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Principles
for achieving
inner peace
Pink Glove Ad
WINNER
Page 6
The
Aligning practice with policy to improve patient care
FREE CE!
Meet checklist
guru Dr. Peter
Pronovost
YES!
Checklists
Work
Tips for
Tackling
VAP
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OR Connection
The
Aligning practice with policy to improve patient care
Subscribing to The OR Connection guarantees that you’ll
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out on our industry updates and articles addressing on-the-
job issues and tips on caring for yourself!
To subscribe, simply go to www.medline.com/orconnection.
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Content Key
We've coded the articles and information in this magazine to indicate which patient care
initiatives they pertain to. Throughout the publication, when you see these icons you'll
know immediately that the subject matter on that page relates to one or more of the
following national initiatives:
• IHI's Improvement Map
• Joint Commission 2009 National Patient Safety Goals
• Surgical Care Improvement Project (SCIP)
We've tried to include content that clarifies the initiatives or gives you ideas and tools
for implementing their recommendations. For a summary of each of the initiatives,
see pages 10 and 11.
Aligning practice with policy to improve patient care 111
Bathing and Showering
Most incisions should be kept dry for several days after surgery, except for incisions closed
with surgical glue. It is usually safe to allow glued incisions to get wet while showering or
bathing. It is important, however, to dry the area around the incision carefully after washing.
Physical Activity and Exercise
Avoid any activity that pulls on the edges of the incision or puts pressure on it. Walking and
other light activities are encouraged to restore normal energy levels and digestive functions.
Do not, however, participate in sports, engage in sexual activity or lift heavy objects until after
your postoperative checkup.
Aspirin
Avoid aspirin or over-the-counter medications containing aspirin for a week to 10 days after
surgery. Aspirin interferes with blood clotting and makes it easier for bruises to form near
the incision.
Sun Exposure
As an incision heals, the new skin that forms over the cut is very sensitive to sunlight and
will burn more easily than normal skin and lead to worse scarring. Keep the incision area
covered from direct sun exposure for three to nine months in order to prevent burning and
severe scarring.
General Hygiene
Infection is the most common complication of surgical procedures. It is important, therefore,
to minimize the risk of an infection when caring for your incision at home.
Observe the following precautions:
• Wash your hands carefully after using the toilet and after touching or handling trash;
pets and pet
equipment; dirty laundry and anything else that is dirty or has been used outdoors
• Ask family members, close friends, and others to wash their hands before contact
with you
• Avoid contact with family members and others who are sick or recovering from a
contagious illness
• Stop smoking (smoking slows down the healing process)
Adapted from www.surgeryencyclopedia.com/Fi-La/Incision-Care.html
Pati ent Handout Forms & Tools
Caring for Your Surgical Incision at Home
The following are general guidelines. Consult your surgical team for more specific instructions.
Aligning practice with policy to improve patient care 3
PATIENT SAFETY
10 Three Important Initiatives for Improving Patient Care
12 Patient Safety News
20 Conversation with Dr. Peter J. Pronovost
24 Checking it Twice: Yes! Checklists Do Save Lives
39 Why the Universal Protocol Hasn’t Eradicated Patient Harm
42 A New Guidebook for Patient Safety in the OR
46 They’re Lurking in the Operating Room and Beyond
74 5-Step Approach for Avoiding VAP
OR ISSUES
36 Preventing Sharps Injury in the OR
55 Medline Joins Greening the Operating Room Initiative
60 Stuck Like Surgical Glue
SPECIAL FEATURES
7 Pink Glove Survey Comments
14 Third Annual Prevention Above All Conference Highlights
30 Patient, Heal Thyself
56 3 Checklists on the Cleaning and Disinfection of
Endoscopic Equipment
69 Product Spotlight: Medline Bioguard Barrier Dressings
92 Pink Glove Dance: The Sequel
CARING FOR YOURSELF
78 Get Set for Winter Illness Season
84 8 Principles for Achieving Inner Peace
96 Healthy Eating: Crock Pot Chili
FORMS & TOOLS
99 AORN Surgical Time Out
100 SCOAP Surgical Safety Checklist – Ambulatory Surgery
101 SCOAP Surgical Safety Checklist
103 Wrong-Site Surgery Prevention Tool
105 Medicare & the New Healthcare Law
109 Tips for Safer Surgery
111 Caring for Your Surgical Incision at Home
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, BSN, RN, CNOR
Margaret Falconio-West, BSN, RN, APN/CNS,
CWOCN, DAPWCA
Rhonda J. Frick, RN, CNOR
Anita Gill, RN
Kimberly Haines, RN, Certified OR Nurse
Carla Nitz, BSN, RN
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, RN, RNFA
St. Luke’s The Woodlands, Texas
Tracy Diffenderfer, MSN, RN
Vanderbilt University Medical Center, Tennessee
Barb Fahey RN, CNOR
Cleveland Clinic, Ohio
Susan Garrett, RN
Hughston Hospital Inc., Georgia
Zaida I. Jacoby, MA, MEd, RN
NYU Medical Center, New York
Jackie Kraft, RN, CNOR
Huntsville Hospital, Alabama
Tom McLaren
Florida Hospital, Florida
Susan Phillips, RN, MSH, CNOR
University of North Carolina Hospitals
Donna A. Pritchard, BSN, MA, RN, CNOR, NE-BC
Kingsbrook Jewish Medical Center, New York
Debbie Reeves, MS, RN, CNOR
Hutcheson Medical Center, Georgia
Diane M. Strout, BSN, RN, CNOR
St. Joseph Medical Center, Washington
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 manage-
ment services.
Meeting the highest level of national and international quality standards, Medline is FDA
QSR compliant and ISO 13485 registered. Medline serves on major industry quality
committees to develop guidelines and standards for medical product use 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.
Page 24
Page 84
Page 92
Page 60
©2010 Medline Industries, Inc. The OR Connection is published by Medline Industries, Inc. One Medline Place, Mundelein, IL 60060. 1-800-MEDLINE.
Page 74
You shouldrecognize andcelebrate your achievements.
Those milestones are what will continue to inspire you and
push you to be your very best. And, when you are at your
best and do your best, everyone wins…especially the
patients you are caring for. So, for 2011, I hope you will
take care of yourself. You are so important to your patients.
Sometimes it takes being a patient or the family member
of a patient to really appreciate all that you do. I’ve been
there, and so have many, many of the people I work with.
We all thank you.
To set the tone for 2011, you might want to start reading on
page 84, “8 Principles for Achieving Inner Peace.” There is
nothing better than an inspirational article like this one to
get those New Year’s resolutions and goals flowing. High-
light the article, take notes, think about the message…and
then figure out what YOU are going to do to make 2011 the
best ever!! Once you’ve put your plan together, look again
at the pictures of the pink glove dancers. Take note of the
hospitals involved, look at the people’s faces, feel their joy.
Breathe in all those positive vibes. Then set the magazine
aside and do something for yourself, something that makes
you feel good. Surprise a co-worker with a smile, ask them
about their holiday, get them a cup of coffee. Or, listen to
your child or your spouse talk about their day. Be there, in
the moment, and forget everything else that is distract-
ing you and taking time away from living.
I know, I know, at some point you have to get back to work
and deal with reality and everyday pressures. But it is
easier to do when you make time for yourself and your
family. I realize it’s hard to do everything, know every-
thing, remember everything…that is why in this issue of
The OR Connection, you are going to learn more than you
probably ever wanted to know about checklists. On the
cover isn’t just another handsome face. It is Dr. Peter
Pronovost, a well-known advocate of patient safety,
quality and the infamous checklist. On page 20, he tells
his own personal story about his father and how it has
inspired him to champion a culture of safety. Whether your
checklist is healthcare-related or a checklist for travel or a
social event, it is easy to forget the simplest things when
our minds are buzzing. We should embrace and adopt
checklists and encourage others to do likewise. If one
life is saved or one error is avoided, it’s worth it, don’t
you think?
This edition is packed full of stories and ideas you can use
in your profession as well as in your personal life. You are
the face of health care. Thank you for making a difference
in so many people’s lives. And don’t forget. Step one is
making sure you take care of YOU.
Sue MacInnes, RD, LD
Editor
4 The OR Connection
The OR Connection
Letter from the Editor
Another New Year is here! It’s a great time to reminisce, to make our New Year’s resolu-
tions and set our goals for 2011. Do you ever just stop and think about what was happening
this time last year or even five years ago? Do you think about what you were doing then?
Have you changed responsibilities, or maybe even careers? Did you get married, have a child,
become a grandparent, move, have to deal with a tragic situation …And when you think back,
do you ever say, “I can’t believe I’ve come this far.” Because if you haven’t, you should!
The results are in!
We’ve tallied your votes and compiled your thoughts about Medline’s pink gloves
and the Pink Glove Dance. Thank you for your heartfelt comments and participation
in last issue’s survey.
Turn the page to find the winner!
And the winning pink glove ad is…
Precious. And Pink.
Soft and shimmery.
Layered with organic aloe.
Fashioned from nitrile.
The Pink Pearl.™
Medline’s newest Generation Pink glove.
Supporting the National Breast Cancer Foundation.
©2010 Medline Industries, Inc. Medline is a registered trademark and Pink Pearl
is a trademark of Medline Industries, Inc.
only wear Pink Pearls.
Only Medline’s Pink Pearl™ gloves combine
aloe, nitrile and breast cancer awareness.
©2010 Medline Industries, Inc. Medline is a registered trademark and Pink
Pearl is a trademark of Medline Industries, Inc.
Yes, They’re Genuine.
Only Medline’s Pink Pearl™ gloves combine
aloe, nitrile and breast cancer awareness.
©2010 Medline Industries, Inc.
Medline is a registered trademark
and Pink Pearl is a trademark of
Medline Industries, Inc.
Yes, They’re Genuine.
Only Medline’s Pink Pearl™ gloves combine
aloe, nitrile and breast cancer awareness.
©2010 Medline Industries, Inc.
Medline is a registered trademark
and Pink Pearl is a trademark of
Medline Industries, Inc.
6 The OR Connection
54% Voted for Pearls!
Aligning practice with policy to improve patient care 7
Q
A
What does the
Pink Glove Dance
mean to you?
What our readers said:
pink glove survey
It means unity, joy, excitement, a cause
“on the go” for all involved.
Shannon Sessoms, RN, BSN, CNOR
Southeast Missouri Hospital
Cape Girardeau, MO
Awareness! Hope! While in the OR I told
co-workers and the patient about this.
It raised our spirits. Big company
that CARES.
Deb Cimino, RN, BSN, CPSN, CNOR
Yardley Plastic & Reconstructive Surgery
Yardley, PA
Celebrating the lives of two of our nurses
who died—and the two who are still
with us.
MJ Balun
Naples Day Surgery
Naples, FL
It is a fun but touching video that shows
the true concern healthcare workers have
for people with breast cancer.
Holly Creel, RN
The Kirklin Clinic
Warrior, AL
8 The OR Connection
My mother had breast cancer, so it
means everything.
Tina Hollis
Northeast Alabama Regional Medical Center
Herflin, AL
Hope for patients with breast cancer.
Beautiful women, strength, good fun.
Patricia Nieszel, RN
Algonquin Surgery Center
Crystal Lake, IL
It shows how caring healthcare workers
of ALL types are towards supporting
the cause!
Helen Aylward, RN, BSN, L.Ac.
Maine Medical Center
Portland, ME
It made me cry to see the teamwork that
went into making it. I’m a breast cancer
survivor.
Carolyn Meyer, RN, BSN, CNOR
St. John Medical Center
Bartlesville, OK
As a breast cancer survivor it means so
much to know that many people care and
want to show it - keep it up!
Ellen Whitehead, RN, CNOR
Georgia Surgical
Acworth, GA
Those with cancer are not alone.
We are out there standing beside
them and showing our support.
Kathleen Ingraham
FirstHealth Moore Regional Hospital
Pinehurst, NC
Shows how much healthcare workers
want to make a difference toward
recognition, education and care of
breast cancer.
Susan Karns, CST, CFA
Kettering Medical Center - Sycamore
Franklin, OH
People from all different walks of life
coming together for a common cause
– fighting breast cancer.
Sue Montgomery, RN
Foothill Presbyterian Hospital
Glendora, CA
Wonderful healthcare providers, not
professional dancers, working hard to
spread the word about breast cancer
awareness.
Mary Valley, RN, CNOR
Frisbie Memorial Hospital
Rochester, NH
Joy for cancer survivors and hope
for more.
Carol Athey, RN, MSN, CNOR
Woodland Heights Medical Center
Lufkin, TX
It makes me smile.
Debra Ann Caise, RN, BSN
Provena St. Mary’s Hospital
St. Anne, IL
Left to right:
Tina Hollis, Patrick
Montgomery and
Cindy Gibson.
Co-workers in the
surgery department
at Northeast
Alabama Regional
Medical Center in
Herflin, AL.
What does the Pink Glove Dance mean to you?
Aligning practice with policy to improve patient care 9
As a breast cancer survivor,
every time I see the videos I cry
with gratitude that so many people
care and did something so fun
and positive as a response. Thank
you to everyone who participated.
And thank you to so-hip Portland
for getting the ball rolling. And as a
lifetime rock and roller, dancer and
silly person, every time I see these
folks dance and carry on, I laugh and I am infused with love of
life and humanity. Boy do they get their groove on!
I was diagnosed with breast cancer in mid-2004. I had two
lumpectomies and two months of radiation, and have been
free and clear ever since (as of October 2010). I had very
good care in Marin County, CA.
I made some wonderful friends in my support group and
became closer to many of the friends I already had. Besides
my support group, I have about ten women friends who
have had breast cancer. I would never wish it on anyone as
a life experience (I don’t believe that things like this happen
to teach us a lesson, but rather that we use what happens
to us in a way that teaches us something), but I used it to
recommit myself to the best health and the best appreciation
of life and friendships that I can muster, which is pretty dang
good. Every single day counts, as does every single person.
In the pink,
Francine Falk-Allen
San Rafael, CA
The dance demonstrates the joy of
living while increasing awareness
about breast cancer.
Paula Bishop, RN, MSN, CNOR
Aultman Hospital
Canal Fulton, OH
The closer we get to a cure! I lost a
sister and have a sister who is a survivor
going on 10 years now! Very close to
my heart.
Lynetta Baldwin
Advanced Surgical Care
Creve Coeur, MO
A hospital works as a unified unit to
complete its mission.
Colleen Witt, RN BSN
Roswell Park Cancer Institute
Buffalo, NY
A way to show support for breast
cancer survivors.
John Ratliff, BS, CST, FAST
York Technical College
Rock Hill, SC
People getting involved to bring
awareness to breast cancer.
Darlene McCraney, RN
South Central Regional Medical Center
Laurel, MS
It energizes you and makes you want to
move, especially when you see everyone
working toward the same goals.
Jerlene McClain, RN, BSN, MHR, CNOR
Reynolds Army Community Hospital - Fort Sill
Lawton, OK
10 The OR Connection
Three Important National Initiatives
for Improving Patient Care
Achieving better outcomes starts with an understanding of current
patient-care initiatives. Here’s what you need to know about national
projects and policies that are driving changes in care.
Origin: Launched by the Institute for Healthcare Improvement (IHI) in January 2009
Purpose: To help hospitals improve patient care by focusing on an essential set of processes needed to
achieve the highest levels of performance in areas that matter most to patients.
Hospitals sign up through IHI and can choose to implement some or all of the recommended interventions.
IHI provides how-to guides and tools for all participating hospitals.
The IHI Improvement Map covers the entire landscape of outstanding hospital care to help hospitals make sense of countless requirements
and focus on high-leverage changes to transformcare. There are 70 processes grouped into three domains: leadership and management,
patient care and processes to support care.
Origin: Developed by Joint Commission staff and the Patient Safety Advisory Group
(formerly the Sentinel Event Advisory Group)
Purpose: To promote specific improvements in patient safety, particularly in problematic areas
Joint Commission-accredited organizations are evaluated for compliance with these goals. The Joint Commission offers
guidance to help organizations meet goal requirements.
Over the next year, the current National Patient Safety Goals (NPSGs) will undergo an extensive review process. As a result,
no new NPSGs will be developed for 2011; however, revisions to the NPSGs will be effective in 2011.
Origin: Initiated in 2003 as a national partnership. Steering committee includes the following
organizations: CDC, CMS, ACS, AHRQ, AHA, ASA, AORN, VA, IHI and the
Joint Commission
Purpose: To improve patient safety by reducing postoperative complications
Goal: To reduce nationally by 25 percent the incidence of surgical complications by 2010
SCIP aims to reduce surgical complications in three target areas. Participating hospitals collect data on specific process and
outcome measures. The SCIP committee believes it could prevent 13,000 perioperative deaths and up to 300,000 surgical
complications annually (just in Medicare patients) by getting performance up to benchmark levels.
IHI Improvement Map
1
Joint Commission 2011 National Patient Safety Goals
2
Surgical Care Improvement Project (SCIP)
3
IHI Improvement Map: 73 Processes to Transform Hospital Care
Surgical Care Improvement Project (SCIP): Target Areas
Joint Commission 2011 National Patient Safety Goals
Aligning practice with policy to improve patient care 11
Patient Safety
Effective January 1, 2011:
• 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.
• The organization identifies safety risks inherent in
its patient population.
• Universal Protocol for Preventing Wrong Site,
Wrong Procedure, and Wrong Person Surgery.™
To learn more about National Patient Safety Goals, go to www.jointcommission.org.
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.
To learn more about the IHI Improvement Map and the 73 processes to transformhospital care, go to www.ihi.org/imap/tool
1. Surgical infections
• Antibiotics, blood sugar control, hair removal, perioperative
temperature management
• Remove urinary catheter on Post Operative Day (POD) 1 or 2
2. Perioperative cardiac events
• Use of perioperative beta-blockers
3. Venous thromboembolism
• Use of appropriate prophylaxis
3 New Key Processes as of June 2010
1. Anticoagulation Management
2. Essential Care for Frail Older Patients
3. Glycemic Control in Non-Critically Ill Patients
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
Visit www.qualitynet.org
By the numbers:
• 3,740 hospitals are submitting
data on SCIP measure #9, representing
75 percent of all U.S. hospitals
• Currently, SCIP has more than 36
association and business partners
12 The OR Connection
APIC, CDC, Other Infection Control Organizations
Pledge to Eliminate HAIs
1
Action steps published in AJIC
A number of professi onal heal thcare organi zati ons,
i ncluding the Association for Professionals in Infection
Control and Epidemiology (APIC), the Society for Healthcare
Epidemiology of America (SHEA), the Infectious Diseases
Society of America (IDSA), the Centers for Disease Control
and Prevention (CDC) and others have joined together to
move toward the elimination of healthcare-associated infec-
tions (HAIs). They announced their plan in a white paper,
“Moving Toward Elimination of Healthcare-Associated Infec-
tions: A Call to Action,” published in the November 2010 issue
of the American Journal of Infection Control (AJIC).
The group proposes to eliminate healthcare-associated
infections through a series of action steps, as outlined in the
paper:
• Adherence to evidence-based practices
• Aligning financial incentives
• Innovation and research
• Gathering data for action
New Hampshire Hospital Initiative Aims to Eliminate
Harm to Patients by 2015
2
In a new effort to promote better and safer patient care, the
New Hampshire Hospital Association and Foundation for
Healthy Communities recently began a new initiative to elim-
inate harm to patients by 2015.
The definition of “harm,” according the New Hampshire
initiative, refers to an injury associated with medical care that
requires or prolongs hospitalization and/or results in perma-
nent disability or death.
A statewide steering committee will spearhead the New
Hampshire Eliminate Harm Initiative and identify which
aspects of harm hospitals will target for elimination.
Death Rate Six Times Higher for Hospital Patients
with HAIs
3
Adults who developed health care-associated infections
(HAIs) due to medical or surgical care while in the hospital in
2007 had a death rate six times higher than patients without
an HAI, according to the latest News and Numbers published
by the Agency for Healthcare Research and Quality (AHRQ).
Patients with HAIs also had to stay in the hospital an
average of 19 days longer. On average, the cost of a hospital
stay of an adult patient who developed an HAI was about
$43,000 more expensive than the stay of a patient without
an HAI. AHRQ also discovered that:
• In 2007, about 45 percent of patients with HAIs
were 65 or older, 33 percent were 45 to 64 and 22
percent were 18 to 44.
• Patients in the 45 to 64 age group had the highest
rate of HAIs.
• The top three diagnoses in hospitalized adult patients
who developed HAIs were septicemia (12 percent),
adult respiratory failure (6 percent) and complications
from surgical procedures or medical treatment
(4 percent).
References
1. Cardo D, Dennehy PH, Halverson P, Fishman N, Kohn M, Murphy CL, et al.
Moving toward elimination of healthcare-associated infections: a call to action.
American Journal of Infection Control. 2010;31(11):1101-1105. Available at:
http://www.journals.uchicago.edu/doi/pdf/10.1086/656912. Accessed October
25, 2010.
2. New Hampshire’s hospitals commit to eliminate harm [news release].
Concord, NH: New Hampshire Hospital Association; September 27, 2010.
www.nhha.org/WhatsNewFiles/EliminateHarm092710.pdf. Accessed October
25, 2010.
3. Health care-associated infections greatly increase the length and cost of
hospital stays. Agency for Healthcare Research and Quality website. October
2010 feature story. Available at: www.ahrq.gov/research/oct10/1010RA1.htm.
Accessed October 25, 2010.
PATIENT SAFETY NEWS PATIENT SAFETY NEWS
Aligning practice with policy to improve patient care 13
Medline Industries, Inc. has signed an agreement with the Joint
Commission Center for Transforming Healthcare to contribute
financially to the Center’s Endowment Fund. The Center for
Transforming Healthcare was developed to help solve health-
care’s most critical safety and quality problems.
In this effort, Medline is joining other leading healthcare
organizations in their commitment to eliminate preventable
complications and transform healthcare.
“Medline is proud to support and share in the mission of solving
healthcare’s most critical safety and quality problems,” said
Andy Mills, president of Medline. “Medline’s approach is to
‘Make it hard for the healthcare worker to do the wrong thing.’
The Center is studying some of the most pressing issues
facing providers, bringing together teams of experts to design
and test practical solutions to healthcare’s everyday challenges.”
Issues the Center is working on include Hand Hygiene,
Surgical Site Infections, Wrong Site Surgery and Hand-off
Communication.
Hospitals and Healthcare Systems Participating
in the Hand-Off Communication Project
• Exempla Lutheran Medical Center,
Wheat Ridge, Colorado
• Fairview Health Services, Minneapolis, Minnesota
• Intermountain Healthcare LDS Hospital,
Salt Lake City, Utah
• The Johns Hopkins Hospital, Baltimore, Maryland
• Kaiser Permanente Sunnyside Medical Center,
Clackamas, Oregon
• Mayo Clinic Saint Marys Hospital,
Rochester, Minnesota
• New York-Presbyterian Hospital, New York
• North Shore-LIJ Health System Steven and Alexandra
Cohen Children’s Medical Center, New Hyde Park,
New York
• Partners HealthCare, Massachusetts General
Hospital, Boston
• Stanford Hospital & Clinics, Palo Alto, California
Medline Partners with The Joint
Commission to Help Solve
Healthcare Quality and Safety Issues
Ways to improve hand-off communication
Healthcare organizations have long struggled with errors and
issues associated with passing along critical patient information
from one caregiver to the next, also known as hand-off
communication.
The Center and participating hospitals set out to solve these
problems and recently released some new solutions using the
acronym SHARE.
Standardize critical content by providing details of the patient’s
history to the healthcare worker who will be taking over the
patient’s care, emphasizing key information about the patient.
Hardwire within your system, which includes developing stan-
dardized forms, tools and methods, such as checklists to assist
in making the hand-off successful.
Allow opportunity to ask questions and use critical thinking
skills when discussing a patient’s case as well as sharing and
receiving information as an interdisciplinary team.
Reinforce quality and measurement, which includes holding
staff accountable, monitoring compliance with use of stan-
dardized forms, and using data to determine a systematic
approach for improvement.
Educate and coach, which includes organizations teaching
staff what constitutes a successful hand-off and making suc-
cessful hand-offs an organizational priority.
14 The OR Connection
The heat is on in health care like never before. Error prevention,
efficiency and cost containment have been top priorities for a
very long time, but now, with the introduction of healthcare re-
form, they are absolutely critical for survival, according to Joint
Commission President Mark Chassin, MD, MPP, MPH.
What to expect from healthcare reform
Dr. Chassin delivered the keynote address at Medline’s 3rd
Annual Prevention Above All Conference devoted to sharing
new strategies for delivering cost-effective, high-quality, evi-
dence-based health care. An audience of more than 100 hos-
pital CEOs, chief nursing officers and other executives attended
the meeting August 16 and 17, 2010, in New York City.
“Today’s message is clear,” Dr. Chassin said. “Solve safety and
quality problems. Don’t say you’re trying; just solve them. Take
care of 30-plus million more people in your organizations.
Become or participate in an accountable care organization. Fig-
ure out bundled payments. Adopt electronic medical records
quickly. And one more thing. You can’t have any more money.”
Overall, Dr. Chassin explained, healthcare reform increases
coverage while experimenting with some new payment and
care delivery ideas. Reform will increase federal costs, and
there is only one vehicle for cost containment: limiting payment
to providers.
Dr. Chassin cautioned, “You will never be paid better than you
are being paid now. This was true six months ago, it’s true now,
and it will be true tomorrow and next week.”
So how do healthcare providers control costs and avoid major
payment cuts and benefit reductions while also maintaining
quality? Dr. Chassin outlined several keys to survival in today’s
era of healthcare reform.
Employ a quality-driven strategy to eliminate overuse of health
services. Examples include discontinuing wasteful practices
such as prescribing antibiotics for colds and inducing labor
earlier than 39 weeks.
“This is one part of health policy that has not received any
attention,” Dr. Chassin explained. “It’s been overlooked for
decades in the research community. We must come together
to do this.” Two more keys to survival are eliminating the waste
inherent in needlessly complex care delivery processes and
putting an end to preventable complications.
Strategies for Thriving in the
New Era of Healthcare Reform
Third Annual Prevention Above All Conference
Aligning practice with policy to improve patient care 15
Deborah Adler, Trent Haywood,
Mark Chassin and Mikel Gray
answer questions from the
audience at the Third Annual
Prevention Above All Conference
held at the Hudson Theatre in
New York City.
Special Feature
A look into the future
Speaking fromhis experience as CEOof NewYork City’s Mount
Sinai Hospital, one of the nation’s largest and busiest hospitals,
Wayne Keathley provided a firsthand look at what he predicts
will be the norm for the average U.S. hospital amidst the new
era of healthcare reform—having to do a lot more with a lot less
at average capacity levels of 95 percent.
“A fair number of you probably don’t recognize the kind of con-
gestion, overcrowding and difficulties with flow that I’m about
to describe,” Keathley said. “I would ask you to indulge in a lit-
tle suspension of disbelief and assume for a minute that as
health reform evolves, possibly because of a whole new group
of patients who will come to you for care … and more likely
because the economics will require you to rethink capacity and
the way you manage it — that the situation I’m going to
describe for us, in fact has some meaning for you.”
Mount Sinai is operating at 95 percent capacity, and they are
currently working with GE Healthcare to implement new
systems to accommodate this level of activity.
Keathley advocates improvement through fixing systems,
not by adding more resources. For example, whereas hospi-
tals often rely on intuition and personal judgment when man-
aging patient flow and locating empty beds, Keathley suggests
that studying capacity patterns and related data leads to
more efficient use of resources. He also encourages collabo-
ration among departments, viewing the hospital as a whole
rather than operating as individual silos.
“If money were no object, we would add more beds, add more
operating rooms, hire more nurses, and we could drive
occupancy back down to the ideal 85 percent,” Keathley
said. “But I am telling you, that fantasy doesn’t exist.”
Prevention Above All
Another solution to meeting the challenges of healthcare reform
lies in preventing costly medical errors and infections that are
indeed preventable. Sue MacInnes, Medline’s Chief Marketing
Officer and host of the Prevention Above All Conference,
reviewed Medline’s growing offering of preventive strategies
for healthcare providers:
The Gold Standard Surgical Safety Program to help prevent
operating room errors, the Hand Hygiene Compliance Pro-
gram, the Pressure Ulcer Prevention Program, Educational
Packaging, the ClearCount Surgical System to help prevent
sponges from being left behind and the Catheter-Associated
Urinary Tract Infection (CAUTI) Foley Catheter Management
System to help prevent CAUTIs.
These six strategies are targeted, focused and achievable evi-
dence-based solutions that are also practical. They fit with
everyday processes and systems currently in place at most
healthcare facilities.
MacInnes emphasized, “Sometimes the simplest solutions
make the biggest difference.”
Left: Keynote speaker
Joint Commission President
Mark Chassin, MD, MPP, MPH.
Above (left to right): Medline
President Andy Mills, Deborah
Adler, Medline Chief Marketing
Officer, Sue MacInnes, RD, LD,
Atul Gawande, MD, MPH,
Medline COO Jim Abrams.
Right: The Third Annual
Prevention Above All Conference
took place at the historic Hudson
Theatre in New York City.
16 The OR Connection
Caroline Fife, MD and Kevin W. Yankowsky, JD
Lawsuits, Technology and Wound Care: How Electronic
Health Records Change Your Legal Risks
“Any time a lawsuit is filed, you and your facility and your
practitioners lose. The only question is the question
of degree ... I would suggest and recommend that you
take a moment to focus on how, in addition to improving
your clinical care, you can take steps to absolutely mini-
mize your risk of ever being involved in the legal system; of
ever being sued in the first place.” - Kevin W. Yankowsky
Trent T. Haywood, MD, JD
Social Practice: Observation
for Understanding and Improving
“One of the key things people have taught us in anything
that has to do with practice improvement is not really what
you don’t know; it’s what you think you knowthat ain’t so.”
Dale Bratzler, DO, MPH
Healthcare-Associated Infections
and Public Accountability
“Clearly, if there is a single practice that we can do better
that will dramatically reduce healthcare-associated infec-
tions, it would be hand hygiene.”
Mikel Gray, PhD, FNP, CUNP, CCCN, FAANP, FAAN
Evolution of Evidence: New Models
for Demonstrating Effectiveness
“Insufficient evidence remains the primary challenge
of evi dence-based practice; demystification of the
research process is urgently needed.”
Atul Gawande, MD, MPH
Author, The Checklist Manifesto
“What we have today, though, is a volume and complex-
ity of medical discovery that has now exceeded our ability
as individual specialized artisans to be able to deliver that
care to the right person, the right way, at the right time
without waste of resources.”
For video clips of the speakers’ presentations from
the 3rd Annual Prevention Above All Conference,
visit www.medline.com/media-room. Or contact
your Medline representative for a free set of DVDs.
What the Experts Are Saying ...
Fife Yankowsky
Haywood Bratzler
Gray Gawande
Aligning practice with policy to improve patient care 17
Continued on page 19
©3M 2010. All rights reserved. ChloraPrep is a registered trademark of Carefusion Corporation. 3M and DuraPrep are trademarks of 3M Company.
3M Infection Prevention Solutions
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Before you standardize
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remember this:
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NQF don’t.
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patient variables and procedure types demand different performance features. Both ChloraPrep
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74% w/w) Patient Preoperative Skin Preparation received NDA approval based on ASTM testing for efficacy set
forth by the FDA. Which may be why both are recommended for the reduction of SSI by AORN, CDC and NQF. To
learn more about the surprising differences between surgical patient preps, visit us at www.3M.com/duraprep.
patient
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n
Practicing Advanced Medicine
Within Outdated Systems
Atul Gawande, MD, a Harvard professor and author of several
books, including his most recent, The Checklist Manifesto,
addressed the challenges of delivering highly advanced medical
care within outdated systems.
He pointed out that we’ve entered a complex medical world in
which we have 13,600 different diagnoses, 6,000 prescription
medications and more than 4,000 medical and surgical
procedures.
Compounding matters, we’ve inherited a structure from 50
years ago that didn’t have nearly so many diagnoses, drugs
and procedures. At that time, the doctor was considered an
artisan, and all you really needed was the physician’s brain,
along with an operating room, a few simple tools and some
skills behind that.
“What we have today, though, is a volume and complexity of
medical discovery that has now exceeded our ability as
individual specialized artisans to be able to deliver that care to
the right person, the right way, at the right time without waste
of resources,” Dr. Gawande said.
The Checklist Manifesto: How to Get Things Right
Atul Gawande, MD, MPH
We l i ve i n a worl d of great and
i ncreasing complexity, where even
the most expert professionals strug-
gle to master the tasks they face.
Longer training, ever more advanced
technologies —neither seems to pre-
vent 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.
AORN: Spreading knowledge,
preventing complications
AORN Executive Director Linda
K. Groah, RN, MSN, CNOR,
NEA-BC, FAAN, began her pres-
entation with these statistics: the
average department of surgery is
responsible for 40 to 60 percent
of expenses, 70 percent of rev-
enue and 50 percent of errors.
To help reduce surgical errors, the Association of peri-
Operative Nurses (AORN) promotes safe surgical prac-
tices and optimal patient outcomes by educating
perioperative nurses and partnering with other profes-
sional and governmental healthcare organizations.
AORN collaborates on patient safety initiatives with a
number of major healthcare organizations, including
the Centers for Medicare & Medicaid Services (CMS),
the Surgical Care Improvement Project (SCIP), the
World Health Organization (WHO), the Joint Commis-
sion, IPPS, Blue Cross and others. In fact, AORN
worked closely with the WHO and Dr. Atul Gawande
to ensure the perioperative nurse’s role was incorpo-
rated into the Surgical Safety Checklist.
As a leader in the perioperative arena, AORN has also
developed a number of its own initiatives for practical
application in the OR. Some of these include Periop-
erative Standards and Recommended Practices, a
complete perioperative curriculum and various toolkits.
“The Perioperative Standards really are the core of
AORN,” Groah said. “They represent the intellectual
property of AORN.” Groah also emphasized that hun-
dreds of hospitals and surgery centers across the
country look to the Perioperative Standards as the
go-to guide for evidence-based surgical practices.
New and revised standards go through up to three
rounds of revisions based on input from surgical pro-
fessionals and the general public.
To learn more about AORN, including group and indi-
vidual membership, visit www.aorn.org.
Aligning practice with policy to improve patient care 19 Aligning practice with policy to improve patient care 19
Conversation with Dr. Peter J. Pronovost
Doctor Leads Quest for Safer
Ways to Care for Patients
by Claudia Dreifus
Dr. Peter J. Pronovost, 45, is medical director of the Quality
and Safety Research Group at Johns Hopkins Hospital in
Baltimore, which means he leads that institution’s quest for
safer ways to care for its patients. He also travels the country,
advising hospitals on innovative safety measures. The Hudson
Street Press has just released his book, “Safe Patients, Smart
Hospitals: How One Doctor’s Checklist Can Help Us Change
Health Care from the Inside Out,” written with Eric Vohr. An
edited version of a two-hour conversation follows.
What got you started on your crusade
for hospital safety?
My father died at age 50 of cancer. He had lymphoma. But
he was diagnosed with leukemia. When I was a first-year
medical student here at Johns Hopkins, I took him to one
of our experts for a second opinion. The specialist said, “If
you would have come earlier, you would have been eli-
gible for a bone marrow transplant, but the cancer is too
advanced now.” The word “error” was never spoken. But it
was crystal clear. I was devastated. I was angry at the
clinicians and myself. I kept thinking, “Medicine has to do
better than this.”
A few years later, when I was a physician and after I’d done
an additional Ph.D. on hospital safety, I met Sorrel King,
whose 18-month-old daughter, Josie, had died at Hopkins
from infection and dehydration after a catheter insertion.
The mother and the nurses had recognized that the little
girl was in trouble. But some of the doctors charged with
her care wouldn’t listen. So you had a child die of dehy-
dration, a third world disease, at one of the best hospitals
in the world. Many people here were quite anguished about
it. And the soul-searching that followed made it possible
for me to do new safety research and push for changes.
20 The OR Connection
Patient Safety
Aligning practice with policy to improve patient care 21
What exactly was wrong here?
As at many hospitals, we had dysfunctional teamwork
because of an exceedingly hierarchal culture. When con-
frontations occurred, the problem was rarely framed in
terms of what was best for the patient. It was: “I’mright. I’m
more senior than you. Don’t tell me what to do.” With the
thing that Josie King died from — an infection after a
catheter insertion, our rates were sky high: about 11 per
1,000, which, at the time, put us in the worst 10 percent in
the country.
Catheters are inserted into the veins near the heart before
major surgery, in the I.C.U., for chemotherapy and for dial-
ysis. The C.D.C. estimates that 31,000 people a year die
from bloodstream infections contracted at hospitals this
way. So I thought, “This can be stopped. Hospital infec-
tions aren’t like a disease there’s no cure for.” I thought,
“Let’s try a checklist that standardizes what clinicians do
before catheterization.” It seemed to me that if you looked
for the most important safety measures and found some
way to make themroutine, it could change the picture. The
checklist we developed was simple: wash your hands,
clean your skin with chlorhexidine, try to avoid placing
catheters in the groin, if you can, cover the patient and
yourself while inserting the catheter, keep a sterile field, and
ask yourself every day if the benefits of catheterization
exceed the risks.
Wash your hands? Don’t doctors
automatically do that?
National estimates are that we wash our hands 30 to 40
percent of the time. Hospitals working on improving their
safety records are up to 70 percent. Still, that means that
30 percent of the time, people are not doing it.
At Hopkins, we tested the checklist idea in the surgical
intensive care unit. It helped, though you still needed to do
more to lower the infection rate. You needed to make sure
that supplies — disinfectant, drapery, catheters — were
near and handy. We observed that these items were stored
in eight different places within the hospital, and that was
why, in emergencies, people often skipped steps. So we
gathered all the necessary materials and placed them
together on an accessible cart. We assigned someone to
be in charge of the cart and to always make sure it was
stocked. We also instituted independent safeguards to
make certain that the checklist was followed.
We said: “Doctors, we know you’re busy and sometimes
forget to wash your hands. So nurses, you are to make
sure the doctors do it. And if they don’t, you are empow-
ered to stop takeoff on a procedure.”
How did that fly?
You would have thought I started World War III! The nurses
said it wasn’t their job to monitor doctors; the doctors
said no nurse was going to stop takeoff. I said: “Doctors,
we know we’re not perfect, and we can forget important
safety measures. And nurses, how could you permit a doc-
tor to start if they haven’t washed their hands?” I told the
nurses they could page me day or night, and I’d support
them. Well, in four years’ time, we’ve gotten infection rates
down to almost zero in the I.C.U.
We then took this to 100 intensive care units at 70 hospitals
in Michigan. We measured their infection rates, imple-
mented the checklist, worked to get a more cooperative
culture so that nurses could speak up. And again, we got
it down to a near zero. We’ve been encouraging hospitals
around the country to set up similar checklist systems.
22 The OR Connection
In your book, you maintain that hospitals can
reduce their error rates by empowering their
nurses. Why?
Because i n every hospi tal i n Ameri ca, pati ents di e
because of hierarchy. The way doctors are trained, the
experiential domain is seen as threatening and unimportant.
Yet, a nurse or a family member may be with a patient for
12 hours in a day, while a doctor might only pop in for five
minutes.
When I began working on this, I looked at the liability claims
of events that could have killed a patient or that did, at several
hospitals — including Hopkins. I asked, “In how many of
these sentinel events did someone know something was
wrong and didn’t speak up, or spoke up and wasn’t heard?”
Even I, a doctor, I’ve experienced this. Once, during a sur-
gery, I was administering anesthesia and I could see the
patient was developing the classic signs of a life threatening
allergic reaction. I said to the surgeon, “I think this is a latex
allergy, please go change your gloves.” “It’s not!” he
insisted, refusing. So I said, “Help me understand how
you’re seeing this. If I’m wrong, all I am is wrong. But if
you’re wrong, you’ll kill the patient.” All communication
broke down. I couldn’t let the patient die because the
surgeon and I weren’t connecting.
So I asked the scrub nurse to phone the dean of the med-
ical school, who I knew would back me up. As she was
about to call, the surgeon cursed me and finally pulled off
the latex gloves.
What can consumers do to protect
themselves against hospital errors?
I’d say that a patient should ask, “What is the hospital’s in-
fection rate?” And if that number is high or the hospital says
they don’t know it, you should run. In any case, you should
also ask if they use a checklist system.
Once you’re an in-patient, ask: “Do I really need this
catheter? AmI getting enough benefit to exceed the risk?”
With anyone who touches you, ask, “Did you wash your
hands?” It sounds silly. But you have to be your own
advocate.
From The New York Times, © March 8, 2010 The New York Times.
All rights reserved. Used by permission and protected by the Copyright
Laws of the United States. The printing, copying, redistribution, or
retransmission of the Material without express written permission
is prohibited.
©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
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• Production-line inspections with picture-driven
build instructions
• Specialized scales along the production line weigh
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24 The OR Connection
Yes! Checklists do save lives
It’s been more than a decade since the Institute of Medicine (IOM) issued its
groundbreaking report, To Err is Human, outlining the poor state of patient safety in the United
States. And yet, progress toward reducing healthcare errors over the past ten years has been
“frustratingly slow,” say the authors of the report.
1
Patients continue to die at a rate of 99,000
per year due to hospital-acquired infections alone, according to the latest estimate from the
Centers for Disease Control and Prevention.
1
Needless to say, healthcare professionals have a long
way to go toward improving patient safety. There are,
however, glimmers of hope, one of which comes in the
form of a checklist.
A checklist for the ICU
Buried on page 171 of the thick To Err is Human report
is one sentence recommending that healthcare organi-
zations use checklists as a way to prevent errors by
avoiding reliance on memory.
2
But it was not until 2006,
with the published results of a study headed by now
renowned patient safety advocate Peter Pronovost, MD,
PhD, that the healthcare checklist came to the forefront
as a proven way to prevent errors and save lives.
3
Dr. Pronovost, a practicing anesthesiologist and critical
care physician at Johns Hopkins in Baltimore, crafted
his first checklist by listing on paper the steps necessary
to avoid catheter-related bloodstream infections (CR-
BSIs).
4
The steps were nothing new; just things that
clinicians may not remember to do every time they place
a new central line. He and fellow researchers then
refined the list, making sure the steps corresponded with
items fromthe CDC guidelines for preventing CR-BSIs.
5
Dr. Pronovost introduced the checklist at Johns Hop-
kins Hospital, asking staff to run through it each time
they inserted a line. The central line infection rate soon
decreased from 11 percent to zero.
4
Next, Dr. Pronovost implemented the ICU checklist and
other related safety interventions at 103 hospitals across
Michigan, resulting in a 66 percent reduction in CR-
BSIs.
6
In the first 15 months of the study, known as the
Keystone Initiative, the checklist is estimated to have
saved 1,500 lives and $175 million in costs.
4
The ICU checklist is simple; as experts recommend
healthcare checklists should be. It requires clinicians to
employ the following evidence-based practices when
placing central venous catheters: hand washing, using
full-barrier precautions during the insertion of the
catheter, cleaning the patient’s skin with chlorhexidine,
avoiding the femoral site, if possible, and removing
unnecessary catheters.
6
To download a sample copy of
Dr. Pronovost’s ICU checklist, go to www.ihi.org/IHI/Pro-
grams/IHIOpenSchool/OnCallPeterPronovostCheck-
lists.htm.
Checking it Twice
Continued on page 27
Patient Safety
Aligning practice with policy to improve patient care 25
Reference
1 Saint S, Kaufman SR, Thompson M, Rogers MA, Chenoweth CE. A reminder reduces urinary catheterization in
hospitalized patients. Jt Comm J Quality Patient Saf. 2005; 31(8): 455-462
2 Patient Safety Quality Measures for the Surgical Care Improvement Project (SCIP). Health Services Advisory Group.
Available at: http://qualitymeasures.ahrq.gov/content.aspx?f=rss&id=16275. Accessed December 7, 2010.
3 Guideline for Prevention of Catheter-associated Urinary Tract Infections, 2009. Centers for Disease Control and Prevention.
Available at: http://www.cdc.gov/hicpac/cauti/001_cauti.html. Accessed December 7, 2010.
©2010 Medline Industries, Inc. Medline is a registered trademark and InserTag is a trademark of Medline Industries, Inc.
Despite SCIP Measure #9 recommending removal of
urinary catheters in surgical patients by postoperative day
one or two,
1
and CDC guidelines advising prompt removal
of catheters,
2
74 percent of hospitals do not keep track of
how long patients have catheters in place.
3
Medline’s Foley InserTag is a sticker to be placed on each
catheter bag as part of the insertion procedure. It has
space to write when the catheter was placed in order
to minimize duration and encourage timely removal. The
InserTag is included with each Medline ERASE CAUTI tray.
Medline’s Foley InserTag. The one little sticker that can
make all the difference.
To learn more about Medline’s Foley InserTag and
the ERASE CAUTI program, attend an informational
webinar at www. medline.com/erase/webinar.asp.
This easy documentation tool lets you know
exactly when your patient’s catheter was placed
Foley
InserTag
MEDLINE’S FOLEY INSERTAG

Finally!
A way to know
when the catheter
was placed
Aligning practice with policy to improve patient care 27
Four Es
for implementing a healthcare checklist
5
Patient safety advocate Peter Pronovost, MD PhD,
offers the following four steps to remember when
implementing a safety checklist at your own facility:
1. Engage staff and physicians with stories and
baseline performance.
2. Educate staff and physicians explicitly on what
needs to be done to carry out the checklist; walk
through the checklist a few times to identify
any glitches
3. Execute the checklist, making sure everyone is
committed to following it.
4. Evaluate how it’s working by analyzing
collected data.
He also recommends determining in advance the prod-
ucts and equipment needed to carry out the items on
the checklist, making sure all
supplies are close at hand when
clinicians go to implement the
checklist.
For more tips, read Safe Patients,
Smart Hospitals: How One Doc-
tor’s Checklist Can Help Us
Change Health Care from the
Inside Out by Peter Pronovost
and Eric Vohr.
Checklists for safer surgery
Not long after the Keystone Initiative study came out,
the World Health Organization (WHO) Surgical Safety
Checklist gained recognition in 2009 with a study pub-
lished in the New England Journal of Medicine describ-
ing how use of the checklist helped reduce patient
morbidity and complications.
7
The WHOSurgical Safety Checklist was used at hospitals
around the world, resulting in a reduction in complication
rates from11 percent to 7 percent. Death rates dropped
from 1.5 percent to 0.8 percent.
7
For a copy of the WHO Surgical Safety Checklist and
tips on how to use it, visit www.safesurg.org.
Another study, just published in October 2010 in the
Journal of the American Medical Association (JAMA),
showed an 18 percent reduction in surgery deaths over
three years at 74 Veterans Affairs hospitals that used a
surgery checklist.
8,9
The Surgical Care and Outcomes Assessment Program
(SCOAP), has developed a surgical safety checklist as
well, which is being used by most hospitals and some
freestanding surgery centers in the state of Washington.
SCOAP links hospitals and surgeons with clinicians from
across Washington to increase the use of best practices
in surgical care. The organization’s goal is to provide the
kind of surveillance of procedures and response to neg-
ative outcomes that exists in the world of aviation.
10
To access a copy of the SCOAP Surgical Checklist,
including a version specifically for ambulatory surgery
centers, go to www.scoap.org/checklist. Copies of the
SCOAP Surgical Checklists are also included in the
Forms & Tools section of this issue.
Checklist success requires teamwork
Both Dr. Pronovost and Atul Gawande, MD, who
co-authored the paper on the WHO Surgical Safety
Checklist, agree that in order to work, checklists must
be studied carefully in advance, and then implemented
wisely.
11
And, although checklists are helpful, they are
only one part of the equation for improving patient
safety. Before a checklist can be useful, healthcare
teams must improve communication and change the
way they work together.
12
Dr. Pronovost wrote, “Until a junior nurse can correct a
senior physician who forgot to use the checklist, until
that conversation goes well, we will continue to harm
patients. In most U.S. hospitals, that conversation does
not go well.”
12
In fact, in the OR, the lowest perceptions
of teamwork are reported by nurses with surgeons.
13
Have a serious discussion with physicians and nurses,
Dr. Pronovost recommends. Instruct nurses to speak up
28 The OR Connection
if a doctor misses a step on the checklist. Explain to the
doctor that it is not about hierarchy or second guess-
ing. It’s about the obligation to make sure every patient
all the time receives evidence-based interventions.
5
Dr. Pronovost also remarked that if any link in the chain
of accountability is not intact, the checklist will not be
effective. He said it is the hospital’s senior leadership
that is ultimately responsible for getting and keeping
staff on board.
14
According to Dr. Pronovost, “To reach our ultimate goal
– making patients safer – we must engage teams to
embrace the concepts behind checklists and become
full partners in developing and improving this lifesaving
tool. And, we must measure our results to make sure
that every patient always gets the care they deserve.”
12
References
1. O’Reilly KB. Patient safety improving slightly, 10 years after IOM report on errors.
American Medical Association. amednews.com. December 28, 2009. Available at
www.ama-assn.org/amednews/2009/12/28/prsb1228.htm. Accessed November 1, 2010.
2. Linda T. Kohn, Janet M. Corrigan, and Molla S. Donaldson, Eds. To Err Is Human:
Building a Safer Health System. Washington, DC: National Academy Press; 2000.
Available at: www.nap.edu/openbook.php?isbn=0309068371. Accessed October
29, 2010.
3. Wachter RM. Patient safety at ten: unmistakable progress, troubling gaps. Health Affairs.
2010;29(1). Available at: http://hospitalmedicine.ucsf.edu/downloads/patient_safety-
_at_ten.pdf. Accessed November 1, 2010.
4. Laurance J. Peter Pronovost: champion of checklists in critical care. The Lancet.
2009;374(9688).
5. Pronovost P. On Call: How a Simple Checklist Can Dramatically Reduce Medical Errors
[audio]. Institute for Healthcare Improvement (IHI) website. Recorded November 3,
2008. Available at: www.ihi.org/IHI/Programs/IHIOpenSchool/OnCallPeter-
PronovostChecklists.htm. Accessed November 2, 2010.
6. Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, et al. An
intervention to decrease catheter-related bloodstream infections in the ICU. The New
England Journal of Medicine. 2006;355(26):2725-2732. Available at:
www.nejm.org/doi/pdf/10.1056/NEJMoa061115. Accessed November 1, 2010.
7. Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AS, Delliner EP, et al. A surgical
safety checklist to reduce morbidity and mortality in a global population. The New
England Journal of Medicine. 2009;360(5):491-499.
8. Tanner L. Big U.S. study shows surgery checklist saves lives. ABC-2 News Baltimore
website. Posted October 21, 2010. Available at: www.abc2news.com/dpp/news/health-
/USMEDSurgery-Checklist_9727648034-wews1287662508003. Accessed November
3, 2010.
9. Neily J, Mills PD, Young-Xu Y, Carney BT, West P, Berger DH, et al. Association between
implementation of a medical team training program and surgical mortality. Journal of the
American Medical Association. 2010;304(15).
10. SCOAP Surgical Checklist Initiative. Surgical Care and Outcomes Assessment
Program website. Available at http://www.scoap.org/checklist. Accessed October
22, 2010.
11. Szalavitz M. Study: a simple surgery checklist saves lives. Time. January 14, 2009.
Available at: http://www.time.com/time/health/article/0,8599,1871759,00.html.
Accessed October 22, 2010.
12. Pronovost P. Checklists alone won’t change health care: the full story. Huffington Post.
February 23, 2010. Available at: http://www.huffingtonpost.com/peter-pronovost-
md-phd/checklists-alone-wont-cha_b_473396.html. Accessed November 1, 2010.
13. Carney BT, West P, Neily J, Mills PD, Bagian JP. Differences in nurse and surgeon
perceptions of teamwork: implications for use of a briefing checklist in the OR.
AORN Journal. 2010;91(6):722-729.
14. Aizenman NC. Hospital infection deaths caused by ignorance and neglect, survey
finds. The Washington Post. July 13, 2010. Available at: www.washingtonpost.com-
/wp-dyn/content/article/2010/07/12/AR2010071204893.html. Accessed October
21, 2010.
1. Assess your organization’s safety culture. A widely
used survey developed by the Agency for Health
care Research and Quality (AHRQ) is available at
www.ahrq.gov/qual/patientsafetyculture.
2. Understand the science of improvement and
reliability. Strive to be a high reliability organization.
3. Foster transparency.
4. Create a formal, written leadership promise that
outlines the steps you personally will take to attain
and maintain patient safety at your facility.
5. Engage physicians in your organization’s
safety efforts.
6. Develop hiring and credentialing processes
grounded in selecting candidates with a desire to
serve, good communication skills, an eagerness
to work in teams, a commitment to excellence and
an appreciation for feedback.
7. Involve board members in the safety journey.
+ 1 Another helpful tool for fostering a safety culture at
your organization is the Comprehensive Unit-Based
Safety Program (CUSP) developed at Johns Hopkins
Hospital by Dr. Pronovost and his team. For details, visit
www.patientsafetygroup.org/program/index.cfm.
Adapted from Rupp W, Bonacum D, Frush K, Balik B, Haraden C. The role of
leadership. In: Frankel A, Leonard M, Simmonds T, Haraden C, Vega KB, eds.
The Essential Guide for Patient Safety Officers. Oakbrook Terrace, IL: Joint
Commission Resources; 2009:1-10.
Seven Steps + 1
to Patient Safety
for Hospital
Executives
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comprehensive kill of transient and resident skin
flora, with a 6 log reduction within two minutes.
2
Patient,
Heal
Thyself
After shorter hospital stays,
doctors raise demands
and time for recovery
By Laura Landro
30 The OR Connection
Special Feature
Aligning practice with policy to improve patient care 31
But recovery was another matter. He needed the crutches
for three weeks, had 12 weeks of physical therapy three
times a week, then six weeks of exercises at home. He
rented a strap-on ice compression device to reduce
swelling, and wore a brace for about five weeks. Though
fully healed now, being responsible for so much of his own
rehabilitation, he says, “was like taking a new baby home
for the first time—you don’t really feel like you’re licensed
to do it.”
Surgery is easier and faster than ever before: Nearly 65%
of all surgeries don’t require an overnight hospital stay,
compared to 16% in 1980. Hospitals that once kept
patients for three weeks after some major operations now
discharge them within a matter of days. But the body still
heals at its own pace, and reduced time in hospital care
means patients are assuming more responsibility for their
own recovery—and more risks. Patients not only have to
performrehabilitation regimens at home, but they are more
often caring for their own incision wounds and dressings
and having to watch for signs of infections and blood clots.
They also may be managing drains, implanted IV ports and
pumps, all of which can be difficult and stressful.
The move to speedier surgeries is largely the result of new
minimally invasive techniques, improvements in anesthesia
and cost-cutting by insurance companies and hospitals.
Surgical procedures now often use smaller incisions, cut
less muscle, and result in less blood loss. Newer anes-
thetics allow patients to regain consciousness quickly or
not go to sleep at all. Pain medications are more effective.
At the same time, concern about rising health care costs
has led to changes in Medicare and insurance plans that
have encouraged the development of outpatient surgical
centers and created financial incentives for hospitals to
shift less complex surgery to their own outpatient facilities.
So, many types of surgeries previously performed in hos-
pitals with overnight stays are now being done on an out-
patient basis: The number of freestanding surgery centers
grew from about 240 in 1983 to more than 5,000 now.
The mean charge for outpatient surgery was $6,100 ver-
sus $39,000 for inpatient surgery in 2007, according to
the most recent report on surgical costs from the federal
government. Insurance companies are also less likely to
pay for stays at rehabilitation centers, places where surgi-
cal patients were often sent after hospital discharge to
recuperate.
With patients going home so quickly, more are having to
grapple with complications on their own. Of all the com-
plications that occur in the 30 days after surgery, such as
infection and blood clots, almost half will surface after a
patient leaves the hospital, according to data fromone mil-
lion patients in a surgical quality improvement program
sponsored by the American College of Surgeons.
“The onus is really on patients to recognize if something is
a problem,” says Clifford Ko, a colorectal surgeon at the
University of California, Los Angeles, and director of
research and optimal patient care for the American College
of Surgeons. “The recovery period is often as important as
the procedure itself, and patients who don’t follow their
discharge instructions could have longer recovery times,
greater risk of a complication, and potentially more pain.”
The Long Road to Recovery
While most surgeries now require much shorter hospital
stays than in years past, patients often face weeks or
months of recovery on their own. The picture for some
common procedures: Knee surgery patients, for example,
are counseled to maintain their weight after surgery. But a
recent study shows that most patients gain weight, which
can jeopardize the health of the other knee. Depression,
For Michael Noonan, knee surgery in April was practically a breeze —
an outpatient procedure that had the 41-year-old investment banker hobbling
home on crutches in a matter of hours after surgeon David Altchek replaced
his anterior cruciate ligament using small incisions.
Continued on page 33
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Other reasons to try MediClip
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Aligning practice with policy to improve patient care 33
another common after-surgery occurrence, also can
inhibit healing, if patients don’t seek treatment.
Efforts are underway to improve follow-up for patients, par-
ticularly those who have surgery in doctor’s offices, which
don’t have the same regulation as outpatient surgery cen-
ters. The Institute for Safety in Office-Based Surgery has
developed a checklist that includes assuring that discharge
instructions are provided and a plan for follow-up care is
clear. “Patients need to be asked things like if there is red-
ness at the incision site, do you know what to do?” says
Fred Shapiro, a Harvard anesthesiologist and president of
the group. (Redness at an incision site can be a sign of
infection.)
Infections that can occur after any surgery can lead to a
severe bloodstream infection that can be fatal. A study
published in July in the Journal of Hospital Infection of
84,000 patients who developed a surgical site infection
found that more than half occurred after discharge,
increasing the risks of an emergency room visit, readmis-
sion to the hospital, and another surgery.
For months after a procedure, surgical patients are also at
high risk of developing blood clots which can travel to the
lung and cause death from a pulmonary embolism. After
joint replacement, for example, though the risk is greatest
within two to five days, a second peak development period
occurs about 10 days after surgery when most patients
have been discharged from the hospital. In knee surgery
patients, a clot can form in the calf if the patient fails to
elevate the leg and perform specific movement exercises.
Blood clots and subsequent pulmonary embolisms remain
the most common cause for emergency readmission and
death following joint replacement, according to the Ameri-
can Academy of Orthopaedic Surgeons.
The American Academy of Orthopaedic Surgeons spon-
sors workshops to teach its members better communica-
tions skills to help patients understand procedures and to
stress the importance of follow-up care, such as providing
clear written instructions and monitoring patients after sur-
gery. “We can have a perfect total knee replacement but
then have a poor outcome if we don’t convince surgeons
that explaining the post-operative care is in everyone’s best
interest,” says John Tongue, a Portland, Ore.-area ortho-
pedic surgeon and clinical associate professor at Oregon
Health & Science University who teaches the workshops.
Insurers have become stricter about paying for inpatient
rehabilitation programs where surgical patients were once
transferred to recover. The move has been spurred partly
by studies that show that cheaper at-home visits from ther-
apists are effective.
But Nina Reznick, a 63-year old patient who had both hips
replaced last July, says the home therapist her insurance
paid for did not have the equipment or time to really help,
so she did extra exercises on her own. She believes that
effort enabled her to walk a week after surgery. “You are
really on your own, and you have to be very motivated,”
she says.
84,000 patients who developed a surgical
site infection found that more than half
occurred after discharge
34 The OR Connection
Blood clots and subsequent pulmonary embolisms
remain the most common cause for emergency
readmission and death following joint replacement.
Some doctors say that the changing demographics of their
patients also can contribute to bumpy recoveries. Dr.
Altchek, who performs knee and rotator cuff surgery at the
Hospital for Special Surgery in New York, says that more
younger patients are opting to replace troublesome knees
and hips so they can resume athletic activities such as ten-
nis and skiing; close to 42% of all knee replacements in
2008 were for patients aged 45 to 65, compared to less
than 35% in 2002, and studies show that waiting too long
once a joint starts to deteriorate before having surgery can
make recovery more difficult.
But younger patients may also be impatient and assume
they are healed, and then quit rehabilitation too early, Dr.
Altchek says.
Andrew Minko, a 41-year-old patient of Dr. Altchek’s who
plays tennis and surfs, has had two surgeries to repair
joints on his left shoulder and now needs surgery on his
right shoulder. Though he healed well, he admits he was
somewhat lax about doing his exercises at home and may
have rushed into some activities too quickly after the
previous procedures. For the upcoming surgery, he says,
“I will be more diligent about the recovery.”
Write to Laura Landro at laura.landro@wsj.com
Reprinted by permission of The Wall Street Journal, Copyright © 2010 Dow Jones & Company, Inc.
All Rights Reserved Worldwide. License number 2537291131129
To download a new guide to help patients take care of themselves at home,
visit www.ahrq.gov/qual/goinghomeguide.htm. “Taking Care of Myself: A Guide
for When I Leave the Hospital” is published by the Agency for Healthcare Research
and Quality (AHRQ).
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36 The OR Connection
Preventing sharps injury in the OR
by Mary Ann Alexander-Magalee, MSN, RN, CNOR-BC
Nearly 30% of the estimated 385,000 needle sticks and
other sharps-related injuries that occur each year happen
in the OR.
1
The CDC’s recommended work practices that
can help ensure safety can be simplified into three points:
Be prepared, be aware, and dispose with care.
1
This arti-
cle describes what you can do to protect yourself from
sharps injury.
Studies indicate that 6% to 16% of all percutaneous
injuries for scrubbed personnel are self-inflicted during
hand-to-hand passing of suture needles, with the non-
dominant hand being the most injured body part.
2
This
often occurs during the loading or repositioning of suture
needles, loading or removing scalpel blades, suturing, tying
sutures with the needle attached, and immediately before
or after the sharp has been used and remains unattended
on the operative field.
2
For nonscrubbed personnel, the greatest risk of injury is
during hand-off of used sharps or disposal of sharps.
Healthcare organizations and their employees are respon-
sible for actively participating in strategies to reduce per-
cutaneous injuries. Wear personal protective equipment
when indicated. Use needless systems or sharps with
injury protection devices, and use a one-handed recap-
ping technique, if no other alternatives exist.
The Occupational Safety and Health Administration
requires healthcare organizations to protect their workers
and have a written exposure control plan.
3
Facilities must
also observe local, state, and federal regulations on injury
prevention.
Common strategies for sharps injury prevention during a
procedure include:
• Double gloving and monitoring gloves for punctures.
2
• Encouraging neutral or hands-free technique for
passing sharp items.
2
• Giving verbal notification when passing a sharp item.
• Loading suture needles using the suture packet to
help mount the needle in the needle holder.
• Using the appropriate instrument to help adjust or
unload the needle.
• Removing the needle before tying the suture, or using
control-release sutures.
• Activating the safety feature of a safety-engineered
device immediately after use.
2
• Using another available instrument or a magnet to pick
up a sharp item that’s fallen on the floor. Discard the
sharp immediately.
Preventing sharps injury in the OR
Aligning practice with policy to improve patient care 37
Aligning practice with policy to improve patient care 37
After the procedure, follow these strategies:
• Transport sharps in a closed, secure container
and place them in an approved, puncture-resistant
container large enough to accommodate the entire
device.
• Don’t put your hands or fingers into the container
to dispose of a device.
1
• Keep your hands behind the sharp tip when
disposing of the device.
In addition to common strategies, using safety scalpels is
recommended, as scalpels are the second most frequent
mechanism of percutaneous injuries (suture needles
are first).
2
If you experience a needle-stick injury, follow your facility’s
policy for postexposure management and report the injury
immediately. Maintaining a sharps-injury log is another
intervention that identifies the number of employees injured
as well as the products and circumstances of the injury.
4
About the author
Mary Ann Alexander-Magalee, MSN, RN, CNOR-BC, is a
professor of nursing at Valencia Community College in Orlando,
Fla., and a board-certified nurse informatist.
References
1. CDC Workbook for Designing, Implementing, and Evaluating a Sharps Injury
Prevention Program. 2008. http://www.cdc.gov/sharpsafety/resources.html.
2. AORN. Guidance statement: Sharps injury prevention in the perioperative
setting. Perioperative Standards and Recommended Practices. Denver, CO:
AORN; 2010:697-702.
3. OSHA. Regulations (Standards-29 CFR) Bloodborne pathogens 1910.1030.
http://wwwloshalgov/pls/oshaweb/owadisp.show_document?p_table=STAN-
DARDS&p_id=10051.
4. Taylor DL. Bloodborne pathogen exposure in the OR—what research has
taught us and where we need to go. AORN J. 2006;83(4):834-848.
Printed with permission. Mary Alexander-Magalee, Preventing sharps injury in the OR,
OR Nurse 2010, September 2010, p. 56.
Be prepared. Be aware. Dispose with care. Points of Sharps Safety
3
OR Issues
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• Safe Medication Practices in the Perioperative Practice Setting
• Tell Me Again Why This Patient Needs a Catheter?
• Why is Pressure Ulcer Assessment So Important?
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Aligning practice with policy to improve patient care 39
WHY THE UNIVERSAL
PROTOCOL HASN’T
ERADICATED PATIENT
HARM
...AND THE THREE
THINGS YOU MUST
DO ABOUT IT
By Steve Harden
According to a recent report in the Archives of Surgery, patients
undergoing surgery still risk being victims of stunning medical mis-
takes including procedures done on the wrong surgical site and
undergoing surgery intended for another patient.
To try to curb the rate of surgical errors, the Joint Commission in
2004 introduced a Universal Protocol for all hospitals, ambulatory
care facilities, and office-based surgical facilities to follow. How-
ever, even though these steps have largely been adopted, errors
continue to happen.
The study’s author, Dr. Philip F. Stahel, a visiting associate profes-
sor at the University of Colorado School of Medicine in Denver, had
this to say about the research: “What is shocking about the data
is that each and every one of those wrong-site, wrong-patient
errors is really an event that should never happen. These happen
much more frequently than we think.”
“This is just the tip of the iceberg,” he said, “introducing the Uni-
versal Protocol has not reduced the frequency of these events.”
During the research done in Colorado, doctors reported 27,370
adverse events that happened between January 2002 and June
2008. Among these, the researchers identified 25 wrong-patient
and 107 wrong-site operations. The report cites the reasons for
these mistakes.
Patient Safety
40 The OR Connection
Not surprisingly, 100 percent had poor communication as a
root cause.
And 72 percent were due to not performing a “Time Out” as
required by the Universal Protocol.
At LifeWings, we’ve helped almost 100 organizations create and
implement a successful Time Out process that really does elim-
inate patient harm. From that experience, here are three things
you can do to fix these problems with your Universal Protocol.
1. Make sure your physicians lead the Time Out. In aviation,
the captain of the aircraft always “calls” for the checklist
at the appropriate time. The captain has the responsibility
to start the checklist and to make sure that it is accomplished
correctly and in its entirety. Once the checklist is started,
he can delegate portions of the checklist to others, but
the captain has the ultimate and final responsibility to lead
the checklist process.
2. To cure communication failures during the Universal Protocol,
give as many folks as possible a “speaking part” in your Time
Out process. Knowing that they have a speaking part and
will have to verbally respond to a checklist item creates
mindfulness, focus on the process and participation. No
one wants to be the person not prepared and gumming
up the works.
3. Make sure your Time Out is a true “challenge and response”
checklist, requiring a real cross check with two or more sets
of eyeballs confirming critical items—and not just a “tick
sheet” where one staff member independently puts a check
in the box when they think an item has been completed.
A “tick sheet” mentality is the number one reason we see
for failing to complete the Time Out as required.
As Dr. Stahel, the author of the report notes, “... Now we hide
behind a safety system that should cover the problem. The Time
Out is performed, but people are not mentally involved—the
system alone cannot protect you from wrong-site surgery.”
Dr. Stahel is absolutely spot on. The Universal Protocol is not
going to protect your patients if your teams are not going to
use the safety system correctly.
About the author
Steve Harden is Chairman of the Board and
CEO of LifeWings Partners LLC and co-founder
of Crew Training International, Inc. (CTI). He has
helped over 80 healthcare organizations in 28
states implement the best safety practices from
aviation and other high reliability industries. He
is the author of Never Go to the Hospital Alone,
published by BPS Books, and co-author of
CRM: The Flight Plan for Lasting Change in Patient Safety, the
definitive how-to text on implementing aviation-based safety tools in
health care, published by HCPro. LifeWings Partners is the industry
leader in using aviation safety, leadership, team building and human
factors tools to reduce patient-harming medical errors and improve
safety and quality.
©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
SAFER CATHETERIZATION
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every tray.
But it’s more than just fun. There’s published evidence
that distraction helps children tolerate unpleasant
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You trust Medline for clinical innovations, such as our
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Introducing Medline’s new
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Children’s
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Bravery Sticker
42 The OR Connection
A New
Guidebook
for Patient
Safety in
the OR
by Connie Yuska, RN, MS, CORLN
Aligning practice with policy to improve patient care 43
Over the last decade, many
organizations have focused on
principles of surgical safety,
such as ensuring accurate
sponge counts, adhering to
hand hygiene standards and
labeling medications on the
surgical field. These practices,
however, have been applied
inconsistently across the country.
1
Building a culture of safety con-
tinues to be a priority for hospi-
tal administrators since the
publication of the Institute of
Medicine’s groundbreaking
report, To Err is Human in 1999.
Awareness of patient safety
has been heightened, but the progress has been sl ow.
I mprovements in safety have grown by only one percent
annually between 2000 and 2009.
1
Over the past decade,
standards that specifically address safety have been
added to the work done by regulatory and accrediting
bodies. For example, The Joint Commission added
National Patient Safety Goals with the purpose of pro-
moting specific improvements in patient safety.
There are many rules and regulations that address safety
and guide healthcare practitioners, but unless a culture of
safety is strong and supported by senior leaders in the
organization, significant progress will continue to be slow,
and patients will continue to be harmed.
The Safe Surgery Guide, released in November 2010 by
The Joint Commission, is specifically designed to provide
More than 50 million
surgical procedures
are performed in the
United States each
year.
1
And while the
number of procedures
is rising, so are the
risks. The risk of
death from a surgical
procedure is 10-100
times greater than
the risk of having
a baby.
1
Surgical
errors are second
only to medication
errors as the most
frequent cause of
error-related death.
1
organizations with direction on how to improve safety in
the surgical suite. The book focuses not only on improving
safety i n procedural and operati ve areas, but al so
addresses the patient’s surgical experience across the
continuum of care.
The book begins with a foreword by patient safety expert
Peter Pronovost, MD, PhD, in which he emphasizes the
need to remove barriers to complying with patient safety
practices and measure performance. He also recognizes
that overcoming the hurdles to patient safety requires cul-
ture change. And so, Chapter 1 discusses effective com-
munication techniques, emphasizing the importance of
senior leadership support in establishing those techniques.
Chapter 2 focuses on hand hygiene, a practice that often
remains difficult for organizations to consistently practice
and enforce. The chapter offers suggestions for improving
hand hygiene compliance in the surgical suite and
throughout the organization.
Chapter 3 outlines all of the preparation that occurs before
the patient enters the surgical suite. These activities
include managing the operating room schedule, cleaning
the room, preparation of the sterile field, ensuring the
proper instruments are available, ensuring proper air quality
and ventilation and controlling traffic in the room and
surrounding areas.
Chapter 4 contains information for a review of everything
that must be ready for the procedure when the patient
arrives in the surgical suite. Information focuses on
assessing the patient for risk, documentation of medica-
tions the patient is currently taking and preparation of the
surgical site.
Patient Safety
to the same goal of providing safe surgical care. The team
must be fiercely dedicated to supporting each other in their
individual roles and keenly aware of all steps needed to
ensure the procedure goes safely from beginning to end.
There are many resources available to assist with estab-
lishing a culture of safety in your hospital. Reading the Safe
Surgery Guide is an excellent place to start.
Reference
1. Schuldt LM, ed. Safe Surgery Guide, Oakbrook Terrace, IL: Joint Commission
Resources; 2010. Available at: http:// www.jcrinc.com/e-books/EBSSW10/2177.
Accessed November 12, 2010.
About the author
Connie Yuska, RN, MS, CORLN, began her nursing career in
the specialty of otolaryngology. Her clinical experience includes
both inpatient and outpatient care of head and neck oncology
patients, and she is certified in otolaryngology and head and neck
nursing. She has held clinical manager and director of nursing
positions in a large academic medical center and also has expe-
rience in the home care setting as vice president of operations for
a large home care agency in the Chicago area. Connie later
joined the executive suite as the chief nursing officer of a large
community hospital in Chicago, and she is currently a vice pres-
ident of clinical services for Medline.
Now available from
Joint Commission Resources!
Safe Surgery Guide
Price: $75 (PDF version);
$85 (hard copy)
ISBN: 978-1-59940-638-1
198 pages
44 The OR Connection
Key points to ensure the readiness of the surgical team are
outlined in Chapter 5. The discussion not only includes
obvious preparation, such as appropriate surgical attire,
but also addresses the attitudes and behaviors of the per-
sonnel involved, a key component to ensuring safety in a
high stress environment such as an OR suite.
Chapter 6 discusses the Joint Commission’s ongoing
efforts to reduce the incidence of surgical errors through its
Universal Protocol for Preventing Wrong Site, Wrong Pro-
cedure, and Wrong Person Surgery. The chapter also
describes the World Health Organization’s Surgical Safety
Checklist.
Monitoring the patient through all aspects of the surgical
procedure i s cri ti cal to ensuri ng safety. Chapter 7
describes the activities of monitoring anesthesia and
sedation levels, medications, body temperature, blood
glucose levels and blood administration.
Chapter 8 discusses some of the problems that can occur
during the surgical procedure and offers suggestions for
handling those issues. Some of the problems discussed
include objects that are inadvertently left in the patient’s
body, fire breaking out and distractions during the proce-
dure that may divert the staff’s attention away from the
patient.
Chapter 9 reviews all of the activities that occur after the
procedure, including disposal of medical waste, trans-
portation of contaminated materials such as sheets and
instruments, and clean-up of the operating suite.
Chapter 10 outlines the care the patient receives following
the procedure, including assessment of the patient’s phys-
iological and mental status, medications ordered post-
operatively and care of the surgical site, including
measures to prevent postoperative infection.
Finally, Chapter 11 is a review of the activities that promote
the patient’s discharge and appropriate care after the
patient leaves the organization.
Attaining a successful, safe surgical outcome is the result
of a TEAM of healthcare professionals who are committed
To order
Call 877-223-6866 (M-F, 8
am to 8 pm Eastern time),
or visit www.jcrinc.com/
e-books/EBSSW10/2177
Promote Correct-Site Surgery
Our Surgical Time Out Procedure (S.T.O.P.™)
safety products alert the surgical team to
perform a time-out verification and help reduce
the risk of wrong-site surgery.
Support Sharps Safety Practices
Transfer trays, scalpel holders and needle
counters with blade guards promote sharps
safety and help make you OSHA compliant.
1
Improve Fluid Disposal Safety
The Safety-Splash™ fluid management system
converts biohazardous fluids into a solid,
minimizing the risk of exposure.
©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
Safety-Splash and S.T.O.P are trademarks of Medline Industries, Inc.
References:
1. Occupational Safety and Health Standards, Toxic and Hazardous Substances,
Bloodborne pathogens. Regulations (Standards - 29 CFR). Available at: http://
www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_
id=10051#1910.1030(d)(2)(i). Accessed October 13, 2010.
Medline’s Gold Standard safety products stand out against the
sea of blue in the OR to alert the surgical team to focus on safety.
For a FREE sample bundle, email
goldstandard@medline.com.
MEDLINE GOLD STANDARD SAFETY COMPONENTS
SAFETY
DESERVES
ATTENTION
4848-AD_GoldStandard-select.indd 1 11/15/10 4:05 PM
46 The OR Connection
T
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e
y

r
e

l
u
r
k
i
n
g

i
n

.
.
.
Aligning practice with policy to improve patient care 47
Remember the old riddle, “Where do most
pressure ulcers occur?” The answer is —
in the ambulance!
Well, the truth is pressure ulcers do occur in the ambulance — and lots of other places you
might not even think about, including the operating room (OR). In fact, the pressure ulcer
incidence rate as a result of surgery may be as high as 66 percent
1
and 42 percent of all
hospital-acquired pressure ulcers are occurring in surgical patients.
2
Here are some more daunting facts:
• 37 percent of patients undergoing head or neck surgery develop sacral ulcers
3
• Cardiac, general vascular and open heart surgeries have a high incidence of occiput
and heel ulcers
• 72 percent of perioperative pressure ulcers occur on heels
4
The following types of surgical patients are at greater risk
for pressure ulcers:
• Neonates
• Elderly
• Malnourished
• Morbidly obese
• Patients with chronic diseases
• Patients with existing pressure ulcers
by Cynthia A. Fleck, RN, BSN, MBA,
ET/WOCN, CWS, DWC, CFCN
Patient Safety
48 The OR Connection
Perioperative risk factors for
pressure ulcer development
Certain conditions specific to the surgical experience can
also contribute to the risk of pressure ulcers. Some of
these conditions include blood volume loss, temperature,
time and moisture.
Blood volume loss. Blood volume loss and shunting can
increase the hazard of pressure ulcers and lack of blood
flow to the lower extremities.
5,6
Temperature. Another consideration is the cold OR envi-
ronment. The body will likely shunt blood away from the
skin into the trunk of the body to protect the vital organs,
which can be dangerous to the skin. The use of warming
blankets tends to occur in lengthy procedures. These can
be helpful to prevent cooling of the body, which can con-
tribute to pressure ulcers, however, the blanket should be
covered with a sheet. In addition, the thermostat on the
unit should be set at a maximum temperature of 42 de-
grees Celsius.
Time. Increased time in the OR is associated with
increased pressure ulcer development as well.
7
Surgeries
lasting between three and four hours had pressure ulcer
incidence rates of 5.8 percent; seven or more hours had
incident rates of 13.3 percent,
8
and there is a significant
increase in pressure ulcer incidence for operations lasting
longer than eight hours.
9
Moisture. We all know moisture can wreak havoc on the
skin and predispose individuals to pressure ulcers, so it is
recommended that pooling of any fluid or blood be moni-
tored intraoperatively. It is suggested that the OR surface
have minimal linens or layering. There are also novel OR
products available (modern-day “chux” that are super
absorbent) that can actually absorb large volumes of fluid
and remain dry to the touch, thus protecting the patient’s skin.
Evaluating surgical surfaces
Always remember that no matter where a patient’s body
resides, pressure ulcers can develop rapidly. OR surfaces
should be evaluated before each case, and the Association
of Perioperative Registered Nurses (AORN) guidelines
recommend using pressure redistribution surfaces for
surgeries lasting longer than two-and-a-half hours.
In fact, I recently had foot surgery, and my surgeon origi-
nally thought it would last only a couple of hours. Lo and
behold, it lasted three hours and 45 minutes, and although
I am a fairly young, well-nourished and healthy individual,
I succumbed to a Stage II perioperative pressure ulcer. The
lesson to be learned: because there is no guarantee how
Perioperative tips for avoiding pressure ulcers
• Assure that the OR table or surface is of
sufficient size to support the patient –
especially important for obese patients whose
bodies may be larger than the average size
OR surface
• Lift – do not drag – the patient from surface
to surface.
• Monitor pressure points when possible during
“time outs”
Post-operative considerations for avoiding
pressure ulcers
• Be aware of a possible delay in visualization
due to bandages and other monitoring
equipment
• Prolonged immobility or confinement to a bed
or chair increases pressure ulcer risk
10
Continued on page 50
HEELMEDIX™ Heel Protector
Pressure relief and skin protection all in one
The heels are the most common site for facility-acquired pressure
ulcers in long-term care, and the second most common site over-
all.
1
According to clinical experts, the most effective aspect of
pressure ulcer prevention for heels is pressure relief, also known
as offloading.
1,2
Offloading is achieved with the use of pillows or
heel protection devices that relieve pressure by elevating the heel.
The HEELMEDIX Heel Protector is designed to help eliminate
pressure, friction and shear on the skin by elevating the heel.
Made of soft, suede-like material on the inside and easy-to-clean
nylon on the outside. Adjustable straps are soft against vulnerable
skin. Includes a mesh laundry bag with patient ID label to simplify
washing and sorting.
Mention this ad to receive a 10 percent discount
on your first order. Contact your Medline sales
representative or call 1-800-MEDLINE.
Relieve Pressure on Vulnerable Heels
©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
1
Fowler E, Scott-Williams S, McGuire JB. Practice recommendations for preventing heel pressure
ulcers. Ostomy Wound Management. 2008;54(10):42:48.
2
Langemo D, Thompson P, Hunter S, Hanson D, Anderson J. Heel pressure ulcers: stand guard.
Advances in Skin & Wound Care. 2008;21(6):282-292.
2 Strapping Methods
50%
LESS
FRICTION
than the leading
competitor
3
50 The OR Connection
long a surgery will take, a pressure redistribution surface
should be available in every operating room.
There are high-quality surfaces that self-adjust (Figure 1),
provide a stable environment for the surgeon and OR staff
to work and conform to the patient’s body. Some of these
surfaces contain the same type of visco or viscoelastic
memory foam many of us sleep on in our own bedrooms.
When evaluating various surfaces, ask the vendor about
the warranty, weight limits, cleaning instructions and com-
parative data such as pressure mapping. This will help you
make an educated decision regarding your purchase.
Important steps to take after surgery
At the hand-off to the post-anesthesia care unit (PACU) it
is advisable to:
• Clean and dry the patient’s skin
• Conduct a post-op skin assessment, noting:
- Skin irritation
- Discoloration
- Bruising
- Swelling
• Provide a thorough report including:
- Results of pre-surgery risk factors and potential
new risks that developed during surgery
- Results of threats and skin assessment performed
before, during and after surgery
- How long the surgery lasted (e.g., my own surgery
was scheduled for two hours and lasted almost
double that time)
Pressure ulcer risk in ancillary services
There is also high risk for pressure ulcers in ancillary
services:
• Radiology
• Renal dialysis
• Cardiac and vascular procedure laboratories
such as cath labs
The problem is that until awareness is increased, we will
continue doing what we always did, and patients will con-
tinue to develop pressure ulcers.
Patients undergoing lengthy radiology procedures have a
53.8 percent incidence of pressure ulcers. Emergency de-
partments are another area of risk, with 40 percent of pa-
tients admitted through the emergency department at risk
for pressure ulcer development.
11
The average emergency department patient waits six to
eight hours lying on a stretcher that usually consists of two
to three inches of open-celled foam and an uncomfortable
non-conformable cover that can contribute to the devel-
opment of pressure ulcers.
This is especially important now that acute care facilities
are financially responsible for acquired pressure ulcers –
which can be quite costly. Many hospitals have instituted
a comprehensive program to prevent pressure ulcers
across the continuum, including the OR, ED and ancillary
areas. Introducing a tool kit on average can reduce a facility’s
Figure 1
AORN guidelines recommend using
pressure redistribution surfaces for
surgeries lasting longer than 2
1
/2 hours.
Continued on page 52
Medline Named One of Becker’s
100 Best Places to
Work in Healthcare
Becker’s recognizes company for
“Excellence in Promoting Teamwork,
Professional Development”
Medline Industries, Inc. has been named one of the “100 Best
Places to Work in Healthcare” for 2010 by Becker's ASC Review
and Becker's Hospital Review, well respected industry publications.
According to Becker’s, the list was developed “through nomina-
tions, recommendations and research, and the organizations were
selected for their demonstrated excellence in creating a work envi-
ronment promoting teamwork, professional development and qual-
ity patient care.”
Benefits Of A Great
Work Environment
Businesses can improve retention and make their organization
the good place to work by following the five-step PRIDE model:
P – Provide a positive working environment
R – Recognize, reinforce, and reward individual efforts
I – Involve and engage everyone
D – Develop the potential of your workforce
E – Evaluate and hold managers accountable
Source: workz.com
By Greg Smith
Join us for this webcast presentation as two
industry experts bring you critical infor-
mation on how the utilization of the nursing
process and proper documentation are vital
components in maintaining the standard of
care and avoiding litigation.
Presented by attorney Kevin W. Yankowsky,
JD, a partner in the health law litigation
group of Fulbright & Jaworski, LLP, Hous-
ton, Texas, and physician Caroline Fife, MD,
the Chief Medical Officer of Intellicure, Inc.
and an associate professor at the University
Texas Medical School at Houston.
LEGAL IMPLICATIONS
OF PRESSURE ULCERS
1 Contact Hour
Courses approved for continuing education by the Florida Board
of Nursing and the California Board of Reigistered Nursing.
To view this webcast, visit
www.medlineuniversity.com
52 The OR Connection
pressure ulcers by 70 percent while substantially increas-
ing the knowledge of licensed staff and nurse assistants.
12
Take your knowledge and pass it on
Consider sharing this article with the emergency depart-
ment, ancillary areas such as the cath lab, dialysis and
other high-risk area personnel, and of course with the
ambulance companies where your patients could be at
risk. If you are on a skin care committee, get the other
members involved, as these care areas present jeopardy that
can be easily mitigated.
When we ask ourselves the age-old question of where
all the pressure ulcers are occurring, now we have more
ammunition to fight the battle. And yes, the ambulance,
with its tiny vinyl-covered two-inch, foam mattress may
be part of the problem. The good news is that we have
answers and products that can make positive change
happen.
About the author
Cynthia Ann Fleck, RN, BSN, MBA,
CWS, DNC, CFCNis a certified wound spe-
cialist, dermatology advanced practice
nurse, certified foot and nail care nurse,
writer, speaker, a past president and chair-
man of the board for the American Acad-
emy of Wound Management (AAWM), past
director for the Association for the Ad-
vancement of Wound Care (AAWC), and Vice President, Clinical
Marketing for Medline Industries, Inc. Cynthia can be reached at
cfleck@medline.com.
References
1. Recommended practices for positioning the patient in the perioperative
practice setting. In: Perioperative Standards and Recommended Practices.
Denver, CO: AORN, Inc; 2010.
2. Beckrich K, Aronovitch SA. Hospital-acquired pressure ulcers: a comparison
of costs in medical vs. surgical patients. Nursing Economics. 1999;
17(5):263-271
3. Recommended practices for positioning the patient in the perioperative
practice setting. In: Perioperative Standards and Recommended Practices.
Denver, CO: AORN, Inc; 2010.
4. Recommended practices for positioning the patient in the perioperative
practice setting. In: Perioperative Standards and Recommended Practices.
Denver, CO: AORN, Inc; 2010.
5. Keller C. The obese patient as a surgical risk. Seminars in Perioperative
Nursing. 1999; 8(3):109-117.
6. McEwen DR. Intraoperative positioning of surgical patients. AORN Journal.
1996; 63(6):1058-1063, 1066-1075, 1077-1082.
7. Papantonio C, Wallop J, Koldner K. Sacral ulcers following cardiac surgery:
incidence and risks. Adv in Wound Care. 1994;7(2):24-36.
8. Aronovitch S. Intraoperatively acquired pressure ulcer prevalence: a national
study. J Wound Ostomy Continence Nursing. 1999;26(3):130-136.
9. Ratliff C, Rodeheaver G. Prospective study of the incidence of OR-induced
pressure ulcers in elderly patients undergoing lengthy surgical procedures.
Adv Skin Wound Care. 1998;11(suppl 3):10.
10. Allman RM, Goode PS, Burst N, Bartolluci AA, Thomas DR. Pressure ulcer
hospital complications and disease severity: impact on hospital costs and
length of stay. Advances in Skin & Wound Care, 1999;12(1):22-30.
11. Tarpey A, Gould D, Fox C, Davies P, Cocking M. Evaluating support surfaces
for patients in transit through the accident and emergency department.
J Clin Nurs. 2000;9(2):189-198.
12. Armstrong DG, Ayello EA, Capitulo KL, Fowler E, Krasner DL, Levine JM, et
al. New opportunities to improve pressure ulcer prevention and treatment:
implications of the CMS inpatient hospital care present on admission (POA)
indicators/hospital-acquired conditions policy. J Wound Ostomy Continence
Nurs. 2008. 35(5):485-492.
©2010 Medline Industries, Inc. Medline, QuickSuite and Sahara are registered trademarks of Medline Industries, Inc.
References
1
Braden Scale for Predicting Pressure Sore Risk. Available at:
www.bradenscale.com/braden.PDF. Accessed November 6, 2008.
2
Recommended practices for positioning the patient in the perioperative practice setting. In:
Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2008.
KEEP YOUR SURGICAL
PATIENTS DESERT DRY.
Medline’s Sahara
®
Super Absorbent OR table sheets
are designed with your patients’ skin integrity in mind.
QuickSuite
®
OR Clean Up Kit
The Braden Scale tells us that moisture is one of the
major risk factors for developing a pressure ulcer.
1
We also
know that as many as 66 percent of all hospital-acquired
pressure ulcers come out of the operating room.
2
That’s why we developed the Sahara Super Absorbent
OR table sheet. The Sahara’s super-absorbent polymer
technology rapidly wicks moisture from the skin and
locks it away to help keep your patients dry.
Sahara OR table sheets are available on their own or
as a component in our QuickSuite
®
OR Clean Up Kits,
which were designed to help you dramatically improve
your OR turnover time and help reduce cross contamina-
tion risk through a combination of disposable products.
To sign up for a FREE webinar on perioperative
pressure ulcer prevention, go to
www.medline.com/pupp-webinar.
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!
For a quick online video demonstration,
visit www.medline.com/ecodrape
©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
EcoDrape and greensmart are trademarks of Medline Industries, Inc.
– the only TRULY eco-friendly surgical drape
The OR Goes Green
Composition Comparison
EcoDrape SMS
Fibers More than 96% No wood
wood pulp pulp
Petrochemical 0% 100% PP
ingredients (plastics)
Additives Bio-based Fluorine
Medline has joined a group of corporate sponsors to sup-
port Practice Greenhealth’s Greening the Operating Room
(GOR) initiative. This initiative to green the nation’s oper-
ating rooms was launched earlier in 2010 to reduce the
environmental footprint of operating rooms in U.S. hospi-
tals. Hospital operating rooms contribute between 20 and
30 percent of the hospital’s total waste.
1
Medline will join the collaborative effort of hospitals, man-
ufacturers and related stakeholders to develop guidance
documents for helping reduce the environmental impact of
the nation’s operating rooms and potentially reduce cost,
increase quality and improve worker or patient safety. The
following are the GOR areas for “green” interventions in the
operating room:
• Single-Use Device (SUD) Reprocessing
• Reusables v. Disposables: Gowns, Surgical Drapes,
Basins and Other Reusables
• OR Kit Formulation
• Waste Anesthetic Gas Scavenging Systems
• Fluid Waste Management Systems
• Energy Use/Lighting & Thermal Comfort
• Regulated Medical Waste (RMW)
Minimization/Segregation
• Substitution of Reusable Hard Cases for Blue
Sterile Wrap
• Recycling of Medical Plastics
• Laser Safety/Smoke Evacuation
• Green Cleaning/Proper Disinfection in a
Surgical Setting
• Medical Equipment and Supplies Donation
To learn more about Practice Greenhealth’s Greening the
OR initiative visit www.greeningtheor.org.
Medline Joins
Greening the Operating Room Initiative
Reference
1. Esaki RK & Macario A. Wastage of supplies and drugs in the operating room. Medscape Anesthesiology. Posted October 21, 2009.
Available at. http://www.medscape.com/viewarticle/710513. Accessed October 22, 2010.
OR Issues
3 Checklists
on the Cleaning & Disinfection of
Endoscopic Equipment
by Lorri A. Downs RN, BSN, MS, CIC
According to the Association for Professionals in Infec-
ti on Control (APIC), many factors contri bute to
endoscopy-associated infection, including numerous
reports of outbreaks associated with equipment cleaning
and disinfection. Infection prevention related to the use
of endoscopy equipment begins with educating and
training practitioners and strict adherence to reprocess-
ing protocols.
1
We know that in busy healthcare environments, check-
lists can help reduce errors and improve adherence to
critical steps. Below you will find three checklists to help
staff quickly and efficiently adhere to infection control
guidelines for reprocessing endoscopic equipment in
the central sterile processing department, same-day
surgery arena and freestanding endoscopy clinics.
The following checklists for the cleaning and disinfec-
tion of endoscopes were adapted from the Society of
Gastroenterology Nurses and Associates (SGNA) Stan-
dards of Infection Control in Reprocessing of Flexible
Gastrointestinal Endoscopes.
2
To see the guidelines in
their entirety, go to www.sgna.org.
56 The OR Connection
Reprocessing of soiled endoscopy equipment begins at the patient’s bedside immediately
upon removal of the endoscope from the patient and prior to disconnecting the endoscope
from the power source.
Have the following equipment available immediately after the procedure:
• Personal protective equipment: gloves, eye protection, impervious gown, face shield
or surgical mask that will not trap vapors.
• Container with detergent solution
• A sponge and a soft, lint-free cloth
• Air and water channel cleaning adapters per manufacturer’s instructions
• Protective video caps if using video endoscopes
Use the following checklist after you have gathered the supplies listed above and put on your
personal protective equipment.
J Immediately wipe the insertion tube with a wet cloth or sponge soaked in freshly
prepared detergent solution. (Note: Do not reuse cloths or sponges between cases.)
J Place distal end of the endoscope in the detergent solution and suction the solution
through the channel. Alternate suctioning, detergent solution and air several times
until the solution is visibly clean. Finish with suctioning air.
J Flush or blow out air and water channels in accordance with the endoscope
manufacturer’s instructions.
J Flush the auxiliary water channel.
J Detach the endoscope from the light source and suction pump.
J Attach the protective video cap if using a video endoscope.
J Transport the endoscope to the reprocessing area in an enclosed container.
1
Checklist 1:
Cleaning the Endoscope Immediately After
the Endoscopy Procedure
Aligning practice with policy to improve patient care 57
Special Feature
58 The OR Connection
Have the following equipment available in the reprocessing area:
• Personal protective equipment: gloves, eye protection, impervious gown, face shield
or surgical mask that will not trap vapors
• Leak-testing equipment
• Channel cleaning adapters (per manufacturer’s instructions)
• Large basin of endoscope detergent prepared per manufacturer’s instructions
• Channel cleaning brushes
• Sponge and lint-free cloth
Use the following checklist after you have gathered the supplies listed above and put on your
personal protective equipment.
J Leak test the endoscope either manually or via computer testing following the
manufacturer’s instructions. If a leak is detected, follow the manufacturer’s
instructions.
J Fill the sink or a basin with a freshly prepared solution (for each endoscope) of water
and a medical grade, low-foaming, neutral pH detergent formulated for endoscopes
that may or may not contain enzymes.
J Immerse the endoscope.
J Wash all debris from the exterior of the endoscope by brushing and wiping the instrument
while submerged in the detergent solution.
J Keep the scope submerged to prevent splashing of contaminated fluid and aerosolization
of bioburden.
J Use a small soft brush to clean all removable parts, including inside and under the suction
valve, air/water valve, and biopsy port cover and openings. Brush all accessible channels,
the scope body, insertion tube and the umbilicus of the endoscope.
J After each passage of the brush, rinse the brush in the detergent solution, removing any
visible debris before retracting and reinserting it. Continue brushing until there is
no visible debris on the brush.
J Clean and high-level disinfect reusable brushes between cases.
J Attach manufacturer’s cleaning adapters for special endoscopic channels. Flush all
channels with detergent solution to remove debris. (Note: Automated pumps are available
for flushing endoscopes. Refer to the manufacturer’s instructions.)
J Soak the endoscope and its internal channels for the period of time specified on the label
of the detergent.
J Thoroughly rinse the endoscope and all removable parts with clean water to remove
residual debris and detergent.
J Purge water from all channels using forced air and dry the exterior of the scope with a
soft, lint-free cloth.
2
Checklist 2:
Cleaning the Endoscope in the Reprocessing Area
Aligning practice with policy to improve patient care 59
• Once the endoscope has been cleaned, it is ready for disinfectants and sterilants.
• Be sure to follow the manufacturer’s instructions for proper use of these chemicals.
• Test the chemical for the minimum effective concentration (MEC) according to the
label on the test strip container.
• Never use the MEC value to extend the “reuse” life claim on the product and never
use beyond the date specified on activation.
• Use product-specific test strips to check for the MEC and keep a log of the test results.
J Completely immerse the endoscope and all removable parts in a basin of high level
disinfectant/sterilant.
J Inject disinfectant into all channels of the endoscope until it can be seen exiting the
opposite end of each channel. Make sure no air pockets remain within the channels
J Do not coil the scope tightly and cover the basin to contain chemical vapors.
J Soak the endoscope in the high-level disinfectant/sterilant for the appropriate time and
temperature.
J Required to achieve high-level disinfection. Use a timer to verify soaking time.
J Purge all channels completely with air before removing the endoscope from the high-
level disinfectant/sterilant.
J Thoroughly rinse all surfaces and removable parts and flush all channels of the endoscope
and its removable parts with clean water and disinfectant per the manufacturer’s
recommendations.
J Purge all channels with air until dry and follow with 70% isopropyl alcohol (even if sterile
water is used to flush) to assist in drying the interior channel surfaces.
J Thoroughly rinse and dry all removable parts and do not store removable parts attached
to the endoscope when not in use.
J Dry the exterior of the endoscope with a soft, lint-free cloth.
J Thoroughly rinse the endoscope and all removable parts with clean water to remove
residual debris and detergent.
J Hang the endoscope vertically with the distal tip hanging freely in a clean, well-vented,
dust-free area.
3
Checklist 3:
High Level Disinfection/Sterilization for Endoscopes
in the Reprocessing Area
References
1. Stricof RL. Endoscopy. In: Carrico R, ed. APIC Text of Infection Control and Epidemiology. 3rd ed. Washington, DC: Association for Professionals
in Infection Control and Epidemiology, Inc.; 2009.
2. Society of Gastroenterology Nurses and Associates, Inc. The Standards of Infection Control in Reprocessing of Flexible Gastrointestinal Endoscopes.
10-19. Available at: http://infectioncontrol.sgna.org/SGNAResources/tabid/55/Default.aspx#standards. Accessed November 10, 2010.
About the author
Lorri Downs, RN, BSN, MS, CIC is a board-certified infection preventionist and vice president of infec-
tion prevention for Medline Industries, Inc. She has a diverse portfolio of more than 25 years in the nursing
professions. 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 ahs lectured on various infection prevention topics.
60 The OR Connection
Aligning practice with policy to improve patient care 61
Continuing Education Article
OR Issues
Stuck Like Glue
NEW USES AND IMPROVED OUTCOMES
Surgical
^
Are your surgeons increasingly requesting surgical glue? If they
aren’t asking for it yet, all indications are that surgical glue will
be a mainstay in operating rooms in the near future. Let’s
explore why use of surgical glue is becoming so prominent
among surgeons.
Current Market Snapshot
Current research on the success of surgical sealants and glues
in clinical practice was published in October 2010 by Med-
Market Diligence, a provider of data and insight on advanced
medical technologies. The report states that the advance-
ments in surgical sealants and glue technology are enabling
these products to increasingly penetrate the existing markets
for sutures and staples, in addition to capturing a caseload of
new applications.
1
A wide array of wound closure products is
now in use by both general surgeons and surgeons special-
izing in gynecologic, orthopedic, gastrointestinal, neurology,
cosmetic, vascular and nearly all other surgical areas.
Many aspects of prevailing surgical methods (from as recently
as 10 years ago) have undergone major changes. The
increased use of surgical sealants and glue is one such
change and is primarily attributable to both new technological
advancements and the expanding caseloads for which these
technologies apply. While traditional wound closure products,
including sutures and staples, still command a sizable portion
of the overall market, their rate of use compared to alternative
products is relatively flat, and in some cases declining, in
certain geographic regions. In contrast, the use of surgical
sealants and glues is growing at an estimated 10 to 15 percent
per year.
1
In August 2010, Outpatient Surgery conducted a poll asking
readers about their use of surgical glue and the results were as
follows:
By Alecia Cooper, RN, BS, MBA, CNOR
and Debashish Chakravarthy, PhD
OUTPATIENT SURGERY MAGAZINE READER POLL
2
“In which types of cases do you use surgical
glue instead of sutures?”
ARTHROSCOPY . . . . . . . . . . . . . . . . . . .28%
ENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1%
GENERAL SURGERY . . . . . . . . . . .34%
GYNECOLOGY . . . . . . . . . . . .11%
PLASTICS . . . . . . . . . . . . .26%
62 The OR Connection
Importance of Surgical Glue Knowledge
Whereas surgeons select and evaluate the effectiveness of
closure devices, including surgical glues, it is the responsibility
of nurses, physician assistants, residents, interns and students
to routinely assist or close the procedure under the surgeon’s
direction. Therefore, it is imperative to have thorough knowl-
edge of these materials and their appropriate application and
use in order to achieve the best performance and results.
Focusing on Cyanoacrylates
Cyanoacrylates were first used in 1949 after being discovered
accidentally while researchers were studying refracting indexes
of coatings on glass.
3
Cyanoacrylates became popular during
the Vietnam War as a hemostat for soldiers wounded in field
combat. These compounds entered the clinical market during
the 1980s and 1990s in dental products, bandages and
wound closure adhesives. Today, several cyanoacrylates have
been cleared and/or approved as medical devices by the FDA.
TYPES OF SURGICAL TISSUE ADHESIVES
Surgical glues, also referred to as surgical tissue adhesives or
sealants, are used after a surgery or traumatic injury to bind
together both deep as well as superficial tissue. These glues
provide a chemical bond to hold tissue together for healing
and serve as a barrier to stop the flow of bodily fluids. Certain
physicians use surgical glues in conjunction with, or as and
alternative to, sutures and staples.
Including surgical closure glues, there are several main types
of surgical glues approved for various surgical applications:
Fibrin sealants. Fibrin sealants are a type of surgical
adhesive derived from both human and animal blood prod-
ucts. Ingredients in the fibrin sealant interact during appli-
cation to form a clot. Fibrin sealants are effective for use in
cardiovascular surgery, lung surgery, the closure of dura,
and to seal spleen and liver lacerations. Fibrin sealants are
not suitable for external or topical use.
Glutaraldehyde-based glues. Glutaraldehyde glues are
protein-based compounds that are crosslinked by
glutaraldehyde, in situ, to make a strong and bioabsorbable
internal seal. These glues are not suitable for external or
topical use.
Collagen-based products. Collagen-based adhesives
may be combined with other hemostatic proteins such as
thrombin to make an effective internal adhesive.
Hydrogels. Hydrogels are synthetic polyethylene glycol
(PEG) polymers commonly used in lung and thoracic surgery
for their ability to seal air leaks. Due to their physical prop-
erties, they are unsuitable as an incision site closure or glue.
Cyanoacrylates. Cyanoacrylates are compounds ideally
suited—because of their physical properties when “set
up”—to close topical incisions, minor lacerations or an inci-
sion site. The subcutaneous tissue is closed with sutures
and the glue is used only to close the dermal and epidermal
incisional defects. These compounds are very commonly
used on laparoscopic incisions and are much stronger than
all the internal glues discussed above. Cyanoacrylates are
also able to withstand the external environment while the
incision heals naturally underneath the glue line. In general,
cyanoacrylates are waterproof, flexible and require
no secondary dressing. Cyanoacrylates are not bio-
absorbable and must be restricted to external and tem-
porary applications.
1
4
5
3
2
Continued on page 64
©2010 Medline Industries, Inc. Medline is a registered trademark and OctylSeal is a trademark of Medline Industries, Inc.
Introducing Medline’s OctylSeal high viscosity
tissue adhesive for closure of simple wounds
• Flexible structure moves with the skin, minimizing the
chance of cracking
• Acts as a barrier to microbial penetration as long as the
adhesive film remains intact
• 40 percent more glue per container than most other
tissue adhesives (0.7 grams versus 0.5 grams)
• Easy, versatile application – interchangeable tips (swab
and nozzle) included in every package; violet color for
easier identification on skin
• Metal tube instead of glass ampule means no risk of
broken glass entering the wound
Indications for use
Topical application only to hold closed easily approximated
edges of wounds from surgical incisions, including punc-
tures from minimally invasive surgery and simple, thoroughly
cleansed trauma-induced lacerations. OctylSeal may be
used in conjunction with, but not in place of deep dermal
sutures. Available by prescription only.
Stick with OctylSeal

Flexible wound closure that’s easy on your budget
To learn more about OctylSeal,
call 847-643-4526.
64 The OR Connection
Two main types: octyls and butyls. There are, in essence,
two main types of cyanoacrylates approved as medical tissue
adhesives. One type is N-butyl-2-cyanoacrylate (simply called
butyl in most cases) and the second type is 2-octyl-
cyanoacrylate (Simply called octyl).
4
The difference between the two types is in the nature of the
chemical chains present in the ester groups of the molecules.
The molecules are sometimes referred to as monomers. In
contrast, the adhesive that is “set up” on skin post application
is the polymer. A butyl cyanoacrylate contains a short chain
(4 carbon length) portion in its structure. An octyl cyanoacry-
late contains a longer chain (8 carbon length) portion.
The polymer film resulting from the use of a butyl glue is con-
sidered to be more rigid than the film resulting from the set up
of an octyl glue on skin, and far less flexible. Thus, butyls are
more prone to cracking and splitting under tension and flex-
ure of the skin, limbs and joints during normal movement. In
summary, a butyl film provides only strength, but very little flex-
ibility, while the octyl film seems to balance both tensile
strength and flexibility without fissures or cracks appearing in
the film.
Since both types of cyanoacrylate adhesives have FDA
approval,
4
how does a surgeon select the preferred product?
Many factors can play into the surgeon’s decision, though top-
ping the list seem to be the features and benefits of each type
of adhesive that appeals to the surgeon, the product type the
surgeon trained on, and the product brand that the hospital
stocks. Table 1 compares octyl and butyl cyanoacrylates and
shows the factors that may play into the clinicians preference
in product choice.
Determining How to Close the Wound
In determining the appropriate type of product to close any
surgical procedure, surgeons take into account many factors
based upon the desired goals.
1. Reason for the surgery
2. Location of where and how the injury occurred
(if applicable)
3. Location of the wound
4. Length of the surgical procedure
Surgical wound closure using a cyanoacylate is best suited for
wounds that are not subject to significant stress or flexion.
Many surgeons follow this rule of thumb: if the skin requires
more than simple pulling together with forceps or fingers to
Potential benefits of surgical wound
closure with cyanoacrylates
6
1. Quicker wound closure
2. Comparable/better scar cosmesis than sutures
or staples
3. Occlusive microbial barrier
4. Non-invasive – less tissue trauma and reduced
inflammatory reaction
5. No secondary dressings required
6. Easy-to-use/quick learning curve
7. Ease of wound visualization
8. Reduced risk of needle-stick injury associated
with suturing
9. Cost-effective
Table 1. Octyl versus butyl cyanoacrylates
Octyl Butyl
No need to refrigerate
Cures or polymerizes as a smooth
surface and an even film
Sets up with a flexible “glue” line at
the application site.
Needs refrigeration
Cures or polymerizes as a rough
surface
Sets up with a brittle “glue” line at
the application site.
Aligning practice with policy to improve patient care 65
achieve approximation of the wound, then deeper sutures
and/or subcutaneous sutures should be used before the glue
is applied.
5
Octyl cyanoacylates appear to work better on
areas of flexion as compared to butyl cyanoacylates, because
they set up with a flexible “glue line” and maintain their micro-
bial barrier.
The best results are obtained when the wound incision is clean
and dry with total hemostasis prior to the application of the
skin adhesive. Cyanoacrylate adhesives close the skin by
forming a polymerized layer across the top of the skin, creat-
ing a a bridge between the skin edges. Therefore, it is impor-
tant for best results to obtain edge-to-edge apposition while
the glue sets over the wound.
If the procedure is a routine, elective surgery and not caused
by a trauma, surgical glue should be considered. If an injury
took place outdoors or on a playground, for example, where
there are potential contaminants, it is best not to consider sur-
gical glue. The duration of surgery may affect the potential for
infection, and surgical glue should be used with caution.
Benefits of Using Surgical Tissue Adhesives
Many surgeons prefer coverage of the suture line with a
cyanoacrylate surgical glue as opposed to a dressing because
the glue allows the incision line to be easily visible.
6
Once com-
fortable with the technique, most surgeons find that surgical
glues offer a fast, simple and effective means of surgical
wound closure, particularly for smaller surgical incisions. In
addition, cosmetic results are superior. Patients are pleased
with the waterproof and microbial barrier nature of glue,
especially octyl glues, which are resistant to cracking and
allow patients to shower soon after the procedure. Additional
benefits of using a surgical glue are the lack of visible dress-
ings or sutures and the absence of procedures to remove
sutures or staples.
5
Trauma
Most surgeons find that surgical glues offer a fast,
simple and effective means of surgical wound closure
SKIN GLUE – TOP TIPS
6
• Make sure the wound is clean and dry
• Stop bleeding prior to application
• Apply glue over tightly and correctly approximated
wound edges
• Hold until glue/tissue adhesive is dry
• No further dressings required, although secondary
dressing will not harm incision site and may provide
additional microbial barrier protection
• Ensure patient/post-op staff know glue was used and
know wound site care
• Provide patient information/instructions at discharge
Microbes and Surgical Tissue Adhesives
Recent in vitro studies have shown that 2-octyl-cyanoacrylate
is an effective microbial barrier for the first 72 hours after
application.
3
A key aspect of using surgical glues is that the skin formed
with 2-octyl-cyanoacrylate is effective against gram-positive
66 The OR Connection
and gram-negative bacteria including Staphylococcus epi-
dermis, S. aureus, Escherichia coli, Pseudomonas aeruginosa,
and Enterococcus faecium. The adhesive creates a protective
layer for the wound and keeps the area moist, resulting in
faster epithelialization. In this way, the system of closure and
protection of the wound using surgical glue can result in
reduced costs and better management in the postoperative
phase.
3
Cyanoacrylate skin adhesives may potentially reduce the risk
of surgical site infections (SSIs) by:
7
1. Forming an occlusive, impermeable, waterproof barrier
2. Prevention of translocation of local skin flora
3. Reducing post-operative wound dressing changes
4. Improving hygiene by allowing patients to shower
Wound Site Care
To allow proper care and management of the incision site
closed with surgical glue, it is imperative to communicate
effectively regarding glue use at handoff in the immediate
post-operative period. Incisions closed with glue typically do
not produce drainage because in general, the use of glue is
restricted to non-draining wounds.
If the incision appears to be opening, the edges should be
pushed together, and then butterfly-type bandages may be
applied to hold the edges together. The surgeon may apply
additional surgical glue to the wound as needed prior to dis-
charge from the hospital. Surgical glues will slough off naturally
as normal skin grows to heal the incision site.
Best practice requires providing education and training on
surgical wound care to the patient and family prior to
discharge so that proper care is extended at home. Postop-
erative evaluation has shown good patient satisfaction when
using surgical glues.
3
Perioperative personnel need to know how to care for inci-
sions closed with glue and should be able to communicate to
patients and their families the methods to properly care for and
maintain the incision site at home.
New Uses and Improved Outcomes
The key to the successful use of surgical glue is that surgeons
should precisely apply the products to the appropriate surgi-
cal wounds. Both surgeons and other clinicians will need to
perfect their technique for applying and using surgical glues.
Proper application of surgical glue can be learned quickly and
easily; the method is not particularly challenging.
As the process for the surgical glue to ”set up” and protect
the incision site happens in about a minute, the use of surgi-
cal glue can save valuable time and improve both patient out-
comes and patient satisfaction. Patients report more
postoperative comfort, appreciate the ability to see the inci-
sion and like being able to bathe immediately following the
procedure.
Surgical glues are relatively inexpensive, comprising only
a small fraction of the overall costs associated with most sur-
geries. There is no need for a secondary dressing or dressing
changes, which adds to costs of treatment. Use of glue also
may eliminate follow-up visits related to post op care and
suture removal. Based upon these myriad factors, the use of
surgical glues is likely to continue growing, and new innova-
tions in the technology will continue to emerge.
References
1. Surgical Sealant and Glue New Uses and Penetration of Traditional Wound Closure,
Hemostasis. MedMarket Diligence, LLC. October 11, 2010. Available at:
http://www.prlog.org/10991463-surgical-sealant-and-glue-new-uses-and-penetration-
of-traditional-wound-closure-hemostasis.html. Accessed November 8, 2010.
2. InstaPoll. In which types of cases do you use surgical glue instead of sutures? Outpatient
Surgery E-Weekly, August 17, 2010. Available at: www.outpatientsurgery.net.
Accessed November 9, 2010.
3. Silvestri A, Brandi C, Grimaldi L, Nisi G, Brafa A, Calabro M, et. al. Octyl-2-cyanoacrylate
adhesive for skin closure and prevention of infection in plastic surgery. Aesthetic Plastic
Surgery. 2006;30(6):695-699.
4. Petrie EM. High strength surgical adhesives. Available at: http://www.specialchem4adhe-
sives.com/home/editorial.aspx?id=3043. Accessed November 18, 2010.
5. Liversedge NH. Get stuck in! Hands on experiences with surgical skin glue. Obs & Gynae
News. 2007;14(1):24-28.
6. Malangoni MA, Cheadle WG, Dodson TF, Dohmen PM, Jones D, Kushagra K, et al.
Roundtable discussion. New opportunities for reducing risk of surgical site infections.
Surgical Infections. 2006;7 Suppl 1:S23-39.
7. Non-invasive closure of laparoscopic surgical incisions. Available at: http://www.admed-
sol.com/Doc/LBL%20Clinical%20Update.pdf. Accessed November 18, 2010.
Linear
Aligning practice with policy to improve patient care 67
CE Test
True/False
1. The use of surgical sealants and glues is growing at
a rate of 10 to 15 percent per year. T F
2. Recent in vitro studies have shown that
2-octyl-cyanoacrylate is an effective microbial barrier
for the first 72 hours after application. T F
3. Butyl cyanoacrylates cure or polymerize as a smooth
surface. T F
4. Octyl cyanoacrylates require refrigeration. T F
5. Cyanoacrylate adhesives first entered the clinical
market in the 1960s. T F
Multiple Choice
6. Which of the following is one of the factors surgeons
take into account when determining the appropriate
type of product to close a surgical incision?
a. Patient’s age
b. Skin temperature
c. Ability to approximate wound edges
d. None of the above
7. Which type of surgical glue is commonly used in lung
and thoracic surgery?
a. Cyanoacrylates
b. Glutaraldehyde glues
c. Hydrogels
d. Fibrin sealants
CE Test Questions
Stuck Like Surgical Glue:
NEW USES AND IMPROVED OUTCOMES
Submit your answers at
www.medlineuniversity.com
and receive 1 FREE CE credit
8. Patients tend to prefer surgical glue over sutures or
staples because __________________.
a. It allows them to lightly wash or shower right
after surgery
b. There is no need for required follow up for removal
c. They provide more postoperative comfort
d. All of the above
9. Glutaraldehyde glues are used in the repair of
_________________.
a. Simple skin lacerations
b. Aortic dissections
c. Massive head wounds
d. Laparoscopic surgical incisions
10. Surgical adhesives derived from both human and
animal blood products are called
_____________________.
a. Fibrin sealants
b. Collagen-based compounds
c. Cyanoacrylates
d. None of the above
Courses approved for continuing education by the Florida Board
of Nursing and the California Board of Reigistered Nursing.
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Aligning practice with policy to improve patient care 69
Special Feature
70 The OR Connection
Efficacy of Medline BIOGUARD
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and Covidien AMD After 24 and 48 Hours*
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Reference
1. S Morrissey. Epidemiology: forging the future:
microbe-busting bandages. Time. 2006; 167(12). Posted
March 12, 2006. Available at: www.time.com/time/maga-
zine/article/0,9171,1172215,00.html.
Accessed November 9, 2010.
2. National Pressure Ulcer Advisory Panel Board of Directors
2010. Available at: www.npuap.org/about.htm.
Accessed November 9, 2010.
3. University of Florida website. Biochemistry and Molecular
Biology. Gregory Schultz, PhD. Available at:
www.med.ufl.edu/IDP/BMB/bmbfacultypages/gschultz.html.
Accessed November 9, 2010.
4. Data on file.
Bioguard is a registered trademark of Derma Sciences, Inc.
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and comprehensive ERASE 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.
A revised checklist for the
medical record
The reformatted checklist is smaller,
making it easier to place in the paper chart
or attach to the electronic medical record.
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.
1
2
3
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 tipsfor the clinician.
74 The OR Connection
Ventilator-associated pneumonia (VAP)
is a hospital-acquired infection that occurs in up
to 27 percent of al l mechani cal l y venti l ated
patients.
1
It is specifically defined as an airway
infection that develops more than 48 hours after a
patient is intubated.
2
Among ICU patients, nearly 90 percent of episodes
of hospital-acquired pneumonia occur during
mechanical ventilation.
1
Because half of all episodes
of VAP occur within the first four days of mechani-
cal ventilation, it is especially critical to prevent the
condition all together.
1
Reducing mortality due to
ventilator-associated pneumonia requires an
organized process that guarantees early recognition
of pneumoni a and consi stent appl i cati on of
evidence-based practices.
2
The Institute for Healthcare Improvement (IHI)
advocates use of a bundle approach to help fight
VAP. The ventilator bundle is a series of interventions
related to ventilator care that, when implemented
together, achieves significantly better outcomes.
2
The five components of the (IHI) Ventilator
Bundle are:
2
1. Elevating the head of the bed 30 degrees
2. Daily “sedation vacations” and assessment
of readiness to extubate
3. Peptic ulcer disease prophylaxis
4. Deep vein thrombosis prophylaxis
5. Daily oral care with chlorhexidine
References
1. Kollef MH. What is ventilator-associated pneumonia and why is it
important? Respiratory Care. 2005;50(6):714-724. Available at:
www.rcjournal.com/contents/06.05/06.05.0714.pdf. Accessed
November 4, 2010.
2. Implement the Ventilator Bundle. Institute for Healthcare
Improvement (IHI) website. Available at: www.ihi.org/IHI/Topics/Criti-
calCare/IntensiveCare/Changes/ImplementtheVentilatorBundle.htm.
Accessed November 4, 2010.
Five Step
Approach
for Avoiding
VAP
Aligning practice with policy to improve patient care 75
Patient Safety
1. Elevating the Head of the Bed 30 Degrees
• Implement a mechanism to ensure head-of-the-bed
elevation, such as including this intervention on
nursing flow sheets and as a topic at
multidisciplinary rounds.
• Create an environment where respiratory therapists
work collaboratively with nursing to maintain
head-of-the-bed elevation.
• Involve families in the process by educating them
about the importance of head-of-the-bed elevation
and encourage them to notify clinical personnel
when the bed does not appear to be in the
proper position.
• Use visual cues to easily identify when the bed is
in the proper position.
• Include this intervention on order sets for initiation
and weaning of mechanical ventilation, delivery of
tube feedings, and provision of oral care.
2. Daily “Sedation Vacations” and Assessment
of Readiness to Extubate
• Implement a protocol to lighten sedation daily at
an appropriate time to assess for neurological
readiness to extubate. Include precautions to
prevent self-extubation such as increased
monitoring and vigilance during the trial.
• Include a “sedation vacation” strategy in your overall
plan to wean the patient from the ventilator; if you
have a weaning protocol, add “sedation vacation”
to that strategy.
• Assess that compliance daily during
multidisciplinary rounds.
• Consider implementation of a sedation scale
(e.g., the Riker Scale) to avoid oversedation.
3. Peptic Ulcer Disease Prophylaxis
• Include peptic ulcer disease prophylaxis as part of
your ICU order admission set and ventilator order
set. Make application of prophylaxis the default
value on the form.
• Include peptic ulcer disease prophylaxis as an item
for discussion on daily multidisciplinary rounds.
• Empower pharmacy to review orders for ICU
patients to ensure that some form of peptic ulcer
disease prophylaxis is in place at all times.
4. Deep Venous Thrombosis Prophylaxis
• Include deep venous prophylaxis as part of your
ICU order admission set and ventilator order set.
Make application of prophylaxis the default value
on the form.
• Include deep venous prophylaxis as an item for
discussion on daily multidisciplinary rounds.
• Empower pharmacy to review orders for ICU
patients to ensure that some form of deep venous
prophylaxis is in place at all times.
5. Daily Oral Care with Chlorhexidine
• Educate registered nurses (RNs) about the rationale
supporting good oral hygiene and its potential
benefit in reducing ventilator-associated pneumonia.
• Develop a comprehensive oral care process that
includes the use of 0.12% chlorhexidine oral rinse.
• Schedule chlorhexidine as a medication, which then
provides a reminder for the RN and triggers oral
care process delivery.
Source: www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/Changes/Implement-
theVentilatorBundle.htm
Tips
for Complying with the
VAP Prevention Bundle
VAPREVENT SYSTEM:
Making it easier to avoid
Ventilator-Associated Pneumonia
Evidence-based innovation in oral care
Easy to identify
which mouthwash
the kit contains
IHI Checklist
of activities
to help
reduce VAP
Strong
built-in IV
pole hanger
Compliance
at a glance –
clearly labeled
and sequenced
in the order
they should
be used
Thumb grip
for easy
dispensing
To schedule your evaluation of the VAPrevent System,
contact your Medline representative or call
1-800-MEDLINE (633-5463).
Easy
identification
of oral care
frequency
Clear visual
identification
of kit
components
Record
start time,
date and
patient
information
VAPrevent is a comprehensive oral care system modeled after the guidelines of
the Institute for Healthcare Improvement (IHI) Ventilator Bundle. It’s designed to
address ventilator-associated pneumonia (VAP)—the second most common
healthcare-associated infection
1
, affecting up to 40 percent of ventilator patients.
2
The VAPrevent System brings you the three Ps to better oral care: the right products
combined with a comprehensive educational program at a value-added price.
Product
Only Medline features these three options for oral care: IHI-recommended
chlorhexidine gluconate (CHG), the alcohol-free moisturizing of Biotene
®
,
or the proven antisepsis of hydrogen peroxide. Color-coded packaging
allows for quick identification, thorough caregiver education and simple
compliance. The system is designed to dispense each kit one-at-a-time
in the right order at the right time.
Program
Products are only as beneficial as knowing how to use them appropriately.
That’s why we also developed the Medline VAP Program, which helps build
your staff’s knowledge and clinical skills with educational modules for novice
and experienced clinicians, as well as an online interactive competency for oral
care. We help you implement the program, and then provide you with 90-
day reports to help you track your incidence of VAP.
Price
All this – and a lower price! The cost of the VAPrevent System is five to 10
percent lower than competitors, who offer less comprehensive systems.
References
1 Bingham M, Ashley J, De Jong M, Swift C. Implementing a unit-level intervention to reduce the probability
of ventilator-associated pneumonia. Nursing Research. 2010; 59(1): S40-S47.
2 Trouillet J, Chastre J, Vuagnat A, Joly-Guillou M, Combaux D, Dombret M, et al. Ventilator-associated
pneumonia cased by potentially drug-resistant bacteria. Am J Respir Crit Care Med. 1998. 157(2):531-539.
©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
Suction Toothbrush
& Catheter Kit
78 The OR Connection
Get Set for
WINTER ILLNESS
SEASON
In much of the Northern Hemisphere, this is prime time
for colds, influenza (flu), and other respiratory illnesses.
While contagious viruses are active year-round, fall and winter
are when we’re all most vulnerable to them. This is due in large
part to people spending more time indoors with others when
the weather gets cold. The Food and Drug Administration
(FDA) regulates medicines and vaccines that help fight
winter illnesses.
Colds and Flu
Most respiratory bugs come and go within a few days, with no
lasting effects. However, some cause serious health problems.
Although symptoms of colds and flu can be similar, the two
are different.
Colds are usually distinguished by a stuffy or runny nose and
sneezing. Other symptoms include coughing, a scratchy
throat, and watery eyes. No vaccine against colds exists
because they can be caused by many types of viruses. Often
spread through contact with mucus, colds come on gradually.
Flu comes on suddenly, is more serious, and lasts longer than
colds. The good news is that yearly vaccination can help pro-
tect you from getting the flu. Flu season in the United States
generally runs from November to April.
Flu symptoms include fever, headache, chills, dry cough, body
aches, fatigue, and general misery. Like colds, flu can cause a
stuffy or runny nose, sneezing, and watery eyes. Young children
may also experience nausea and vomiting with flu.
Caring for Yourself
Aligning practice with policy to improve patient care 79
Prevention Tips
Get vaccinated against flu. According to the Centers for
Disease Control and Prevention (CDC):
• More than 200,000 people in the United States are
hospitalized from flu-related complications each year,
including 20,000 children younger than age 5.
• Flu-associated deaths number in the thousands each
year. Between 1976 and 2006, the estimated number of
flu-related deaths every year ranged from about 3,000
to about 49,000.
Flu vaccine, available as a shot or a nasal spray, remains the
best way to prevent and control influenza. The best time to get
a flu vaccination is from October through November, although
getting it in December and January is not too late. A new flu
shot is needed every year because the predominant flu viruses
change every year.
All people 6 months of age and older should be vaccinated.
However, you should talk to your health care professional
before getting vaccinated if you
• have certain allergies, especially to eggs
• have an illness, such as pneumonia
• have a high fever
• are pregnant
Flu vaccination for health care workers is urged because
unvaccinated workers can be a primary cause of outbreaks in
health care settings. Certain people are more at risk for devel-
oping complications from flu; they should be immunized as
soon as vaccine is available. These groups include:
• people 65 and older
• residents of nursing homes or other places that house
people with chronic medical conditions such as diabetes,
asthma, and heart disease
• adults and children with heart or lung disorders,
including asthma
• adults and children who have required regular medical
follow-up or hospitalization during the preceding year
because of chronic metabolic diseases (including diabetes),
kidney dysfunction, a weakened immune system, or
disorders caused by abnormalities of hemoglobin
(a protein in red blood cells that carries oxygen)
• young people ages 6 months to 18 years receiving long-term
aspirin therapy, and who as a result might be at risk for
developing Reye’s syndrome after being infected with
influenza (See aspirin information in the section “Taking
OTC Products.”) Note that only one vaccine is needed
for the 2010-2011 influenza season.
During last flu season, two different vaccines were needed; one
to prevent seasonal influenza and another to protect against
the 2009 H1N1 flu virus. This year’s seasonal flu vaccine pro-
tects against three strains of influenza, including the 2009
H1N1 flu virus.
Also, a vaccine specifically for people 65 years and older is
available this year. Called Fluzone High-Dose, this vaccine
induces a stronger immune response and is intended to better
protect the elderly against seasonal influenza.
This vaccine—which was approved by FDA in 2009—was
developed because the immune system typically becomes
weaker with age, leaving people at increased risk of seasonal
flu-related complications which may lead to hospitalization
and death.
Wash your hands often. Teach children to do the same. Both
colds and flu can be passed through coughing, sneezing, and
contaminated surfaces, including the hands.
CDC recommends regular washing of your hands with warm,
soapy water for about 15 seconds.
Tips for Avoiding
WINTER BUGS:
• Get vaccinated against flu
• Wash your hands often
• Limit exposure to infected people
• Keep stress in check
• Eat right
• Sleep right
• Exercise
80 The OR Connection
FDA says that while soap and water are undoubtedly the first
choice for hand hygiene, alcohol-based hand rubs may be
used if soap and water are not available. However, the agency
cautions against using the alcohol-based rubs when hands are
visibly dirty. This is because organic material such as dirt
or blood can inactivate the alcohol, rendering it unable to
kill bacteria.
Try to limit exposure to infected people. Keep infants away
from crowds for the first few months of life. This is especially
important for premature babies who may have underlying
abnormalities such as lung or heart disease.
Practice healthy habits.
• Eat a balanced diet.
• Get enough sleep.
• Exercise. It can help the immune system
better fight off the germs that cause illness.
• Do your best to keep stress in check.
Also, people who use tobacco or who are exposed to
secondhand smoke are more prone to respiratory illnesses and
more severe complications than nonsmokers.
Already Sick?
Usually, colds and flu simply have to be allowed to run their
course. You can try to relieve symptoms without taking medi-
cine. Gargling with salt water may relieve a sore throat. And a
cool-mist humidifier may help relieve stuffy noses.
Here are other steps to consider:
• First, call your doctor. This will ensure that the best course
of treatment can be started early.
• If you are sick, try not to make others sick too. Limit your
exposure to other people. Also, cover your mouth with a
tissue when you cough or sneeze, and throw used tissues
into the trash immediately.
• Stay hydrated and rested. Fluids can help loosen mucus
and make you feel better, especially if you have a fever.
Avoid alcohol and caffeinated products. These may
dehydrate you.
• Know your medicine options. If you choose to use medicine,
there are over-the-counter (OTC) options that can help
relieve the symptoms of colds and flu.
If you want to unclog a stuffy nose, then nasal decongestants
may help. Cough suppressants quiet coughs; expectorants
loosen mucus so you can cough it up; antihistamines help stop
a runny nose and sneezing; and pain relievers can ease fever,
headaches, and minor aches.
In addition, there are prescription antiviral medications
approved by FDA that are indicated for treating the flu. Talk to
your health care professional to find out what will work best
for you.
Taking OTC Products
Be wary of unproven treatments. It’s best to use treatments
that have been approved by FDA. Many people believe that
products with certain ingredients—vitamin C or Echinacea, for
example—can treat winter illnesses.
3
Things You Can Do:
1. Wash your hands often with soap
and warm water.
2. Get vaccinated against the flu.
3. Choose over-the-counter medicines
that treat only your specific symptoms.
Continued on page 82
©2010 Medline Industries, Inc. Medline is a registered trademark
and Remedy is a trademark of Medline Industries, Inc
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82 The OR Connection
Unless FDA has approved a product for treatment of specific
symptoms, you cannot assume that the product will treat those
symptoms. Tell your health care professionals about any
supplements or herbal remedies you use.
Read medicine labels carefully and follow directions. People
with certain health conditions, such as high blood pressure,
should check with a health care professional before taking a
cough and cold medicine. Some medicines can worsen
underlying health problems.
Choose appropriate OTC medicines. Choose OTC medi-
cines specifically for your symptoms. If all you have is a runny
nose, only use a medicine that treats a runny nose. This can
keep you from unnecessarily doubling up on ingredients, a
practice that can prove harmful.
Check the medicine’s side effects. Certain medications such
as antihistamines can cause drowsiness. Medications can
interact with food, alcohol, dietary supplements, and each other.
The safest strategy is to make sure your health care profes-
sional knows about every product you are taking, including
nonprescription drugs and any dietary supplements such as
vitamins, minerals, and herbals.
Check with a doctor before giving medicine to children.
Get medical advice before treating children suffering from cold
and flu symptoms. Do not give children medication that is
labeled only for adults.
Don’t give aspirin or aspirin-containing medicines to chil-
dren and teenagers. Children and teenagers suffering from
flu-like symptoms, chickenpox, and other viral illnesses
shouldn’t take aspirin.
Reye’s syndrome, a rare and potentially fatal disease found
mainly in children, has been associated with using aspirin to
treat flu or chickenpox in kids. Reye’s syndrome can affect the
blood, liver, and brain.
Some medicine labels may refer to aspirin as salicylate or
salicylic acid. Be sure to educate teenagers, who may take
OTC medicines without their parents’ knowledge.
When to See a Doctor
See a health care professional if you aren’t getting any better or
if your symptoms worsen. Mucus buildup from a viral infection
can lead to a bacterial infection.
With children, be alert for high fevers and for abnormal behavior
such as unusual drowsiness, refusal to eat, crying a lot, holding
the ears or stomach, and wheezing.
Signs of trouble for all people can include
• a cough that disrupts sleep
• a fever that won’t go down
• increased shortness of breath
• face pain caused by a sinus infection
• worsening of symptoms, high fever, chest pain, or a
difference in the mucus you’re producing, all after
feeling better for a short time
Cold and flu complications may include bacterial infections
(e.g., bronchitis, sinusitis, ear infections, and pneumonia) that
could require antibiotics.
Remember: While antibiotics are effective against bacterial
infections, they don’t help against viral infections such as the
cold or flu.
Find this and other Consumer Updates at
www.fda.gov/ForConsumers/ConsumerUpdates
Sign up for free e-mail subscriptions at www.fda.gov/con
Article courtesy of the Food and Drug Administration (FDA).
©2010 Medline Industries, Inc. Medline is a registered trademark
and Liqui-Loc is a trademark of Medline Industries, Inc.
Introducing a fluid management system that saves
time, adds convenience and reduces waste.
Medline Suction Canister with patent
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• No more elbows to lose or misplace
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• Designed and tested with
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• FREE accessory program!
Eligible customers may
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84 The OR Connection
Aligning practice with policy to improve patient care 85
by Wolf J. Rinke, PhD, RD, CSP
Travel alerts, seemingly never ending natural and manmade
disasters, cranky patients bugging you…stress accelerat-
ing at logarithmic speed! We certainly live in a very unsettling
and stressful time. A time where achieving inner piece
seems totally out of reach. And yet I have found that you
can attain it by relentlessly practicing the eight principles
that follow.
1. Be honest
BP, politicians, clergy … do I need to
say more? But before you get too smug,
better look at the face in the mirror.
Study after study has shown that most
people lie. We inflate our resumes,
fudge our accomplishments and exag-
gerate even inconsequential events.
And when we lie there is no trust, and
without trust you can’t have solid relationships, without
relationships there is no love, and without love you won’t
have inner peace. Call me old-fashioned; I believe there is
no excuse for lying … none. There is not even a good rea-
son for exaggerating. Because if you do, you will have to
talk from the head, always checking your memory to make
sure you are consistent. And who can keep track of that,
when most of us have trouble remembering where we put
our car keys. Only by getting in the habit of always telling
the truth—especially if it is at your own expense—will you be
able to talk form the heart and that will set you free. This in
turn will enhance your leadership skills because people
follow people they can trust. And it will put you on the fast
track in any endeavor. It will also enrich your personal rela-
tionships and, most importantly, will get you to like and
respect yourself—the foundation for achieving inner peace.
2. Think empowering thoughts
As a man thinkest, so he becomes, says
the Bible. And yet most of the time we
are totally inattentive to our thoughts.
It’s almost like they run amok—totally
out of control—doing their own thing. To
achieve inner peace requires us to first
become aware of our thoughts—instead
of just letting them ruminate at the sub-
conscious level. Second we must ask ourselves: is this a
thought that empowers me and makes me stronger, or does
it make me feel mad, bad or sad? And third we must be-
come aware that at any one nanosecond our minds can
hold only one thought. It can be a positive thought that gives
us inner peace and improves our quality of life, or it can be
a negative thought that does just the opposite. It’s so sim-
ple, yet difficult, to develop this powerful new awareness
and transform it into a habit.
3. Take advantage of the
abundance all around you
When we are struggling and having trou-
ble making ends meet, it is really difficult
to see the abundance. What we see
instead—almost oppressively—is scarcity.
I know firsthand. Having been born right
after World War II in Germany, with my
parents losing all their earthly posses-
sions—yes, everything—we had less than scarcity, we had
desperation. Finding enough food and shelter to keep us
alive is what consumed my parents. Then some 17 years
later—when I immigrated to the United States—scarcity,
although not as extreme, reared its ugly head again. Basi-
8Principles
For Achieving Inner Peace
Caring for Yourself
86 The OR Connection
cally I only spoke a few words of English, had $20 in my pocket
and the proverbial shirt on my back. And I certainly had trouble
finding all “the milk and honey” that supposedly was just wait-
ing for me. However, it was all around me, and over time
I learned to find it by internalizing a powerful concept that I
learned from several different mentors: If you want more of
something, you have to give it first. I know it sounds counterin-
tuitive. (By the way, lots of things are…otherwise men would
ride sidesaddle. If that didn’t at least make you smile, you’re
taking this much too seriously.) Here is how it works: If you want
more love in your life, give more love. If you want to be happier,
make others happy. If you want people to trust you, give
unconditional trust. Of course the only way you can take
advantage of this principle is to internalize the next one.
4. Take really great care of #1 first
Gotcha! Especially if you are a cynic. Those
who are cynics immediately translate this
into selfishness, conceit and greed. Nothing;
however, could be further from the truth.
(Why do you suppose that in an emergency,
you are told to put your oxygen mask on
first, before you help anyone else, even your
own child?)
It’s also important to remember that you can’t give away what
you don’t own. Going back to the previous paragraph. If you
want to love someone you must first love yourself, if you want
to be happier you must choose to be happy. It you want to trust
someone…I’m sure by now you’re catching on.
Achieving inner peace requires you to begin to love who you
are, not who you ought to be…by someone else’s standard,
whether that’s your parents, spouse or friend. The unvarnished
fact is that at this very nanosecond you are who you are. And
no wishing, hoping or praying is going to change that one iota.
Now, who you will become in the future will be determined by
your thoughts (see Principle #2), which in turn will drive the
actions you take.
So begin right now to become your own best friend, because if
it is not you, who is it going to be? In addition to taking really
great care of your thoughts, also take extraordinary care of your
body. And if you want to avoid psychosomatic illnesses—which,
as you probably know, account for the majority of illnesses in
this country—then you must eat right—which means you learn
to stop when it tastes the best. Get adequate rest—seven to
eight hours of sleep is a great start—and do 25-30 minutes of
aerobic exercise three times per week, alternating with strength
training for the other three days. (Go ahead and take Sunday
off.) It also means that you don’t put stuff into your body that
does not belong there—read drugs and nicotine. (Please don’t
yawn. This is important. You only will be given one body—a the
one you’ve got is it. So treat it accordingly.)
5. Become your own creator
Movi e di rectors, such as James
Cameron of Avatar, are geniuses at cre-
ating exciting “realities.” You can be your
own “creator” once you realize that there is
no reality. There is only perception. (No, I
haven’t lost it.) Let me explain with a won-
derful story: A young man was interviewing
for his dream job. He had done his home-
work. He spent hours on the Internet learning all he could about
the hospital of his choice and the people he was going to be
interviewing with. He had read the last three annual reports and
knew the hospital’s mission, vision and core values by heart.
In short he was ready to ace this interview. On the big day, he
entered the impressive lobby of the hospital and had to check
in with the security guard to get his visitor badge. Wanting to
leave no stone unturned he said to the elderly gentleman behind
the desk, “Sir, I’m interviewing for my dream job today. Tell me
about the people at this hospital. What are they like?”
The elderly man replied with a question. “Tell me young man,
what were the people like at the last hospital you worked for?”
“Oh, they were deceitful, unsupportive and mean. There simply
was no vestige of teamwork or joy. In fact that’s why I left.”
“Well,” the security guard answered, “I believe you will find the
same kind of people here.”
8 Principles For Achieving Inner Peace
Continued on page 88
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Medline natural OR towels
88 The OR Connection
Just about an hour later the scene repeated itself all over again.
Except this time it was a young lady who was also interviewing
for the same job. She, too, had done her homework and
wanted to make a great impression. She also asked the secu-
rity guard, “What are the people like around here?”
In turn, he asked, “What were they like where you came from?”
The vivacious young lady answered, “Oh, I just loved the people
at my former hospital. They were kind, supportive and hard-
working. Everyone worked together as a team. We cared so
much for each other that I developed some of the best friend-
ships. It’s really a shame that my husband is relocating to this
area. I just hate to leave all those wonderful people behind.”
“Well,” the wise elderly man answered, “I believe you will find
the same kind of people here.”
6. Let go of the past
It’s amazing how much we mental energy
we spend in a place over which we have
absolutely no control—the past. It was Dr.
Wayne Dyer who likened our past to a bag
of manure that we carry around with us. We
keep putting more and more manure into
the bag. Once in a while we put the bag
down, reach in and smear manure all over
us. And then, we wonder why our life stinks. Part of what we
carry around in our bag is resentment, hate and blame. All of
these emotions will attack our souls and diminish the quality of
our spirit and our physiology.
Instead, go ahead pay tribute to your past. Visit it. And then
toss it in the trash. You can make that happen by taking own-
ership of all that is going on in your life. Your life is not a func-
tion of what other people have done to you; it is today what it
is because of the choices you have made in the past. And if
your feelings of resentment, hate and blame are attributed to
the actions of others, then you have to wait for those people to
change—which may never happen. And don’t even try to
change them! Think about how many of us have difficulty
changing ourselves, let alone others. Instead live by the axiom:
If it is to be it is up to me. Once you’ve done that, you are ready
to take it to the next level by substituting the emotions of love,
empathy and kindness for resentment, hate and blame, which
will put you on the fast track to inner peace.
And while you are at it, force yourself to get off your case, quit
living in the past, and become future-oriented by learning from
every action. If an action gives you the results you desired, keep
doing it. If the action did not accomplish the intended result,
Aligning practice with policy to improve patient care 89
review what happened; make a commitment to do it differently
in the future, then quit doing it and let it go. No wait, I mean
really let it go. Get on with your life by refocusing your thoughts
on the only moment you and I have any control over, the now.
7. Kill your ego
Ego, right along with greed and envy, is one
of the most powerful destroyers of inner
peace. A look at history confirms that these
emotions are responsible for more evil.
Think Napoleon, Stalin and Hitler—and more
corporate catastrophes. Think Toyota’s and
even venerable Johnson & Johnson’s recent
recalls—as well as relationship killers. And
yet we can get rid of our ego with just five
powerful phrases expressed liberally and from the heart:
• You are right about that. Any time you get into a conflict,
use this phrase and you will have no more conflict—
guaranteed!
• I’ve made a mistake. This phrase helps you get off your
high horse gracefully. All human beings make mistakes—
and since you are a…I think you get it. There is only one
omnipotent force in the universe—and it is not you. So
quit defining unrealistic expectations for yourself.
• I changed my mind. You are an evolving human being,
one who is like red wine and gets better all the time. That
means you have to let go of your past beliefs. (Remember
that the only person who can change his/her mind is the
one who has one.)
• I don’t know. Admit it. You don’t know everything. It lets
other people know that you have high levels of self-esteem.
(Only people who are OK inside of their own skin can admit
they don’t know everything.)
• Let’s agree to disagree. The phrase to use if all else fails.
By the way, do try all five of these at home; the positive
results will astound you.
8. Never give up on your dreams
The purpose of life is not to make it safely to
the grave. Pursue your dreams no matter
how late or how “weird.” Let me share an
example. Doris Haddock had a passion. She
felt that Congress needed to get off their
duff and change the campaign finance
laws! Unlike most of us; however, Doris did
not sit around and complain and whine.
Instead, Doris started to walk from
Pasadena, Calif.; walking 10 miles a day, every day. Fourteen
months and 3,200 miles later she arrived in Washington, DC.
Now, here comes the startling part of the story. Doris, better
known as Granny D, had a severe case of arthritis, wore a brace
and turned 90 years “young” while on the trail. And for an added
measure, she was arrested twice demonstrating for her beliefs.
Why? Because she had a dream and a passion. So whatever
you do, don’t ever give up on your dreams, it’ll make you
cranky. Instead, get off your butt and act on your dreams today,
and you, too, will be on the road to achieving the most coveted
of all possessions—inner peace.
© 2010 Wolf J. Rinke
Dr. Wolf J. Rinke, RD, CSP is a keynote
speaker, seminar leader, management con-
sultant, executive coach and editor of the free
electronic newsletter Read and Grow Rich,
available at www.easyCPEcredits.com. In
addition he has authored numerous CDs,
DVDs and books including Make It a Winning
Life: Success Strategies for Life, Love and
Business, Winning Management: 6 Fail-Safe
Strategies for Building High-Performance Organizations and Don’t
Oil the Squeaky Wheel and 19 Other Contrarian Ways to Improve
Your Leadership Effectiveness; available at www.WolfRinke.com.
His company also produces a wide variety of quality pre-approved
continuing professional education (CPE) self-study courses, avail-
able at www.easyCPEcredits.com, including his Beat the Blues:
How to Manage Stress and Balance Your Life, approved for 28
CPEUs, from which this article was extracted. Reach him at
WolfRinke@aol.com.
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92 The OR Connection
Pink Glove Dance: The Sequel
PGD2
From Halifax, Novia Scotia to San Francisco, Califor-
nia, Medline traveled across North America in 2010
showcasing the spirit of breast cancer survivors and
caregivers who performed in the Pink Glove Dance:
The Sequel. To see videos of Pink Glove Dancers in
action visit www.pinkglovedance.com.
Pink Gloves for a Cause
Our goal is to create a Pink Glove Nation – that is, get
as many people as possible talking about breast can-
cer and to raise awareness for early detection. To that
end, partial proceeds from our pink gloves and other
pink ribbon products are donated to the National
Breast Cancer Foundation (NBCF) to help fund mam-
mograms for women who cannot afford them.
Medline presents a donation check to the NBCF
each year during the Breast Cancer Awareness Break-
fast at the Association of periOperative Nurses
(AORN) Congress.
Thank you, Pink Glove Dancers, for welcoming us to
your city!
• New York, NY
• Chicago, IL
• San Francisco, CA
• Indianapolis, IN
• Minneapolis, MN
• Richmond, VA
• Tallahassee, FL
• Newark, NJ
• La Jolla, CA
• Portland, OR
• New Orleans, LA
• Denver, CO
• Halifax, Novia Scotia
• Plano, TX
• Baltimore, MD
Special Feature
Aligning practice with policy to improve patient care 93
Providence St. Vincent
Medical Center. Portland, OR
New York City Survivors at Times Square. New York, NY
The Medical Center of Plaino. Plano, TX
SAVE THE DATE!
Medline’s Breast Cancer
Awareness Breakfast
AORN Congress
March 19 - 24, 2011
Philadelphia, PA
94 The OR Connection
San Francisco Survivors at the Golden Gate Bridge. San Francisco, CA
Providence St. Vincent Medical Center. Portland, OR
University of Minnesota Medical Center, Fairview. Minneapolis, MN
Pink Glove Dance: The Sequel
Aligning practice with policy to improve patient care 95
HCA Johnston – Willis Hospital. Richmond, VA
Tallahassee Memorial Healthcare, Inc. Tallahassee, FL
Indiana University Melvin and Bren Simon Cancer Center. Indianapolis, IN
Pink Glove Dance: The Sequel
96 The OR Connection
Healthy Eating
1 lb. lean ground beef
1 lb. lean ground turkey
4 teaspoons chili powder
1 teaspoon ground cumin
1 large onion, chopped
2 jalapeno peppers, chopped
1 green pepper, chopped
4 teaspoons minced garlic
1 16-ounce can tomato sauce
1 16-ounce can diced tomatoes
1 15-ounce can chili with beans
1 6-ounce can tomato paste
1 15-ounce can kidney beans
1 15-ounce can spicy chili beans
1 bottle beer
1 teaspoon black pepper (or to taste)
Hot sauce to taste
Directions:
Place ground beef and ground turkey in a large skillet, along with
1 teaspoon chili powder and 1 tsp. ground cumin. Cook until
crumbled and brown. Drain and place in crock pot.
Spray empty skillet with cooking spray. Saute onion, garlic,
jalapenos and green pepper until tender. Place in crock pot. Add
tomato sauce, diced tomatoes, beer, chili with beans and
tomato paste. Simmer 20 minutes on high setting.
Add kidney beans, chili beans, 3 teaspoons chili powder, pepper
and hot sauce and simmer at least 30 minutes.
“I find the longer it simmers, the better the
taste, so after the last round of ingredients
are added, I let it simmer on low for 6 to 8
hours,” Jennifer said.
Senior Product Specialist Jennifer
Sutschek, who has worked Medline’s
corporate headquarters in Mundelein, Ill.
since 1998, won second place for this
recipe in Medline’s 2010 Chili Cookoff. She offers product
expertise for Medline customers, sales representatives and cus-
tomer service reps in the areas of diabetic testing, diagnostics,
sharps containers, over-the-counter medications, enterals, oral
care, ReadyBath and wet wipes.
Jennifer originally found her chili recipe in one of her husband’s
fitness magazines, and they have tweaked it a little over the
years to get it just right.
“It’s a healthier chili recipe, made with lean meat,” she said. You’ll
also notice that the onions and peppers are sautéed with cooking
spray rather than oil.
Jennifer has always enjoyed cooking, having learned by watching
her mother from the age of six. Her favorite meals include
seafood with lots of butter and garlic.
In addition to cooking, Jennifer, who lives on Illinois’ Chain
O’Lakes with her husband and two children, enjoys water
sports, such as boating, and in the winter months, she
enjoys snowmobiling and skiing.
Crock Pot Chili
Nutrition
Information
Servings: 6
Calories: 749
Fat: 19.5 g
Sodium: 1427 mg
Fiber: 21.8 g
Aligning practice with policy to improve patient care 97
Forms & Tools
The following pages contain
practical tools for implementing
patient-focused care practices
at your facility.
Surgical Safety
AORN Surgical Time Out . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .99
SCOAP Surgical Safety Checklist - Ambulatory Surgery . . . . . . .100
SCOAP Surgical Safety Checklist . . . . . . . . . . . . . . . . . . . . . . . .101
Wrong-Site Surgery Prevention Tool . . . . . . . . . . . . . . . . . . . . . .103
Patient Education
Medicare & the New Healthcare Law . . . . . . . . . . . . . . . . . . . . .105
Tips for Safer Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .109
Caring for Your Surgical Incision at Home . . . . . . . . . . . . . . . . . .111
The benefits of counting
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SmartSponge is a registered trademark and SmartWand-DTX is a trademark of ClearCount
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single surgery. And because it is the only FDA-approved
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identifies each sponge , so you can use the SmartWand-DTX™
to find missing sponges below, beside or inside a patient
A quick demonstration of how the ClearCount SmartSponge
System can make your time in the O.R. a little less stressful.
Call your Medline representative for details.
TIME OUT
I COMMIT TO SUPPORT
FOR EVERY PATIENT, EVERY TIME
NAME: _______________________________________
DATE: ________________________________________
The use of Time Out is recommended by the Association of periOperative Registered Nurses (AORN),
the Joint Commission Universal Protocol, and the World Health Organization (WHO).
For more information on Time Out and how it can save patient lives, visit aorn.org.
Surgi cal Ti me Out Forms & Tools
Aligning practice with policy to improve patient care 99

Ambulatory Surgery Version 1.1

Š Adapted from the WHO "Safe Surgery Saves Lives" campaign and the WASCA/Proliance Surgeons Surgical Checklist Š
SCOAP is a program of the Foundation for Health Care Quality
www.scoapchecklist.org rev 1/19/2010
Step 1: Prior to Incision
ALL TEAM MEMBERS STOP ACTIVITY AND BEGIN CHECKLIST
‰ Team Members introduce themselves (when personnel have changed)
‰ Introduce patient, verify consent, procedure
‰ Confirm site marked and if there is a single or multiple operative field
Anesthesia Team Reviews
‰ Airway issues or other patient-specific concerns (special meds, health conditions affecting recovery,
etc.)
‰ Patient allergies reviewed ‰ N/A
‰ Antibiotics given within 60 mins before incision ‰ N/A
Surgeon Reviews
‰ Brief description of procedure and anticipated difficulties
‰ Describe implants needed, unusual instruments OR supplies ‰ N/A
‰ Confirm that essential imaging is displayed and correctly oriented ‰ N/A
Nursing Team Reviews
‰ Confirm that supplies and implants are available ‰ N/A
‰ If using an implant, confirm expiration dates ‰ N/A
Step 2: Process Control
IF PROCEDURE IS EXPECTED TO BE LONGER THAN ONE HOUR:
‰ Active warming in place ‰ N/A
‰ Glucose checked for diabetic patients ‰ N/A
‰ VTE prophylaxis ‰ N/A
Step 3: Debriefing—At Completion of Case
‰ (Surgeon and Nursing) Before closure: Confirm that instrument, sponge, and needle counts correct
‰ If counts incorrect, confirm x-ray negative
‰ (Surgeon and Nursing) Confirm specimen, label & instructions to pathologist ‰ N/A
‰ (All) Confirm name of procedure
‰ (All) Equipment issues to be addressed? ‰ No ‰ Yes, and response plan formulated (Who/When)
‰ (All) What could have been better? ‰ Nothing ‰Something, with plan to address (Who/ When)
‰ (Surgeon and Anesthesia) Key concerns for recovery (e.g., plan for pain management,
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Forms & Tools Surgi cal Checkl i st
100 The OR Connection
SCOAP Surgical Checklist
Version 3.7
(July 2010)

Before Skin Incision:
Briefing


Al l Team Members
(Attendi ng Surgeon Leads):
Each person introduces self
by name and role
Surgeon, Anesthesia team and
Nurse confirm patient (at least 2
identifiers), site, procedure
Personnel exchanges: timing,
plan for announcing changes
Description of procedure and
anticipated difficulties
Expected duration of procedure
Expected blood loss & blood availability
Need for instruments/supplies/IV
access beyond those normally
used for the procedure
Questions/issues from any
team member and Invitation to speak up
at any time in the procedure
Nursi ng/ Tech reviews:
Equipment issues (instruments
ready, trained on, requested
implants available, gas tanks full)
Sharps management plan
Other patient concerns
Anesthesi a reviews:
Airway or other concerns
Special meds
(beta blockers, etc.)
Allergies
Conditions affecting recovery


Process Control



All cases:
Surgeon reviews (as applicable):
Essential imaging displayed;
right and left confirmed
Antibiotic prophylaxis given in
last 60 minutes
Active warming in place
Special instruments and/or implants

If case expected to be 1 hour, add:
Surgeon reviews:
Glucose checked for diabetics
Insulin protocol initiated if needed
DVT/PE chemoprophylaxis and/or mechanical
prophylaxis plan in place
If patient on beta blocker, post-op
plan formulated
Re-dosing plan for antibiotics
Specialty-specific checklist


Just Before Closure of Operative Field
No Retained Objects


Attendi ng Surgeon:
Perform methodical visual and physical
sweep of the wound

Nursi ng/ Tech:
All music, conversation, and distractions halted
Perform preliminary count of
needles/sponges/instruments
Show Surgeon and Anesthesia all sponges and
laps in holders (“Show Me Ten”)


After Skin Closure Complete:
No Retained Objects, Debriefing, Care Transition

Al l Team Members (Attendi ng Surgeon Leads):
Confirm final needles/sponges/ instruments count correct
Nursing/Tech show Surgeon and Anesthesia all sponges and laps in
holders (“Show Me Ten”)
Confirm name of procedure
If specimen, confirm label and instructions (e.g., orientation of
specimen, 12 lymph nodes for colon CA)
Equipment issues to be addressed?
Response planned (who/when)
What could have been better?
Improvement planned (who/when)
Surgeon and Anesthesi a:
Key concerns for patient recovery
What is the plan for pain management?
What is the plan for prevention of PONV?
Does patient need special monitoring (time
in RR, ICU, tele?)
If patient has elevated blood glucose, plan for
insulin drip formulated
If patient on beta blocker, post-op continuation
plan formulated






































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































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Aligning practice with policy to improve patient care 101
Surgi cal Checkl i st Forms & Tools
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 incision:
• 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.
ARGLAES
®
IN THE OR
ANTIMICROBIAL SILVER TECHNOLOGY
©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
Arglaes is a registered trademark of Giltech Limited Corporation.
Use silver to fight bacteria and surgical site infections
To schedule a FREE demonstration of Arglaes
in your OR, contact your Medline representative,
call 1-800-MEDLINE or visit www.medline.com.
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Wrong-Si te Surgery Forms & Tools
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104 The OR Connection
Forms & Tools Wrong-Si te Surgery

MAY 2010
C E N T E R S F O R M E D I C A R E & M E D I C A I D S E R V I C E S
Medicare and the New Health Care Law —
What it Means for You
A Message from Kathleen Sebelius,
Secretary of Health & Human Services
e Aordable Care Act passed by Congress and signed by President
Obama this year will provide you and your family greater savings and
increased quality health care. It will also ensure accountability
throughout the health care system so that you, your family, and
your doctor—not insurance companies—have greater control
over your care.
ese are needed improvements that will keep Medicare
strong and solvent. Your guaranteed Medicare benets won’t
change—whether you get them through Original Medicare or
a Medicare Advantage plan. Instead, you will see new benets
and cost savings, and an increased focus on quality to ensure
that you get the care you need.
is brochure provides you with accurate information about
the new services and benets to help you and your family now
and in the future.
e Centers for Medicare & Medicaid Services (the federal
agency that runs the Medicare, Medicaid, and Children’s Health
Insurance Program) will continue to provide you with up-to-date
information about these new benets and will ensure that your personal
information is safe.
Remember—rely on your trusted sources of information when it comes
to accurate information about Medicare, and don’t hesitate to call
1-800-MEDICARE or go on-line at Medicare.gov if you have questions
or concerns. Don’t give your personal Medicare information to anyone
who isn’t a trusted source.
Aligning practice with policy to improve patient care 105
Pati ent Handout - Medi care Forms & Tools
2
HEALTH CARE LAW
What Stays the Same
The guaranteed Medicare benefits you currently receive will remain the same. During open enrollment
this fall, you will continue to have a choice between Original Medicare and a Medicare Advantage plan.
Medicare will continue to cover your health costs the way it always has, and there are no changes in
eligibility. But, there are some important benefits that you and your family can take advantage of starting
this year. Look for more details in your Medicare and You Handbook coming this fall.
Improvements in Medicare You Will See Right Away
More Affordable Prescription Drugs
• If you enter the Part D “donut hole” this year, you will receive a one-time, $250 rebate check if you
are not already receiving Medicare Extra Help. These checks will begin mailing in mid-June, and will
continue monthly throughout the year as beneficiaries enter the
coverage gap.
• Next year, if you reach the coverage gap, you will receive a 50%
discount when buying Part D-covered brand-name prescription drugs.
• Over the next ten years, you will receive additional savings until the
coverage gap is closed in 2020.
Important New Benefits to Help you Stay Healthy
• Next year you can get free preventive care services like colorectal
cancer screening and mammograms. You can also get a free annual
physical to develop and update your personal prevention plan based
on current health needs.
Improvements to Medicare Advantage
• Today, Medicare pays Medicare Advantage insurance companies over
$1,000 more per person on average than Original Medicare. These
additional payments are paid for in part by increased premiums by all
Medicare beneficiaries—including the 77% of seniors not enrolled in a
Medicare Advantage plan.
• The new law levels the playing field by gradually eliminating Medicare
Advantage overpayments to insurance companies.
• If you are in a Medicare Advantage plan, you will still receive guaranteed Medicare benefits.
• Beginning in 2014, the new law protects Medicare Advantage members by taking strong steps to ensure
that at least 85% of every dollar these plans receive is spent on health care, rather than administrative costs
and insurance company profits.
106 The OR Connection
Forms & Tools Pati ent Handout - Medi care
Aligning practice with policy to improve patient care 106
HEALTH CARE LAW
Improvements in Medicare You Will See Soon
Better Access to Care
• Your choice of doctor will be preserved.
• The law increases the number of primary care doctors, nurses, and physician assistants to provide better
access to care through expanded training opportunities, student loan forgiveness, and bonus payments.
• Support for community health centers will increase, allowing them to serve some 20 million new patients.
Better Chronic Care
• Community health teams will provide patient-centered care so you won’t have to see multiple
doctors who don’t work together.
• If you’re hospitalized, the new law also helps you return home successfully—and avoid going back—by
helping to coordinate your care and connecting you to services and supports in your community.
3
Improvements Beyond Medicare That You and Your Family Can Count On
Improves Long-Term Care Choices
• New tools and resources in the Elder Justice Act, which was included in
the new law, will help prevent and combat elder abuse and neglect, and
improve nursing home quality.
• The new law creates a new voluntary insurance program called CLASS
to help pay for long-term care and support at home.
• Individuals on Medicaid will receive improved home- and community-
based care options, and spouses of people receiving home- and community-
based services through Medicaid will no longer be forced into poverty.
Helps Early Retirees
• To help offset the cost of employer-based retiree health plans, the new law creates a program to preserve
those plans and help people who retire before age 65 get the affordable care they need.
Helps People with Pre-existing Conditions
• The new law provides affordable health insurance through a transitional high-risk pool program for
people without insurance due to a pre-existing condition.
• Insurance companies will be prohibited from denying coverage due to a pre-existing condition for
children starting in September, and for adults in 2014.
• Insurance companies will be banned from establishing lifetime limits on your coverage, and use of
annual limits will be limited starting in September.
Expands Health Coverage for Young People
• Young people up to age 26 can remain on their parents’ health insurance policy starting in September.
Aligning practice with policy to improve patient care 107
Pati ent Handout - Medi care Forms & Tools
HEALTH CARE LAW
For More Information
4
CMS Product No. 11467

The New Law Preserves and Strengthens Medicare
New Tools to Fight Fraud and Protect Your
Medicare Benefits
• The new law contains important new tools to help
crack down on criminals seeking to scam seniors
and steal taxpayer dollars.
• It reduces payment errors, waste, fraud, and
abuse to make Medicare more efficient and return
savings to the Trust Fund to strengthen Medicare
for years to come.
• You are an important resource in the fight against
fraud. Be vigilant and rely only on your trusted
sources of information about your Medicare
benefits.
• Call 1-800-MEDICARE if you have any questions
or want to report something that seems like fraud.
Keeps Medicare Strong and Solvent
• Over the next 20 years, Medicare spending will
continue to grow, but at a slightly slower rate as
a result of reductions in waste, fraud, and abuse.
This will extend the life of the Medicare Trust
Fund by 12 years and provide cost savings to
those on Medicare.
• In 2018, seniors can expect to save on average
almost $200 per year in premiums and over $200
per year in co-insurance compared to what they
would have paid without the new law.
• Upper-income beneficiaries ($85,000 of annual
income for individuals or $170,000 for married
couples filing jointly) will pay higher premiums.
This will impact about 2% of Medicare
beneficiaries.
For more information about the new health care law now, visit
www.medicare.gov. If you have any questions, call 1-800-MEDICARE
(1-800-633-4227) or your State Health Insurance Assistance Program (SHIP).
Visit www.medicare.gov or call 1-800-MEDICARE to get their telephone
number. TTY users should call 1-877-486-2048. If you need help in a language other than English or
Spanish, say “Agent” at any time to talk to a customer service representative.
Visit the Eldercare Locator at www.eldercare.gov to find out how to access home- and community-
based services and benefits counseling, transportation, meals, home care, and caregiver support services.
You can also call 1-800-677-1116. The Eldercare Locator, a public service of the U.S. Administration on
Aging, is your first step for finding local agencies in every U.S. community.
108 The OR Connection
Forms & Tools Pati ent Handout - Medi care
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QSFWFOUFE8IBUEPFTUIJTNFBOUPZPVBTBQBUJFOU*GZPVSEPDUPSTBOEOVSTFTGPMMPXTPNFTJNQMFTUFQT
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One way you can help lower your risk for problems from
your surgery is to talk with a member of your surgical
care team before surgery about the type of care you
should receive. Your care team includes your surgeon,
your anesthesiologist and your nurses. Ask your doctor
or nurse who you should discuss this tip sheet with and
when. ɨis tip sheet will help you know what to ask.
5PBWPJEJOGFDUJPOo
If I need antibiotics before surgery, when will I
receive the antibiotic and for how long?
Antibiotics should given within 60 minutes before
surgery and should be stopped within 24 hours in most
cases. Given properly, antibiotics can greatly lower your
chances of getting an infection after surgery.
If hair needs to be removed from the part of my body
that is having surgery, what will you use?
Your doctor or nurse should use electronic clippers to
remove hair if needed at the site of your surgery. Using a
razor to remove hair before surgery can cause infections
because of the risk of leaving small cuts on the skin.
5PBWPJECMPPEDMPUTo
What will you do to prevent blood clots?
Blood clots can lead to heart attacks and strokes. When
you have surgery, you are at risk of getting blood clots
because you do not move while under anesthesia. ɨe
more complicated your surgery, the higher your risk.
Your doctor will know your risk for blood clots and steps
that will help prevent them, such as giving you the right
medicine before surgery.
5PBWPJEIFBSUBUUBDLTo
If I take medicine for heart disease, should I keep
taking it?
Taking certain medicines together can cause problems.
Tell your doctor about all the medicines you are taking,
including over-the-counter things like aspirin and
herbal remedies. Your doctor or nurse will tell you
which medicines you should continue to take and which
medicines you should stop taking before surgery.
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Aligning practice with policy to improve patient care 109
Pati ent Handout Forms & Tools
v Tell your doctor about other medical problems
you may have, such as allergies or diabetes.
ɨese problems could affect your surgery
and treatment.
v Patients who smoke get more infections. Talk
to your doctor about how you can quit.
v If you do not see them do so, ask your care
team members to wash their hands before
examining you.
v Speak up if you have questions or concerns. If
you don't understand, ask again. It's your body
and you have a right to know.
v For information on preparing for surgery, please
visit http://www.ahrq.gov/consumcr/surgcry/
surgcry.htm, which oĊers additional questions
to ask your physician and surgeon about your
surgery.
v For information on quality of hospital care,
visit Hospital Compare at http://www.
hospitalcomparc.hhs.gov. It includes information
on how often hospitals provide some of the
recommended care to get the best results for
most patients.
v For information on the Joint Commission's
Speak Up` program, which includes safety tips
for surgical patients and infection prevention,
visit www.jointcommission.org/PaticntSafcty/
SpcakUp.
v For patient information concerning
anesthesia, please visit http://www.asahq.org/
paticntEducation.htm.
v For more information concerning surgery, visit
the American College of Surgeons at http://
www.facs.org/public_info/ppscrv.html.
v If you have additional questions, please contact
your doctor.
About SCIP
ɨe Surgical Care Improvement Project (SCIP)
is a large national partnership dedicated to
reducing the number of preventable surgical
complications. SCIP includes a number of
steps that surgeons, anesthesiologists, nurses
and patients can take to lower the number of
surgical problems.
Projcct Coordinators:
Oklahoma Foundation for Mcdical Quality
14000 Quail Springs Parkway - Suitc 400
Oklahoma City, Oklahoma 73134
405.840.2891 - SCIPpartncrship@okqio.sdps.org
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110 The OR Connection
Forms & Tools Pati ent Handout
OR Connection
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Aligning practice with policy to improve patient care
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To subscribe, simply go to www.medline.com/orconnection.
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Content Key
We've coded the articles and information in this magazine to indicate which patient care
initiatives they pertain to. Throughout the publication, when you see these icons you'll
know immediately that the subject matter on that page relates to one or more of the
following national initiatives:
• IHI's Improvement Map
• Joint Commission 2009 National Patient Safety Goals
• Surgical Care Improvement Project (SCIP)
We've tried to include content that clarifies the initiatives or gives you ideas and tools
for implementing their recommendations. For a summary of each of the initiatives,
see pages 10 and 11.
Aligning practice with policy to improve patient care 111
Bathing and Showering
Most incisions should be kept dry for several days after surgery, except for incisions closed
with surgical glue. It is usually safe to allow glued incisions to get wet while showering or
bathing. It is important, however, to dry the area around the incision carefully after washing.
Physical Activity and Exercise
Avoid any activity that pulls on the edges of the incision or puts pressure on it. Walking and
other light activities are encouraged to restore normal energy levels and digestive functions.
Do not, however, participate in sports, engage in sexual activity or lift heavy objects until after
your postoperative checkup.
Aspirin
Avoid aspirin or over-the-counter medications containing aspirin for a week to 10 days after
surgery. Aspirin interferes with blood clotting and makes it easier for bruises to form near
the incision.
Sun Exposure
As an incision heals, the new skin that forms over the cut is very sensitive to sunlight and
will burn more easily than normal skin and lead to worse scarring. Keep the incision area
covered from direct sun exposure for three to nine months in order to prevent burning and
severe scarring.
General Hygiene
Infection is the most common complication of surgical procedures. It is important, therefore,
to minimize the risk of an infection when caring for your incision at home.
Observe the following precautions:
• Wash your hands carefully after using the toilet and after touching or handling trash;
pets and pet
equipment; dirty laundry and anything else that is dirty or has been used outdoors
• Ask family members, close friends, and others to wash their hands before contact
with you
• Avoid contact with family members and others who are sick or recovering from a
contagious illness
• Stop smoking (smoking slows down the healing process)
Adapted from www.surgeryencyclopedia.com/Fi-La/Incision-Care.html
P a tie nt Ha ndout Forms & Tools
Caring for Your Surgical Incision at Home
The following are general guidelines. Consult your surgical team for more specific instructions.
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Industries, Inc.
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