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Aligning practice with policy to improve patient care
Volume 5, Issue 2
Let Us Hear From You!
Back To Basics: Retained Objects
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la Ce t o r nt y er S u s rg
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Aligning practice with policy to improve patient care
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We've coded the articles and information in this magazine to indicate which patient care initiatives they pertain to. Throughout the publication, when you see these icons you'll know immediately that the subject matter on that page relates to one or more of the following national initiatives: • IHI's Improvement Map • Joint Commission 2009 National Patient Safety Goals • Surgical Care Improvement Project (SCIP) We've tried to include content that clarifies the initiatives or gives you ideas and tools for implementing their recommendations. For a summary of each of the initiatives, see pages 8 and 9.
Editor Sue MacInnes, RD, LD Clinical Editor Alecia Cooper, BS, MBA, RN, CNOR Senior Writer Carla Esser Lake Creative Director Mike Gotti Clinical Team Jayne Barkman, RN, BSN, CNOR Margaret Falconio-West, BSN, RN, APN/CNS, CWOCN, DAPWCA Rhonda J. Frick, RN, CNOR Anita Gill, RN Kimberly Haines, RN, Certified OR Nurse Jeanne Jones, RNFA, LNC Carla Nitz, RN, BSN Connie Sackett, RN, Nurse Consultant Claudia Sanders, RN, CFA Megan Shramm, RN, CNOR, RNFA Angel Trichak, RN, BSN, CNOR Perioperative Advisory Board Larry Creech, RN, MBA, CDT Carilion Clinic, Virginia Sharon Danielewicz, MSN, BSN, RN, RNFA St. Luke’s The Woodlands, Texas Tracy Diffenderfer, RN, MSN Vanderbilt University Medical Center, Tennessee Barb Fahey RN, CNOR Cleveland Clinic, Ohio Susan Garrett, RN Hughston Hospital Inc., Georgia Zaida I. Jacoby, RN, MA, M.Ed NYU Medical Center, New York Jackie Kraft, RN, CNOR Huntsville Hospital, Alabama Tom McLaren Florida Hospital, Florida 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 Shore University Health System, Illinois Page 58 About Medline Medline, headquartered in Mundelein, IL, manufactures and distributes more than 100,000 products to hospitals, extended care facilities, surgery centers, home care dealers and agencies and other markets. Medline has more than 800 dedicated sales representatives nationwide to support its broad product line and cost management services.
8 Three Important National Initiatives for Improving Patient Care 12 New Joint Commission Report Shows Continued Improvement in Quality of Patient Care 13 The Joint Commission Tracer Methodology: Surgical Site Infections 22 #2 on the Joint Commission List: Retained Foreign Objects 48 CAUTI Alert: Proceed with Caution 54 Reducing CAUTI with Bladder Ultrasound
10 Ambulatory Surgery Center Quality Collaboration Expands Mission 18 Indiana Surgeon Lowers Surgical Site Infection Rates 30 Harm is Not an Option: Lessons from HROs 58 New Regulations for Infection Prevention in Ambulatory Surgery Centers
5 Let’s Talk About You! Survey 20 The Future is Now for New Learning Technologies 42 Preparing Your Organization for Color-by-Discipline Uniforms 62 A State-of-the-Art Hybrid Program for the OR 65 Never Lose Sight of Why We Are Nurses 68 Medline Hosts 5th Annual Breast Cancer Awareness Breakfast
CARING FOR YOURSELF
74 Win-Win Negotiation: How to Get More of What You Want 82 Healthy Eating: Syrian Salad
FORMS & TOOLS
85 2009 AAAHC/CMS Crosswalk for Infection Control 89 Pressure Ulcer Prevention Checklist: Perioperative Services 93 WHO Surgical Safety Checklist
Meeting the highest level of national and international quality standards, Medline is FDA QSR compliant and ISO 13485 registered. Medline serves on major industry quality committees to develop guidelines and standards for medical product use including the FDA Midwest Steering Committee, AAMI Sterilization and Packaging Committee and various ASTM committees. For more information on Medline, visit our Web site, www.medline.com.
©2010 Medline Industries, Inc. The OR Connection is published by Medline Industries, Inc. One Medline Place, Mundelein, IL 60060. 1-800-MEDLINE.
Aligning practice with policy to improve patient care 3
THE OR CONNECTION I Letter from the Editor
Wow! This edition of The OR Connection is just full of informative material! Beginning with the cover, let me introduce to you Dr. Michael Turner, a neurosurgeon with Goodman Campbell Brain and Spine in Indianapolis, Ind. We were delighted to meet with Dr. Turner, who invited us to join him in surgery to observe what he is doing to reduce surgical site infections. See page 18 for more information or go to http://www.medline.com/turner-video to view a short video clip of Dr. Turner describing his techniques. Next, you’ll notice on the opposite page a fun survey you can take online. We have survey information from AORN attendees, but now we want to open it up to everyone who reads The OR Connection. We will be posting the survey results in our next edition and sharing success stories from our readers on innovative programs, initiatives and solutions in the OR! Can’t wait to show you what we have so far. Another part of the survey asks questions about technologies you use, such as cell phones and Blackberries and iPhones. We have been taking a close look at how our lives have changed and continue to change based upon new and exciting technology releases. We know that as more and more new nurses and physicians enter the work force, the way they communicate may be much different from someone who has been in health care for 25 or 30 years. It is important that the industry keeps in step with the rest of our culture, so we are excited to announce that Medline has just released its first-ever iPhone app. It’s on Medline University now, and it’s FREE! You can download the app on your iPhone or iPod Touch. Some of the app features include real-time industry news, video courses, audio download courses, competencies and the list goes on. Now learning can be fun and interactive! Medline University “students” also have the ability to report completed courses to their employer. Learn anywhere, anytime! How’s that for keeping up with the times? You will also find updates on the activities of the Ambulatory Surgery Center Quality Collaboration, tracking surgical site infections using The Joint Commission Tracer Methodology, and on pages 38 and 39, some highly recommended books to read! As you know, for the past five years Medline has been an active supporter of breast cancer awareness. This year, once again, we hosted a Breast Cancer Awareness breakfast attended by the biggest crowd ever, over 1,200 people! Our guest speaker was Peggy Fleming, Olympic Gold Medalist from 1968 and a breast cancer survivor. I can remember when she won; the young girl in the chartreuse dress, winning the only gold medal from the United States at the Grenoble Olympics. Prior to the breakfast, I had the pleasure of interviewing Peggy Fleming. I was in third grade when she won, and now so many years later I was interviewing her for The OR Connection. Today, she is every bit the person I remembered… graceful, calm and oh, so strong. Take a look at page 68 for highlights from Congress. Finally, I am so excited to show you our newest nurse doll. She is the “Pink Glove Doll,” and her name is Deb. Deb is a true inspiration of the caring spirit we have inside and the support we bring to such a great cause. Take a closer look at Deb on page 73. Medline is committed to providing quality products, educational offerings and innovations to make your job easier. We want to continually lead the way in developing cost-effective, safe and practical solutions. There are a host of things on the horizon, and we are excited to hear your reaction. Please call or e-mail me any time! I’d love to hear from you.
Medline is committed to providing quality products, educational offerings and innovations to make your job easier.
Sue MacInnes, RD, LD Editor
On the cover: Indianapolis neurosurgeon Michael Turner, MD, applies Arglaes after closing a surgical incision.
The OR Connection
Let’s Talk About
First Prize Second Prize
All winne will be featu rs upcoming is red in sues of
The OR Connection !
Step 1: Complete the Survey!
The ﬁrst 1000 survey submissions will receive the latest and greatest addition to our Medline Doll collection. Results of the survey will be published in the next issue of The OR Connection!
Step 2: Answer the Bonus Question!
In 50 words or less, describe an innovative program, initiative and/or solution implemented at your facility that made a signiﬁcant impact on quality and patient/resident care.
The entire Medline Doll collection A plaque awarding the 2010 Contribution to The OR Connection!
There will be several second place award winners, who will all receive the entire Medline Doll collection.
Everyone can be a winner!
You can submit the survey three ways:
1. Complete the survey online at www.medline.com/orconnection 2. Manually complete the survey, tear it out and fax it to 847-949-3073. 3. Mail it back to us at Medline Industries, Inc., One Medline Place, Mundelein, IL 60060 Attn: Marketing Department – The OR Connection
MEDLINE HEALTHCARE SURVEY Let’s talk about you!
1. Tell us about yourself Name ________________________________ Credentials (i.e., RN, LPN, etc.)______________ Facility ______________________________ Street Address ________________________ City/Town ____________________________ State/Providence ______________________ Zip/Postal Code ________________________ Phone ( ) ________________________ 5. What are your top three priorities? 1. __________________________________ 2. __________________________________ 3. __________________________________ 6. Which of the following is most helpful in improving patient care? ❏ Continuing Education ❏ Competency 7. How often do you believe education is transferred by the clinician to bedside practice? 2. Where do you work? ❏ Hospital ❏ Surgery Center ❏ Other (please specify) 8. Which staff member are you most concerned about when it comes to 3. Number of beds at your facility? ❏ < 100 ❏ 200-349 4. What is your job title? ❏ Chief Nursing Ofﬁcer (CNO) ❏ Director of Nursing (DON) ❏ Staff Nurse - OR ❏ Staff Nurse ❏ Staff LPN - OR ❏ Staff LPN ❏ OR Nurse Manager ❏ OR Aide/Technician ❏ VP/Director of Perioperative Services ❏ Wound Care Nurse ❏ Clinical Educator - OR ❏ Risk/Quality Manager ❏ Aide/Technician ❏ Other (please specify) ❏ Online (e-Learning) ❏ Written ❏ Audio ❏ Video/CD/DVD ❏ Live Presentation ❏ Webinar ❏ Other (please specify) 15. What percentage of time do you feel the facility protocol is followed? ❏ 25% ❏ 50% ❏ 75% ❏ 100% 9. What medium would you like to see education materials offered in? (Choose all that apply) 14. How much time do you spend on perioperative pressure ulcers during new employee orientation? ❏ 350-499 implementing the necessary changes at your facility to be successful? ❏ Nursing ❏ Aides/Technicians ❏ Managers ❏ Physicians ❏ Other (please specify) 12. Do you see perioperative pressure ulcers as a problem in your facility? ❏ Yes ❏ No ❏ 0% – 20% ❏ 21% – 40% ❏ 41% – 60% ❏ 61% – 80% ❏ 81% – 100% 11. Circle your top three worst custom procedure tray experiences below: 1. Unauthorized changes/situations 2. Delays in requested change 3. Running without - supply(ies) missing from kit/tray 4. Foreign body found in tray (e.g., insect, hair, etc.) 5. Inventory supply out 6. Waste (unused items) 7. Wrong items/missing items (e.g., non-radiopaque sponges/miscounted sponges) 10. Are the number of Foley catheters placed for surgical procedures increasing or decreasing at your facility? ❏ Increasing ❏ Staying the same ❏ Decreasing
❏ 101-199 ❏ 500+
13. Do you have a facility protocol for prevention of perioperative pressure ulcers? ❏ Yes ❏ No
The OR Connection
16. Do you currently have protocols in place for handoff communication? ❏ Yes ❏ No
(For a chance to win the entire Medline Doll Collection)
Everyone whose answer is chosen for publication in The OR Connection will receive the collection. In 50 words or less, describe an innovative program, initiative and/or solution implemented at your facility that made a signiﬁcant impact on quality and patient care.
17. What is your facility’s pressure ulcer incidence?
18. What are your biggest barriers to pressure ulcer prevention in the OR?
19. Has your organization ever been involved in a legal suit involving pressure ulcers? ❏ Yes ❏ No
20. Have you personally ever been involved in a legal suit involving pressure ulcers? ❏ Yes ❏ No
21. Which of the following technologies do you have? (Check all that apply) ❏ PDA (Blackberry®, Palm®, iPhone®) ❏ Cell phone ❏ iPod®/mp3 ❏ DVD player ❏ CD player ❏ Electronic reading device (Kindle®, Sony®, iPad®) ❏ Computer 22. If you checked PDA, what type do you have? ❏ iPhone® ❏ Palm
Submit your survey online at:
Blackberry is a registered trademark of Research In Motion Limited Palm is a registered trademark of Research In Motion Limited iPhone is a registered trademark of Apple Inc. iPod is a registered trademark of Apple Inc. Kindle is a registered trademark of Amazon Technologies, Inc. Sony is a registered trademark of Sony Corporation Droid is a trademark of Lucasﬁlm Ltd.
❏ Droid™ ❏ Other
Aligning practice with policy to improve patient care 7
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.
IHI Improvement Map
Launched by the Institute for Healthcare Improvement (IHI) in January 2009 To help hospitals improve patient care by focusing on an essential set of processes needed to achieve the highest levels of performance in areas that matter most to patients.
Hospitals sign up through IHI and can choose to implement some or all of the recommended interventions. IHI provides how-to guides and tools for all participating hospitals. The IHI Improvement Map covers the entire landscape of outstanding hospital care to help hospitals make sense of countless requirements and focus on high-leverage changes to transform care. There are 70 processes grouped into three domains: leadership and management, patient care and processes to support care.
Joint Commission 2010 National Patient Safety Goals
Developed by Joint Commission staff and the Patient Safety Advisory Group (formerly the Sentinel Event Advisory Group) To promote specific improvements in patient safety, particularly in problematic areas
Joint Commission-accredited organizations are evaluated for compliance with these goals. The Joint Commission offers guidance to help organizations meet goal requirements. Over the next year, the current National Patient Safety Goals (NPSGs) will undergo an extensive review process. As a result, no new NPSGs will be developed for 2010; however, revisions to the NPSGs will be effective in 2010.
Origin: Purpose: Goal:
Surgical Care Improvement Project (SCIP)
Initiated in 2003 as a national partnership. Steering committee includes the following organizations: CDC, CMS, ACS, AHRQ, AHA, ASA, AORN, VA, IHI and the Joint Commission To improve patient safety by reducing postoperative complications To reduce nationally by 25 percent the incidence of surgical complications by 2010
SCIP aims to reduce surgical complications in three target areas. Participating hospitals collect data on specific process and outcome measures. The SCIP committee believes it could prevent 13,000 perioperative deaths and up to 300,000 surgical complications annually (just in Medicare patients) by getting performance up to benchmark levels.
The OR Connection
IHI Improvement Map: 70 Processes to Transform Hospital Care
The IHI Improvement Map is an online tool that distills the best knowledge available on the key process improvements that lead to exceptional patient care.
Top 5 Key Processes Viewed by Improvement Map Users 1. Acute Myocardial Infarction (AMI) Core Processes 2. Set Direction: Aims 3. CA-UTI 4. Communication and Teamwork 5. Central Line Bundle Top 5 Key Processes Shared by Improvement Map Users 1. Central Line Bundle 2. CA-UTI 3. Anti-Biotic Stewardship 4. Falls Prevention 5. Heart Failure Core Processes
To learn more about the IHI Improvement Map and the 70 processes to transform hospital care, go to www.ihi.org/imap/tool
Joint Commission 2010 National Patient Safety Goals
• Improve the accuracy of patient identification. • Improve the effectiveness of communication among caregivers. • Improve the safety of using medications. • Reduce the risk of healthcare-associated infections. • Accurately and completely reconcile medications across the continuum of care. • Reduce the risk of patient harm resulting from falls. • Prevent healthcare-associated pressure ulcers (decubitus ulcers). • The organization identifies safety risks inherent in its patient population. • Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery.™
No new NPSGs have been developed for 2010. Effective January 1, 2010, organizations are expected to have fully implemented the requirements related to healthcare-associated infections established in 2009.
To learn more about National Patient Safety Goals, go to www.jointcommission.org.
Surgical Care Improvement Project (SCIP): Target Areas
1. Surgical infections • Antibiotics, blood sugar control, hair removal, perioperative temperature management • Remove urinary catheter on POD 1 or 2 2. Perioperative cardiac events • Use of perioperative beta-blockers 3. Venous thromboembolism • Use of appropriate prophylaxis
By the numbers: • 3,740 hospitals are submitting data on SCIP measures, representing 75 percent of all U.S. hospitals • Currently, SCIP has more than 36 association and business partners
Aligning practice with policy to improve patient care 9
(Left to right) David Shapiro, MD, Donna Slosburg, BSN, LHRM, CASC and Kimberly Wood, MD of the ASC Quality Collaboration.
Our goal is to help ASCs learn about the new regulations and supplement their existing infection control programs with helpful tools and resources for key infection control processes.
10 The OR Connection
Ambulatory Surgery Center Quality Collaboration Expands Mission
Back in 2006, when the Ambulatory Surgery Center (ASC) Quality Collaboration was created, its mission was – as it is now – to improve the quality of care and safety in ambulatory surgery centers. In the four years of its existence, it has quite an impressive list of accomplishments. According to co-chairs David Shapiro, MD, and Kimberly Wood, MD, when the collaboration began, one of its main initiatives was to identify a standardized set of quality measures appropriate to ASCs. Like other segments of health care, such as hospitals, the goal was to develop speciﬁc quality measures by which individual ASCs could measure or benchmark themselves in order to improve quality of patient care. At the time, there were no nationally endorsed ASC benchmarking measures, though the Ambulatory Surgery Foundation had a successful comprehensive data collection instrument available for some time. The leadership also had the vision to be the first healthcare entity to voluntarily report data on its own industry to publicly show its commitment to quality. The data also could be used in “discussions on pay-for-performance, responding to state data collection initiatives, collaborating with payors and others in providing consumer information, and benchmarking information primarily for quality improvement goals in individual ASCs.” But what they found, according to Dr. Shapiro, was that none of the existing quality measures in healthcare ﬁt exactly with ASCs. “Now we had to become developers of quality measures,” said Dr. Shapiro. Consensus of the leadership group was to initially focus on patient safety-related measures. The ASC Quality Collaboration worked with several industry groups to study and then develop the following initial ASC facility-level performance measures: • Patient Falls in the ASC • Patient Burns • Hospital Transfer/Admission • Wrong Site, Side, Patient, Procedure, Implant • Prophylactic IV Antibiotic Timing • Appropriate Surgical Site Hair Removal Starting in 2008, the data became publicly available. The National Quality Forum has endorsed these measures, and the data – updated quarterly – can be found on the ASC Quality Collaboration website at www.ascquality.org. The data is currently being collected on these measures from approximately 1,000 ASCs nationwide through the following organizations: Ambulatory Surgery Center Association, Ambulatory Surgical Centers of America (ASCOA), AmSurg, HCA Ambulatory Surgery Division, National Surgical Care (NSC), Nueterra, Surgical Care Afﬁliates (SCA), Symbion and United Surgical Partners International (USPI). “We hope ASCs look at the data,” said ASC Quality Collaboration Executive Director Donna Slosburg, BSN, LHRM, CASC, “and see where they stand with these industry benchmarks to ensure they are achieving a high level of quality.” The Collaboration’s most recent project stems from revised ASC Conditions for Coverage, which CMS implemented on May 18, 2009, and which represent the ﬁrst signiﬁcant changes to the Conditions since 1982. Dr. Wood explained these new changes would expand the scope of the CMS surveys. Among the changes in the Conditions for Coverage were new requirements for infection control. Surveyors would now have a speciﬁc tool to gather information on infection control practices in ASCs. “The surveyors are now looking at the infection control practices of ASCs more intensely and with much more scrutiny than ever before,” Dr. Wood said. “Our goal is to help ASCs learn about the new regulations and supplement their existing infection control programs with helpful tools and resources for key infection control processes.”
Aligning practice with policy to improve patient care 11
New Joint Commission Report Shows Continued Improvement in Quality of Patient Care
Hospitals accredited by The Joint Commission continue to improve quality of patient care, according to the recently released Improving America’s Hospitals: The Joint Commission’s Annual Report on Quality and Safety 2009. The fourth annual report shows continual improvement over a seven-year period (2002-2008) on 12 quality measures reflecting the best evidence-based treatments – practices demonstrated by scientific evidence to lead to the best outcomes. The magnitude of national improvement on these measures ranged from 4.9 percent to 58.8 percent. Surgical measures in all three areas of antibiotics administration have shown a steady improvement from 2005 to 2008. (See chart below.)
Improved quality saves lives, improves health and reduces costs
“In addition to saving lives and improving health, improved quality reduces health care costs by eliminating preventable complications,” said Mark R. Chassin, MD, MPP, MPH, president, The Joint Commission. “Quality improvement is an important aspect of the ongoing reform effort to make health care accessible to more Americans and ‘bend the curve’ on increasing costs. By eliminating the preventable complications that today drive up the cost of care, we would easily save the many billions of dollars lawmakers are struggling so hard to locate.”
Surgical Care Measures
National Performance Summary, 2005-2008 2005 Antibiotics within one hour before the ﬁrst surgical cut Appropriate prophylactic antibiotics Stopping antibiotics within 24 hours 81.8% N/A 73.5% 2006 86.6% N/A 79.1% 2007 89.5% 94.9% 85.6% 2008 93.5% 96.8% 90.5%
Source: Improving America’s Hospitals: The Joint Commission’s Annual Report on Quality and Safety 2009. Available at: http://www.jointcommission.org/NR/rdonlyres/22D58F1F-14FF-4B72-A870-378DAF26189E/0/2009_Annual_Report.pdf
12 The OR Connection
The Joint Commission Tracer Methodology: Surgical Site Infections
Connie Yuska, RN MS CORLN
The Joint Commission introduced the tracer methodology into the survey process in 2004. The purpose behind the tracer methodology is to help the surveyor assess the facility’s compliance with selected standards and evaluate systems for providing care and services. When using the tracer methodology, the surveyor selects a patient, resident or client, and then, using the medical record as a road map, follows that individual through the facility. As surveyors trace a patient’s path of care, they may identify compliance issues in one or more elements of performance. The process allows the surveyor to identify trends in compliance that may point to potential system-level issues.
Aligning practice with policy to improve patient care 13
Tracer Methodology in Action
Patient Room Recovery
One example of a tracer that touches several hospital departments is surgical site infection (SSI). Having effective infection control and prevention policies in place is critical to providing safe, quality patient care. Following patients through their hospitalization can help the organization assess the overall quality of care provided and make improvements if gaps are uncovered. Infection control system tracers are applicable in any healthcare setting and are linked with National Patient Safety Goal 07.05.01. This patient safety goal asks that hospitals and ambulatory healthcare organizations “implement evidencebased practices for preventing surgical site infections” and require compliance with the following elements of performance:1 • Educate surgical staff, licensed independent practitioners, patients and families about SSIs and SSI prevention. • Implement policies and procedures to reduce the risk of SSIs. • Measure SSI rates and provide process and outcome measure results. • Conduct periodic risk assessment, check SSI measures, monitor compliance, and evaluate effectiveness. • Administer prophylactic antimicrobial agents. • Use only clippers or depilatories for hair removal.
The tracer process requires a healthcare organization to work as a team rather than prepare one particular area for a Joint Commission survey. In addition, it enables the organization to quickly identify issues related to communication between departments. Organizations have found that this process results in less time spent on document review and more time spent on actual observation of what happens to a patient as they move through the organization. The information collected from the tracer process is invaluable, as it gives the organization a roadmap for identification of potential breakdowns in care. This provides the opportunity to focus on improving processes to help ensure patient safety and provide high quality care.
14 The OR Connection
Now available from Joint Commission Resources! Mock Tracer Workbook
Tracer methodology is the most prevalent part of The Joint Commission and Joint Commission International on-site accreditation survey process. So what’s the best way for health care professionals to learn about tracers? Practice. Let’s take a look at a typical tracer that involves a patient who was admitted to a community hospital through the same-day surgery area, entered the operating room for a left hip replacement and two days after surgery was discovered to have an SSI. The surveyor typically begins the tracer in the area where the patient is currently located and receiving post operative care, in this case, on the orthopedic unit. Questions that the surveyor may ask the staff nurse include the following: • How did you assess the patient for SSI risk factors associated with orthopedic surgery? • What did you do when you suspected the patient had an SSI? • What is the process to receive orders for and administer prophylactic antibiotics? • What education was provided to the patient about his surgery and SSI prevention? • What is your hospital’s SSI prevention plan? • How do you monitor for SSIs after surgery? • How do you conduct and document assessments after a patient has surgery? • How are the patient and their loved ones told about an SSI? • What type of ongoing training do you receive about preventing SSIs? The next step would be to follow the path that the patient took two days earlier into the operating room suite. The entire operative process as it relates to SSI prevention should be traced. Speciﬁc measures in the pre-, peri- and postoperative areas can be examined to determine their effectiveness in preventing SSIs. The Mock Tracer Workbook provides practical exercises to help healthcare professionals practice skills needed to conduct an effective tracer in any healthcare setting. During an on-site survey, surveyors use tracers to evaluate the care of an individual or to evaluate a speciﬁc care process as part of a system. By doing so, the tracer provides an accurate assessment of the daily functions at a healthcare organization. Order your copy today! Mock Tracer Workbook Price: $89 Item number: MTW09 ISBN: 978-1-59940-306-9 148 pages To order, call 877-223-6866 (M-F, 8 am to 8 pm Eastern time), or online at www.jcrinc.com/Books-and-E-books/Mock-TracerWorkbook/1637.
Questions for the staff in the operative area may possibly include the following: • Describe how you prepare the patient’s surgical site. • What is your organization’s policy on hair removal? On prophylactic antibiotic use? • How would you care for a patient with a preoperative infection? • Describe your stafﬁng levels. • What and how do you communicate when the patient transitions out of the operating room to the post anesthesia recovery room? • What is the organization’s SSI reduction program?
Aligning practice with policy to improve patient care 15
Using a focused approach like the tracer methodology allows you to examine your organization from the patient’s perspective.
The surveyor may then ask the patient if she could ask him a few questions about his hospital experience. The patient may express concern about the infection, but hopefully the surveyor will hear that the physician has explained how the infection occurred and what is being done to treat it. The next step for the surveyor would be to conduct a broader system-based infection control tracer. At this point, the infection preventionist would share their surveillance data related to SSIs. The surveyor would ask how this data is communicated to key stakeholders and what kinds of risk assessments are performed. The surveyor will be looking for an ongoing process that is effective in reducing surgical site infections.
The surveyor may ask the infection preventionist the following questions:2 • What policies and procedures are implemented regarding SSI prevention? • What data do you collect regarding SSIs? • How do you evaluate the data and communicate to key stakeholders in the organization? • How often are the data communicated? • What kinds of improvements have you implemented as a result of your data collection and analysis? • What kind of initial and ongoing training about SSIs is provided to surgical staff? Using a focused approach like the tracer methodology allows you to examine your organization from the patient’s perspective. This can provide valuable information about your systems and processes and can help you make improvements that will improve the quality and safety of the care that you provide.
References 1. 2009 Hospital Accreditation Standards. Oakbrook Terrace, IL : Joint Commission Resources, Inc.; 2009. 2. Tracer methodology 101: infection control tracer—surgical site infection focus. The Joint Commission: The Source. 2010; 8(3):6-10.
16 The OR Connection
ARGLAES IN THE OR
ANTIMICROBIAL SILVER TECHNOLOGY
Use silver to ﬁght bacteria.
Arglaes provides: • • • • • Antimicrobial protection for up to 7 days Moist wound healing Fewer dressing changes Non-attaining assay Transparency for wound monitoring The Arglaes family of products has something for every wound: • Arglaes Film is ideal for managing bacterial penetration on post-op incision and line sites. • Arglaes Island features a calcium alginate pad for ﬂuid management in addition to controlled-release silver.
To schedule a FREE demonstration of Arglaes in your OR, contact your Medline representative, call 1-800-MEDLINE or visit www.medline.com.
©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
Indiana Surgeon Reduces Surgical Site Infections with Optifoam and Arglaes
Neurosurgeon Michael Turner, MD, was looking for a way to reduce surgical site infections in his patients at Park Nicollet Methodist Hospital’s Surgery Center in Indianapolis, Ind. Most of his surgeries involve implanting morphine pumps, spinal cord stimulators and shunts. He found the solution in Medline’s Optifoam and Arglaes wound dressings. Dr. Turner explained that if an infection develops in an implant patient, it often means having to perform a second surgery, discarding a $20,000 to $30,000 device, plus the expense to replace the implant. Not to mention the patient having to endure not only an infection and related physical deﬁcits, but also the trauma of another surgery. “So infection avoidance is really very important to us,” Dr. Turner said. Dr. Turner and his team had always applied surgical prep to the patient’s skin to lower colony-forming units, followed by an iodine-impregnated drape. But the challenge was ﬁnding a way to destroy and avoid spreading the infection-causing organisms that emerge when the hair follicles and sweat glands are exposed after making the surgical incision. Surgical staff next have to touch the organism-laden incision to make room for the implant. In the process, they pick up organisms on their gloved hands, which then transfer onto the implant, further spreading the organisms in the process. “So we needed to put a barrier there,” Dr. Turner said. “A number of studies have shown it only takes 100 organisms to develop a clinical infection. Trying to get rid of the 100 organisms is really where we’re aiming – and Optifoam does that.” Dr. Turner applies Optifoam to the edges of the incision seconds after making the cut. “We found that Optifoam has a great consistency, and it contains silver to kill organisms.”
Dr. Turner also uses Arglaes surgical wound dressings to lower the rate of abscess infections at suture sites. He said the antimicrobial silver and creation of an anaerobic environment combine for good wound healing. Before using Optifoam and Arglaes, study data from Methodist Hospital Surgery Center showed high infection rates among patients with pump implants. Dr. Turner said these rates declined signiﬁcantly after using Optifoam and Arglaes. He also found greatly reduced infection rates in one of the most highrisk groups of stimulator implant patients: obese smokers. “We’ve continued to use Optifoam long after our study, and really find that our infection rate continues to drop as we become better at putting it on earlier and maintaining that environment of not touching the skin with our gloves at any time,” Dr. Turner concluded.
18 The OR Connection
Prot ted An e t Exc ction w imicrob epti ial ona ith l Ab sorb enc y
Opt ifoam ® Dres sing Ag Targ s e
Optifoam Ag helps you manage both the wound and the bioburden. A safe, targeted release of ionic silver provides antimicrobial protection for up to seven days without harming healthy tissue. Plus, with Optifoam Ag’s excellent ﬂuid handling properties you can: • Change the dressing less frequently • Decrease potential pain and discomfort for your patients • Reduce staff time and supply costs Non-cytotoxic and non-staining, Optifoam Ag conforms to the wound and manages repeated bacteria introduction.1 For managing post-operative wounds, Optifoam Ag is your key to success.
1. Data on ﬁle.
To receive a FREE trial of Optifoam® Ag, contact your Medline representative or call 1-800-MEDLINE today!
©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
The Future is
for New Learning Technologies
Don’t get left behind!
Advances in technology have resulted in numerous online educational opportunities that are both free and easy to access. In fact, electronic learning tools have nearly eliminated the need to actually attend a class for continuing education. Online webinars, e-textbooks and podcasts are just a few of the options. And how about iPhone® apps? Beginning with the 2008-2009 school year, all incoming freshmen at Abilene Christian University in Texas are required to have an iPhone. Apps are used to turn in homework, look up campus maps and check class schedules and grades. For classroom participation, there’s even polling software so students can digitally raise their hand to answer questions.1 William Rankin, a professor at Abilene Christian, comments, “This is a question of how do we live and learn in the 21st century now that we have these sorts of connections? I think this (the iPhone) is the next platform for education.”1
Other colleges and universities are catching on to the iPhone as an educational tool as well. Students enrolled in the undergraduate journalism program at the University of Missouri are required to have an iPod Touch® or an iPhone to download course material.2 And the Blackboard app is gaining popularity at many high schools and colleges as a way to post assignments, grades, documents, discussion boards and anything else associated with a course.3 Posted on wired.com by: Panacea | 12/8/09 | 6:04 pm1 The community college where I teach nursing piloted giving iPods to students a few years ago, with the idea of using iTunes U. They like being able to replay lectures. I don’t do a traditional lecture in class anymore. The students download their lectures. Class time is for interactive assignments such as care mapping, case studies, and discussion. Students still get to ask questions about the iTunes content. Grades have been steadily improving over the last 3 years since I’ve moved to iTunes U. Retention has improved 15%.
20 The OR Connection
Teaching & Learning: THE PRINT AGE
Course activity typically focuses on presentation of information with students contextualizing, practicing or using information at home. The classroom is the primary site of access to course content, and access is often “linear” – students cannot typically return to previous class presentations.
Teaching & Learning: THE DIGITAL AGE
Course activity typically focuses on students contextualizing, practicing, or using information with presentation of information occurring at home through media or online access. Access to course content is augmented by electronic sources and media, and access is often recursive or “on-demand,” allowing students to return to content when and as often as they’d like. In addition to classroom access, students and teachers have access to one another via “virtual” means – online discussions, e-mail, chat, social networking, etc.
Students and teachers have access to one another primarily in the classroom.
Source: Dr. William Rankin, “Abilene Christian University 2008-09 Mobile-Learning Report.” Available at: http://www.acu.edu/technology/mobilelearning.
References: 1. Chen BX. How the iPhone could reboot education. Wired – Gadget Lab. Available at: http://www.wired.com/gadgetlab/2009/iphone-university-abilene. Accessed March 29, 2010. 2. Dignan L. Apple’s iPod Touch, iPhone as education tool: should universities dictate whether you’re a Mac or PC? Available at: http://blogs.zdnet.com/BTL/?p=17775. Accessed March 29, 2010. 3. The Next Generation of Educational Leadership: A blog for educational leaders who want to learn, share and discuss 21st-century education leadership strategies. March 29, 2009. Available at: http://nextgeneduleaders.blogspot.com/2009/blackboard-app-for-iphone-great-tool.html. Accessed March 31, 2010.
Aligning practice with policy to improve patient care 21
22 The OR Connection
Back to Basics
Twelfth in a Series
#2 on the Joint Commission List:
Retained Foreign Objects
By Alecia Cooper, RN, BS, MBA, CNOR
“Foreign objects like sponges, scalpels and surgical instruments should never be left in the body cavity after an operation. Surgeons who commit this serious and completely avoidable medical error must be held accountable. At Friedman, Domiano & Smith, our lawyers ﬁle medical malpractice lawsuits in Ohio courts, calling attention to this serious problem and working to achieve the best possible results for our clients. To talk conﬁdentially about how a retained object has affected you, contact the law ofﬁces of Friedman, Domiano & Smith.”1
Whether or not you have been part of a retained objects lawsuit, it’s important to know that the issue of retained foreign objects (RFOs) is a serious, preventable complication that is increasing in incidence and complexity. The California Department of Public Health reported 141 retained foreign objects in patients during ﬁscal year 20072008, and the count increased to 196 for 2008-2009. In addition to sponges, found objects included catheters, dentures, drill bits, electrodes and screws.5 The Joint Commission considers retention of a foreign body a sentinel event. They recommend taking the following steps if a foreign object is retained in the patient:6 • Report the incident according to state regulations • Report the incident to the Joint Commission. Although this step is not mandatory, unreported sentinel events can adversely affect accreditation. • Conduct a root cause analysis to thoroughly investigate how and why the situation occurred. • Develop a detailed action plan to prevent similar occurrences in the future For FY 2007, CMS recorded 750 incidents of foreign objects retained after surgery, which incurred an average cost of an additional $63,631 per case. As of October 1, 2008, CMS introduced new regulations that deny reimbursement for healthcare expenses related to retained for-
“Admitted to a Macon, GA, hospital in 2004 for surgery for diverticulitis of the colon, Lucille Davis, then 67, left with an undetected and dangerous souvenir: a surgical sponge. The error resulted in a $10 million settlement.”2
“These cases require a thorough understanding of appropriate operating room procedures and the various roles of the surgeons and surgical nursing staff. At Williamson & Lavecchia, L.C., our attorneys have successfully handled many cases involving retained objects during surgery. Examples include sponges left during surgery to remove a gallbladder, a hysterectomy, and a Cesarean section. In each case, the patient required further surgery, lengthy recuperation and the patient incurred signiﬁcant medical expenses.”3
Aligning practice with policy to improve patient care 23
eign objects and other hospital-acquired conditions.7 It’s still too soon to tell whether this measure will help reduce the incidence of these conditions.7
Reasons for RFOs
With sponge counting as a routine procedure in most ORs, and heightened awareness of patient safety, why are foreign objects continuing to be retained after surgery? Several studies suggest possible explanations. A 2003 study by Gawande et al. reviewed medical records associated with a retained surgical sponge or instrument between 1985 and 2001. The study included 54 patients and a total of 61 retained foreign bodies.8 Findings showed that patients with retained foreign bodies were more likely to have had emergency surgery or an unexpected change in surgical procedure. These patients also had a higher mean body mass index (BMI) and were less likely to have had counts of sponges and instruments performed during their surgery. In another study that reviewed 191,168 operations performed at the Mayo Clinic from 2003 to 2006, there were 34 cases of retained foreign objects discovered after the patient left the OR. Root cause analysis of the events showed the most common contributing factor was breakdown in communication, particularly failure of team members to communicate when an item was placed in the body.9
Another study found that 88 percent of retained foreign objects were associated with a count that was thought to be correct. Similarly, a study by Cima et al. showed that 62 percent of retained foreign object cases involved a correct sponge, sharp and instrument count.9 In a study looking at the reasons for count discrepancies, 41 percent of the discrepancies were attributed to human errors involving addition mistakes, incorrect documentation or miscounting. For these reasons, the American College of Surgeons (ACS) and the Association of periOperative Registered Nurses (AORN) recommend methodical wound exploration in addition to a surgical count.9
Ways to avoid RFOs
The two most frequently used methods to try to prevent retained foreign objects are counting sponges, instruments and sharps before and after surgery and X-raying the body cavity before a procedure closes. (OR sponges and towels often contain X-ray detectable material inside for this purpose.) Despite these measures, many studies have shown foreign objects being found inside the body after surgery in a signiﬁcant number of cases in which counts were performed and reconciled or radiographs came up negative for foreign bodies before closing. A few of these studies are summarized below. In 2008, 1,564 reports received by the Pennsylvania Patient Safety Authority involving incorrect sponge, sharps or instrument counts indicated that a radiograph was performed. In 1,123 (71 percent) of those reports, the radiograph was negative for a retained foreign object.9
Factors that affect surgical count accuracy6 • Failure to develop and implement an effective policy and procedure for surgical counts • Failure to follow the policy and procedure • Disruptions during the performance of surgical counts • Change in personnel during a procedure and the lack of proper handoff • Staff fatigue, especially during lengthy and emergency cases • A knowledge deﬁcit about performance of surgical counts by any team member • Failure to use X-ray detectable items (such as sponges) • Failure to count all components of an instrument (all removable parts) and failure to inspect all items for completeness (a broken needle, for example)
Innovative products to minimize the risk of RFOs
In addition to the use of X-rays to detect surgical objects inside the body, medical device companies have developed several options to minimize the retention of foreign objects and assist with surgical counts. New systems such as these are recommended by the Pennsylvania Patient Safety Authority as additional safety measures and technological support to further reduce the risk of retained foreign objects.9
24 The OR Connection
Integrated laparotomy pad/retractor.10 This device is composed of an outer lap pad consisting of 12 layers of absorbent cotton wrapped around a malleable inner stainless steel mesh. The device reduces the use of individual pads while also providing needed retraction. It may be shaped to the individual needs of the operating ﬁeld, providing excellent exposure while also reducing the risk of retained foreign bodies. In addition, the radiologic image of the laparotomy pad/retractor is signiﬁcantly more radioopaque that a traditional lap pad, providing a greater sense of security that the device will be detectable by X-ray. RFID.11 The RFID (radiofrequency identiﬁcation) system consists of a mobile console with an electronic monitor screen, a scanning surface for counting sponges “in” and a waste bucket for counting sponges “out.” Each RFID sponge has its own unique identiﬁcation tag sewn into it, which the system reads. Sponge counts are then displayed on the monitor in real time. Also included is a wand that may be passed over the patient’s body to detect sponges before the case is closed. Developers of the RFID system note that the idea for the device was conceived by an operating room nurse. After conducting observations in operating rooms across the country, the nurse concluded that sponge counts were problematic in every surgery. Therefore, the RFID system was created with an internal counting mechanism to safeguard against miscounts. RF.12 The RF system is similar to the RFID system, but it consists of a wand device only, which is passed back and forth and side to side over the patient’s body to detect sponges before the case is closed. It can also be used to scan the ﬂoor and other surfaces for missing sponges. The system consists of three components: a handheld scanning wand connected to a compact, self-calibrating console and micro RF tags that are embedded in surgical gauze, sponges and towels. Bar codes. Similar to the electronic RF and RFID tags, bar codes are placed inside sponges as a tracking mechanism. An individual data matrix code is embedded onto each sponge. Each sponge is scanned by a handheld computer before being placed into the patient and after surgery is completed.13
Aligning practice with policy to improve patient care 25
In a study to determine the effectiveness of bar codes,14 a total of 33 incidents of misplaced sponges were detected. Of those misplaced, 30 sponges were found in the trash, under drapes, on the ﬂoor or elsewhere on the sterile ﬁeld outside the patient. The remaining three sponges were found inside the patient. The bar code system was found to be more effective than manual counting for the detection of sponges; however, it also takes longer than manual sponge counting, according to the study.
What does the future hold?
Although technology has focused mainly on the detection of sponges, methods for detecting surgical instruments are also under development.10 Clearly, more research and technological advances are needed to further pinpoint the reasons for retained foreign objects and reduce their occurrence.
AORN Recommended Practices for Sponge, Sharp and Instrument Counts15
I. Sponges should be counted on all procedures in which the possibility exists that a sponge could be retained. II. Sharps and other miscellaneous items should be counted on all procedures. III. Instruments should be counted for all procedures in which the likelihood exists that an instrument could be retained. IV. Additional measures for investigation, reconciliation, documentation, and prevention of retained surgical items should be taken. V. Sponge, sharp and instrument counts should be documented on the patient’s intraoperative record by the registered nurse circulator. VI. Policies and procedures for sponge, sharp, and instrument counts should be developed, reviewed periodically, revised as necessary, and readily available in the practice setting.
References 1. When retained objects injure Ohio patients. Friedman, Domiano, Smith Co., L.P.A. website. Available at: http://www.fdsmedicalmalpractice.com/Surgical_Errors/ Retained-Objects.shtml. Accessed March 26, 2010. 2. Japsen B. Technology cuts risks of surgical sponges: objects left in patients expensive to remove. January 1, 2008. BlueCross BlueShield website. Available at: http://www.bcbs.com/news/national/technology-cuts-risk-of-surgical-spongesobjects-left-in-patients-expensive-to-remove.html. Accessed March 5, 2010. 3. Williamson & LaVecchia, LC website. Available at: http://www.wllc.com/practice_areas/retained-objects-from-surgery.cfm. Accessed March 5, 2010. 4. Updated sentinel event statistics. Joint Commission Online. April 7, 2010. Available at: http://www.jointcommission.org/NR/rdonlyres/9621C0D4-0222-465A-B4A5069FBB2169ED/0/jconlineApril710.pdf. Accessed April 12, 2010. 5. Clark C. Surgeons still forgetting to remove objects from patients. Health Leaders Media. February 1, 2010. Available at: http://www.healthleadersmedia.com/ QUA-245777/Surgeons-Still-Forgetting-To-Remove-Objects-from-Patients. Accessed March 5, 2010. 6. Campione BA. Know the risk factors for retained foreign bodies. OR Nurse. July 2009:56. 7. Centers for Medicare & Medicaid Services. Proposed Changes to the Hospital IPPS and FY2009 rates. Available at: http://edocket.access.gpo.gov/2008/pdf/E817914.pdf. Accessed April 7, 2010. 8. Gawande AA, Studdert DM, Orav EJ, Brennan TA, Zinner MJ. Risk factors for retained instruments and sponges after surgery. New England Journal of Medicine. 2003;348(3):229-235. 9. Beyond the count: preventing retention of foreign objects. Pennsylvania Patient Safety Advisory. 2009;6(2):39-45. 10. Enker WE, Martz JE, Picon A, Wexner SD, Fleshman JW, Koulos J, et al. An incremental step in patient safety: reducing the risks of retained foreign bodies by the use of an integrated laparotomy pad/retractor. Surgical Innovation. 2008;35(3):203-207. 11. McGowan A. “Smart” sponge detection. Surgical Products. Available at: http://www.surgicalproductsmag.com/scripts/ShowPR~PUBCODE~0S0~ ACCT~0006505~ISSUE~0904~RELTYPE~PR~PRODCODE~2805~ PRODLETT~A.asp. Accessed March 29, 2010. 12. RF Surgical Systems, Inc. Features. Available at: http://www.rfsurg.com/features.htm. Accessed April 1, 2010. 13. Bar codes help improve safety in operating room; system helps identify additional miscounts. HealthCare Benchmarks and Quality Improvement. August 2008. Available at: http://ﬁndarticles.com/p/articles/mi_m0NUZ/is_8_15/ai_n32370597. Accessed April 1, 2010. 14. Greenberg CC, Diaz-Flores R, Lipsitz SR, Regenbogen SE, Mulholland L, Mearn F, et al. Bar-coding surgical sponges to improve safety. Annals of Surgery. 2008; 247(4):612-616. 15. Recommended practices for sponge, sharp, and instrument counts. In: Retzlaff K, ed. Perioperative Standards and Recommended Practices. Denver, Colo.: Association of PeriOperative Registered Nurses; 2010:207-216.
26 The OR Connection
The beneﬁts of counting and detection in one advanced system.
The SmartSponge® System takes the worry out of ﬁnding and counting surgical sponges
For stressed nurses facing time pressures and distractions, there’s nothing more relieving than getting an accurate surgical sponge count. So it’s worth noting that the SmartSponge® System counts, locates and recounts each sponge up to 80,000 times during a single surgery. And because it is the only FDA-approved system that uses radio-frequency identiﬁcation, it uniquely identiﬁes each sponge, so you can use the SmartWand-DTXTM to ﬁnd missing sponges below, beside or inside a patient. A quick demonstration will give you the practical proof of how the ClearCount SmartSponge System can make your time in the O.R. a little less stressful. Call your Medline representative or 1-800-MEDLINE today and ﬁnd out how you can get 10% off your ﬁrst order.
Visit Booth 3601 at AORN Congress
©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc. SmartSponge® is a registered trademark of ClearCount Medical Solutions.
Back to Basics
CE Test Questions
#2 On the Joint Commission List: Retained Foreign Objects
True/False 1. The incidence of retained foreign bodies has been declining in recent years. T F 2. Staff fatigue during lengthy and emergency procedures is one factor that affects surgical count accuracy. T F 3. The Joint Commission does NOT consider retention of a foreign body a sentinel event. T F 4. New technologies for counting surgical instruments are currently under development. T F 5. The California Department of Public Health reported 141 retained foreign objects in patients during ﬁscal year 2007-2008. T F Multiple Choice 6. Which of the following sponge detection technologies does NOT include a wand? a Bar coding b. RF c. RFID d. None of the above 7. Which of the following is NOT recommended by the Joint Commission if a foreign object is retained in the patient? a. Conduct a root cause analysis to thoroughly investigate how and why the situation occurred. b. Develop a detailed action plan to prevent similar occurrences in the future. c. Find out who is to blame for the incident. d. Report the incident according to state regulations. Submit your answers at www.medlineuniversity.com and receive 1 FREE CE credit 8. According to AORN Recommended Practices, policies and procedures for sponge, sharp and instrument counts should be developed, reviewed periodically, revised as necessary and ______________. a. Kept in a locked ﬁle cabinet b. Shared only with surgeons c. Made readily available in the practice setting d. Forwarded to the Joint Commission 9. The two most frequently used methods to try to prevent retained foreign objects are counting sponges, instruments and sharps before and after surgery and __________________. a. Using a bar code system b. X-raying the body cavity before a procedure closes c. Minimizing trafﬁc ﬂow in the OR during surgery d. None of the above 10. For FY 2007, the Centers for Medicare & Medicaid Services (CMS) recorded 750 incidents of foreign objects retained after surgery, which incurred an average cost of an additional $__________ per case. a. 1,153 b. 63,631 c. 138,954 d. 14,849
This course is approved for one continuing education hour by the Florida Board of Nursing and the California Board of Registered Nursing
28 The OR Connection
KEEP YOUR SURGICAL
PATIENTS DESERT DRY.
Medline’s Sahara® Super Absorbent OR table sheets are designed with your patients’ skin integrity in mind.
The Braden Scale tells us that moisture is one of the major risk factors for developing a pressure ulcer.1 We also know that as many as 66 percent of all hospital-acquired pressure ulcers come out of the operating room.2 That’s why we developed the Sahara Super Absorbent OR table sheet. The Sahara’s super-absorbent polymer technology rapidly wicks moisture from the skin and locks it away to help keep your patients dry. Sahara OR table sheets are available on their own or as a component in our QuickSuite® OR Clean Up Kits, which were designed to help you dramatically improve your OR turnover time and help reduce cross contamination risk through a combination of disposable products.
QuickSuite® OR Clean Up Kit
To sign up for a FREE webinar on perioperative pressure ulcer prevention, go to www.medline.com/pupp-webinar.
Braden Scale for Predicting Pressure Sore Risk. Available at: www.bradenscale.com/braden.PDF. Accessed November 6, 2008. Recommended practices for positioning the patient in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2008.
©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
Harm is Not an Option:
Lessons from HROs
(High Reliability Organizations)
By Spencer L. Byrum and Kathleen Bartholomew, RN, RC, MN
hen you board an airplane, do you stop and ask which pilot is in command for that particular ﬂight? Do you query his team and ask others what they think of his/her ﬂying? Of course not!
30 The OR Connection
Aligning practice with policy to improve patient care 31
When you or a close relative is scheduled for surgery, do you request a particular surgeon?
Because you know that all pilots follow very speciﬁc proven procedures that all but guarantee they won’t forget anything. That’s why even though 3,400 commercial airlines controlled by 6,800 pilots ﬂy across the United States every day, not a single passenger died in a ﬁve year span from 2001 to 2006. Airlines, like nuclear power plants, infectious disease researchers, atomic submarines and high-rise construction companies are all high reliability organizations (HROs) that have one thing in common. They have learned how to make their organizations exceptionally safe despite operating in an extremely challenging environment. These organizations simply can’t afford not to get it right the ﬁrst time. When you or a close relative is scheduled for surgery, do you request a particular surgeon? If you work in a hospital, then you most likely do. Why? Because you have witnessed ﬁrsthand that outcomes vary. You know which surgeons or teams you like to scrub in with, as well as the ones you would rather avoid at all costs. Most of all, you know exactly who you will recommend to your loved ones for their surgical procedure. Do you know the healthcare safety record during the same ﬁve years there were no accidents in aviation? If you translated it into aviation terms, the equivalent of 1,427 Boeing 747s ﬁlled with passengers crashed, and 500,000 people died. These healthcarerelated deaths still have not made the headlines; and there are no major TV documentaries or advocacy groups storming the Capi-
tol for justice. Except for a few famous people, such as the Dennis Quaid twins, these accidents and deaths have gone unnoticed. The sad truth is that because these deaths occur one-by-one in a litigious culture that swears to secrecy and vows to “cover each other’s backs,” the dramatic impact of the 21 people per hour who die from preventable healthcare errors is virtually ignored. The same is not true for other industries. For example, when General Motors experiences a fatality or serious accident in their facility, the plant immediately shuts down until the system issue is addressed so the error will never happen again. When a worker is harmed or killed at a petroleum reﬁnery, everything comes to a halt immediately, and everyone is briefed about the event. But when two patients died within one month on the same telemetry unit as the result of communication errors at a Florida hospital, 99 percent of all hospital staff never knew the events occurred –
THE VOLUME AND COMPLEXITY
OF KNOWLEDGE TODAY has exceeded our ability as individuals to properly deliver it to people – consistently, correctly, safely. We train longer, specialize more, use ever-advancing technologies, and still, we fail.” A. Gawande
Continued on page 34
32 The OR Connection
PROTECTION, PERFORMANCE & COMFORT
SensiCare® surgical gloves address a rising concern in the OR — latex allergies.
The American Latex Allergy Association estimates that 8 to 17 percent of healthcare workers are sensitized to natural rubber latex.1 Medline’s Sensicare® latex-free polyisoprene surgical gloves are made from Isolex™ (synthetic polyisoprene) that has a molecular 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 ﬁts your needs. • SensiCare® with Aloe – standard thickness, smooth grip • SensiCare® LT with Aloe – standard thickness, textured grip • SensiCare® Green with Aloe – 10% thinner for enhanced tactile sensitivity • SensiCare® Ortho – 40% thicker for extra protection for enhanced tactile sensitivity • SensiCare® SLT – A non-aloe version of SensiCare LT that’s slightly thinner for improved sensitivity
Get a FREE one-day supply of SensiCare surgical gloves to try for yourself. To learn more, contact your Medline representative, call 1-800-MEDLINE or e-mail firstname.lastname@example.org.
References: 1 American Latex Allergy Association. Latex Allergy Statistics. Available at: www.latexallergyresources.org/topics/LatexAllergyStatistics.cfm. Accessed March 2, 2010. ©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
The same lack of coordination and communication that bedevils health care’s adoption of HRO principles was the primary cause of the Three-Mile Island meltdown, which changed the nuclear power industry forever.
even weeks later. A hospital is supposed to be a high reliability organization, but the vast majority of hospitals still have not adopted the practices that have demonstrated time and again how to prevent human error in a dangerous and complex system.
did things a certain way simply because no one was willing to risk the lives of any or all of the team members. So what exactly is it that HROs do to perform so well in a timecompressed, high-risk and stressful environment? They realized that reducing the number of variables was critical, so these organizations standardized processes and procedures whenever possible. They deﬁned roles, practiced rigorously and conducted both a pre-procedure and post-procedure brieﬁng for every complex procedure, and by doing so, they became predictably safe. High stress…High tech….High chance something could go wrong. By nature, most people want to do their best. But stress can be exceedingly high, processes can be ﬂawed and preventable errors are still a common occurrence in hospitals. All HROs conduct a pre-procedure brieﬁng and a post-procedure debrieﬁng every single time for every error-intolerant process. They report all incidents, regardless of whether there was any actual or perceived harm, in order to learn and apply this knowledge to avoid future accidents. HROs recognize that in time- and task-intensive environments, good people still have the potential to make serious errors, but the impact of those errors can be signiﬁcantly reduced or even eliminated if they are identiﬁed early. Standard operating procedures are followed without exception, as well as checklists for best practice, because they’re not willing to bet their life (or another team member’s life) on the chance that someone could inadvertently make a mistake. Today’s healthcare culture, howContinued on page 36
What is an HRO?
By deﬁnition, a high reliability organization (HRO) is an organization that manages an inherent risk with great precision and few, if any, serious accidents or incidents ever occur. The term HRO was coined by Karl Weick, a professor of organizational behavior and psychology at the University of Michigan. Dr. Weick identiﬁed a group of organizations that stood out because of consistently superior performance despite the fact that all of their environments were exceptionally demanding and contained signiﬁcant elements of time compression and stress.
Common Characteristics of HROs
1. High individual and organizational accountability 2. Preoccupation with avoiding failure 3. Broad knowledge base and high situational awareness 4. Rebound quickly after an undesired event 5. Consistently link cause and effect – continuous learning He found that these organizations were “highly reliable” because the errors they experienced were caught and corrected before they progressed to a catastrophic event. Because failure of one member of the team could mean death to the whole team, they
34 The OR Connection
The OR Goes Green
– the only TRULY eco-friendly surgical drape
Medline’s new patent-pending EcoDrape is the only eco-friendly surgical drape available today. Made of more than 96% wood pulp, EcoDrape will biodegrade in only two to ﬁve months in a landﬁll – polypropylene drapes take hundreds of years to break down. EcoDrape has all the same great features as other Medline drapes, including hook-and-loop line holders, large reinforcement zones, and premium tape and incise film ﬂush to the fenestration. Try the new EcoDrape and take your OR to the next level of green!
Composition Comparison EcoDrape SMS
Fibers Petrochemical ingredients (plastics) Additives
More than 96% wood pulp 0% Bio-based
No wood pulp 100% PP Fluorine
To schedule a FREE demonstration of the EcoDrape contact your Medline representative, call 1-800-MEDLINE or visit www.medline.com.
©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc. EcoDrape is a trademark of Medline Industries, Inc.
ever, tolerates quite the opposite. A recent data review revealed that physician compliance with protocols is far from ideal.1 There are many exceptions to the rule; and even best practices are not always implemented. Here are some examples: Last week the surgeon walked into the OR with his coffee cup, unmasked. We wrote it up in an incident report, and the next day, he did the exact same thing – with an attitude. So we stopped writing it up. “I don’t want to hurt my team’s feelings because I depend on them, so let’s pretend this whole thing (sentinel event) never happened. A review of 189 closed malpractice claims demonstrated that 40 percent of adverse outcomes related to intrapartum fetal hypoxia may have been avoided if 24-hour in-house coverage had been available. Despite this information, this coverage does not represent the current standard of care.2 An HRO culture would simply not allow maverick behavior, noncompliance or failure to report an error or do the right thing. A pilot who “didn’t feel like using the takeoff checklist” because he was in a hurry; or an infectious disease specialist who didn’t use best practice for isolating a Level 3 virus because it was too costly, would be quickly unemployed. Yet, the current healthcare culture still tolerates non-HRO practices? Why? Barriers to HRO technique application. The greatest barrier to adopting HRO principles and practices is a culture of hierarchy where autonomy is the core value. Physicians, the very people who we need desperately to champion a cultural change, frequently complain that the applicability of HRO principles to their practice is “cookbook medicine.” Many physicians claim tools such as checklists detract from their autonomy and lack a personal touch. Knowing what we know today about human error, these objections are not only dangerous, but absurd. Very simply put, if you had the opportunity to choose between an OR that could statistically ensure greater safety by using HRO principles and one that did not, which one would you choose? From an ethical perspective, healthcare demands that we “get it right” the ﬁrst time. It is our moral obligation to signiﬁcantly decrease the chance for human error.
Case Study – Individual
Dr. Z., a high energy, demanding emergency physician, was the biggest skeptic. He was known for his volatile temper, which was evident every time things weren’t going smoothly, and he put staff on edge. He even went to administration complaining about the “toxic culture” of the unit. One day he attended a workshop on HRO team processes – not because he wanted to further his knowledge, but rather to show what a waste of time it was. He came away with a profound sense of amazement and actually went back to administration to say he thought his own behavior and attitudes had been contributing to the chaos in the ED. He ﬁnally recognized that the more effectively the team functions, the better it communicates, and the better the collective decisionmaking for the patient. Even the EMTs noticed the ED was less chaotic and functioned more smoothly. And both patient and staff satisfaction increased signiﬁcantly.
Case Study – Organizational Use of HRO Techniques1
The rate of cesarean deliveries in the United States has continually increased (except for a plateau trend in the 1990s because of VBACs). Malpractice claims have increased with the rise of cesarean delivery rates. The use of three speciﬁc drugs was noted as a common denominator, and protocols for administration and checklists were put in place, combined with effective peer review. Incorporating HRO features at 120 facilities improved outcomes, reduced the cesarean delivery rate, lowered maternal and fetal injury and reduced litigation ﬁve-fold.1
36 The OR Connection
HRO 101. The element that is undoubtedly the most crucial part of becoming an HRO is effective communication. Members of the team are encouraged to speak up any time to anyone. High functioning HRO teams realize silence is never an option. They embrace their responsibility as a member of the team to share their observations and knowledge using precise, standardized terminology. HRO teams focus on making every critical communication clear, timely and solutions-driven, despite the inevitable chaos of daily events. HRO leaders understand that it is their ethical and moral responsibility to remove the hierarchy and create an environment where everyone feels safe. In the operating room, the surgeon is in the best position to encourage questions and create an atmosphere conducive to a two-way ﬂow of information. Following this six-step communication procedure is a great start for any ambulatory surgery center or OR.
Six-Step Communication Procedure in the OR3
1. Make sure team members know each other. 2. Verify patient’s identity and procedure. 3. Specify what the procedure involves, and review necessary supplies: a. Ask the surgeon to articulate the procedure and speciﬁc steps. b. Complete process for identifying and marking the proper site. 4. Ask questions: Nurse circulator should ask if there are any questions. 5. Discuss past procedures: Was anything done in a past procedure that could inﬂuence today’s operation? 6. Debrief after every procedure: This is the best opportunity to improve communication, safety and quality.
Healthcare is a decade or more behind other high risk industries in its attention to ensuring basic safety. Institute of Medicine
(Editor’s note: This procedure is similar to the Surgical Safety Checklist developed by the World Health Organization (WHO). A copy of the WHO checklist is available at www.who.int/patientsafety/safesurgery/en and in the “Forms & Tools” section of this issue.)
Continued on page 40
Aligning practice with policy to improve patient care 37
To help you enhance your high reliability organization
The Checklist Manifesto: How to Get Things Right
Atul Gawande, MD Henry Holt and Company, 2009 We live in a world of great and increasing complexity, where even the most expert professionals struggle to master the tasks they face. Longer training, ever more advanced technologies— neither seems to prevent grievous errors. But in a hopeful turn, acclaimed surgeon and writer Atul Gawande ﬁnds a remedy in the humblest and simplest of techniques: the checklist. First introduced decades ago by the U.S. Air Force, checklists have enabled pilots to fly aircraft of mind-boggling sophistication. Now innovative checklists are being adopted in hospitals around the world, helping doctors and nurses respond to everything from flu epidemics to avalanches. Even in the immensely complex world of surgery, a simple 90-second variant has cut the rate of fatalities by more than a third. revolution into ﬁelds well beyond medicine, from disaster response In riveting stories, Gawande takes us from Austria, where an emergency checklist saved a drowning victim who had spent half an hour underwater, to Michigan, where a cleanliness checklist in intensive care units virtually eliminated a type of deadly hospital infection. He explains how checklists actually work to prompt striking and immediate improvements. And he follows the checklist An intellectual adventure in which lives are lost and saved and one simple idea makes a tremendous difference, The Checklist Manifesto is essential reading for anyone working to get things right. to investment banking, skyscraper construction and businesses of all kinds.
38 The OR Connection
To Err is Human: Building a Safer Health System
Linda T. Kohn, Janet M. Corrigan, and Molla S. Donaldson, eds. National Academy Press, 2000 This now classic Institute of Medicine report, according to many experts, marks the beginning of the patient safety movement in U.S. health care. As many as 98,000 people die each year from medical errors that occur in hospitals. That's more than die from motor vehicle accidents, breast cancer, and AIDS – making medical errors the ﬁfth leading cause of death in this country. The Institute of Medicine seeks to improve the quality of care in America by focusing on the facts and making wide-ranging recommendations. Skilled and caring professionals can – and do – make mistakes because, after all, to err is human. It's time to build a better system.
updated, the second edition of Managing the Unexpected uses HROs is a template for any institution that wants to better organize for high reliability. The authors reveal how HROs create a collective state of mindfulness that produces an enhanced ability to discover and correct errors before they escalate into a crisis. A mindful infrastructure continually: • Tracks small failures • Resists oversimpliﬁcation • Is sensitive to operations • Maintains capabilities for resilience • Takes advantage of shifting locations of expertise
Why Hospitals Should Fly
John Nance, JD Second River Healthcare Press, 2008 Did you know that a checked bag on
This report called for a comprehensive effort by healthcare providers, government, consumers and others. Claiming that knowledge of how to prevent these errors already existed, it set a minimum goal of 50 percent reduction in errors over the next ﬁve years. Though not currently quantiﬁed, as of 2007 this ambitious goal had yet to be met.
an airline ﬂight is still exponentially safer than a patient in an American hospital? It is not very comforting to consider that a toothbrush has a better chance of reaching its destination than a patient has of leaving a hospital unscathed. This begs the question…why? John J. Nance, JD frames the issue this way:
Managing the Unexpected: Resilient Performance in an Age of Uncertainty
Karl E. Weick and Kathleen M. Sutcliffe Wiley and Sons, 2007 Why are some organizations better able than others to maintain function and structure in the face of unanticipated change? The authors answer this question by pointing to high reliability organizations (HROs), such as emergency rooms in hospitals, flight operations of aircraft carriers, and ﬁreﬁghting units, as models to follow. These organizations have developed ways of acting and styles of learning that enable them to manage the unexpected better than other organizations. Thoroughly revised and
“Nine long years after the Institute of Medicine told us nearly 100,000 patients die each year from avoidable errors in our hospitals (To Err Is Human, 2000), the struggle to signiﬁcantly reduce major patient injuries has barely begun. The primary reason it’s so tough to change the system is that no less than the culture of medical practice has been challenged and is, in effect, resisting change. Hospitals will only ﬂy when doctors, nurses, CEOs, trustees and every healthcare stakeholder overcomes the inertia that is anchoring hospitals to the failed cultural foundations of the past and embraces a new paradigm of patient-centered care. The time to take this ﬂight is now and this is your boarding call.
Aligning practice with policy to improve patient care 39
There is no doubt that HRO best practices reduce risk, gain efﬁciencies, enhance our ability to function as a productive team and communicate more effectively.
“The application of improvement tools is not only essential to modernizing care delivery but also the key to preserving the values to which our current system aspires.”4
The only real question is why do we hesitate? What prevents us from adopting proven tools that have been demonstrated time and again to improve patient outcomes? The Hippocratic Oath stands in stark contrast to the current reality where thousands of patients die yearly from preventable mistakes mainly because our culture impedes adoption of HRO practices. “First do no harm” isn’t a suggestion. It is the most basic of all promises that we make to patients who entrust us with their care.
About the authors
Interested in Learning More About HROs? Recommended reading
Articles • Swensen SJ, Meyer GS, Nelson EC, Hunt GC, Pryor DB, Weissberg JI, et al. Cottage industry to post-industrial care – the revolution in health care delivery. The New England Journal of Medicine. 2010;362(5):e12(10)-e12(4). Available at: http://content.nejm.org/cgi/reprint/NEJMp09\111 99.pdf?ssource=hcrc. • Weick KE. Organizational culture as a source of high reliability. California Management Review. 1987;29:112-127.
Spencer L. Byrum is managing partner of Convergent HRS LLC, a premier human performance improvement company that was speciﬁcally created and designed to enhance individual and team decision-making in high-risk industries. His specialty is taking lessons learned in aviation and developing innovative process improvements and training for professions in which people need to make critical decisions in a stressful, demanding environment. He spent his ﬁrst career as a Coast Guard pilot in charge of safety at two major air stations. He oversaw everything from hazardous materials compliance to complex ground and flight mishap inquiries. He has been a member on military, Federal Aviation Administration (FAA) and National Transportation Safety Board (NTSB) accident investigations. Kathleen Bartholomew, RN, RC, MN, has been a national speaker for the nursing profession for the past seven years. Her background 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. She also wrote Stressed Out About Communication, 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. To increase performance with High Reliability Organization methods, Kathleen has now partnered with ConvergentHRS.
References 1. Clark SL, Belfort MA, Byrum SL, Meyers JA, Perlin JB. Improved outcomes, fewer cesarean deliveries, and reduced litigation: results of a new paradigm in patient safety. American Journal of Obstetrics and Gynecology. 2008;199(2):105.e1-105.e7. 2. Clark SL, Belfort MA, Dildy GA, Meyers JA. Reducing obstetric litigation through alterations in practice patterns. American Journal of Obstetrics and Gynecology. 2006; 112(6):1279-1283. 3. Follow six-step communications procedure in OR to improve outcomes. Ambulatory Surgery Compliance and Reimbursement Insider. August 2004. Brownstone Publishing: New York. 4. Swensen SJ, Meyer GS, Nelson EC, Hunt GC, Pryor DB, Weissberg JI, et al. Cottage industry to post-industrial care – the revolution in health care delivery. The New England Journal of Medicine. 2010;362(5):e12(10)-e12(4). Available at: http://content.nejm.org/cgi/reprint/NEJMp0911199.pdf?ssource=hcrc. Accessed March 9, 2010.
40 The OR Connection
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42 The OR Connection
Carla Nitz, RN, BSN
Healthcare uniforms have come a long way since the days when registered nurses wore only white. Today’s nurses – and nearly all other hospital staff members – wear scrubs. And because scrubs come in all different colors, patterns and styles, it can be difﬁcult to differentiate a registered nurse from a respiratory therapist or a housekeeper. Staff members representing as many as 13 different disciplines may enter a patient’s room each day, leaving the patient wondering, just “who is my nurse?” It’s not uncommon for patients to report that “the nurse” gave them instructions, only to ﬁnd out later that it was a physical therapist or a dietitian. In an effort to improve patient care and satisfaction by making it easier for patients to identify their caregivers, many hospitals across the country have converted to color-by-discipline uniform programs. The color of the scrub uniform denotes the discipline the healthcare professional represents. Patients and staff are provided with a color key, allowing them to immediately recognize each healthcare discipline according to the color they wear. At the Medical Center of the Rockies, in Loveland, Colo., for example, nurses wear blue, lab employees wear black and radiology employees wear burgundy.
The prospect of changing uniforms has the potential to be unpopular at ﬁrst. We’re all creatures of habit, and change can be uncomfortable. Another argument staff often raise is that uniforms strip them of their individuality. Employees at the Medical Center of the Rockies found a new way to express their personality – with accessories! Kay Miller, the medical center’s vice president and chief nursing ofﬁcer, said some nurses decorate their name badges with cute pins, and others wear fun, brightly colored shoes. In addition, the dress code allows staff to wear theme print tops underneath their scrubs for special occasions such as Halloween and Christmas. Similarly, at the Medical University of South Carolina (MUSC) hospital in Charleston, S.C., staff can choose to wear either solid-color scrub tops and bottoms designated for their discipline or solid-color bottoms with a print top. Registered nurses are also allowed to combine white with their color or print top. This decision was well-received and allowed staff members to express their individuality.1 When building support for your proposed color-by-discipline program, introduce the idea gradually by generating discus-
Preparing your Organization for Color-by-Discipline Uniforms
Aligning practice with policy to improve patient care 43
sions at department meetings and through hospital memos and newsletters. Many hospitals also appoint a task force consisting of representatives from all disciplines (e.g., nursing, pharmacy, radiology, laboratory) to develop their color-bydiscipline program. Goals for the task force might include: • Communicating with other hospitals that have implemented a color-by-discipline program • Reviewing relevant data from your hospital’s patient satisfaction surveys • Researching colors and styles of uniforms • Finding a vendor • Revising the hospital dress code • Choosing a target date for implementation of the new uniform program Points to consider when choosing a uniform vendor: • Wide selection of uniform styles and colors • Ability to have on-site sales several times a year • Ease of ordering and distribution (online, in person, by mail) • Ability to customize scrubs with your facility logo
It is important to choose colors that are ﬂattering to most skin tones and suitable for both men and women. Connie Yuska, vice president of clinical services at Medline, who implemented a color-by-discipline program while serving as chief nursing ofﬁcer at a community teaching hospital in the Chicago area, recommends allowing staff to vote for their uniform color. The task force at her hospital narrowed the color choices to three per discipline and organized a voting process. Staff members at MUSC also voted on their uniform colors. With guidance from the task force, each discipline selected a few color choices for voting. The different color scrubs were displayed in the hospital lobby for two days. A Web-based voting tool was developed giving all staff members the opportunity to vote on their color choice. Employees of each MUSC discipline voted on their ﬁrst, second and third choices.1 At the Medical Center of the Rockies, Miller cut to the chase, and instead of voting, she had a representative from each discipline draw a color from a hat on a ﬁrst-come, ﬁrst served basis. “We decided on that approach because choosing colors was where we encountered the greatest bumps in the process,” Miller said.
Continued on page 46
44 The OR Connection
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With SuiteStyles you will also receive:
• Scrubs sizing events to try on garments before ordering • Bag-by-name delivery - orders are individually bagged, boxed by department and delivered to each department • Custom online store for employee reorders that complements your unique uniform program
What people are saying about SuiteStyles…
…I have personally been able to compare the before and after! I had surgery in December when everyone was wearing whatever they wanted. Then, in July, I had an emergency operation and was thrilled to know who (nurse, tech, other) was walking into my room before he/she got close enough for me to see their tag. Wow, what a difference!” - Mary McMahon, Director Perinatal Services, Memorial Health System
Visit www.SuiteStyles.com to learn more about color-by-dicipline and browse a sample store.
©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
Tips for Success!
1. Views on uniform requirements are many and packed with emotion. Be patient and listen to staff comments. 2. Give all staff members a voice in selection of the uniform. Web-based voting is an effective and efficient method. 3. Set a short time frame for implementation and do not let the process take months to accomplish. Deadlines longer than four months can add to the opposition and a belief that the change will not occur. 4. Answer staff questions in a timely manner and develop a communication tool such as an intranet site accessible to all staff members, keeping the process transparent. 5. Provide each staff member with a one-time stipend to aid in the purchase of their initial two sets of scrubs. Offer payroll deduction as an option to pay for additional scrubs.
At MUSC patients and family members learn about the role-speciﬁc scrub schema via the GetWell Network, which provides patients and families access to the Internet, entertainment, education and communications via their hospitalroom television. A website was also developed to display the scrub colors, frequently asked questions and the dress code policy.1 The Medical Center of the Rockies also includes the color coding information in all new employee orientation packets.
Change can be difficult for everyone, but if a uniform policy allows for choice within parameters it can be very successful. Building consensus and including the staff in the decisionmaking process will pay off in the end with a successful colorby-discipline program. It will also improve the professional appearance of your staff, improve your patient satisfaction scores and contribute to an environment in which every patient, physician and employee can identify the various members of the healthcare team. A lab employee at the Medical Center of the Rockies said the color coding has helped her quickly identify other staff. On one occasion, a patient asked her about a radiology procedure. She did not know the answer, but then she spotted a person in burgundy scrubs (radiology) walking down the hall. Even though she did not know the person, she immediately identiﬁed their role, allowing the patient’s question to be answered quickly and correctly. Similarly, a cardiac nurse from the Medical Center of the Rockies said color-coded uniforms allow her to quickly identify which staff members are visiting her patients – even from down the hall. If she sees a person in green, for example, she knows her patient is having his respiratory treatment. “The color coding really is a time saver,” she said. It also saves staff members time getting ready for work not having to choose what to wear. Although many staff members at MUSC were opposed at ﬁrst to changing to the new dress code, a number of them later voiced a change of heart. A psychiatric liaison nurse stated that she was initially opposed to the plan and felt it would have a negative impact on nurse retention.1
Once your plan is ﬁnalized, you will need to communicate the color-coding to staff, patients and visitors. Begin by sharing the revised dress code with staff about three months prior to the conversion, recommends Yuska. Effective communication tools after implementation of the program are tent cards and/or posters in each patient room and throughout the hospital, showing which discipline each color represents and an explanatory section in the patient admission packet.
46 The OR Connection
She now appreciates the ability to identify at a glance all of the different healthcare professionals by the color of their scrubs. As a consultant with responsibilities on units throughout the hospital, she is now able to immediately identify the patient’s nurse and other caregivers.1 At Yuska’s hospital, the implementation date went very smoothly, and in fact, several nurses commented on the improved professional appearance of the staff. In addition, on the ﬁrst day, a patient said he was so relieved to know that he could instantly identify who the nurse on the ﬂoor was…he didn’t have to guess. He told the manager that the color-coding gave him a sense of comfort and security in an environment in which he felt totally out of control. “Patients want to know who’s in charge of their care. And research shows that patients who are actively involved in their own care and communicate with their healthcare team have a safer, more satisfactory experience,” Yuska said. “The goal is to help patients with identiﬁcation and instill conﬁdence that they are being treated by an organized, professional team.” For more information on Medline’s color-coded uniform programs, visit www. SuiteStyles.com.
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Reference 1. Darby J. Thinking about changing your dress code. Gastroenterology Nursing. 2008; 31(4):295-296. Available at: http://www.nursingcenter.com/library/ journalissue.asp?Journal_ID=54035&Issue_ID=810887. Accessed April 1, 2010.
©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
48 The OR Connection
CAUTI ALERT: PROCEED WITH CAUTION
Jayne Barkman BSN, RN, CNOR
Joe and Sandy exchanged a knowing glance as they took their seats at the monthly patient safety council meeting. They were pleasantly surprised to see both the CEO and CNO. The agenda included discussion of the efﬁcacy of the strategies recently implemented throughout the hospital to prevent catheter-associated urinary tract infections (CAUTI). Brianna, the infection control practitioner, arrived, and the meeting was underway. Brianna was pleased to announce that the prevent CAUTI interventions had been an enormous success. During the
past six months that the evidence-based CAUTI strategies were in place, the rate of catheter-associated urinary tract infections had dropped from 16 percent to zero hospital wide. After congratulating the nursing units on this accomplishment, Brianna asked the representative from each unit to explain the initiatives they took to reduce and prevent CAUTI. She signaled to Joe and Sandy, the OR representatives, to speak ﬁrst. Joe said initially he and Sandy collaborated with the surgeons in each specialty to review and revise the standing orders for Foley catheter insertion. As a result of this initiative, Foley catheter use in the OR had dropped by 50 percent.
Aligning practice with policy to improve patient care 49
Open heart was the only specialty where a catheter was still routinely inserted. For all other surgical specialties, the use of an indwelling catheter was evaluated on a patientby-patient basis.
Sandy continued, explaining that prior to implementing the CAUTI protocol, the standard of care in the OR was to insert a 14 FR Foley in male patients and a 16 FR Foley in females. Because the size of the catheter differed for males and females, prior practice was to insert the catheters using an open system. A Foley insertion kit containing PVP prep, cotton balls, gloves and lubricating jelly was opened and the appropriate size gender-speciﬁc catheter, as well as either a drainage bag or urinemeter, were added to the insertion kit. This practice resulted in several single sterile items being opened on the small sterile surface of the insertion kit, potentially increasing the risk for contamination as the supplies were opened on the sterile ﬁeld.
Catheterassociated urinary tract infections account for 40 percent of nosocomial infections.1
had an indwelling urinary catheter. Sandy explained that the OR also instituted urinary catheter insertion as part of the annual staff competencies.
Monica, the medical/surgical unit representative, said the nursing staff in the med/surg areas also found the design of the single layer tray to be user friendly. Since not all staff routinely inserted urinary catheters, the instructions included in the tray were very helpful and the closed system enabled the nurses to insert the catheter aseptically. The packets of hand sanitizing gel included in the Foley kit increased hand hygiene compliance before and after placement of the indwelling catheter. In addition, computerized prompts reminding the physicians and staff to remove the Foley catheters within 24-48 hours were now part of the chart for patients with a urinary catheter. Like the OR, urinary catheter insertion was also added to the med/surg annual competencies. Jess from the ICU said the majority of the patients admitted to the ICU arrived with indwelling catheters. The prevent CAUTI strategies implemented in the ICU were incorporating the use of antibacterial wipes for morning and evening peri/meatal care on patients with a catheter while the catheter remained in place. The nurses also were trained to use a bladder scanner to assess urinary retention. And nurses now had the authority to assess whether a urinary
The new standard of care was to insert a 14 FR catheter in both male and female patients using a closed system in accordance with the Centers for Disease Control and Prevention (CDC) recommendations for indwelling catheter insertion. Joe said the staff found the new kit with the troughed single layer tray design much easier to use. After insertion, each catheter was properly secured and labeled with the insertion date. In addition, the handoff report for the PACU or ICU included notiﬁcation that the patient
50 The OR Connection
A critical step in preventing CAUTI is to maintain a closed drainage system.2
catheter was still needed, and they could remove it, if appropriate, without a physician order. Tom, the CEO, closed the meeting by saying he was truly impressed by the staff’s dedication to excellence in patient care and proud of their accomplishments during the prevent /erase CAUTI mandate. In the course of your perioperative practice have you ever witnessed a colleague using poor sterile technique when inserting a urinary catheter? Have you seen a colleague missing the urethra in a female patient and using the same catheter for insertion rather than obtaining a new sterile catheter? Catheter-associated urinary tract infections can and should be prevented. CAUTI complications increase patients’ length of stay and the use of antibiotics, not to mention incurring needless costs. So, proceed with caution when inserting urinary catheters. Your patients’ safety is in your hands.
References 1. Smith JM. Indwelling catheter management: from habit-based to evidence-based practice. Ostomy Wound Management. 2003;49(12). Available at: http://www.o-wm.com/issues/994. Accessed March 16, 2010. 2 Smith JM. Indwelling catheter management: from habit-based to evidence-based practice. Ostomy Wound Management. 2003;49(12). Available at: http://www.o-wm.com/issues/994. Accessed February 24, 2010.
ARE YOUR PHYSICIANS MAKING THE GRADE?
A recent survey graded physicians’ abilities to recognize, assess and document Stage III and IV pressure ulcers at a “D” level. Medline’s 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 Medline’s 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
About the author
Jayne Barkman, BSN, RN, CNOR, has over 30 years of perioperative experience in various roles, including surgical technologist, staff nurse and clinical educator. She currently works as a clinical nurse consultant.
To learn more about Medline’s Pressure Ulcer Prevention Programs and FREE webinars for acute care and perioperative services, call your Medline representative, or visit www.medline.com/pupp-webinar.
©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
What did we do after designing a revolutionary new catheter tray system?
We found THREE more ways to make it even better.
We’re obsessed with engineering new and better technology for healthcare workers. So after we revolutionized the outdated Foley catheter tray with a unique, one-layer system design, we immediately turned our attention to addressing how we could make it even easier to use. We studied how the tray was being used in the ﬁeld. The result was three more great improvements. Combined with the previous innovative tray redesign and comprehensive ERASE CAUTI education, these three new features help to improve patient safety and quality, while reducing avoidable costs associated with waste and urinary tract infections. To learn about the ERASE CAUTI system, as well as other strategies for minimizing the risk of CAUTI, sign up for a free Innovation in the Prevention of CAUTI webinar at www.medline.com/erase/webinar.
©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
Real photography on the outside – so you know exactly what’s inside A photo on the package helps identify the contents of the kit, serves as an educational tool for the clinician and can be used to discuss the procedure with the patient. Also, the label opens up to a booklet with step-by-step instructions and helpful tips for the clinician.
A checklist that ﬁts better in the medical record The reformatted checklist is smaller, making it easier to ﬁt in the patient chart or medical record. It is also available as an attachment for electronic documentation. Education you’ll want to present to your patient There’s nothing like the new Patient Education Care Card. Designed to look and feel like a “Get Well Soon” card, it tells patients about catheterization so they know you are providing them the best care possible.
CING REDU UTI CA WITH DDER BLA UND RASO ULT
54 The OR Connection
An alternative to urinary catheterization
Kimberly Haines, RN, CNOR
Urinary catheters are commonly used throughout the acute care setting, from the emergency department to surgery, yet up to 50 percent are placed unnecessarily.1 The problem is that urinary catheterization can lead to urinary tract infections. In fact, catheter-associated urinary tract infections (CAUTIs) account for more than 40 percent of all nosocomial infections.2 The best way to avoid the risk of CAUTI is by using alternatives to catheterization. One alternative, bladder ultrasound, will be explored here.
Urinary catheters in the OR
Let’s take a look at perioperative services, where catheters are used to monitor bladder volume to help avoid urinary retention. Urinary retention is reported to occur in four to 38 percent of patients.3 The incidence is independent of type of anesthesia, but administration of excessive perioperative intravenous fluids, as well as anticholinergic and adrenergic medications, increases the incidence and severity of urinary retention.3 Postoperative monitoring of the patient’s bladder volume serves to prevent overdistension, which can lead to irreversible muscle damage and a permanent inability to empty the bladder.3 Intermittent catheterization is the traditional way of monitoring bladder volume, however, this can be labor intensive for nurses, a nuisance for patients and a recipe for infection. So what’s the alternative? Bladder ultrasound. Using a portable bladder ultrasound scanner is an easy, accurate, reliable and non-invasive way to measure bladder volume without having to catheterize the patient. The device, usually no larger than a notebook computer, is wheeled to the bedside. The nurse simply applies gel to the device’s probe and places it on the patient’s lower abdomen. An image of the bladder and a bladder volume measurement appear on the device’s screen in just minutes. Depending on the results, the nurse then determines whether catheterization is needed to empty excess urine from the bladder.
Aligning practice with policy to improve patient care 55
Using the bladder scanner to decrease urinary catheterization
A study by Dromerick and Edwards associated residual urine volumes of greater than 150 ml with development of urinary tract infections, so if the bladder scanner shows a volume measurement of less 150 ml, (or whatever amount determined by your facility), then the bladder need not be emptied, and catheterization would not be indicated. An ultrasound scanner is a simple and reliable non-invasive monitor of urinary bladder ﬁlling, and should be a part of routine monitoring equipment in the PACU.4 Similarly, Phillips described one facility’s attempt to decrease hospital-acquired urinary tract infections and the associated cost analysis. A portion of this program encouraged the use of a bladder ultrasound protocol after indwelling catheter removal. It included bladder scanning four hours after the catheter was removed. If the bladder volume was greater than 300 ml, a straight catheterization was performed. The bladder scanner was used again four hours later and the patient was catheterized for urine volumes over 300 ml. An estimated 27 UTIs and 1,392 catheterizations were avoided related to use of the bladder ultrasound device.4 Moore and Edwards reviewed one hospital’s attempt to decrease healthcare-acquired UTIs. They reported that of 57 catheterized patients, 19 percent developed urinary tract infections when all patients were catheterized. After introducing a bladder ultrasound, there was a 50 percent reduction in urinary tract infections.4
References 1. Stokowski LA. Preventing catheter-associated urinary tract infections. Medscape Nursing Perspectives. February 3, 2009. Available at: http://www.medscape.com/viewarticle/587464_4. Accessed March 25, 2010. 2. Smith JM. Indwelling catheter management: from habit-based to evidence-based practice. Ostomy Wound Management. 2003;49(12). Available at: http://www.o-wm.com/issues/994. Accessed March 16, 2010. 3. Rosseland LA, Stubhaug A, Breivik H. Detecting postoperative urinary retention with an ultrasound scanner. Acta Anaestesiologica Scandinavica. 2002;46:279-282. 4. Stevens E. Bladder ultrasound: avoiding unnecessary catheterizations. MedSurg Nursing. 2005; 14(4):249-253. Available at: http://ﬁndarticles.com/p/articles/mi_m0FSS/is_4_14/ai_n17210413. Accessed March 24, 2010.
Research has shown that healthcare-acquired infections are costly for the patient and the hospital. Regarding urinary retention, noninvasive bladder ultrasound devices can assess bladder volumes accurately and reliably. When bladder ultrasound is used, many unnecessary catheterizations can be avoided.
About the author
Kimberly Haines, RN, CNOR, currently a clinical nurse consultant, has been a registered nurse for 16 years. Previously, she was a staff nurse at a number of acute care facilities and ambulatory surgery centers.
56 The OR Connection
BioCon™- 500 Bladder Scanner Safely Measures Bladder Volume
Minimize unnecessary catheterization
Research has shown that 80 percent of urinary tract infections acquired at healthcare facilities are associated with an indwelling urethral catheter.1 This type of infection is known as CAUTI, or catheter-associated urinary tract infection. What’s more, Medicare no longer reimburses for treatment of CAUTI if it happens while a patient is hospitalized, giving hospitals a major incentive to prevent it. But how? Avoiding unnecessary catheter use is a primary strategy for preventing CAUTI, and clinical guidelines recommend the consideration of alternatives to catheterization.2 Bladder scanners can be used in place of a urinary catheter to assess bladder volumes, and many catheterizations can be avoided.3
To learn more about CAUTI prevention, visit www.medline.com/erase or contact your Medline sales representative.
1. Lo E, Nicolle L, Classen D, Arias A, Podgorny K, Anderson DJ, et al. SHEA/IDSA practice recommendation: strategies to prevent catheter-associated urinary tract infections in acute care hospitals. Infect Control Hosp Epidemiol. 2008;29:S41-S50. 2. Stokowski, LA. Preventing catheter-associated urinary tract infections. Medscape Nursing Perspectives. February 3, 2009. 3. Stevens E. Bladder ultrasound: avoiding unnecessary catheterizations. Med/Surg Nursing. 2005; 14(4):249-253.
©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
NEW REGULATIONS FOR INFECTION PREVENTION IN AMBULATORY SURGERY CENTERS: ARE YOU READY?
By Lorri Downs, RN, BSN, MS, CIC
In May 2009, the Centers for Medicare & Medicaid Services (CMS) updated the conditions of participation (CfCs) for ambulatory surgery centers (ASCs). Included in this update are new requirements for infection prevention requiring ASCs to administer an infection prevention program overseen by an infection prevention professional. The main goal is to provide a “safe and sanitary environment for surgical services, to avoid sources and transmission of infections and communicable diseases.”1
Disease Control and Prevention (CDC) has noted an increasing trend in healthcare-associated infections related to poor infection prevention techniques within ASCs. One example is a 2008 outbreak of hepatitis and HIV at an ASC in Nevada. This very large outbreak was linked to poor injection practices. An article in the January 6, 2009 edition of the Annals of Internal Medicine revealed the occurrence of 33 outbreaks of viral hepatitis in non-hospital healthcare settings over the last decade. All of these outbreaks involved failure on the part of healthcare providers to adhere to fundamental infection control practices, most notably by reusing syringes.2
Why focus on infection prevention?
You may be asking what prompted CMS to take a closer look at infection prevention techniques in ambulatory surgery centers. One reason is the Centers for
58 The OR Connection
Elements of a Complete Infection Prevention Program
1. 2. 3. 4. Infection prevention and surveillance plan Surveillance data and reporting Infection prevention employee education Reporting and preventing transmission of communicable diseases 5. Environment of care monitoring 6. Employee health program
Aligning practice with policy to improve patient care 59
Eight Tips for Safe Injection Practices The following recommendations apply to the use of needles, cannulae that replace needles, and, where applicable, intravenous delivery systems:2 1. Use aseptic technique to avoid contamination of sterile injection equipment. 2. Do not administer medications from a syringe to multiple patients, even if the needle or cannula on the syringe is changed. Needles, cannulae, and syringes are sterile, single-use items; they should not be reused for another patient or to access a medication or solution that might be used for a subsequent patient. 3. Use ﬂuid infusion and administration sets (i.e., intravenous bags, tubing and connectors) for one patient only and discard appropriately after use. Consider a syringe or needle/cannula contaminated once it has been used to enter or connect to a patient’s intravenous infusion bag or administration set. 4. Use single-dose vials for parenteral medications whenever possible. 5. Do not administer medications from single-dose vials or ampules to multiple patients or combine leftover contents for later use. 6. If multidose vials must be used, both the needle or cannula and syringe used to access the multidose vial must be sterile. 7. Do not keep multidose vials in the immediate patient treatment area and store in accordance with the manufacturer’s recommendations; discard if sterility is compromised or questionable. 8. Do not use bags or bottles of intravenous solution as a common source of supply for multiple patients.
These guidelines are from the Safe Injection Practices section of Standard Precautions, from the 2007 CDC/HICPAC Guideline for Isolation Precautions
What to expect during a regulatory survey
A spontaneous regulatory survey can be stressful. Organization is the key to reducing staff anxiety and demonstrating conﬁdence and knowledge to the survey team. Keep your documents current. Record and report any clusters or outbreaks of disease to the appropriate regulatory agencies. Regulatory survey teams look for documentation showing how you prevented the spread of contagion, so document what you did, when you did it and who you notified. Regulatory survey teams will observe and interview staff to ensure infection prevention policies have transferred into clinical practice. Conduct mock surveys to help prepare for a surprise survey. Coaching your staff to answer questions will enable them to respond easily and brieﬂy to the surveyors’ questions. The infection preventionist will be interviewed and expected to answer questions about the organization’s infection prevention program, policies and data collection methods. Share your employee education program and required staff infection prevention competencies with the surveyors. Finally, after reviewing your written infection control program, touring the facility, observing and interviewing staff and physicians; the facility administration plus the survey team will participate in an exit conference to share the ﬁndings.
60 The OR Connection
Documents CMS Surveyors Will Request ❏ The facility’s infection prevention plan and documentation that the plan is reviewed annually. ❏ A copy of nationally recognized infection prevention deﬁnitions (CDC deﬁnitions) ❏ The ASC infection risk assessment ❏ Infection prevention policies and procedures (e.g. hand hygiene, transmission- based precautions, standard precautions, sterilization and disinfection) ❏ Exposure control plan and tuberculosis control plan ❏ Outbreak investigation plan and emergency preparedness plan ❏ Log documenting communicable disease cases reported to department of public health. ❏ Surgical site infection surveillance data ❏ Hand hygiene program and surveillance data ❏ Management of employee sharps injuries, employee health records/vaccination rates and documentation of reporting to OSHA
Note: Additional documents may be requested as well.
References: 1. CMS Manual for Interpretive Guidelines for Ambulatory Surgery Centers. Available at: http://www.cms.hhs.gov/transmittals/downloads/R56SOMA.pdf. Accessed March 15, 2010. 2. One and Only Campaign Safe Injection Practices. The Safe Injection Practices Coalition. Available at: www.oneandonlycampaign.org. Accessed March 10, 2010.
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.
For a complete copy of the actual CMS Infection Control Surveyor Worksheet, visit http://www.cms.hhs.gov/transmittals/downloads/R56SOMA.pdf and see Attachment 2.
For further help preparing for the infection control portion of the CMS survey, contact your Medline representative about Medline’s new CMS Survey Readiness Program for Ambulatory Surgery Centers.
Aligning practice with policy to improve patient care 61
Booth Centennial Healthcare Linen Services
A State-of-the-Art Hybrid Program for the OR
by Maria Ash and Mario Muff
Booth Centennial Healthcare Linen Services (BCHLS) has launched its newest program for the OR – the Complete Delivery Hybrid System™ (CDHS), a reusable/disposable hybrid solution for the OR that simpliﬁes every step of the supply chain. A complete delivery system can only truly be “completed” by returning it to its origin, making it a full cycle. Or recycled! BCHLS expertly packages the correct mix of reusables and disposables, and then delivers the OR materials to the hospital in a container of choice. There is heightened concern to reduce biohazardous waste within the hospital setting, not only helping green the environment, but reducing expensive disposal costs. OR budgets can be helped immensely as, in many cases, a reusable item simply has a lower unit cost than a disposable item. Each CDHS program is designed based on the facility's particular supply chain needs. A no-risk analysis is used to determine savings and efﬁciency opportunities. The analysis reveals the potential to signiﬁcantly simplify and streamline the clinical supply chain and identiﬁes the right mix of reusable and single-use surgical drapes, packs and gowns. “It’s what we call ‘the next step’ in healthcare efﬁciency,” General Manager Joe Grummel said. “By replacing certain disposable items with reusable ones, our custom packs are turned into a hybrid CDS pack, also known as CDHS.”
Booth Centennial was the proud recipient of an OHA Green Award for Energy Efﬁciency.
The BCHLS Surgical Services division inspects each piece of laundry. Our surgical services area has stainless steel tables to reduce the spread of infectious material. Each towel pack is labeled and scanned to a cart for tracking purposes prior to sterilization.
62 The OR Connection
Once the packs have been sterilized, they must stay in the cool down room until the batch has been examined. Once cleared, the packs are scanned to tickets for shipment to hospitals.
Through OR analysis, BCHLS ﬁnds that many accessory pieces of disposable apparel are added to the case carts to complete the pick list. These are often disposable gowns, drapes and towels that can be replaced with high quality reusable linens made from advanced barrier fabrics that make them stronger, lighter and easier to drape. These fabrics also handle wash and dry cycles and sterilization better than ever before. Many other items within the custom pack can be reusable as well, such as Mayo stand covers, back table covers, ¾ sheets, half sheets and full custom drapes. “Adding a reusable component to the CDS is truly an outstanding way to make a huge positive impact on the environment and help cost-conscious hospitals save large sums of money by reducing unnecessary touch points,” Grummel said. All pick list items, custom packs, accessories and reusable components are delivered daily in a whole case cart. Then BCHLS picks everything up at the end of day and does it all over again the next day. Daily delivery and return by BCHLS makes this a true Complete Delivery Hybrid Solution!
Soiled linen is stored in large bags on an automated future rail system and sorted by type. The bags are then transferred to a speciﬁed station for processing. This design reduces the need for manual movement of linen in carts on the plant ﬂoor and reduces congestion.
Each piece of surgical linen is examined and hand folded to ensure no defects prior to sterilization.
About Booth Centennial Healthcare Linen Services
Booth Centennial Healthcare Linen Services (BCHLS) in Ontario, Canada, was founded in 1968 and is now one of the largest and most state-of-the-art healthcare laundry facilities in North America. The business focuses solely on health care, and their mission is to provide ever-expanding value in superior linen, sterilization and logistics services to hospitals and healthcare facilities. BCHLS’ rapidly growing Surgical Solutions division specializes in reusable, high-barrier surgical gowns, covers, drapes and towels and currently processes more than 1,250,000 reusable sterile packs annually for operating rooms across Ontario. BCHLS surgical packs utilize cutting edge, innovative fabrics and products that are superior to their disposable counterparts in protection, comfort and long-term costs. Complete draping systems and custom packs are suited to customer requirements.
General Manager Joe Grummel at the Booth plant.
Aligning practice with policy to improve patient care 63
THE N NEW SHAP OF SUR SHAPE PE SURGERY RGERY
The DASHTM absorbent retractor bends DASH retracto or into just the shape you need into jus st you
Fewer sponges, gentler retraction. The DASH retractor sp ponges, retraction. retractor is 12 times more absorbent than a stand d lap sponge, standard time more es dar with a smooth stainless steel core that you can’t miss. sm mooth core y can’t It’s It’s the core that gives the DASH device strength and co e or e strength malleabil . malleability. Shape it into almost any form to gently retract lity form retract tissues from the surgical ﬁeld—without the pinch-point from r t trauma traditional retractors can cause. tr raditional retractors Strong and solid to retract with conﬁdence. Formable to Strong an nd retract conﬁden nce. Formable adapt to many patients and procedures. Absorbent to procedures s. reduce sponge reduce sponge count. The DASH retractor may reshape retrac ctor reshape your surgical technique. surg gical Once you see the DASH in action you’ll never want to u retractors. go back to old, bulky metal retractors. To find out how to get your free DASH Retractor To d how to get your free DASH Retractor sample, log on to www.medline.com/offers/dash. sampl , le to www.medline.com ffers/dash. m/of Before DASH™ B Before DASH™ Ch Challenging access hallenging After DASH™ A DASH™ Maximum exposure Max ximum exposure
©2009 Medline Industries, Inc. Medline is registered trademark of Medline Industries, Inc. ©2009 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
Never Lose Sight
of Why We Are Nurses
Sharon Danielewicz, RN, MSN, MHA, HSA, RNFA
I began my career as an administrator of an ambulatory surgery center directly upon completion of my associate degree. The ﬁrst day I ever stepped foot into an operating room was one of the most memorable moments in my career. I have been a nurse for 19 years, and I have gone from earning an associate degree to obtaining two master’s degrees in nursing and health care administration. Throughout the last 19 years, I (like most other nurses) have experienced and witnessed everything imaginable to the human mind that pertains to nursing. Being in a leadership role for my entire career, it has always been part of my responsibility to attempt to motivate the nurses I oversee on a daily basis. Leadership comes with a price tag. You are continually attending meetings, addressing administrative responsibilities, putting out ﬁres and attempting to make sure that patients, surgeons and staff are as happy as possible. Due
to the demands of this role, it is not uncommon to get caught up in day-to-day tasks and ﬁnd the days ﬂying by before your eyes. Being a type A personality, I generally attempt to maintain a very strict schedule that allows me to complete administrative responsibilities early in the morning so I can focus on and actively participate in patient care throughout the day. I encourage others in leadership roles to do this as much as possible so that you never lose sight of our number one priority – the patients. One recent evening at approximately 7:00, I was leaving work after a long and very intense day. The exit from the department to the parking lot requires a walk through the family waiting room, where I was greeted by a screaming infant. I saw a couple, maybe in their 70s, pacing as the woman attempted to calm the child. I placed my bags on a nearby chair and asked if I could be of assistance. The couple explained that the mother of the infant (their grand-
Aligning practice with policy to improve patient care 65
It is not about the thanks you will receive; it is about the care you will give that comes from your heart. Never lose sight of the patient.
daughter) was in the recovery area. The baby was hungry, but his mother had his bottle. The woman explained that she was not comfortable with the baby and had attempted everything to stop him from crying without any success. I asked her if she would mind if I held the child while I let her go to the recovery area to get the bottle from her granddaughter. The woman handed me the baby and left to get the bottle. While holding the child, I noticed he needed to be changed, so I asked the grandfather for a diaper and proceeded to change the infant. Shortly thereafter, the woman returned with the bottle. She was again apprehensive about feeding the child, so I offered to feed him. I sat with the child, fed him his bottle and rocked him off to sleep. Before I knew it, 45 minutes had passed, and the child’s mother exited from the recovery area. She was very grateful that I had assisted her grandparents with the baby. She also explained that the baby was born just three weeks before, and he had colic. She felt badly about leaving him with her grandparents in the waiting room, but she had no one else to watch him. She could not thank me enough for helping them. I explained that it was a pleasure to help and that it brought back memories of caring for my own children so many years before. Right there, in our family waiting room, on a day when I was physically and emotionally exhausted, I was once again reminded of the true meaning of nursing. We all get caught up in the day-to-day functions of our jobs; however, it is extremely important never to forget that patients are the reason we are
here. My advice to others is never be too busy to stop and take a moment to assist patients, who are much more than just another person coming through your department. It only takes one experience such as this one to create many moments of memories you will carry for a lifetime. It is not about the thanks you will receive; it is about the care you will give that comes from your heart. Never lose sight of the patient.
About the author
Sharon Danielewicz, RN, MSN, MHA, BSN, HSA, RNFA is a director of perioperative services with 19 years of experience. She began her career in 1991 after completing an associate degree in nursing from a then small community college in Nanticoke, Penn. She later relocated to Lansdale, Penn., where she worked in the surgery services department of a small community hospital for ﬁve years. In 2004, Sharon, her husband and two children relocated to San Antonio, Tex., and Sharon began working for a large medical center. After a few years, she accepted a position for Job Corps as a health services administrator while pursuing two master’s degrees. In 2008 she received both a Master of Nursing and Master of Health Care Administration. Shortly thereafter, she accepted a position as director of perioperative services for a facility in Houston, Tex.
66 The OR Connection
JOIN THE PROGRAM TO
REDUCE PRESSURE ULCERS
We’ve made pressure ulcer prevention easy.
Systematic efforts at education, heightened awareness and speciﬁc interventions by interdisciplinary healthcare teams have demonstrated that a high incidence of pressure ulcers can be reduced.1 The main challenges to having an effective pressure ulcer prevention program are: lack of resources; lack of staff education; behavioral challenges; and lack of patient and family education.2 Medline’s comprehensive Pressure Ulcer Prevention Program offers solutions to these challenges. The Pressure Ulcer Prevention Program from Medline will help you in your efforts to reduce pressure ulcers in your facility. The program includes: • Education for RNs, LPNs, CNAs and MDs • Teaching materials for you to help train your staff • Practical tools to help reduce the incidence of pressure ulcers • Innovative products supported by evidence-based information that results in better patient care
This has been a great learning experience for our staff and for our facility as a whole. I am thankful Medline had this program and that we were able to access it. I can’t imagine recreating this wheel!”
Katrina “Kitty” Strowbridge, RN Quality Improvement Coordinator St. Luke Community Healthcare Network Ronan, Montana
For more information on the Pressure Ulcer Prevention Program, contact your Medline representative, call 1-800-MEDLINE or visit www.medline.com/pupp-webinar to register for a free informational webinar.
References 1 Holmes A, Edelstein T. Envisioning a world without pressure ulcers. ECPN. 2007;122(8):24-29. 2 CMS Roundtable, Omni Hotel, Chicago, Ill. March 10, 2008. ©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
5th Annual Breast Cancer
68 The OR Connection
at the AORN 57th Congress
More than 1,200 operating room nurses attended this year’s Breast Cancer Awareness Breakfast, “Together We Can Save Lives Through Early Detection” to hear Olympic gold medalist Peggy Fleming talk about her skating career and battle with breast cancer. The forum was held March 15, 2010, in conjunction with the start of the Association of periOperative Registered Nurses’ 57th Congress held in Denver, Colo.
Aligning practice with policy to improve patient care 69
Breast cancer survivor and Olympic gold medalist Peggy Fleming presents the keynote speech, “The Fight of a True Champion.”
The crowd was also treated to surprise appearances by the staff members from Providence St. Vincent Medical Center in Portland, Ore., who starred in the “Pink Glove Dance,” a YouTube video sensation that has more than 8.7 million views to date. “My mother was diagnosed with breast cancer at the age of 80,” said Kate Moser, a nurse at William S. Middleton Memorial Veterans Hospital in Madison, Wisc. “Now she is 85 and going strong. Hearing Peggy Fleming’s story and seeing the people from the Pink Glove Dance today is exciting and inspiring.” Fleming, who won a gold medal at the 1968 Olympics at the age of 19, was diagnosed with breast cancer in 1998. She is now cancer free.
Raising breast cancer awareness among nurses is a key goal of Medline’s campaign, as it is the leading cause of death for women age 40-55. The average age of a nurse is 46. At the event, Medline President Andy Mills presented National Breast Cancer Foundation (NBCF) President Janelle Hail with a check for $117,000 to help fund mammograms for underserved women. Of that total, $17,000 came directly from the sale of Medline’s Generation Pink exam gloves. Over the past four years, Medline has donated more than $500,000 to the NBCF as part of its campaign to promote early detection and awareness of breast cancer. Early detection (mammography is among the best forms of screening for breast cancer) can increase the five-year survival rate by more than 95 percent.
70 The OR Connection
When the true heroes, the BREAST CANCER SURVIVORS stood up, the room broke into
Medline President Andy Mills presents a check for $117,000 to National Breast Cancer Foundation President Janelle Hail. Of the total, $17,000 came from the sale of Medline’s Generation Pink exam gloves.
Martie Moore, assistant administrator, nursing and patient care, Providence St. Vincent Medical Center, Portland, Ore., site of the Pink Glove Dance video, which has received more than 8.7 million hits on YouTube – and counting.
Participants enjoy a buffet breakfast before the presentations begin.
Exhibit showcases previous Medline Breast Cancer Awareness Breakfasts at AORN Congress.
Aligning practice with policy to improve patient care 71
A world without breast cancer is in our hands.
Medline’s Generation Pink latex-free, patented 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.
Unit of Measure
PINK6073 PINK6074 PINK6075 PINK6076 PINK6077
XS S M L XL
100/bx, 10bx/cs 100/bx, 10bx/cs 100/bx, 10bx/cs 100/bx, 10bx/cs 90/bx, 10bx/cs
To watch the “Pink Glove Dance” video and order Medline’s Generation Pink Gloves, go to www.pinkglovedance.com
©2010 Medline Industries, Inc. The cross-ﬁngered pink glove hand image is a trademark of Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
Starring in “The Pink Glove Dance”
Deb is the coolest person to dance the Pink Glove Dance while at the same time skillfully caring for patients, especially those battling breast cancer. In her Generation Pink Gloves, pink bouffant cap and scrubs, she energetically raises awareness for the “Together We Can Save Lives Through Early Detection” campaign. To order the Deb doll visit www.medline.com/dolls
Take an online tour of the booklet and view the entire doll collection, visit www.medline.com/dolls
Introduced in 2005, the Medline Doll Collection was created to recognize the caring and dedicated healthcare professionals in our industry. Since then, Medline has introduced seven dolls, including Deb, who made her debut in March 2010.
74 The OR Connection
Wolf J. Rinke, PhD, RD, CSP
How to get more of what you want
Times are tough, and virtually all of us have a need to get more “bang for our buck,” whether it’s when we want to make a purchase, attempt to get a promotion or talk our children out of getting that expensive “must-have” new toy. And yet most of us consider negotiating or “haggling” a distasteful activity that should be avoided at all costs. That is especially true if you are a woman. Research shows that women are far less likely to negotiate than men, and when they do, they do it in a way that is less assertive. One study found that 20 percent of women do not negotiate at all. To help you overcome the distaste for negotiation, master the following strategies, and you will get more of what you want.
Manage Your Perceptions
Lots of people lose in negotiations because they don’t manage their perceptions. For example, have you noticed that when you’ve tried to sell your house, there seemed to be houses for sale everywhere? Conversely, when you were looking to buy a house there were virtually none to be found? That happens because of selective perception—whatever we focus on, we tend to ﬁnd. Similarly, how many times have you interviewed for a job and felt the prospective employer had all the power because you really needed the job while the employer appeared to have all the applicants in the world? Having been in both roles— interviewer and applicant—let me assure you nothing could be further from the truth. The employer almost always needs you just as much as you need him (assuming of course you have the right skill set), even during these tough times. These biases come about because you are committing an “attribution error.” For example, because the employer has certain visible attributes of power you assume she has more power than you do which, right or wrong, becomes your “reality.”
Aligning practice with policy to improve patient care 75
In other words, your perception controls your reality, which in turn impacts how you negotiate. For example, back to buying that house. If you perceive that there are very few houses on the market you will feel compelled to make a quicker and potentially higher offer than if your perception is that there are lots of houses on the market. The same is true when you are interviewing for a job. If you assume that the employer has all the power, then you are going to be negotiating from a position of weakness and you probably will compromise your expectations. So the ﬁrst step in every negotiation is to manipulate your perceptions and “do a positive number on yourself” by convincing yourself that you deserve to have your needs met. In other words, you deﬁne an empowering positive self-fulﬁlling prophecy that at a minimum equalizes the perceived power between you and the other party. Of course, it is even better if you can convince yourself you have more power than the other party, which is quite feasible since you are always in control of your own perceptions. (If you would like help with this, devour my Make It a Winning Life book available at www.WolfRinke.com.)
Know Your BATNA, WAP and ROSA
BATNA – Best Alternative to a Negotiated Agreement – is a concept developed by Roger Fisher and William Ury, authors of Getting to Yes. Negotiating Agreement Without Giving In, one of the most popular negotiation books ever written. According to them, BATNA “is the standard against which any proposed agreement should be measured.” For example, if I’m negotiating with a client for a consulting contract I have priced at $95,000/year, my BATNA may be $95,000 if I value my free time more than the $95,000. Or it may be $45,000 if I need the money to pay my mortgage, have very little work in the pipeline, and could hope to generate about $45,000 from writing another book in case I do not get the contract. According to Fisher and Ury high quality negotiation is only possible if you know your BATNA, since it is the only way you can protect yourself from accepting unfavorable terms or from rejecting a minimally acceptable deal. A WAP or Walk-Away Price, also known as the reservation price, “is the least favorable point at which one will accept a deal.” A CEO I coach wanted to sell his business. A protracted long negotiation ended up with what I thought was a very sweet deal--$23.5 million for the business and the opportunity to start a new online business with ﬁnancial support from the
Be Willing to Walk Away
Being able to walk away is the single most important concept to internalize if you want to get more of the things you want! Anytime you want something so bad you are not willing to walk away, it is extremely likely you will become a deal taker not a deal maker. For example, Superwoman—that’s my wife of over 40 years— and I are avid cross-country skiers, hikers, bikers and mushroom hunters. So approximately four years ago we found this super idyllic resort in Canaan Valley, West Virginia. We fell in love with a unit that was perfectly decorated and had an awesome view. We just had to have it. As a result, when it came time to negotiate price, we were not willing to walk away, and we ended up paying full price.
76 The OR Connection
new owners. The CEO had established a WAP of $26 million and his BATNA was that he was going to continue to run his business as he had in the past, and be open to other offers as they were coming along. Although I thought it was a very fair offer, he walked away from it, which he would probably would not have done if he was not very clear about his WAP and BATNA. He sold that business several years later and got a much better deal. ROSA is your Range Of Satisfactory Agreement. “It is the area or range in which a deal that satisﬁes both parties can take place.” For example, let’s say that you want to buy a used car, which has a sticker price of $2,900. The seller says to himself, I will not take less than $2,400. That’s the seller’s WAP, which usually is not known to the buyer. On the other hand, you say to yourself, I will not pay more than $2,700. That’s the buyer’s WAP, which is usually not known to the seller. The ROSA in this case is the area from $2,400 to $2,700. All other things being equal, an agreement should be feasible between $2,400 and $2,700. If you handle this purchase like a distributive negotiation, (i.e., Win-Lose or Lose-Lose, your conversation might go something like this: You: This car has quite a few dents and a lot of mileage. I’ll give you $2,200. Seller: Thanks, but since that is way below the “Blue Book” value I’ll wait until I get a better offer. You: I’m sure you’d like to get it sold and I don’t really like to haggle. I’ll give you $2,400, take it or leave it. Seller: $2,600 and it is yours. You: I tell you what, let’s just split the difference. I’ll give you $2,500. Seller: You got yourself a deal. In this case, even though both parties compromised (LoseLose), they probably feel pretty good about the deal because they both got a better price than their WAP.
Negotiate Over Interests, Not Positions
Let’s look at a father-daughter encounter. Father: “Drink your milk.” (That’s his position). Daughter: “I don’t like milk.” (That’s her position). Of course, from here on, it all goes downhill. So if the father is a “Tough Battler,” he might say: “I’m your father and you will listen to me,” or “I’m smarter than you,” or “I’m wiser than you” etc; “Now, damn it, drink your milk, or you will be grounded!” (Win-Lose.) If the daughter is a “Tough Battler” as well, it might go something like this: “I hate milk. If you make me drink it I will throw up.” Even though on the surface it might appear that the father has all the power, it’s likely that in this case the daughter will win; after all, the father is probably not particularly keen to clean up her vomit (Win-Lose). Of course, the father could compromise with his daughter: “I tell you what, just drink half of your milk, and I’ll forget you are being so nasty to your old dad.” (Lose-Lose.) If all else fails, he might bribe her: “If you drink your milk, I will take you to the movies.” (Of course, that is reinforcing various undesired outcomes, such as: “If I rebel, good stuff happens. So next time I can’t get what I want, I’ll just rebel.”)
Aligning practice with policy to improve patient care 77
Putting those unanticipated outcomes aside, all of these approaches will likely end up in either Win-Lose or Lose-Lose outcomes, which neither the father nor his daughter are going to be particularly happy with. Now let’s take a look at how this might work if we focus on interests, needs or wants instead of positions. Father: “I understand you don’t like milk. So please tell me what you really want.” Daughter: “I want food that tastes good, and milk just doesn’t taste good to me.” Father: “I appreciate that. Now let tell you what I want. I would like you to get food that is nutritious and high in calcium. Why don’t we take a moment and come up with a list of foods that meet both of our needs.” (This is separating option generation from decision-making. See the next section). At this point, the father and daughter will probably be able to come up with a long list of foods that meet both of their objectives – food that tastes good, is nutritious and high in calcium – such as cheese, ice cream, yogurt, pizza and the list goes on. (Win-Win.) In the Win-Lose approach, we saw how the parties’ egos became identiﬁed with their position. Once that happens, the negotiators have a new interest to satisfy – such as saving face – which has nothing to do with the original interests. As you discovered, the longer the parties attempt to reconcile positions, the less attention they will devote to addressing their real concerns, needs or wants. The result is it takes longer; it’s likely to raise people’s negative emotions such as anger, and is less likely to generate a Win-Win outcome. Plus, it will likely damage the relationship between the bargaining parties.
Separate Option Generation from Decision-Making
As you learned from the previous example, most of us tend to focus on two mutually exclusive outcomes: either you get what you want and I lose, or I get what I want and you lose. (Win-Lose.) If instead we learn to get in the habit of engaging the brain power of both parties, many not-so-obvious ideas can be generated that will meet or even exceed both parties’ needs (Win-Win.). In other words, if we separate option generation from decision-making, we can almost always make the pie bigger, and if we can’t, then we can establish objective criteria before attempting to reach an agreement (see the next section). Unfortunately, we tend to fall into the trap of skipping the option generation step because most of us want to get the negotiation process over with, and one way to do that is to come up with the answer both of us can agree on as fast as possible.
78 The OR Connection
At this point you might be saying: “That just doesn’t make any sense.” Going back to the used car selling example, the only thing both parties are concerned with is price! Not necessarily! It’s likely that both parties had other things that factored into the sale. For example, if the buyer had said to the seller: “Before we talk about price, tell me what you want out of this deal.” The seller might have said, “I’m interested in selling the car now, but keeping it for another two weeks because my daughter’s new car won’t be delivered until then.” She might also have said, “I would like to get cash so I don’t have to worry about a bounced check.” Or she might have said, “I love this car like my own child and I would really like to sell it to someone who will take really great care of it.” The buyer, on the other hand, might have said: “I would like to make sure I’m not buying a lemon; I would like a car that has been well taken care of; I would like to drive it away today; I would like to deal with someone I can trust”…and the list goes on. All of these may have economic value to either the seller or the buyer and hence could have been used not only to inﬂuence the purchase price of the car, but could have resulted in both parties getting far more than just a good price, i.e., getting a Win-Win outcome.
If All Else Fails Resort to Objective Criteria
You will of course encounter real “fixed pie” scenarios. For example, if you have only one vacancy in your department and there are three people applying, even after all the best negotiations in the world, there will still be two losers and only one winner. To improve negotiation whenever you are involved in a true distributive negotiation process, where one party must lose and the other win, it is wise to resort to objective criteria such as standards, rules, independent mediators, arbitration, ﬂipping a coin, drawing straws or other forms of chance, or any other criteria that produces a perceived fair outcome. The classical example of this is the challenge of dividing one piece of cake between two siblings. If you have children, I’m sure you can identify with this dilemma, and you may remember how much potential bickering can ensue. There is of course a very elegant solution to that problem, which dates back to biblical times. Have one child cut the cake and the other choose the piece she wants.
In the case of hiring a new employee, perceived fairness is enhanced if you make the selection criteria and the selection process public. There are other situations where it may be beneﬁcial for both parties to resort to objective criteria. Let’s say for example, your best friend is interested in purchasing your car. In this case, both of you express a desire to arrive at a fair price without haggling because your relationship is more important than getting the best price. As a result, you both agree not to negotiate the price at all and instead abide by the “Blue Book” value. According to Fisher and Ury, there are three basic strategies that will make resorting to objective criteria work: 1. Frame the proposal as a joint search for objective criteria. In the case of selling our car to your best friend, you both decided the “Blue Book” value would represent a “fair” price for the car. 2. Reason and be receptive to the other person’s reason regarding which standard is most applicable and should be used to arrive at a “fair” outcome. If you are selling your house, you may propose to use an average sales price of three similar houses that have sold in your neighborhood during the past year as the “fair” price. The buyer, however, prefers an average of three independent appraisals as a fair price. In this case, it’s important to be receptive not only to the proposal but also the underlying reason for the proposal. 3. Don’t yield to pressure, yield to principles. Pressure may come in a variety of forms: bribes, side payments, threats or a refusal to budge. If the other side uses these types of pressures, ask him to tell you the reasoning behind his proposal, suggest legitimate objective criteria and state why they represent a fair outcome to both of you. If the other party can’t do that, stick to your guns, and if that fails you still have the option to ... you guessed it . . . walk away.
© 2010 Wolf J. Rinke
About the author
Dr. Wolf J. Rinke, RD, CSP is a keynote speaker, seminar leader, management consultant, executive coach and editor of the free electronic newsletters Make It a Winning Life and The Winning Manager. To subscribe go to www.WolfRinke.com. He is the author of numerous books, CDs and DVDs including Make It a Winning Life: Success Strategies for Life, Love and Business, Winning Management: 6 Fail-Safe Strategies for Building High-Performance Organizations and Don’t Oil the Squeaky Wheel and 19 Other Contrarian Ways to Improve Your Leadership Effectiveness. All are available at www.WolfRinke.com. His company also produces a wide variety of quality preapproved continuing professional education (CPE) self-study courses including Win-Win Negotiation: Fail-Safe Strategies to Help You Get More of What You Want, on which this article is based, available at www.easyCPEcredits.com. Reach him at WolfRinke@aol.com.
80 The OR Connection
MEDLINE SURGICAL PACKS
THE HIGHEST QUALITY STANDARDS
Medline Surgical Packs – The Highest Quality Standards • Over 350 quality assurance specialists • Production-line inspections with picture-driven build instructions • Specialized scales along the production line weigh each pack to detect missing components • Assembly in dedicated clean rooms • Our Kaizen program implements employee suggestions for process improvement and standardization • Validated EO sterilization process If there is a problem, our formal procedure includes: • Investigation – determining why it happened • Correction – ensuring it doesn’t happen again • Communication – informing all possibly affected customers • Satisfaction – providing customers with an appropriate and timely resolution
Medline’s Decrease in Customer Complaints
COMPLAINTS PER $100K OF MEDLINE PACK SALES
Our customer satisfaction has never been higher.*
*Internal trending data on ﬁle.
For a FREE virtual tour of our manufacturing facilities, contact your Medline representative today or call 1-800-MEDLINE.
Over the 15 years that I’ve been using Medline as the manufacturer of my surgical procedure trays, quality complaints have effectively gone down to zero.”
Larry Creech, Senior Vice President, Carilion Clinic, Roanoke, VA
Stop by Booth 3601 at AORN Congress.
©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
Nutrition Information Servings: 8 Calories: 79 Fat: 3.3 g Sodium: 273 mg Fiber: 3.1 g
Syrian Salad (8 servings)
• • • • • • 1 head romaine lettuce 1 cucumber, thinly sliced 5 radishes, thinly sliced 1 red bell pepper, seeded and sliced 1 green bell pepper, seeded and sliced 2 large tomatoes, cut into wedges • • • • • • 2 scallions, chopped 1 small red onion, sliced 3 oz. feta cheese, sliced or crumbled ½ cup fresh parsley, coarsely chopped Several black olives 2 tablespoons capers (optional) Dressing: • ¼ c. olive oil • Juice of 1 lemon, or 3 tablespoons lemon concentrate • 1 tablespoon wine vinegar • 1 clove garlic, pressed or minced • Salt and pepper, to taste
Directions: Rinse the romaine, tear into bite-size pieces and put into salad bowl. Arrange other vegetables attractively over the romaine, topping with the feta, parsley, olives and capers. Combine the dressing ingredients and drizzle over the salad. Vendor data analyst Vicki Mirshak, who works at Medline’s Vernon Hills, Ill., office, won a silver medal for this recipe in the International Cookoff during Employee Appreciation Week 2008. “This is a light, very easy-to-make salad that’s very nutritious. It’s especially good for people who are watching what they eat,” Vicki said.
She encourages experimenting with different ingredients and herbs. “Add a little more garlic and different herbs. Fresh herbs are always better than dried.” Vicki applies those same principles to other recipes as well. “I tend to do a lot with chicken, trying different herbs and spices and different cooking methods – poaching, grilling, baking. It’s best to stick with a basic recipe, and then add a little to it here and there to change it up.”
82 The OR Connection
Forms & Tools
The following pages contain practical tools for implementing patient-focused care practices at your facility.
Infection Control 2009 AAAHC/CMS Crosswalk for Infection Control . . . . . . . . . . . .85 Pressure Ulcer Prevention Pressure Ulcer Prevention Checklist: Perioperative Services . . . .89 Surgical Safety WHO Surgical Safety Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . .93
Aligning practice with policy to improve patient care 83
Medline University Introduces ...
At home, at work or on the go… earn free CE credits It’s even easier to maintain licensure and certiﬁcation and validate competencies! All Medline University courses are now available as free iPhone® and iPodTouch® apps that can be downloaded from The Apple® Store. As always, you can also access courses online on your computer and download podcasts to your MP3 player. New courses and competencies are more interactive with graphics, sound and animation to make learning fun. Nurses Are Getting Wired In a recent poll of 762 Medline customers and subscribers of The OR Connection and/or Healthy Skin magazine: • 41 percent were RNs • 10 percent own an iPhone Of those who own an iPhone: • 89 percent said they would download available content from Medline • 88 percent have downloaded content from the iTunes store • 64 percent were 40 or older • 30 percent currently use their iPhone as a reference at work Visit www.medlineuniversity.com today and start earning CE credits* – FREE.
* Courses approved for continuing education by the Florida Board of Nursing and the California Board of Registered Nursing
©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc. iPhone and iPod Touch are registered trademarks of Apple, Inc.
Infection Control 416.51
Forms & Tools
2009 A AAAHC/CMS Crossw for Crosswalk walk
Infec Infection Control 416.51 ction Control 416 51 6.51 6
Cond Condition for dition Covera (CfC) # Coverage age
CMS Requirements Requ ements uir
AAAHC Standards/Additional Standards s/Additional Medicare requirements Medicare re uirements equ (CFR=Code of Federal Regulations) Feder ral
The ASC must maintain an infection control p ogram that seeks n control program pr g to minimize infections and communicable diseases communiicable diseases.
416.51 Condition: Infection C Control Control NEW CON CONDITION NDITION
The ASC must maintain an infection control program contro program ol that seeks to minimize infecm tions and communicable comm municable diseases.
Ch. 8. N MS 2 N-MS-2 NEW
416.51(a) S Standard: Sanitary en onment environment nvir NEW STANDARD STANDARD TAN
The ASC must provide provide a functional and sanitary d environment for the provienvironment r provision of surgical services by adhering to professionally professionally acceptable standards of stan ds ndar practice.
A safe environment for treating surgical patients, including environment treating surgical adequate safeguards to protect the patient from cross-infection, safeguards protect from cross-infection, is assured through the provision of adequate space, equipment, assured through provision a and personnel. 1. Provisions have been made for the isolation or immediate Provisions th he transfer of patients with a communicable disease. communicable 2. All persons entering operating rooms are properly attired. ro ooms are properly attired. 3. Acceptable aseptic techniques are used by all persons in the ar ae surgical are and all such persons must decontaminate hands are s either by using a hygienic hand scrub or by washing with a s disinfectant soap prior to and after direct contact with each after direct patient. 4. Only authorized persons are all in the surgical or treatment are n treatment area, including laser rooms. area ea, rooms ooms. 5. Suitable equipment for rapid and routine sterilization is availd routine available to ensure that operating room materials are sterile. ensure roo om are 6. Sterilized materials are packaged and labeled in a consistent are d manner to maintain sterility and identify sterility dates. id dentify 7. Environmental controls are implemented to ensure a safe Environmental controls are imple emented ensure and sanitary environment. environment. 8. Suitable equipment is provided for the regular cleaning of all provided fo or regular interior surfaces. 9. Operating/procedure rooms are appropriately cleaned before Operating/procedure rooms are a opriately appr before each procedure. procedure.
The Accreditation Association for Ambulatory Hea Care 2009 | Effective 5-18-09 Acc creditation Ambulatory Health r alth
Aligning practice with policy to improve patient care 85
Forms & Tools
Infection Control 416.51
Con Condition for ndition Cover Coverage (CfC) # rage
CMS Requirements Req ements quir
AAAHC Standards/Additional Standards/Additional r Medicare requirements Medicare req ements quir (CFR=Code of Federal Regulations) Federal
The ASC must maintain an ongoing p ogram designed to ongoing pr g g ng program g prevent, control, prevent, control, and investigate infections and communicable , , g in nfections diseases. In addition, the infection control and p evention p o, n control prevention pr pr prog gram must include documentation that the ASC has considn ered, ered, selected, and implemented nationally recognized infection , , p y recognized g control guidelines. control g
416.51(b 416.51(b) b) Standard Standard: d: Infection control program control program NEW CONDITION CO ONDITION
The ASC must maintain and t ongoing progra designed program am to prevent, con ol, and prevent, control, ntr investigate infections and infe ections communicable diseases. In e addition, the infection control in nfection control and prevention program must prevention program n include docum documentation that mentation the ASC has considered, considered, selected, and implemented implemented nationally recog recognized infecgnized infec tion control guiidelines. The control guidelines. program program is—
Ch. 8. N-MS-3 NEW
416.51(b 416.51(b) b) Standard Standard: d: Infection control program control program NEW STA STANDARD TANDARD
(1) Under the direction of a e direction designate and qualidesignated ed ﬁed profe professional who essional has training in infection training control; control;
Ch. 8. N-MS-4 NEW
The infection control and p evention p ogram is under the direccontrol prevention pr g pr program direction of a designated and q g qualiﬁed professional who has training professional g in infection control. control.
416.51(b 416.51(b) b) Standard Standard: d: Infection control program control program NEW STA STANDARD TANDARD
(2) An integral part of the integr ral ASC’s qu ASC’s quality assessuality ment and performance d improvem improvement program, ment program, and;
Ch. 8. N-MS-5 NEW
The infection control p ogram is an integral p of the ASC’s control program a pr g g part ASC’s q quality assessment and performance improvement p ogram, y performance improvement program, p p pr g , and; ;
416.51(b) 416.51(b) (b) Standard Standard: d: Infection control program control program NEW STANDARD STA TANDARD
(3) Responsible for p oviding ( ) Responsib p ble pr providing g a plan of a action for prepreventing, identifying, and identifying, managing infections and communic communicable diseases cable and for immediately immediately implement implementing correcting corrective and preventative preventative r measures measures that result in result improveme improvement. ent.
Ch. 8. N-MS-6 NEW
The infection control p ogram is responsible for p oviding a p control program re p pr g esponsible providing plan pr g of action for p eventing, identifying, and managing infections pr preventing, identifying g, y g, g g g and communicable diseases and for immediately implementing y p g corrective corrective and p eventive measures that result in improvement. preventive measure pr es result improvement. p
The Accreditation Association for Ambulatory Health Care 2009 | Effective 5-18-09 Accredita ation Ambulatory r C
86 The OR Connection
TAKE THE PRESSURE OFF YOUR SURGICAL PATIENTS
It’s estimated that up to 66 percent of pressure ulcers occur as a result of surgery.1 What can you do to help prevent your patients from becoming statistics? Medline’s pressure redistribution OR table and stretcher pads can help redistribute the pressure that can occur before surgery while lying on stretchers, on the table during surgery and while being transported to the postoperative care unit. All of our OR table and stretcher pads are designed with state-of-the-art materials to offer an advanced level of pressure redistribution. Each pad offers a different level of pressure redistribution and can be custom-made to ﬁt any OR table. Finally — product solutions to help you meet your pressure ulcer prevention goals! To sign up for a FREE webinar on perioperative pressure ulcer prevention, go to www.medline.com/pupp-webinar. Completely conforms to the body
Reference 1 AORN. Recommended practices for positioning the patient in the perioperative practice setting. Perioperative Standards and Recommended Practices. 2008 Edition. Denver, Colo.: AORN Publications; 2008. ©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
PRESSURE ULCER EDUCATION
More important than ever before
Medline’s Pressure Ulcer Prevention Program now has a component designed speciﬁcally for perioperative services. The easy-to-use interactive CD addresses the following: • Hospital-acquired conditions • CMS reimbursement changes • Best practices for pressure ulcer prevention • Perioperative assessment tools • Critical patient and equipment risk factors To learn more about Medline’s Pressure Ulcer Prevention Programs and FREE webinars for acute care and perioperative services, call your Medline representative or visit www.medline.com/pupp-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
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 Recognition program is separate from the AORN, ANCC Accredited Provider Unit and therefore does not include any CE credit for programs. ©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc. The AORN Seal of Recognition is a trademark of AORN, Inc., All rights reserved.
Pressure Ulcer Prevention Policy and Procedure
Forms & Tools
Pressure Ulcer Prevention Checklist: Perioperative Services
Yes No Position Responsible Comments/Notes
Do you have a policy and procedure for skin and risk assessment that addresses: a. How and when a patient is considered at risk for development of a pressure ulcer and in need of prevention intervention(s)? b. Who is responsible for developing, implementing and monitoring the prevention care plan? Do you have prevention protocols for staff to implement when specific pressure ulcer risk factors are identified? Do you have a policy and procedure for positioning patients at risk for pressure ulcer that addresses: a. Pressure redistribution OR table pads for procedures lasting longer than two hours? b. The use of gel table pads when indicated? Do you warm your patients 30 minutes prior to the surgical procedure to maintain core body temperature intraoperatively? Does the individualized care plan for each patient at risk for pressure ulcers address the following prevention interventions: a. Pressure, friction and shear reduction 1. Pressure redistribution OR table pads or overlays (foam, gel)? 2. Positioning/repositioning techniques? 3. Positioning devices (foam, gel, wedges, etc.) to prevent pressure on bony prominences? 4. Mechanical aids (lifts, slide boards, sliding sheets) for lifting, moving and positioning/repositioning? 5. Protection for head, elbows and heels? 6. OR tables of sufficient sizes to fit your patient population? b. Skin care 1. Does skin inspection occur prior to and immediately following the surgical procedure? 2. Is skin is kept dry during the surgical procedure with minimal exposure to moisture, perspiration and drainage? 3. Is it ensured that warming blankets are not placed between the pressure redistribution table pad and the patient in high-risk patients?
Aligning practice with policy to improve patient care 89
Forms & Tools
Pressure Ulcer Prevention Policy and Procedure
Yes 4. Is skin cleansed with a skin-cleansing agent and thoroughly dried as soon as the surgical procedure is complete (before moving to the holding room)? 5. Do you minimize skin-drying factors? Do your protocols address repositioning patients whenever possible (head, heels, arms etc.) in long surgical procedures at least every two hours? Are there adequate supplies and equipment for staff to provide prevention interventions to all patients who require them? Does the care plan include routine monitoring of the effectiveness of the prevention interventions? Is there a protocol for when the prevention care plan should be evaluated and revised?
90 The OR Connection
Sterillium® Comfort Gel™
Your hands will love you for it.
Sterillium® Comfort Gel™ is gentle on your hands but tough on bacteria.
You’ll want to reach for Sterillium Comfort Gel again and again. It includes a balanced blend of moisturizing emollients that leverages technology shared with well-known skincare products NIVEA® and Eucerin®. The result is a product proven to increase skin hydration by 14 percent in just two weeks.1 Sterillium Comfort Gel delivers greater efficacy than other alcohol-based hand antiseptics by virtue of its ethyl alcohol concentration. It does more for your infection control efforts by using up to 50 percent less volume per application. Available in various sizes to suit any need.
To watch online interviews with international hand hygiene experts Didier Pittet and Günter Kampf, go to www.medline.com/media-room and choose featured article number 3.
©2010 Medline Industries, Inc. Medline® is a registered trademark of Medline Industries, Inc. Sterillium® is a registered trademark of BODE Chemie GmbH. NIVEA and Eucerin are registered trademarks of Beiersdorf AG. Sterillium® Comfort Gel® is a registered trademark of Bode Chemie GmbH.
Increased efﬁcacy. Incredible comfort. Improved compliance. Sterillium®Comfort Gel™
References 1. Data on file
Setting a new standard in patient safety.
Medline’s Gold Standard Safety Program— a complete tool kit for surgical safety.
Designed to break down barriers to surgical safety compliance by offering easy-to-use tools to help you reach your safety goals, Medline’s Gold Standard Safety Program offers three 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 Dual Tip Marker remind OR staff to take time to verify key information before the ﬁrst incision to reduce wrong site surgery. 3. Med-Pack™: Electronic pack audit and a review of safety components.
Visit www.medline.com/goldstandard for a quick video overview on how Medline’s Gold Standard Safety Program can help improve safety in your OR.
©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
Surgical Safety Checklist
Before skin incision
(with nurse, anaesthetist and surgeon) Conﬁrm all team members have introduced themselves by name and role. Conﬁrm the patient’s name, procedure, and where the incision will be made. Has antibiotic prophylaxis been given within the last 60 minutes? Yes Not applicable Anticipated Critical Events
Before induction of anaesthesia
Before patient leaves operating room
(with nurse, anaesthetist and surgeon)
(with at least nurse and anaesthetist)
Has the patient conﬁrmed his/her identity, site, procedure, and consent? Yes
Is the site marked? Yes Not applicable
Is the anaesthesia machine and medication check complete? Yes
Nurse Verbally Conﬁrms: The name of the procedure Completion of instrument, sponge and needle counts Specimen labelling (read specimen labels aloud, including patient name) Whether there are any equipment problems to be addressed To Surgeon, Anaesthetist and Nurse: What are the key concerns for recovery and management of this patient?
Is the pulse oximeter on the patient and functioning? Yes
Does the patient have a:
To Surgeon: What are the critical or non-routine steps? How long will the case take? What is the anticipated blood loss? To Anaesthetist: Are there any patient-speciﬁc concerns? To Nursing Team: Has sterility (including indicator results) been conﬁrmed? Are there equipment issues or any concerns? Is essential imaging displayed? Yes Not applicable
Surgical Safety Checklist
Known allergy? No Yes
Difﬁcult airway or aspiration risk? No Yes, and equipment/assistance available
Risk of >500ml blood loss (7ml/kg in children)? No Yes, and two IVs/central access and ﬂuids planned
Forms & Tools
Aligning practice with policy to improve patient care 93
This checklist is not intended to be comprehensive. Additions and modiﬁcations to ﬁt local practice are encouraged.
Revised 1 / 2009
© WHO, 2009
Your hands will love you even more.
Sterillium® Rub’s surgical scrub with high alcohol content delivers a devastating blow to microorganisms — not your skin.
Sterillium® Rub’s balanced emollient blend leaves hands feeling soft and smooth, never greasy or sticky, and makes gloving a breeze. But that doesn’t mean that Sterillium® Rub makes any sacriﬁces in efﬁcacy. In fact, it meets FDA requirements for efﬁcacy speciﬁcations. It’s also CHG, latex and non-latex glove compatible.
Increased efﬁcacy. Incredible comfort. Improved compliance. Sterillium® Rub.
Be one of the first 1,000 to try a FREE sample of Sterillium Rub. Send name/facility, address and e-mail to handhygienecompliance.com.
©2010 Medline Industries, Inc. Medline® is a registered trademark of Medline Industries, Inc. Sterillium® is a registered trademark of BODE Chemie GmbH.
FREE MEDICLIP TRIAL!
Why choose MediClip?
Clippers can help you avoid nicking or cutting the patient’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 to conduct your own extensive test of MediClip! Get up to 10 clippers and ﬁve cases of blades FREE!* Visit www.medline.com/special/MediClip-Trial.asp today.
* This offer is good through 6/30/2010. It applies to new customers only and is good for up to 10 MediClip Clippers and up to ﬁve cases of MediClip blades. ©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
New Techniques for Pressure Ulcer Prevention, Hand Hygiene and CAUTI Prevention
PERIOPERATIVE PRESSURE ULCER PREVENTION
Learn about pressure ulcer prevention in the perioperative arena and the implications of the 2008 CMS inpatient hospital care “Present on Admission (POA)” indicator.
4th 12:00 pm - 1:00 pm 19th 1:00 pm - 2:00 pm 27th 11:00 am - 12:00 pm
3rd 11:00 am - 12:00 pm 22nd 1:00 pm - 2:00 pm 29th 12:00 pm - 1:00 pm
J U LY
7th 11:00 am - 12:00 pm 20th 12:00 pm - 1:00 pm 27th 1:00 pm - 2:00 pm
12th 1:00 pm - 2:00 pm 17th 12:00 pm - 1:00 pm 20th 11:00 am - 12:00 pm
Sign up at www.medline.com/PUPP-webinar
HAND HYGIENE COMPLIANCE IMPROVEMENT STRATEGIES
As the number one defense against healthcare-acquired conditions, hand hygiene plays an important role in the prevention of infections. Learn how hospitals and healthcare facilities are combining best-in-class products and education to achieve hand hygiene compliance while dramatically improving the skin condition of healthcare workers.
14th 11:00 am - 12:00 pm 19th 12:00 pm - 1:00 pm
14th 11:00 am - 12:00 pm 17th 12:00 pm - 1:00 pm
J U LY
8th 11:00 am - 12:00 pm 21st 2:00 pm - 3:00 pm
17th 2:00 pm - 3:00 pm 23rd 1:00 pm - 2:00 pm
Sign up at www.medline.com/handhygiene
INNOVATION IN THE PREVENTION OF CAUTI
Join your colleagues from around the country to learn more about strategies to prevent catheter-acquired urinary tract infections as well as Medline’s ERASE CAUTI system.
5th 10th 11th 18th 21st 24th 12:00 pm - 1:00 pm 11:00 am - 12:00 pm 2:00 pm - 3:00 pm 2:00 pm - 3:00 pm 12:00 pm - 1:00 pm 11:00 am - 12:00 pm
7th 9th 11th 18th 21st 22nd 11:00 am - 12:00 pm 2:00 pm - 3:00 pm 12:00 pm - 1:00 pm 12:00 pm - 1:00 pm 11:00 am - 12:00 pm 2:00 pm - 3:00 pm
J U LY
7th 7th 8th 20th 20th 21st 11:00 am - 12:00 pm 2:00 am - 3:00 pm 12:00 pm - 1:00 pm 12:00 pm - 1:00 pm 2:00 pm - 3:00 pm 12:00 pm - 1:00 pm
12th 12th 16th 16th 25th 25th 11:00 am -12:00 pm 1:00 pm - 2:00 pm 11:00 am -12:00 pm 2:00 pm - 3:00 pm 11:00 am - 12:00 pm 2:00 pm - 3:00 pm
Sign up at www.medline.com/erase/webinar.asp
Hosted by Alecia Cooper, RN, MBA, CNOR and Lorri Downs, RN, BSN, MS, CIC
All schedules are based on Central Daylight Time
©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.