’s actions.
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.”
My consistent advice is deceptively simply but extremely
powerful: If in doubt, check it out.
4. Utilize Adult Language
According to Eric Berne and Thomas Harris, of the transac-
tional analysis (TA) fame, all of us utilize three different internal
“recordings” that represent our “ego states”: child, parent
and adult.
The child ego state refers to the behavior pattern, thoughts
and feelings we learned as children. They include helpless-
ness, blaming and emotional expressions such as “I can’t
help it,” “Don’t blame me,” “It’s your fault,” etc. Nonverbal
cues of the child ego state include whining, whistling, laughing,
teasing, expressing dejection, pouting, nail biting, moving
restlessly and looking rebellious, nervous or sad.
Our parent ego state was developed by observing parents
and other authority figures. When we are in a parent role we
tend to be very judgmental, critical, controlling, comforting or
nurturing, and use such phrases as “You can’t do that,” “You
have to,” “Always,” “Never,” etc. Nonverbal cues include
finger pointing, looking at your watch while communicating,
finger tapping, pressing lips tight, grinding teeth, checking
up on others, scowling, sneering, patronizing or expressing
sympathy.
The third internal recording is that of the adult. An adult is a
fact finder, information seeker, analyzer and logical problem
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.”
OR11. 2. qxp: La yout 1 8/ 12/ 09 8: 01 AM Pa ge 59

60 The OR Connection
6. Listen Actively
Even though it’s been said by the prolific author Anonymous,
“It is better to remain quiet and be thought a fool than to
speak and remove all doubt,” most of us are very good at re-
moving all doubt. One reason is that most of us are very
good at “talking and telling” instead of “listening and learn-
ing.” To become an active listener, remind yourself that there
must be a reason that we were born with only one mouth
and two ears.
The better you get at listening, the more you’ll find out what
the other party really wants. Once you know that, you are
communicating from a position of strength. Your husband
says: “For our next vacation I want to go to Phoenix.” Un-
fortunately you are tired of Phoenix. Instead of telling him
why Phoenix is a bad idea, ask questions to find out what he
really wants. “Please tell me what you would like to do in
Phoenix?” He might say, “I want to play golf where the air is
warm and dry.” Now you can put your thinking caps on to
identify lots of places that will meet both of your needs. Here
are several related strategies:
• When someone asks a question, keep your mouth shut
until the other person has finished speaking. Do this even
though you know the answer when the other person
begins to speak. Remember, when the mouth is
engaged, the ears are out of gear.
• Show the person speaking that you are listening actively
by totally focusing all of your mental energy on what the
other person is saying, not only with her words but also
her body. You can achieve that by making strong eye
contact, leaning slightly forward and using your body
language to acknowledge the message and
the messenger.
solver. When you use your adult recording, you ask why?
what? when? where? who? how? and say such things as “I
made a mistake,” “I changed my mind,” “I don’t know,”
“I don’t understand,” “It’s my opinion,” “Let me check on
that,” and “What can we learn from this?” When you are in
this ego state, you tend to be clear, calm and non-judg-
mental. Your nonverbal expressions include straight but
relaxed posture, comfortable eye contact and a friendly face
that says, “I’m interested in what you have to say. I’m alert,
thoughtful and attentive.”
Communication effectiveness is dramatically enhanced
when you express yourself in an adult ego state, especially
when both you and the other party are playing the same
recording. Since it is difficult to change other people,
I strongly urge you to get in the driver’s seat of your trans-
actions by using adult language whenever you are commu-
nicating. If you would like more help with this, read my How
to Maximize Professional Potential CPE program available
from www.easyCPEcredits.com.
5. Accept 111 Percent Responsibility
for the Entire Communication Process
Most of us are experts at playing the blame game. Have you
noticed that when there is a breakdown in communication,
it’s almost always the fault of someone or something else,
but seldom the person who is making the excuses! To make
this point, ask someone who arrives late for a meeting,
“Would you have been on time if $1,000 were riding on it?”
The typical answer is “Of course!”
To achieve dramatic improvements in your communication
effectiveness, I strongly recommend that you buy 111 per-
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.)
It is better to remain quiet and be thought a fool
than to speak and remove all doubt,”
— Anonymous
OR11. 2. qxp: La yout 1 8/ 12/ 09 8: 01 AM Pa ge 60
Aligning practice with policy to improve patient care 61
• Listen to the “music” as well as the words. In order to
really understand what’s being communicated, it’s
important that you hear more than the words, which
you can achieve by tuning into the mood, atmosphere
and emotional tone that put the words into context.
• Demonstrate empathy by getting inside the other
person’s thoughts and feelings. This can be expressed
by saying “I see,” “I understand,” “I follow you,” “I’m with
you,” and so on.
• Take off your mask and be yourself. This engenders
trust, and trust is essential to effective communication.
• Before ending your communication, summarize and do
a reality test, as previously discussed.
7. Express Yourself in Positive Terms
When we speak, we can say things negatively or positively.
For example, you can say, “I don’t have an answer for that,”
or “I can answer that the next time we get together.” Which do
you think is easier to understand? Research has demon-
strated that positively worded statements are one-third eas-
ier to comprehend than their negative counterparts. The
reason is that human beings are unable to move away
from the reverse of an idea. Instead, we move toward that
which we visualize in our minds. Don’t believe it? Let me ask
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
from the reverse of an idea. Take advantage of this phenom-
enon by expressing yourself in positive terms.
8. Master the PIN Technique
The PIN technique is a powerful way to reframe your percep-
tions and turn the negatives into positives. Here is how it
works. When you are confronted with anyone or anything that
would cause you to react negatively, PIN it. For example, your
team member says, “Boss, you know how morale has gone
down the tube? Let’s close the hospital and go on a cruise.”
Instead of NIPing anything “weird,” focus your mental energy
first on the:
P - Positive. Ask yourself what could be positive about your
employee’s suggestion: “Well at least she seems interested in
making things better.” After you’ve done that in your mind’s
eye, next evaluate the …
I - Interesting or Innovative. Ask what could be interesting
or innovative about your team member’s suggestion. “Maybe
there is a need for more celebration around here.” Once
you’ve evaluated that, and only after you’ve exhausted all the
Ps and Is, then ask yourself: “What is the downside, or the
…”
N - Negative. Because in communication, just like in life,
nothing ever goes one way, there is yin and yang, health and
sickness, life and death, high stock market and low stock
market and the list goes on. PINing it will enable you to eval-
uate both the upside and downside of every conversation.
However, if you NIP comments, ideas or suggestions in the
bud, it’s like closing the proverbial shade, which prevents you
from seeing opportunities.
9. Convey Integrity at All Times
People prefer to deal with communicators they can trust,
rather than those they have to second-guess. The fact is that
without trust, relationships die and your ability to communi-
cate is severely compromised. So be sure to be congruent,
which means that your body language, vocal patterns and
pitch support what you’re saying. And the way to achieve 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
To turbo-charge your communication
effectiveness, pretend that all people you
communicate with have printed across
their forehead a big bold sign that reads
MAKE ME FEEL IMPORTANT!
Continued on Page 63
OR11. 2. qxp: La yout 1 8/ 12/ 09 8: 01 AM Pa ge 61
OR11. 2. qxp: La yout 1 8/ 12/ 09 8: 01 AM Pa ge 62
Aligning practice with policy to improve patient care 63
people use habitually without being aware of their implica-
tions. For example, avoid saying, “Let me be absolutely
honest with you.” If you say that to me, I’m thinking: “What are
you normally?”
10. Strive For Win-Win
When you are communicating be on the lookout for things
that will be beneficial to the other party. For example, if you are
talking with a team member, instead of saying “You have to
yada, yada, yada,” use: “How can I help you with . . .?” When
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
the “battle” because it causes the other person to become
defensive. So what’s a better approach? Make the other per-
son right. My Superwoman and I have taken this to another
level. Anytime we find ourselves getting into conflict, one of
us will raise his/her hand with all five fingers extended, which
stands for: “You are right about that.” (One finger for each
word.) So you don’t sound like a parakeet, use other phrases
that make the other person right, such as: “That is a very
interesting idea;” “I’ve never thought of it that way;” “This
seems very important to you,” etc. So make it a habit to agree
with people and you will find that you will get much better
results with far less resistance. (For other powerful techniques
read my Win-Win Negotiation CPE program, available at
www.easyCPEcredits.com.)
12. Make Them Glad They Communicated
with You
To turbo-charge your communication effectiveness, pretend
that all people you communicate with have printed across
their forehead a big bold sign that reads MAKE ME FEEL
IMPORTANT! This phrase will remind you to always focus on
their needs first, because once they get the feeling you want
to help them, most people will do whatever they can to
reciprocate, which in the long run will help you get more of
what you want.
Dr. Wolf J. Rinke, RD, CSP is a keynote speaker, seminar leader,
management consultant, executive coach and editor of the free
electronic newsletters Make It a Winning Life and The Winning
Manager. To subscribe go to www.WolfRinke.com. He is the
author of numerous books, CDs and DVDs including Winning
Management: 6 Fail-Safe Strategies for Building High-Performance
Organizations and Don’t Oil the Squeaky Wheel and 19 Other
Contrarian Ways to Improve Your Leadership Effectiveness available
at www.WolfRinke.com. His company also produces a wide variety
of quality pre-approved continuing professional education (CPE)
self-study courses including his latest The Power of Communication:
How to Increase Your Personal and Professional Effectiveness
on which this article was based. It is available at www.easyCPE-
credits.com. Reach him at WolfRinke@aol.com.
OR11. 2. qxp: La yout 1 8/ 12/ 09 8: 01 AM Pa ge 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.
www.medline.com
OR11. 2. qxp: La yout 1 8/ 12/ 09 8: 01 AM Pa ge 64
5
Aligning practice with policy to improve patient care 65
Support
Breast Cancer
Awareness
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 www.nationalbreastcancer.org.
In partnership with NBCF, Medline
has helped fund grants to hospitals
and other healthcare organizations
that offer free mammograms to
women in need. Through this part-
nership, Medline continues its mis-
sion to give back to customers and
their communities, help promote the
early detection of breast cancer and
ultimately save lives. We hope this
campaign will help spread the word –
early detection and mammograms save lives!
New Breast Cancer Awareness Web Page
Medline has just launched a new Web page dedicated to breast
cancer awareness and the “Together We Can Save Lives”
campaign. Raising breast cancer awareness among nurses is
one of our key goals, as it is the leading cause of death for
women ages 40-55. The average age of a nurse is 46.
The Web page contains background on the breast cancer
campaign, AORN breakfast forum special event details with
photo galleries and keynote speaker bios. Visit today at
www.medline.com/breast-cancer-awareness.
Pink Ribbon Products
Medline Industries, Inc. also promotes breast cancer
awareness by displaying the pink ribbon logo on products.
By purchasing a pink ribbon product from Medline, you are
helping to support Medline’s $100,000 annual contribution
to the NBCF.
Some of the products include pink exam gloves, the pink rib-
bon rollator, pink ribbon bouffant caps and breast cancer
awareness scrubs and other apparel. Ask your Medline
rep for details or visit www.medline.com/breast-cancer-
awareness.
Caring for Yourself
OR11. 2. qxp: La yout 1 8/ 12/ 09 8: 01 AM Pa ge 65
66 The OR Connection
More than 1,000 guests attend Medline’s annual Breast Cancer
Awareness Breakfast during the AORN Congress.
Famous breast
cancer survivors
Ann Jillian (left)
and Dr. Marla
Shapiro.
Guests at the 2009 Medline Breast Cancer Awareness Breakfast.
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
i nspiring stories from famous breast cancer survivors.
In 2009 Medline was proud to host TV journalist Linda Ellerbee.
Past speakers have i ncl uded Dr. Marl a Shapi ro, Rue
McClanahan and Ann Jillian.
If you attended our Breast Cancer Awareness Breakfast at the
AORN Conference this past spring, and signed up for our
breast cancer awareness mailing list, you will be receiving sev-
eral education and awareness mailings, including information
on our campaign, breast cancer news and events and
special gifts.
Not on the list? Go to www.medline.com/breast-cancer-
awareness and sign up today!
Save the Date!
Medline’s Breast Cancer
Awareness Breakfast
AORN Congress, Denver, CO
March 3-8, 2010
OR11. 2. qxp: La yout 1 8/ 12/ 09 8: 01 AM Pa ge 66
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.
2. Before a Mirror
Inspect your breasts with your
arms raised high overhead. Next,
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
will not match exactly. Few
women’s breasts do match.
3. Lying Down
Place pillow under right shoulder,
right arm behind your head.
With fingers of left hand flat,
press right breast gently in small
circular motions, moving vertically
or in a circular pattern covering
the entire breast.
Use light, medium and firm pressure. Squeeze nipple,
check for discharge and lumps. Repeat these steps on
your left breast.
Recommendations for Routine
Mammography Screening
Age 40: A baseline mammogram as a standard for future
comparison
40-49: a mammorgram every one or two years, depending
on previous findings
50 and older: a mammogram every year
Compliments of Medline’s “Together We Can Save Lives
Through Early Detection” campaign. To learn more go to
www.medline.com//breast-cancer-awareness.
Breast Self-Examination
• Each year, more than 211,000 American women learn
they have breast cancer.
• The chance of a woman having invasive breast cancer
sometime during her life is about 1 in 8. The chance
of dying from breast cancer is about 1 in 35.
• About 192,370 estimated cases of breast cancer for
women and about 1,910 estimated cases of
breast cancer for men will be diagnosed in 2009.
Of these, 40,170 cases for women and 440 cases
for men will result in death.
• Nearly 90 percent of women diagnosed with breast
cancer will survive their disease at least five years.
• The chance of getting breast cancer goes up as a
woman gets older. Most cases occur in women
over 60.
• Women 40 and older should have a mammogram
every one to two years. Mammograms are the most
effective way to detect breast cancer.
• Breast cancer death rates are falling, probably as a
result of early detection and improved treatment.
References
American Cancer Society, www.cancer.org
National Cancer Institute, www.cancer.gov
Breast
Cancer
Facts
OR11. 2. qxp: La yout 1 8/ 12/ 09 8: 01 AM Pa ge 67
68 The OR Connection
24-Hour Dill Pickles
(24 servings)
Healthy Eating
•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
into spears)
•1 bulb garlic, separated, peeled and
sliced thin
•5 to 6 heads fresh dill
Directions:
Put first four ingredients in a large pot and bring
to a rolling boil. Set aside and cool completely.
Place cucumbers in a half gallon jar, along with the garlic
and dill. If you like spicy, add a little crushed pepper as
well. Next, pour the cooled liquid mixture into the jar.
Attach a lid and store in the refrigerator. (It must be kept
refrigerated.) After 24 hours, they are ready, but if you leave
them for 48 hours, they taste even better. The pickles will
keep three to six months in the refrigerator.
This recipe, which was created by
Medline employee Vicki Brown,
was a Gold Medal Winner at Med-
line’s I nternati onal Cookoff dur-
i ng Employee Appreciation Week
2008. Vi cki chose the reci pe
because it was quick and easy, plus
she could use home grown vegeta-
bles to make it.
As Operations Manager for Medline’s Information Services
Department, Vicki said she tested her pickle recipe with
the department’s 130 employees before the cookoff,
and it was a big hit. “I still have people calling me and
asking when they can get their next jar! They don’t just like
the pickles – they crave them. If you eat one, you just want
more.”
She added, “Vegetable gardening was part of my life
growing up, and we did a lot of canning. I’ve gotten back
into gardening as an adult, using only organic materials for
growing and fertilizing.” She said she would never even
dream of using anything other than home grown cucum-
bers to make her pickles.
This year she will be entering the Employee Cookoff again,
possibly in the entrée category, again making a recipe
using her home grown veggies.
Nutritional
Information
Servings: 24
Amount per serving
Calories: 25
Total fat: 0 g
Sodium: 1,571 mg
Fiber: 0.3 g
OR11. 2. qxp: La yout 1 8/ 12/ 09 8: 01 AM Pa ge 68
Forms & Tools
Aligning practice with policy to improve patient care 69
The following pages contain practical tools for implementing
patient-focused care practices at your facility.
Surgical Care Improvement Project (SCIP)
Prophylactic Antibiotic Regimen Selection for Surgery . . . . . . . . .71
VTE Prophylaxis Options for Surgery . . . . . . . . . . . . . . . . . . . . . .73
CATS Decrease Surgical Site Infections – English . . . . . . . . . . .81
CATS Decrease Surgical Site Infections – Spanish . . . . . . . . . . .82
Institute for Healthcare Improvement (IHI)
What You Need to Know About Infections After Surgery:
A Fact Sheet for Patients – English . . . . . . . . . . . . . . . . . . . . . . . .75
What You Need to Know About Infections After Surgery:
A Fact Sheet for Patients – Spanish . . . . . . . . . . . . . . . . . . . . . . .77
World Health Organization (WHO)
How to Handrub? (Non-surgical) . . . . . . . . . . . . . . . . . . . . . . . . . .79
Medline’s double-door and tabletop warming
cabinets are the perfect way to ensure that
the warm blankets and fluids your patients
need before, during and after surgery are
right at your fingertips.
Studies have shown that hypothermia may
delay healing, predispose patients to wound
infections and increase the length of hospital
stays.
1
Clearly, taking measures to prevent
hypothermia in the perioperative setting
is crucial.
All of our blanket and fluid warmers have
conveniently located keypads and digital
controls for easy operation. The uniform
heating and open shelf design provide
greater temperature accuracy, and the
simplified control panel is a snap to use!
Best of all, Medline blanket and fluid
warmers are so affordable that you can
cover your needs on every floor!
To learn more about Medline
blanket and fluid warmers, contact
your Medline representative,
call 1-800-MEDLINE or visit us
at www.medline.com.
Reference
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.
1996;334:1209-1216.
©2009 Medline is a registered trademark of Medline Industries, Inc.
www.medline.com
Halt Hypothermia with Medline Warmers
OR11. 2. qxp: La yout 1 8/ 12/ 09 8: 01 AM Pa ge 70
Aligning practice with policy to improve patient care 71

Prophylactic Antibiotic Regimen Selection for Surgery
Surgical

Procedure Approved Antibiotics

CABG, Other
Cardiac or
Vascular

Cefazolin, Cefuroxime or Vancomycin** If -lactam allergy:
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
Considerations

*For cardiac, orthopedic, and vascular surgery, if the patient
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.
SCIP Forms & Tools
OR11. 2. qxp: La yout 1 8/ 12/ 09 8: 01 AM Pa ge 71
72 The OR Connection
Forms & Tools SCIP
Prophylactic Antibiotic Regimen Selection for Surgery
Surgical

Procedure Approved Antibiotics

Hip/Knee
Arthroplasty

Cefazolin or Cefuroxime or Vancomycin** If -lactam allergy:
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
Considerations

*For cardiac, orthopedic, and vascular surgery, if the patient
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.
OR11. 2. qxp: La yout 1 8/ 12/ 09 8: 01 AM Pa ge 72
Aligning practice with policy to improve patient care 73
VTE Forms & Tools

VTE Prophylaxis Options for Surgery
Surgery Type Recommended Prophylaxis Options*

Any of the following:


Intracranial
Neurosurgery
• 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
Neurosurgery.

Any of the following:

General Surgery
• 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.

Any of the following:

General Surgery with
a reason for not
administering
pharmacological
prophylaxis
• Graduated compression stockings (GCS)
• Intermittent pneumatic compression devices (IPC)

Any of the following:

Gynecologic Surgery
• 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

Any of the following started within 24 hours of surgery:

Elective Total Hip
Replacement
*Patients who receive
• Low molecular weight heparin (LMWH)
• 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.
OR11. 2. qxp: La yout 1 8/ 12/ 09 8: 01 AM Pa ge 73
74 The OR Connection
Forms & Tools VTE

VTE Prophylaxis Options for Surgery
Surgery Type Recommended Prophylaxis Options*

Any of the following:

Elective Total Hip
Replacement with a
reason for not
administering
pharmacological
prophylaxis
• Venous foot pump (VFP)
• Intermittent pneumatic compression devices (IPC)
Any of the following:

Hip Fracture Surgery
with a reason for not
administering
pharmacological
prophylaxis
• Graduated Compression Stockings (GCS)
• Intermittent pneumatic compression devices (IPC)
• Venous foot pump (VFP)
Any of the following:

Hip Fracture Surgery
• Low-dose unfractionated heparin ( LDUH)
• Low molecular weight heparin (LMWH)
• Factor Xa Inhibitor (Fondaparinux)
• Warfarin
Any of the following:

Elective Total Knee
Replacement
• Low molecular weight heparin (LMWH)
• Factor Xa Inhibitor (Fondaparinux)
• Warfarin
• Intermittent pneumatic compression devices (IPC)
• Venous foot pump (VFP)
Any of the following:
Urologic Surgery This
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.
OR11. 2. qxp: La yout 1 8/ 12/ 09 8: 01 AM Pa ge 74
Aligning practice with policy to improve patient care 75

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.


Surgi cal Infecti ons Forms & Tools
What You Need to Know about Infections after Surgery:
A Fact Sheet for Patients and Their Family Members
OR11. 2. qxp: La yout 1 8/ 12/ 09 8: 01 AM Pa ge 75

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
surgery.
• 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.
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.



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.

76 The OR Connection
Forms & Tools Surgi cal Infecti ons
OR11. 2. qxp: La yout 1 8/ 12/ 09 8: 01 AM Pa ge 76
Aligning practice with policy to improve patient care 77
Surgi cal Infecti ons Español Forms & Tools

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
afeitarse.
• 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.


Lo Que Usted Debe Saber sobre las Infecciones después de las Cirugías:
Pagína de Informe para Pacientes y Sus Familiares:
OR11. 2. qxp: La yout 1 8/ 12/ 09 8: 01 AM Pa ge 77
78 The OR Connection
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.
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
Improvement).


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.

Forms & Tools Surgi cal Infecti ons Español
OR11. 2. qxp: La yout 1 8/ 12/ 09 8: 01 AM Pa ge 78
Aligning practice with policy to improve patient care 79
RUB HANDS FOR HAND HYGIENE! WASH HANDS WHEN VISIBLY SOILED
Apply a palmful of the product in a cupped hand, covering all surfaces; Rub hands palm to palm;
Right palm over left dorsum with
interlaced fingers and vice versa;
Palm to palm with fingers interlaced; Backs of fingers to opposing palms
with fingers interlocked;
Rotational rubbing of left thumb
clasped in right palm and vice versa;
Rotational rubbing, backwards and
forwards with clasped fingers of right
hand in left palm and vice versa;
Once dry, your hands are safe.
How to Handrub?
Duration of the entire procedure: 20-30 seconds
May 2009
1a 1b 2
3 4 5
6 7 8
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.
Handrub (Non-surgi cal ) Forms & Tools
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.
Other reasons to try MediClip
• User instructions are right on the handle for
ease of use
• Ergonomic handle design provides a
comfortable grip
• Hands-free blade disposal protects the user
• Clean-up is easy with the sealed,
waterproof handle
• Smooth surface has no screws, crevices
or engraving to trap dirt and debris
Sign up now at to conduct your own extensive test of
MediClip! Get up to 10 clippers and five cases of blades
FREE!*
Sign up online at
www.medline.com/special/MediClip-Trial.asp
* 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
to five cases of MediClip blades.

Patent pending
FREE MediClip
®
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And now ...
Introducing the first
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Contact your Medline
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OR11. 2. qxp: La yout 1 8/ 12/ 09 8: 01 AM Pa ge 80
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 refect CMS policy.
Publication No: AZ-9SOW-6.2.3-071909-01 www.hsag.com
CATS Decrease
Surgical Site Infections
Clippers
Antibiotics
Temperature
Sugar
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.
Normothermia:
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 www.medqic.org.
Aligning practice with policy to improve patient care 81
CATS - SSI Forms & Tools
OR11. 2. qxp: La yout 1 8/ 12/ 09 8: 01 AM Pa ge 81
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 www.hsag.com
‘GATO’ Disminuye
Infecciones en el Sitio de Cirugía
Glucosa
Antibióticos
Temperatura
Opciones para
remover pelo
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.
Más información sobre la diminución de infecciones en el sitio de cirugía es disponible a www.medqic.org.
Antibióticos proflácticos:
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.
Normotheremia:
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
afeitar.
82 The OR Connection
Forms & Tools CATS - SSI Español
OR11. 2. qxp: La yout 1 8/ 12/ 09 8: 01 AM Pa ge 82
OR Connection
The
Aligning practice with policy to improve patient care
Subscribing to The OR Connection guarantees that
youʼll continue to receive this info-packed magazine
and wonʼt miss out on our industry updates and
articles addressing on-the-job issues and tips on
caring for yourself!
To subscribe, simply go to www.medline.com/
orconnection. You will need to provide:
Your name
Facility and position
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Never miss an issue of The OR Connection!
Subscriptions are free and signing up is a snap!
We also welcome any suggestions you might have on how we can continue to improve
The OR Connection! Love the content? Want to see something new? Just let us know!
Content Key
We've coded the articles and information in this magazine to indicate which patient
care initiatives they pertain to. Throughout the publication, when you see these
icons you'll know immediately that the subject matter on that page relates to one
or more of the following national initiatives:
• IHI's Improvement Map
• Joint Commission 2009 National Patient Safety Goals
• Surgical Care Improvement Project (SCIP)
We've tried to include content that clarifies the initiatives or gives you ideas and
tools for implementing their recommendations. For a summary of each of the
initiatives, see pages 6 and 7.
Medline’s Sahara
®
Super Absorbent OR table sheets are
designed with your patients’ skin integrity in mind. The
Braden Scale tells us that moisture is one of the major
risk factors for developing a pressure ulcer.
1
We also
know that as many as 66 percent of all hospital-acquired
pressure ulcers come out of the operating room.
2
That’s why we developed the Sahara Super Absorbent
OR table sheet. The Sahara’s super-absorbent polymer
technology rapidly wicks moisture from the skin and
locks it away to help keep your patients dry.
Sahara OR table sheets are available on their own or
as a component in our QuickSuite
®
OR Clean Up Kits,
which were designed to help you dramatically improve
your OR turnover time and help reduce cross contamina-
tion risk through a combination of disposable products.
References
1 Braden Scale for Predicting Pressure Sore Risk. Available at:
www.bradenscale.com/braden.PDF. Accessed November 6, 2008.
2 Recommended practices for positioning the patient in the perioperative practice
setting. In: Perioperative Standards and Recommended Practices. Denver, CO:
AORN, Inc; 2008.
www.medline.com
Keep your surgical patients desert dry.
To learn more about Sahara OR table sheets and
Medline’s comprehensive product line, contact your
Medline representative, call 1-800-MEDLINE or visit
us at www.medline.com.
44453_cvr.indd 2 8/12/09 12:44:04 PM
The
Aligning practice with policy to improve patient care
Volume 4, Issue 2
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