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The

Aligning practice with policy to improve patient care

Volume 6, Issue 1
FREE CE!

Special
AORN
Issue!
Breast Cancer
Awareness
Section Page 84

Turn up the heat on

HYPOTHERMIA Man on a
Mission: Hand
Hygiene Expert
Nurse Leaders Professor
Rate Patient
Experience #1 Didier Pittet
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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 8 and 9.
PATIENT SAFETY
Editor
6 Mission: Improving Hand Hygiene
Sue MacInnes, RD, LD
8 Three Important Initiatives for Improving Patient Care
Clinical Editor
Alecia Cooper, BS, MBA, RN, CNOR
10 Patient Safety News
Senior Writer 11 Provider Preventable Conditions
Carla Esser Lake 14 Turn Up the Heat: Avoiding Surgical Complications with
Creative Director Adequate Patient Warming
Mike Gotti
30 ClearCount Clearly Makes a Difference in Patient Safety at
Clinical Team Hunt Regional Hospital Page 14
Jayne Barkman, BSN, RN, CNOR
34 VAP: What is the Perioperative Nurse’s Role in Prevention?
Lorri Downs, RN, BSN, MS, CIC
Margaret Falconio-West, BSN, RN, APN/CNS,
47 The Quest to Improve Staff and Patient Safety: How One
CWOCN, DAPWCA Health District Converted to Latex-Free Surgical Gloves
Rhonda J. Frick, RN, CNOR 61 Unity Hospital: Utilizing Medline’s ERASE CAUTI Program
Anita Gill, RN
Kimberly Haines, RN, Certified OR Nurse
OR ISSUES
Rebecca McPherson RN, MSN
Carla Nitz, BSN, RN
40 The Ins and Outs of Hernias and Ways to Repair Them
Claudia Sanders, RN, CFA 79 Upcoming Green Events & Green Facts Page 68

Megan Shramm, RN, CNOR, RNFA 84 Study of Breast Biopsies Finds Surgery Used Too Extensively
Angel Trichak, RN, BSN, CNOR
101 Less Invasive Surgery Just as Effective for Some
Perioperative Advisory Board Breast Cancer Patients
Larry Creech, RN, MBA, CDT
Carilion Clinic, Virginia
SPECIAL FEATURES
Sharon Danielewicz, MSN, RN, RNFA
Cedar Park Regional Medical Center, Texas 5 International Hand Hygiene Expert Urges U.S. to Use
Tracy Diffenderfer, MSN, RN “Five Moments” to Reduce Infection
Page 77
Vanderbilt University Medical Center, Tennessee 56 Nurse Leaders Survey Results: Patient Experience Is #1
Barb Fahey RN, CNOR
68 12 Ways to Reduce Hospital Readmissions
Cleveland Clinic, Ohio
77 Medline Joins Greening the Operating Room Initiative
Susan Garrett, RN
Hughston Hospital Inc., Georgia 78 Medline Launches Sustainability Program
Zaida I. Jacoby, MA, MEd, RN 88 Celebrating Six Years of Spreading Breast Cancer Awareness
NYU Medical Center, New York
92 Straight from the Heart: Quotes About the Pink Glove Dance
Jackie Kraft, RN, CNOR
95 Beyond a Reasonable Doubt: Open Communication Helps
Huntsville Hospital, Alabama
Jill Eikenberry Raise the Bar for Breast Cancer Awareness Page 92
Tom McLaren
Florida Hospital, Florida
Susan Phillips, RN, MSH, CNOR CARING FOR YOURSELF
University of North Carolina Hospitals 102 How to Energize Your Team
Donna A. Pritchard, BSN, MA, RN, CNOR, NE-BC 110 Recipe: Aunt Judy’s Tortilla Roll-Ups
Kingsbrook Jewish Medical Center, New York
Debbie Reeves, MS, RN, CNOR
FORMS & TOOLS
Hutcheson Medical Center, Georgia
Diane M. Strout, BSN, RN, CNOR
113 Highlights of AORN’s Revised Recommended Practices
for Surgical Attire Page 102
St. Joseph Medical Center, Washington
120 CDC Hand Hygiene Poster
121 How Well Do You Know Pressure Points?

About Medline
Medline, headquartered in Mundelein, IL, manufactures and distributes more than 100,000 products to hospitals, extended care facilities, surgery centers, home care dealers
and agencies and other markets. Medline has more than 800 dedicated sales representatives nationwide to support its broad product line and cost management services.

©2011 Medline Industries, Inc. The OR Connection is published by Medline Industries, Inc. One Medline Place, Mundelein, IL 60060. 1-800-MEDLINE.
The OR Connection
Letter from the Editor

Last night I had the opportunity to have dinner with Professor HCAHPS, the patient experience survey that is on the minds
Didier Pittet (one of the foremost authorities on hand hygiene). of many nurse executives. I think it is so important to be
He spoke with great energy and passion about a number of aware of the concerns and priorities of hospital administration,
pertinent topics, including The World Health Organization’s so I’ve included on page 56 very recent survey results on
Hand Hygiene Campaign, the “Five Moments of Hand what’s most important to nursing leaders today.
Hygiene,” and the hand hygiene compliance rates of most
facilities in the United States as compared to other countries. Prior to Dr. Haywood’s visit, I had met with Kaiser Perma-
nente on the West Coast to talk about healthcare innova-
What a fascinating man he is. One of his achievements is tions that can be explored and tested. I don’t mean
being appointed Commander of the British Empire (or CBE, innovations that are made up in a lab or in some corporate
an international honor that includes knighthood). This honor office, but real-life examples of how healthcare professionals,
was awarded by Queen Elizabeth II in 2007 for his services thought leaders and industry can work together to make
in the prevention of healthcare-associated infection in the your jobs simpler and to make the chaos of everyday
United Kingdom. He told the story, with great charm and practice easier to navigate. We’ve all been accustomed to
humility, of what is was like to be “knighted” by the Queen of how things have always been done. But this is a new era of
England for his contributions to safety and health care. He change designed to support the healthcare worker while
said that while it was a great honor, it was also quite stressful, improving care. And you are a very important part of this
as he was allowed to bring only two people with him to the model.
actual ceremony … he chose his two daughters. You can
probably imagine their pride as they got to watch their dad This edition of The OR Connection is being launched at the
become only the second person from Switzerland ever to AORN 58th Congress, March 18-24, 2011, in Philadelphia,
be so honored. Pennsylvania – my hometown. For those attending the Con-
gress, Medline has included a list of items on page 66 that
I was enthralled, sitting across the table from this icon of we will be featuring at our Booth #3408. If you don’t get a
healthcare safety and listening to his stories of knighthood, chance to attend, but you would still like information on any
his early training and his current projects, which include of our programs or products, please give me a call at
recording the English narration for the “Hand Hygiene 847-643-4093. Although we would love to tell you more
Dance Video,” originally performed and filmed at the about our products and programs, we are just as interested
University of Geneva. (Our cover photo for this edition is from in your ideas for innovation, so my line is open to you. This
the recording session.) Watch for an online link to the final is our biggest issue yet. There are so many things going on
production to be printed in an upcoming issue of The OR in our industry, I’m sure within these pages there is something
Connection! that will be of interest you.

Dr. Pittet’s visit was just one of the amazing experiences I’ve Sincerely,
had in the last few weeks. Barely a week ago I met with Dr.
Haywood, Senior Vice President and Chief Medical Officer
of VHA, and his team to discuss research pertaining to
Sue MacInnes

VISIT MEDLINE BOOTH #3408 AT AORN CONGRESS


4 The OR Connection
Special Feature

Coming to America:
International Hand Hygiene Expert Urges U.S.
to Use ‘Five Moments’ to Reduce Infection
International hand hygiene expert Professor Didier Pittet, “Five Moments for Hand Hygiene” defines the key times for
MD, MS traveled from Geneva, Switzerland to Chicago this hand hygiene, presents a unified vision on proper hand hygiene
spring to partner with U.S. healthcare workers to improve technique and promotes a strong sense of ownership.
hand hygiene compliance.
While in Chicago, Dr. Pittet, along with Mark Chassin, presi-
Dr. Pittet emphasized that despite hand hygiene’s proven ben- dent of The Joint Commission, also addressed more than 200
efits in reducing infection, “It’s very frightening first to realize senior clinicians and infection preventionists at Loyola Univer-
that the compliance is so low,” he said. “On average it’s around sity Medical Center in Chicago. Their unified message was
40%, at the best, and it’s not rare that when you come in a clear – a highly compliant and successful hand hygiene
unit or a ward the average compliance will be around 20%.” program starts at the top of an organization with its leader-
ship. The event, called “Safe Care Town Hall Forum” was
Dr. Pittet began his visit to Chicago at a recording studio where co-hosted by Medline and Loyola, and is the first in a series of
he recorded English narration for a short film that promotes the patient safety forums to be held around the country.
World Health Organization’s (WHO) “Five Moments for Hand
Hygiene.” The film is called “O Les Mains!” – translated in Eng- Dr. Pittet also spoke before medical and nursing students at
lish it means “Raise your Hands.” Dr. Pittet currently uses Loyola’s Stritch School of Medicine. Dr. Pittet believes teaching
the film, which features professional dancers, to encourage healthcare professionals about proper hand hygiene techniques
and teach proper hand hygiene techniques at his hospital in early in their careers will instill good habits that will stay with
Geneva. With Medline’s help, Dr. Pittet hopes to get the video them long term.
to go “viral” to inspire healthcare workers in the U.S. and
around the world to learn proper hand hygiene.

Aligning practice with policy to improve patient care 5


Mission:
Improving hand hygiene
Joint Commission Center for Transforming Healthcare
Targeted Solutions Tool for Hand Hygiene

Joint Commission-accredited hospitals now have access to Commission. “Consistent excellence in hand hygiene is vital
an interactive tool that simplifies processes for solving to our larger aim of eliminating preventable health care-asso-
healthcare quality and safety. The Targeted Solutions ciated infections. The Targeted Solutions Tool provides hos-
Tool™ (TST) encapsulates the work of the Joint Com- pitals with powerful new knowledge and methods they
mission Center for Transforming Healthcare and pro- can use right away to make substantial advances toward
vides step-by-step processes to measure this goal.”
performance, identify barriers to excellent perform-
e

Ide
anc

ance, and implement proven solutions. Data validates effectiveness of hand hygiene tool
nti
orm

At the start of the project in April 2009, the par-


fy
erf

Bar

The first set of targeted solutions focuses on ticipating hospitals were surprised to learn that
e p

rie

improving hand hygiene. It was created by their rate of hand hygiene compliance aver-
sur

rs
Mea

eight of the country’s leading hospitals and aged 48 percent. By June 2010 they had
healthcare systems working with the reached an average rate of 82 percent that
Center. The TST provides accredited had been sustained for eight months.
hospitals the foundation and Nineteen small, medium and large hos-
Implement Proven Solutions
framework of an improvement pitals across the country also collabo-
method that, if implemented well, will improve hand hygiene rated with the Center to test the work of the original eight
compliance and contribute substantially to reducing health hospitals and provide guidance on the development of the
care-associated infections. solutions that are now available through the TST. These
hospitals are experiencing similar gains as the original eight.
The complimentary data-driven tool provides validated and
customized solutions to address particular barriers to excel- For a free electronic copy of the Targeted Solutions Tool for
lent performance. Self-paced and confidential, the TST offers hand hygiene, “Hand Hygiene Factors and Solutions,” go to
instantaneous data analysis. http://www.centerfortransforminghealthcare.org/tst.aspx.

“I encourage hospital leaders to use these tools to identify Medline Industries, Inc. is a proud sponsor of the Center for
very specific ways to improve their hand hygiene programs,” Transforming Healthcare Endowment Fund.
said Mark R. Chassin, MD, MPP, MPH, president of the Joint

6 The OR Connection
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evaporates quickly for faster OR preparation. surgical scrub with 80% (w/w) ethyl alcohol —
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— never sticky or tacky — minimizing friction rub available in the US. Its long-lasting, persistent
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©2011 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc. Sterillium is a registered trademark of Bode Chemie GmbH
Three Important National Initiatives
for Improving Patient Care
Achieving better outcomes starts with an understanding of current
patient-care initiatives. Here’s what you need to know about national
projects and policies that are driving changes in care.

1 IHI Improvement Map


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

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

The IHI Improvement Map covers the entire landscape of outstanding hospital care to help hospitals make sense of countless requirements
and focus on high-leverage changes to transform care. There are 70 processes grouped into three domains: leadership and management,
patient care and processes to support care.

2 Joint Commission 2011 National Patient Safety Goals


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

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

Over the next year, the current National Patient Safety Goals (NPSGs) will undergo an extensive review process. As a result,
no new NPSGs will be developed for 2011; however, revisions to the NPSGs will be effective in 2011.

3 Surgical Care Improvement Project (SCIP)


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

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

8 The OR Connection
Patient Safety

IHI Improvement Map: 73 Processes to Transform Hospital Care


The IHI Improvement Map is an online tool that distills the best knowledge available on the key process
improvements that lead to exceptional patient care.

3 New Key Processes as of June 2010 Top 5 Key Processes Shared by Improvement Map Users
1. Anticoagulation Management 1. Central Line Bundle
2. Essential Care for Frail Older Patients 2. CA-UTI
3. Glycemic Control in Non-Critically Ill Patients 3. Anti-Biotic Stewardship
4. Falls Prevention
5. Heart Failure Core Processes

To learn more about the IHI Improvement Map and the 73 processes to transform hospital care, go to www.ihi.org/imap/tool

Joint Commission 2011 National Patient Safety Goals


Effective January 1, 2011:
• Improve the accuracy of patient identification. • The organization identifies safety risks inherent in
• Improve the effectiveness of communication its patient population.
among caregivers. • Universal Protocol for Preventing Wrong Site,
• Improve the safety of using medications. Wrong Procedure, and Wrong Person Surgery.™
• Reduce the risk of healthcare-associated
infections.
• Accurately and completely reconcile medications
across the continuum of care.

To learn more about National Patient Safety Goals, go to www.jointcommission.org.

Surgical Care Improvement Project (SCIP): Target Areas


1. Surgical infections
By the numbers:
• Antibiotics, blood sugar control, hair removal, perioperative • 3,740 hospitals are submitting
temperature management data on SCIP measure #9, representing
• Remove urinary catheter on Post Operative Day (POD) 1 or 2 75 percent of all U.S. hospitals
2. Perioperative cardiac events • Currently, SCIP has more than 36
• Use of perioperative beta-blockers association and business partners
3. Venous thromboembolism
• Use of appropriate prophylaxis

Visit www.qualitynet.org

Aligning practice with policy to improve patient care 9


PATIENT SAFETY NEWS

134,000 Medicare patients per month hurt at hospitals1


The Department of Health and Human Services recently
released its findings that about 134,000 Medicare patients
experienced adverse events in hospitals during a single
month in 2008. About 44 percent of the events were con-
sidered to be preventable. The cost to treat the affected
patients was estimated at $324 million.

The Centers for Medicare and Medicaid Services (CMS)


responded that it will aggressively pursue efforts to expand
adverse event reporting and the types of events that are
considered reportable. Only six states currently require
public reporting of medical errors.

New suggestions for blood glucose National Patient Safety Foundation


management during outpatient surgery launches new membership organization
The Society for Ambulatory Anesthesia (SAMBA) issued a for healthcare professionals
consensus statement at the end of 2010 outlining glucose
The American Society of Professionals in Patient Safety
management suggestions for anesthesia providers. The
(ASPPS) is a new membership organization launched by the
significant practice changes include:2
National Patient Safety Foundation (NPSF). It is seeking mem-
• Preoperative advice to the patient regarding the use
bers from across the spectrum of healthcare disciplines to
of their anti-diabetic drug on the day of surgery
help extend the group’s agenda of accelerating the delivery of
• The use of rapid-acting insulin rather than regular
safe patient care and establishing consistency in safety prac-
insulin during surgery
tices and tools. The organization plans to implement a certi-
• Use of the 1500/1800 formula for determining the
fication program to validate competencies and practices that
dose of insulin
are proven to reduce medical errors. Information on mem-
• Avoiding the temptation to normalize blood glucose
bership and the May 2011 Patient Safety Congress can be
levels in patients with inadequately controlled levels
found at www.npsf.org/hp/ASPPS.php.

References
1. Hospitals hurt 134,000 Medicare patients a month. Outpatient Surgery
Magazine. November 30, 2010.
2. SAMBA issues suggestions for blood glucose management in diabetic
patients. Outpatient Surgery Magazine. December 2010.

10 The OR Connection
Patient Safety

Provider Since the summer of 2008, the Centers for Medicare and
Medicaid Services (CMS) has encouraged states to model their
Medicaid payment rules after the federal Medicare program.
Preventable Now, the Affordable Care Act (ACA) has mandated that the
Medicare rules for withholding payment for “never events” now
Conditions: be extended to state-run Medicaid programs. The Affordable
Care Act (ACA) requires the new rules extension be effective

Expanding July 1, 2011.

The eleven CMS-recognized preventable conditions are:


Never Event/No-Pay • Retained items after surgery
• Air embolism

Regulations • ABO blood incompatibility


• Catheter-associated urinary tract infection (CAUTI)
• Pressure ulcers
• Central line-associated bloodstream infection (CLABSI)
• Surgical site infection (SSI)/mediastinitis
• Falls and certain other traumas
• SSI after certain elective procedures
• Poor glycemic control manifestations
• Deep vein thrombosis (DVT)/pulmonary embolism (PE)

This list is exhaustive for Medicare, but for Medicaid CMS has
intentionally granted states the flexibility for including other con-
ditions beyond the eleven that CMS has already identified.

The different nature of Medicaid and the services it pays for has
created a new set of terminology to learn. HAC, hospital-
acquired condition is now passé, as is HCAC, the more generic
healthcare-acquired condition. The preferred new term is
provider preventable condition, or PPC. The definition of a PPC
is “a condition that could have reasonably been prevented

Aligning practice with policy to improve patient care 11


CMS “no pay for never events” policy used to
be Medicare only. In July it’s set to be part of
all 50 state Medicaid plans.

What does all this mean?


Like any significant policy change such as this one, there will be
both expected results and unexpected consequences. The
original Medicare claims denials for HACs are running at
approximately $20 million per year. Over the next five years, the
Medicaid claims denials for PPCs are expected to total $35 mil-
lion, or an average of an additional $7 million per year. The Med-
icaid savings are divided approximately 60/40 between Federal
and state savings.

There will be costs associated with this new rule, too. CMS
estimates that both states’ and providers’ regulatory and
reporting compliance will be relatively small. Providers, however,
will incur additional costs to reduce PPCs. These costs may be
from hiring more nurses and infection control professionals as
well as training staff on best practices for PPC prevention.
Equipping staff with evidence-based products and programs
that help deliver better outcomes may be seen as an additional,
through the application of evidence-based guidelines.” PPCs but very necessary cost as well. Most hospitals have taken
would encompass the same healthcare-acquired conditions as these PPC prevention steps to comply with Medicare rules.
defined for Medicare purposes, plus other PPCs defined by However, most non-hospital health care settings will now find it
states and approved by CMS. necessary to make expenditures to address the PPCs that
occur in their environment.
Perhaps more significant than the “what” of a PPC is the
“where” it may occur. CMS proposes using PPC as an umbrella While the explicit purpose of the regulation is cost containment
term for both hospital and non-hospital conditions identified by through administrative action, the implicit purpose is the public
a state for nonpayment. PPCs would encompass hospital- benefit of an overall reduction in PPCs and a corresponding
acquired conditions, as defined for Medicare purposes, and increase in healthy years of life. CMS is quick to point out, how-
other PPCs applicable to service settings beyond the inpatient ever, that the regulation itself is not responsible for the better
hospital setting. CMS notes that preventable conditions can health of the population, but rather the responses made to it by
occur in an outpatient hospital, nursing facility and ambulatory hospitals and other care providers.
care settings. The denial of claims for PPCs happening in any
of these environments is a significant expansion of the existing For more information, visit: https://www.federalregister.gov/
regulations. articles/2011/02/17/2011-3548/medicaid-program-payment-
adjustment-for-provider-preventable-conditions-including-health

12 The OR Connection
SAFETY
DESERVES
ATTENTION

MEDLINE GOLD STANDARD SAFETY COMPONENTS


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.
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, For a FREE sample bundle, email
minimizing the risk of exposure. goldstandard@medline.com.

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.

©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.
CE Article

Avoiding Surgical Complications


with Adequate Patient Warming
14 The OR Connection
SCIP-Inf-101
“Measure: Surgical patients should be actively warmed during surgery or have at least
one recorded body temperature equal to or greater than 96.8 degrees Fahrenheit
within 30 minutes prior to the end of anesthesia to 15 minutes after anesthesia ends.
(Patients with intentional hypothermia are excluded from this measure.)”

In 2003, the Joint Commission and the Centers for Medicare and
Medicaid Services (CMS) teamed up to align their common meas-
ures. In the process, they decided to add a set of measures for Sur-
gical Infection Prevention (SIP), which was quickly added as a core
measure set.2 In July, 2006, SIP was renamed the Surgical Care
Improvement Project (SCIP).

Members of the SCIP Steering Committee include the Association


of periOperative Nurses (AORN), the Joint Commission, the Centers
for Medicare and Medicaid Services (CMS), Agency for Healthcare
Research and Quality (AHRQ), American College of Surgeons
(ACS), American Hospital Association (AHA), American Society of
Anesthesiologists (ASA), Centers for Disease Control and Prevention
(CDC), Department of Veterans Affairs, and the Institute for Health-
care Improvement (IHI).3 This national partnership of organizations
works together to improve the quality of surgical care.

To date, SCIP has introduced 10 measures, plus three others


specifically addressing cardiac patients and venous thromboem-
bolism. All measures are to be followed in order to reduce surgical-
site infections and other complications of surgery. (For the complete
list of all SCIP Measures, turn to the back of this article.)

SCIP-Infection (Inf.)-10, also known as SCIP Measure 10 – “Surgery


Patients with Perioperative Temperature Management,” went into
effect October 1, 2009.4 When the measure was first adopted, the
best available temperature management evidence was on patients
having colectomies while under general anesthesia. Consequently,
the measure initially focused on this population.

Currently, SCIP-Inf.10 applies to patients of any age undergoing


surgical or therapeutic procedures while under general or neurax-
ial anesthesia for one hour or more. It does not include patients
undergoing cardiopulmonary bypass.5

Continued on Page 17
Innovation in Patient Warming

Underbody Warming for All


Patients and Procedures
For protection from unintentional hypothermia in patients
undergoing surgery, PerfecTemp is an excellent alternative
to forced-air warming systems.

While other systems use disposable blankets to force


warm air on top of patients, PerfecTemp’s unique
surgical table pads offer.
• Efficient underbody warming as effective as
forced-air systems for preventing unintentional
hypothermia.1
• More accurate patient monitoring
• Complete patient access
• Silent operation
• Reduced staff time
• No blowing air
• Energy conservation

PerfecTemp™
Flexible and durable carbon heating
element for uniform heating.

OR Patient Warming System


References
1. Egan C, Bernstein E, Reddy D, et al. A Randomized Comparison of Intraoperative Warming With the LMA PerfecTemp
and Forced Air During Open Abdominal Surgery.

©2011 Medline Industries, Inc. Medline and PerfecTemp are registered trademarks of Medline Industries, Inc.
CE Article

Under SCIP-Inf-10 clinicians must either actively warm patients


during surgery or record a body temperature of 36 degrees C (96.8 Intraoperative core temperatures
degrees Fahrenheit) or higher within 30 minutes before or 15 minutes
immediately after the end of anesthesia. Clinicians must provide clear about two degrees Celsius below
documentation of the temperature during active warming or in rela-
tion to the end of anesthesia.
normal increase the incidence
of wound infection threefold and
What causes perioperative hypothermia?
As warm-blooded creatures, human beings’ organ systems are prolong hospitalization by about
designed to operate within a narrow temperature range. Hypother-
mia occurs when a person’s body loses more heat than it can pro-
20 percent.5
duce, leading to a core body temperature drop. In nature, we know
what makes us cold and we can respond. Exposure to cold air
encourages us to get out of the cold or bundle up. Being damp
causes us to seek drier conditions. We put on jackets or seek shel-
ter to get out of the wind. In the OR, perioperative hypothermia is
common, resulting from the effects of anesthesia on the body’s ther-
moregulatory control system.6

Many factors can contribute to unplanned perioperative hypother-


mia, including cool air temperature in the OR, length of surgery (the
longer the surgery, the greater the likelihood of hypothermia occur-
ring), blood and fluid loss, and effects from anesthesia, which alters
the patient’s ability to regulate body temperature. A patient’s body
type can also affect heat loss. Very thin, malnourished patients as
well as those who are very young or elderly are more susceptible to
perioperative hypothermia.7

Elderly patients are more susceptible to hypothermia for a number


of reasons. The body's ability to regulate temperature and to sense
cold may lessen with age. Comorbidities that affect temperature reg-
ulation are more likely in older adults, including conditions such as
hypothyroidism, stroke, severe arthritis, Parkinson’s disease, and
neuropathies including diabetic neuropathy. They are also frequently
more dehydrated and malnourished than the general population.
Finally, medications including some antipsychotics and sedatives
(both of which are used more frequently in long-term care settings)
can impair the body’s ability to regulate its temperature.

Core body temperature changes occur in three stages, beginning


with the onset of general anesthesia. During the first hour, redistrib-
ution is the main cause of potential perioperative hypothermia.

Aligning practice with policy to improve patient care 17


CE Article

During this stage, warmer blood from the core is allowed to mix
with cooler blood from the rest of the body. The blood cools as
Did you know?
it circulates, and the cooled blood that returns to the heart can
Some patients report that shivering and being
cause a decrease in body temperature8 of up to one degree
cold are worse than surgical pain. Hypothermia
Celsius.7
can cause a vigorous shivering response, which
increases carbon dioxide production and increases
Redistribution is followed by the second phase, which occurs
oxygen consumption 400 to 500 percent.10
during the second and third hours of anesthesia, during which
heat loss exceeds the body’s ability to produce heat. During this
phase, warming the patient can effectively limit further heat loss.
Finally, after about three to five hours of anesthesia, the patient’s
Complications associated with perioperative hypothermia
Hypothermia, which is defined as having a core body temperature
temperature reaches a plateau, which usually remains constant
of less than or equal to 36 degrees Celsius or 96.8 degrees
for the remainder of the surgery, regardless of how long the rest
Fahrenheit, is associated with several complications and an in-
of the procedure takes.
creased risk of death. Perioperative hypothermia can result in: 11
UNINTENDED HYPOTHERMIA • three times the incidence of surgical site infection
• increased bleeding and increased need for blood transfusions
Typical Pattern of Hyp • three times the risk for cardiac complications
• a higher risk for developing pressure ulcers
0 • prolonged recovery after surgery

Preciptious drop in
Surgical site infection. Hypothermia causes the blood vessels
patient temperature to constrict, decreases blood flow to tissues and decreases oxy-
-1
within the first hour of genation of surgical wounds, allowing a more favorable environ-
6CORE TEMP ($C)

anesthesia induction ment for bacterial growth. In 1996 Andrea Kurz, MD, and
colleagues published a study involving 200 colorectal surgery
-2
patients; 100 were randomly assigned to undergo surgery with
warming and the other 100 without warming. For those who did
not receive warming, the final mean intraoperative core temper-
-3
ature was 34.7 degrees Celsius. The final mean temperature for
those who were warmed was 36.6 degrees Celsius. Surgical
wound infections were found in 19 percent of the hypothermic
0 2 4 6 group and in six percent of the normothermic group. The
ELAPSED TIME
authors concluded that intraoperative core temperatures about
two degrees Celsius below normal increase the incidence of
After inducing anesthesia, a patient’s
core body temperature drops rapidly.9 wound infection threefold and prolong hospitalization by about
20 percent.12

Melling et al. also conducted a study of wound infection rates


following surgery. The random controlled trial included 421
patients and resulted in a four percent infection rate among
patients who received local warming and 15 percent among
those who were not warmed.8

Continued on Page 20

18 The OR Connection
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Published evidence shows
high rates of complications
among hypothermic surgical
patients, making it important
for perioperative professionals
to keep patients warm.

One suspected cause of surgical site infections has been Cardiac complications. A 1993 study by Johns Hopkins anes-
understood to be a lack of oxygen, in particular bactericidal thesiologist S.M. Frank, MD, and colleagues revealed that a
oxide radicals. As a drop in core temperature leads to vaso- greater number of hypothermic patients (36 percent) experi-
constriction to preserve heat in the body, less oxygenated blood enced myocardial ischemia compared with normothermic
flows to a wound site on the skin. That reduction in available patients (13 percent). The incidence of angina postoperatively
oxygen at the wound site makes it more conducive to bacterial was also greater among the hypothermic group (18 percent)
growth. One study found that dissolved oxygen (pO2) is a compared with the normothermic group (1.5 percent).15 All 100
strong predictor of infection. Measuring levels of subcutaneous subjects in the study underwent a vascular reconstruction
oxygen in post-surgical patients, he found that none with an procedure.
oxygen tension greater than 90 mmHg developed a SSI
whereas 43 percent of patients with an oxygen tension between It is important to recognize the difference between unintended
40 and 50 mmHg did develop a SSI. hypothermia that leads to cardiac conditions, and the growing
practice of therapeutic, induced hypothermia in cardiac patients.
Increased blood loss. A meta-analysis published in 2008 by Unintentional hypothermia (perioperatively or otherwise) can lead
Daniel Sessler, MD, professor and chair of the Department of to an unusually slow or irregular heart rate, which manifests as
Outcomes Research at Cleveland Clinic, and colleagues found a weak or slow pulse or other arrythmias.16 Therapeutic hy-
that less than one degree of hypothermia is enough to increase pothermia is an evidence-based intervention that attempts to
blood loss by about 16 percent and increase the need for in- lower core temperatures to around 33 degrees Celsius
traoperative transfusion by about 22 percent. Normothermia, for 24 hours after a cardiac event for the purpose of improving
however, was associated with a reduced chance of blood loss neurological outcomes.
and a reduced need for transfusion.13 Similarly, an earlier study
by Schmied and colleagues in 1996 also found that mild hy- Perioperative pressure ulcers. Because of circulatory and
pothermia can increase blood loss and the need for transfusion metabolic changes that occur during surgery, the etiology of
during surgery.14 perioperative pressure ulcers is more complex than those that

20 The OR Connection
CE Article

occur in medical patients. 17 In a 2001 study researchers


hypothesized that patients’ capacity to withstand mattress pres-
sures during surgery would increase if hypothermia were
prevented. They performed a randomized control trial to explore
the relationship between tissue viability and patient core
temperatures during surgery and to test the hypothesis that
patient warming would reduce the incidence of pressure ulcers.
Their trial involving 324 surgical patients resulted in an eight
percent pressure ulcer incidence among patients who were
warmed with a forced air over-blanket, versus a 65.4 percent
incidence among patients who were not warmed.18

Prolonged recovery. Rainer Lenhardt, MD, clinical director of


the Neuroscience-Anesthesia Intensive Care at the University of
Louisville School of Medicine, and colleagues hypothesized that
intraoperative hypothermia may prolong immediate surgical
recovery by increasing the potency of the anesthetic, delaying
drug metabolism or depressing cognitive function. They followed
150 patients undergoing elective major abdominal surgery and
discovered that hypothermic patients required about 40 minutes
longer than normothermic patients to reach fitness for discharge.19

Length of stay in the post-anesthesia care unit (PACU) is an


important issue for health care managers. PACU nurses care for
a small number of patients because of the high level of attention
and care needed by a person recovering from anesthesia. Some
have calculated that the personnel cost for two-hours in the
PACU stay is similar to the personnel cost for a full day on a general
care unit in a hospital.20 In an era of cost control, decreasing
recovery time is economically desirable for the institution.

Warming methods
As summarized above, published evidence shows high rates of
complications among hypothermic surgical patients, making it
important to maintain normothermia. There are several kinds of
surgical warming devices available.

Types of warming devices include forced air over or under the


body; circulating warm-water devices; or conductive, active
warming devices, which include under-the-body warming
mattresses or over-the-body warming blankets. In addition to
requiring perioperative professionals to maintain normothermia
in patients, SCIP-Inf.-10 also requires clear documentation
regarding the use of active warming devices.11

Aligning practice with policy to improve patient care 21


How to prevent perioperative hypothermia • Pulmonary artery. The most accurate measurement
Although SCIP recommends keeping patients warm during of the core body temperature is through the pulmonary
surgery, it does not recommend how to keep them warm.21 artery, which is bathed in blood from the core. This
Nursing organizations, including the Association of invasive form of monitoring, however, is not justified
periOperative Registered Nurses (AORN) and the American solely for temperature assessment.
Society of Perianesthesia Nursing have developed standards
for preventing hypothermia during surgery. The following Recommendation IV
are highlights from AORN’s “Recommended Practices for The core temperature of patients at risk for unplanned
Prevention of Unplanned Perioperative Hypothermia.”22 hypothermia should be monitored pre-operatively,
intraoperatively and postoperatively.
Recommendation I
The perioperative registered nurse should assess the Recommendation V
patient for risk of unplanned perioperative hypothermia. Interventions should be implemented to prevent
unplanned hypothermia.
Recommendation II
The perioperative registered nurse should develop Recommendation VI
a plan of care to minimize the risk of unplanned Warming devices should be used in a manner that
perioperative hypothermia in patients identified at risk. minimizes the potential for patient injuries.

Recommendation III Recommendation VII


Equipment to monitor core temperature should be Competency
selected based upon reliability and access to the route. Personnel should receive initial education and competency
validation and updates on the prevention of unplanned
III.a.1 hypothermia and the use of warming equipment.
There are four reliable sites for measurement of core
temperature: Recommendation VIII
• Tympanic membrane. The tympanic membrane Documentation
temperature, measured by a thermocouple, is the Patient assessments, the plan of care, interventions
preferred method in many perioperative and postoperative implemented, and evaluation of care to prevent unplanned
areas. This method is noninvasive, and the monitoring perioperative hypothermia should be documented.
site receives blood supply from the carotid artery, which
supplies the thermoregulatory center of the hypothalamus. Recommendation IX
• Distal esophagus. The distal esophagus is considered Policies and Procedures
a desirable site to measure temperature, particularly in Policies and procedures for prevention of unplanned
the operating room, and is less prone to artifact than most hypothermia should be developed in collaboration with
others. It is an alternative to the pulmonary artery and is anesthesia care providers, reviewed periodically, revised as
widely used intraoperatively. Placement of the probe in the necessary, and readily available in the practice setting.
lower fourth of the esophagus prevents artifactual cooling
of the probe by respiratory gases. Recommendation X
Quality
• Nasopharynx. The nasopharynx is another reliable
A quality improvement/management program should
monitoring site for intraoperative measurement because it
be in place to evaluate the structure, process, and
approximates core temperature. A thermistor probe is
outcomes of interventions used to protect patients from
inserted through the nares to the nasopharynx.
unplanned perioperative hypothermia.
Measurements may be influenced by the temperature
of inspired gases and often are 0.5 degrees Celsius
lower than pulmonary artery temperatures.

22 The OR Connection
Methods of Patient Warming
Warm IV Fluids
Conductive Warming Devices
Warming Blankets
Forced Air
Circulating Water Garments
Increased Operating Room Temperature

In an interview with OR Manager, perioperative hypothermia near the patient’s skin to continuously monitor and control the
expert Dr. Sessler stated that it doesn’t matter which warming heat generation of the pad. Warming can begin as soon as the
method is used as long as the patient’s temperature is approx- patient is positioned on the OR table. The anesthesiologist can
imately normal at the end of the surgery.21 Dr. Sessler is a lead- select one of five preset temperatures of 37, 38, 39, 40, or 40.5
ing researcher in surgical warming and has co-written many degrees Celsius. The heating element is placed below one inch
studies on how hypothermia affects surgical patients and the of viscoelastic memory foam to provide pressure redistribution
effectiveness of warming devices. for the patient. The entire pad is encased in a fluid proof cover
and all seams are sealed to prevent penetration by spilled fluids,
Warm IV fluids. Warming IV fluids is another way to increase meaning the mattress can be cleaned and reused, eliminating
body temperature, but only under certain circumstances. unnecessary environmental waste. In addition, because the
AORN’s “Recommended Practices for Prevention of Unplanned patient is warming from underneath, blankets need not be
Perioperative Hypothermia” states:22 placed on top of the patient, allowing for greater surgical access.
The device also operates with no noise.
“Warming intravenous (IV) fluids should be considered only if
large volumes (i.e., more than two liters/hour for adults) are Warming blankets. Warming blankets are one option that is
being administered. Warming IV fluids to near 37 degrees Cel- portable, easy-to-use and effective. The downside, however, is
sius (98.6 degrees Fahrenheit) prevents heat loss from the that nurses must make multiple trips to and from the blanket
administration of cold IV fluids and should be considered as an warming cabinet to ensure the patient always has a warm blanket.
adjunct to skin surface warming. When less than two liters of This can reduce efficiency and increase laundry costs.23 Also,
volume is given, fluid warming is of limited value because fluid- adding too many layers of warmed cotton blankets is ineffective
induced cooling is minimal.” in raising the patient’s body temperature. The first blanket can
reduce heat loss by 33 percent, however, adding another blanket
Conductive warming devices. One type of patient warming only adds another 18 percent reduction in heat loss. Adding
pad on the market is an electrical resistive/conductive device three or more blankets adds no further warming.8
that warms underneath the patient’s body. It takes the place of
an existing OR table mattress pad. The device incorporates dual Forced air warming. Another widely used option is forced air
fiber optic interface temperature sensors under the pad cover warming. The system consists of a warming unit and a remov-

Aligning practice with policy to improve patient care 23


able disposable blanket. The warming unit, which resembles an “Differences in perioperative patient warming systems result
industrial vacuum cleaner, draws in air from the room and largely from what tissues are in contact with what heating ele-
warms it to a specified temperature. The warm air is then ment and the available surface area. Heat transfer also depends
pumped through a hose into a disposable blanket that covers on physical characteristics of the heater-skin interface. For
the patient. According to Dr. Sessler, operating rooms tend to example, the surface area of the lung is enormous, but airway
use forced-air warming covers because they are effective, safe heaters and humidifiers transfer trivial amounts of heat because
and inexpensive. The blowers are often provided, and the blan- the thermal capacity of air is small.
kets are inexpensive.21
With any cutaneous warming system, heat transfer into the ther-
One difficulty with forced air warming is that it cannot always mal core depends on skin temperature, tissue insulation, and
sufficiently warm a large enough surface to maintain normoth- circulatory convection of heat within the body. Device efficacy
ermia during very large procedures when the patient is not in thus depends on which surface area is heated because the core
the supine position. For example, it can be difficult to maintain is relatively isolated from distal skin surfaces. But most impor-
normothermia in a patient undergoing a colectomy in the litho- tantly, cutaneous heat transfer depends on skin temperature.
tomy position. So much skin is exposed that there is not enough Nearly all commercially available patient-warming systems are
surface area to warm. In cases like this, a combination of patient electrically powered; there is, therefore, no intrinsic physical limit
warming devices and an ambient operating room may be the to the calories that can be provided. Instead, the limitation is al-
solution for maintaining normothermia.21 ways the skin temperature that can be tolerated without undue
risk of burns.
Some surgical staff reject the use of forced air warming because
it can contribute to field contamination and the unit itself can be Despite the high heat capacity and thermal conductivity of water,
a source of pathogens. Another criticism of forced-air warming the efficacy of conventional circulating-water mattresses is mod-
is that it can create too warm an environment for the surgeon.8 est. Poor efficacy results because 1) the posterior surface is a
The blowing can also create a considerable amount of noise in relatively small fraction of the body surface area, 2) this area is
the OR. poorly perfused because the weight of the body compresses
cutaneous capillaries, and, 3) most heat is lost via radiation and
Circulating water garments. These devices circulate water convection from the anterior surfaces rather than conduction
through a segmented garment that is wrapped around the
anterior and posterior sides of the patient. This is in contrast to
circulating water mattresses, which the patient lies on in a
supine position, thereby warming the posterior side of the body.

Research conducted by Dr. Sessler has shown that circulating


water garments and energy transfer pads warm patients about
Despite the high heat
50 percent better than forced air because they warm both over
and under the body. These systems tend to be more costly,
capacity and thermal
however, experts argue the cost is justified by better patient out-
comes when compared with other warming methods.
conductivity of water, the
The following is an excerpt from a study by Taguchi et al., which
efficacy of conventional
compares the efficacy of circulating water garments versus
forced air to maintain perioperative normothermia.6 To read the
circulating-water
study in its entirety, go to www.ncbi.nlm.nih.gov/pmc/arti-
cles/PMC1409744/?tool=pubmed. Akiko Taguchi, MD, is an in-
mattresses is modest.
structor in the Department of Anesthesiology at Washington
University in St. Louis, MO.

24 The OR Connection
For most patients, raising the room CE Article

temperature to more than 73.4º F may


reduce the severity of hypothermia.

into the operating-table mattress. As might thus be expected, tner et al. who found that peripheral tissues isolate the core from
the circulating-water garment transferred only 21 kcal/h across heat applied to the skin surface in the post-anesthetic period.
the posterior skin surface. This is more than reported previously Similarly, Szmuk et al. found that core rewarming was slowed by
with a conventional circulating-water mattress, possibly be- postoperative vasoconstriction. In contrast, peripheral-to-core
cause of a better interface material. However, it is roughly the heat transfer is unimpeded during anesthesia, whether subjects
same change in cutaneous heat transfer that is provided by a are vasodilated or vasoconstricted. The critical distinction
single cotton blanket in a normothermic subject. amongst these studies is that volunteers were fully anesthetized
in the later protocols whereas they were unanesthetized in the
Anterior surface heat transfer was comparable with each warm- former ones. Although our volunteers remained intubated, they
ing system, and the change in anterior surface heat gain from 0 were very lightly anesthetized and fully vasoconstricted. It is thus
to 0.5 elapsed hours averaged ≈65 kcal/h with each treatment. unlikely that they were given sufficient anesthesia to cause di-
Heat transfer per anterior unit area was thus similar with each rect arteriolar vasodilation that seems to be critical for rapid pe-
system. A corollary of this observation is that virtually the entire ripheral-to-core heat transfer.
difference between the two tested warming systems resulted
from heat transfer into posterior surfaces, that is from the portion Although core temperatures were virtually identical at onset of
of the circulating-water garment that acts as mattress. Core warming, peripheral tissue temperature was slightly cooler on the
temperature increased 0.4 degrees Celsius/h faster with circu- circulating-water day. This lower initial skin temperature and greater
lating water than forced air, a result that is consistent with Jan- initial core-to-peripheral tissue-temperature gradient increases the
icki et al. Although not tested in this study, our results suggest apparent efficacy of circulating water. However, the tissue tem-
that heat transfer and core rewarming with the circulating-water perature difference was only a few tenths of one degree Celsius
garment would be similar to that provided by combining a and thus unlikely to have substantially altered the results.
forced-air cover and a conventional circulating-water mattress.
Traditional circulating-water mattresses are associated with ‘pres-
The core and peripheral thermal compartments were of similar sure-heat necrosis’ (i.e., burn) that results when tissue com-
size (e.g., weight). However, active warming increased periph- pressed by the weight of the patient is simultaneously warmed.
eral tissue heat content roughly three times as much as the core Gali et al. recently reported the case of a 67-year-old woman who
over the course of the study. The differences were even more developed burns on her back after 6.5 hours of surgery while
pronounced during the initial warming phase. For example, being warmed with the same circulating-water garment we used.
peripheral heat content after one hour of circulating water Thus, when using this system, clinicians should consider any risk
increased 114 kcal whereas core content increased only factors such as age, length of surgery, and nutritional status,
34 kcal. The analogous values for forced air were 71 and 9 kcal. which may predispose a patient to skin injury.
Peripheral compartment heat content thus increased 60-80 kcal
more than the core compartment with each device. These data In summary, the circulating-water garment transferred more heat
indicate that tissue insulation restricted rapid flow of heat from than forced air, especially during the first hour of warming, with
the periphery to the core. In other words, applied heat was the difference resulting largely from posterior heating. Excessive
constrained by the insulating properties of peripheral tissues, heating of peripheral thermal compartment indicates that pe-
thus significantly limiting the rate at which core temperature ripheral tissues insulated the core, thus slowing heat transfer. ”
increased.
Increasing operating room temperature. When active skin
That peripheral tissues insulated the core and slowed heat warming is not feasible or skin warming by itself is inadequate for
transfer in our volunteers is consistent with observations of Plat- maintaining normothermia, increasing the room temperature is

Aligning practice with policy to improve patient care 25


an option. For most patients, raising the room temperature to 6 Taguchi A, Ratnaraj J, Kabon B, Sharma N, Lenhardt R, Sessler DI, et al. Effects
more than 23 degrees Celsius (73.4 degrees Fahrenheit) may of a circulating-water garment and forced air warming on body heat content and
core temperature. Anesthesiology. 2004; 100(5):1058-1064.
reduce the severity of hypothermia.22
7 Lynch S, Dixon J, Leary D. Reducing the risk of unplanned perioperative
hypothermia. AORN Journal. 2010; 92(5):553-562.
Combining warming techniques 8 Weirich TL. Hypothermia/warming protocols: why are they not widely used in the
Some have suggested the need for a holistic approach incor- OR? AORN Journal. 2008;87(2):333-344.
9 Sessler D & Todd M. Perioperative heat balance. J Amer Soc Anesth. 2000;
porating several different warming techniques to adequately
92(2):578.
warm a patient. Overall, depending on the surgeon, the surgi-
10 Paulikas CA. Prevention of unplanned perioperative hypothermia. AORN Journal.
cal team, and patient and the circumstances, the best method 2008; 88(3):358-364.
of active warming may vary.23 11 Wagner VD. Patient safety chiller: unplanned perioperative hypothermia. AORN
Journal. 2010; 92(5):567-571.
12 Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the inci-
Conclusion dence of surgical-wound infection and shorten hospitalization. The New England
Looking to the future, as surgical team awareness and further Journal of Medicine. 1996;334(19):1209-1215.
research into normothermia continues to develop, even more 13 Rajagopaian S, Mascha E, Na J, Sessler DI. The effects of mild perioperative hy-
pothermia on blood loss and transfusion requirement. Anesthesiology.
effective patient-temperature management devices are sure to
2008;108(1):71-77.
follow. Warming device experts predict the development of more
14 Schmied H, Kurz A, Sessler DI, Kozek S, Reiter A. Mild hypothermia increases
sustainable technologies that can be cleaned and re-used, blood loss and transfusion requirements during total hip arthroplasty. The Lancet.
unlike forced air warming which creates environmental waste 1996; 347(8997):289-292.
15 Frank SM, Beattie C, Christopherson R, Norris EJ, Perler BA, Williams GM et al.
with its disposable blankets. In addition, developing effective
Unintentional hypothermia is associated with postoperative myocardial ischemia.
equipment that covers less of the body surface than forced-air Anesthesiology. 1993; 78(3):468-476.
warming or circulating water devices can offer greater conven- 16 Mayo Clinic Researchers Confirm Value of Therapeutic Hypothermia. February 18,
ience and access for anesthesiologists and surgical teams.23 2011. Available at: http://www.mayoclinic.org/news2011-rst/6184.html. Accessed
March 4, 2011.
17 Rogan J. Pressure ulcer risk during the perioperative period focusing on surgery
References
duration and hypothermia. Wounds. 2007; 3(4):66-74.
1 Measure Information Form. SCIP-Inf-10. Available at:
18 Scott EM, Leaper DJ, Clark M, Kelly PJ. Effects of warming therapy on pressure
http://www.hsag.com/App_Resources/Documents/SCIP_LS3_Inf10_MIF.pdf.
ulcers—a randomized trial. AORN Journal. 2001; 73(5):921-938.
Accessed February 25, 2011.
19 Lenhardt R, Marker E, Goll V, Tschernich H, Kurz A, Sessler DI, et al. Anesthesiol-
2 Surgical Care Improvement Project. The Joint Commission Web site. Available at:
ogy. 1997;87(6):1318-1323.
http://www.jointcommission.org/surgical_care_improvement_project/. Accessed
March 4, 2011. 20 Waddle JP, Evers AS, Piccirillo JF. Postanesthesia care unit length of stay: quanti-
fying and assessing dependent factors. Anesthesia and Analgesia 87. 1998;
3 National SCIP Partnership Developing to Reduce Surgical Complications. The
87(3):628-633.
Leapfrog Group website. Available at:
http://www.leapfroggroup.org/news/leapfrog_news/144968. Accessed February 21 Mathias JM. Taking steps to keep OR patients warm. OR Manager.
27, 2011. 2006;22(12):14-16.
4 Gunn M. SCIP expanded normothermia measure to go into effect for all surgical 22 Recommended Practices for Prevention of Unplanned Perioperative Hypothermia.
patients in October. AORN Management Connections. July 2009. Available at: In: 2010 Perioperative Standards and Recommended Practices. Denver, CO: As-
http://www.aorn.org/News/Managers/July2009Issue/Normothermia. Accessed sociation of PeriOperative Register Nurses; 2010.
February 25, 2011. 23 Cantrell S. New normothermia measure heats up patient-temperature manage-
5 Wagner VD. Patient safety chiller: unplanned perioperative hypothermia. AORN ment. Healthcare Purchasing News. March 1, 2010. Available at: http://www.hp-
Journal. 2010; 92(5):567-571. nonline.com/inside/2010-03/1003-IC.html. Accessed February 25, 2011.

26 The OR Connection
Patient Safety Quality Measures for the
Surgical Care Improvement Project

Measure Rationale Strategy

Studies find that the lowest incidence of post- x Include administration and documentation of
operative infection is associated with the antibiotic in the surgical time out.
Prophylactic antibiotics are antibiotic administration during the one hour
x For one-hour antibiotics, the antibiotic is hung
SCIP-Inf-1 administered one hour prior to prior to surgery. The risk of infection
in pre-op, a surgical team member administers
incision. increases progressively with greater time
and documents the antibiotic infusion.
intervals between administration of the
antibiotic and the skin incision.
Use an agent that is safe, cost-effective, and x The use of pre-printed orders that include the
has a spectrum of action that covers most of recommended antibiotic will assist surgeons
Prophylactic antibiotics are
the probable intraoperative contaminants for with choosing appropriate antibiotics.
consistent with current
SCIP-Inf-2 the operation. First- or second-generation
guidelines (specific to each type x Vancomycin is appropriate if there is a risk of
cephalosporins satisfy these criteria for most
of surgical procedure). MRSA.
operations, although anaerobic coverage is
needed for colon surgery.
Administration of antibiotics for more than a x Begin antibiotics in the PACU.
Prophylactic antibiotics are to be
few hours after the incision is closed offers no
discontinued within 24 hours x Administer cephalosporins every 6 hours
additional benefit to the surgical patient.
after anesthesia end time. rather than every 8 hours.
SCIP-Inf-3 Prolonged administration increases the risk of
The discontinuation time
Clostridium difficile infection and the x Antibiotics are not provided for more than 24
extends to 48 hours for cardiac hours after surgery without appropriate
development of antimicrobial resistant
surgery patients. documentation.
pathogens.
Hyperglycemia in the immediate x Blood glucose levels are monitored from pre-
Cardiac surgery patients with postoperative phase increases the risk of op through 48 hours post operative.
controlled 6 a.m. blood glucose infection in both diabetic and non-diabetic
SCIP-Inf-4 x The use of an insulin protocol for treating
(”0 mg/dL) for the first two patients; the higher the level of
hyperglycemia with an insulin drip is strongly
postoperative days. hyperglycemia, the higher the potential for
recommended.
infection in both patient populations.
Surgery patients with There is no strong evidence to contraindicate x Take ALL razors out of the peri-operative area.
appropriate surgical site hair preoperative hair removal; however, there is
x Instruct patients not to shave the surgical site.
SCIP-Inf-6 removal. No hair removal, hair strong evidence against hair removal with a
removal with clippers, or razor. Shaving is considered inappropriate.
depilatory is appropriate.

It is well-established that the risk of catheter- x Create a system of alerts or reminders to


Surgical patients with urinary associated urinary tract infection (UTI) identify all patients with urinary catheters and
catheter removed on increases with increasing duration of assess the need for continued catheterization.
Postoperative Day 1 or indwelling urinary catheterization.
Postoperative Day 2 with day of x Develop guidelines and protocols for nurse-
SCIP-Inf-9 directed removal of unnecessary urinary
surgery being day zero. (This
measure does not apply to catheters and management of postoperative
certain urological, gynecological urinary retention.
or perineal procedures.) x Consider the use of external catheters for
cooperative males

Aligning practice with policy to improve patient care 27


Measure Rationale Strategy

Surgical patients should be Research has correlated impaired wound x Use aggressive warming measures during
actively warmed during surgery healing, adverse cardiac events, altered drug surgery.
or have at least one recorded metabolism, and coagulopathies with
x Ensure accurate documentation of post-
body temperature equal to or unplanned perioperative hypothermia. A study
operative temperature.
SCIP-Inf- greater than 96.8° F within 30 by Kurtz, et al. (1996), found that incidence of
S 10 minutes prior to the end of culture-positive surgical site infections among
anesthesia to 15 minutes after those with mild perioperative hypothermia
anesthesia end time. (Patients was three times higher than the normothermic
with intentional hypothermia are perioperative patients.
excluded from this measure.)

The American College of Cardiology and the x Instruct patients to take their beta blockers the
American Heart Association recommend day of surgery.
Surgery patients on beta- continuation of beta-blocker therapy in the
blockers prior to admission x Educate in-house clinicians about the
SCIP- perioperative period as a class I indication, importance of patients receiving their beta
should continue beta-blocker and accumulating evidence suggests that
CARD-2 blockers the day of surgery, even while the
therapy during the perioperative titration to maintain tight heart rate control
period. patients are otherwise NPO.
should be the goal.
x Meet with physician office staff to ensure
consistent instructions to the patients.

Despite the evidence that VTE is one of the x Use pre-printed orders that include nationally
T most common postoperative complications recommended guidelines for VTE prophylaxis.
and prophylaxis is the most effective strategy x A “hard stop” would be not to allow patients to
Surgery patients with to reduce morbidity and mortality, it is often leave the recovery area until VTE orders are
recommended venous underused. completed by the surgeon.
SCIP-VTE- thromboembolism (VTE) The frequency of venous thromboembolism
1 prophylaxis ordered anytime (VTE), which includes deep vein thrombosis
x Ensure that surgeon “preference” cards mirror
from hospital arrival to 48 hours national guidelines.
and pulmonary embolism, is related to the
 after Anesthesia End Time. type and duration of surgery, patient risk x Pharmacists should assist surgeons with
factors, duration and extent of postoperative understanding the risk of bleeding with
immobilization, and use or nonuse of pharmacological interventions.
prophylaxis.
Timing of prophylaxis is based on the type of x (Please note that rates for SCIP-VTE- 2 may
procedure, prophylaxis selection, and clinical be lower than those for SCIP-VTE-1 as a result
judgment regarding the impact of patient risk of more stringent criteria. SCIP-VTE-2 requires
factors. The optimal start of pharmacologic documentation that prophylaxis was ordered
Surgery patients who received
prophylaxis in surgical patients varies and and actually started, whereas SCIP-VTE-1
appropriate venous
must be balanced with the efficacy-versus- requires only documentation of an order. )
thromboembolism (VTE)
SCIP-VTE- bleeding potential. Due to the inherent
prophylaxis within 24 hours prior x Organizations with decreased VTE 2 rates
2 variability related to the initiation of
to Anesthesia Start Time to 24 should assess their processes to determine
prophylaxis for surgical procedures, 24 hours
hours after Anesthesia End why physician orders are not being
prior to surgery to 24 hours post surgery was
Time. implemented.
recommended by consensus of the SCIP
Technical Expert Panel in order to establish a
timeframe that would encompass most
procedures.

This material was prepared by Health Services Advisory Group, Inc., the Medicare Quality Improvement Organization for Arizona, under contract with
the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do
not necessarily reflect CMS policy. Publication No. AZ-9SOW-6.2.3-110609-01

28 The OR Connection
CE Test

Turn Up the Heat


Avoiding Surgical Complications
with Adequate Patient Warming

True/False
1. Extremely thin and malnourished patients are more 8. In the Scott study, what was the incidence of
susceptible to perioperative hypothermia T F pressure ulcers among patients who were not
warmed during surgery?
2. SCIP Inf.-10 went into effect April 1, 2007. T F a. 72.5 percent
b. 15.3 percent
3. Forced air warming is a widely used option for patient c. 65.4 percent
warming. T F d. 22.8 percent

4. Cool air temperature in the operating room can 9. Which of the following is NOT a known complica-
contribute to unplanned perioperative hypothermia. T F tion of perioperative hypothermia?
a. Surgical site infection
5. Perioperative hypothermia can cause a drastic drop in b. Prolonged recovery
blood pressure. T F c. Myocardial ischemia
d. Pneumonia
6. Some surgical professionals reject the use of
forced air warming because it can contribute to 10. During anesthesia, core body temperature
field contamination. T F changes occur in ____ stages.
a. Three
b. Five
Multiple Choice
c. Two
7. A 2008 study by Sessler and colleagues found that less d. Seven
than one degree of hypothermia during surgery is
enough to increase blood loss by about ___ percent.
a. 25 Visit www.medlineuniversity.com
b. 46 and login or create an account.
c. 16 Choose your course to take
d. None of the above
the test and receive
1 FREE CE credit.

Courses approved for continuing education by the Florida Board


of Nursing and the California Board of Registered Nursing.

Aligning practice with policy to improve patient care 29


Patient Safety

ClearCount Clearly Makes a Difference


in Patient Safety at Hunt Regional Hospital
By Rebecca McPherson, MSN, RN

The following is a true story shared by nurses Kathy Magee and Many questions and concerns arise such as:
Emily Sundee from Hunt Regional Hospital, Greenville, TX. • Could it be in the patient’s cavity?
• Was it thrown away in the linens?
Imagine this scenario • Did we miscount?
A patient arrives at the hospital for a scheduled abdominal sur- • Is it possible the previous shift made the error?
gery. Everything is running on time. The patient is placed on the
operating room table, a Time Out is called, and anesthesia is The surgeon quickly decides to use the SmartWand-DTX and is
administered. The patient is intubated and placed on a able to locate and retrieve the missing sponge. The patient has
mechanical ventilator. The sponges are counted by the circulator a good outcome.
nurse and the scrub nurse. The surgery begins. The procedure
is going well; however, the surgery extends through a shift Exploring technology
change for the scrub nurses. Upon arrival of the second shift, Hunt Regional is community-based hospital with 192 beds
the patient experiences a large amount of blood loss and packs located in Greenville, Texas. The organization takes pride in a
of sponges are counted and quickly used. As the surgeon culture of innovation and transparency. If any staff member says
focuses on recognizing the reasons for blood loss, the nurses “this is a safety issue” it’s viewed as very important and the lead-
are instructed to order a back up blood supply for the patient. ership team is committed to following up and resolving the con-
The surgeon controls the bleeding and begins to close the cern. Hunt Regional is dedicated to patient safety and quality
patient’s incision. The staff realizes there is an unreconciled outcomes. That is one of the reasons they were the first hospi-
sponge count. The staff attempts to recover the missing sponge. tal in the state of Texas to begin using ClearCount. Hunt Regional
realizes that retained objects is a standard problem for hospitals
nationwide.
Continued on Page 32

30 The OR Connection
INTRODUCING

“Retained Surgical Items”


AORN’s latest confidence-based learning (CBL) module.

AORN’s Confidence Based Learning (CBL) is a


unique educational program that is designed to
help you achieve mastery in both knowledge and
confidence of that knowledge when providing care
that meets AORN Standards and Recommended
Practices. CBL is used to train, teach and retain
perioperative professionals. CBL supports the
learner in reducing time to master knowledge and
increasing retention of critical information.

Visit Medline booth # 3408 or Clear Count booth # 537


at AORN Congress for a FREE DEMO of the “Retained
©2011 Medline Industries, Inc. Surgical Items” module.
The retention of a foreign object is considered a serious and pre- Hunt Regional Hospital
ventable event by the National Quality Forum.1 The Centers for
Medicare & Medicaid Services (CMS) includes the retention of
foreign objects in its list of hospital-acquired conditions for which
reimbursement will not be provided.2 The Joint Commission cat-
egorizes the unintended retention of a foreign object as a sentinel
event.3 The Joint Commission’s sentinel event statistics reported
360 instances of unintentional retention of a foreign body during
the period of 2005 through March 2010.4

National adverse event data demonstrates that retained surgical


items are the most frequent and costly surgical “Never Events,”
with surgical sponges representing the bulk of these incidents.
Human error is a reality; however, Hunt Regional Hospital
According to CMS, the cost of a retained foreign object (RFO)
accepted responsibility, and their objective is to address retained
after surgery is $62,631 per hospital stay.5 In addition to hospi-
surgical sponges head-on. They could not accept just any solu-
tal costs, RFOs can produce major litigation expenses. The total
tion. Efficiency is important to them as well, particularly in the
cost of an RFO, including legal defense, indemnity payments,
healthcare reform climate.
and surgical costs unreimbursed by CMS, would be approxi-
mately $166,135. At the previously quoted incidence of 1 in
The nursing team was highly focused on patient safety. After fur-
5,500 operations, the cost of an RFO amortizes to approximately
ther research, they discovered publications from AORN that
$30 per operation.
made them aware of new technology for the prevention of
retained sponges.
The concern of retaining sponges or foreign objects can occur
even when the staff follows procedures. The risk elevates with
Surgeons also prefer using ClearCount and SmartWand.
emergency procedures, deviation from planned procedures, type
According to Joshua K. Trussell, MD, board certified general sur-
of procedure, patients with a higher mean body-mass index
geon, Primary Care Associates Affiliated and medical director of
(obesity), and failure to count or inaccurate counts during the
the Trauma Program at Hunt Regional Medical Center in
procedure.7 The longer the patient spends on the operating
Greenville, Texas, “Using the lap sponge and raytec (X-ray gauze)
table, the greater the chance of developing pressure ulcers.
have not changed practice or the way I operate, in fact, they are
The incidence of postoperative pressure ulcers may be as high
very user friendly and increase the level of confidence of the
as 66 percent.8 The Institute for Healthcare Improvement (IHI)
physician.”
estimates nearly one million people develop pressure ulcers each
year, with some 60,000 deaths related to complications. The
About the author
cost of treatment ranges up to $11 billion annually.9
Rebecca McPherson, MSN, RN, is vice president of clinical serv-
ices for Medline Industries, Inc. Prior to joining Medline, Rebecca
Hunt Regional made the commitment to reducing or eradicating
worked at Sherman Healthcare Systems as the director of opera-
the incidence of retained surgical sponges by recognizing that
tions for the immediate care centers. Her background also includes
even one such event is one too many.
emergency nursing.

ClearCount benefits the patient and the organization by:


1. Centers for Medicare & Medicaid Services. Hospital-acquired conditions
• reinforcing safe, efficient, quality care (present on admission indicator)[online]. 2009 Feb 19 [cited 2009 March11].
• creating reassurance for the physician and staff that there 2. National Quality Forum. Serious reportable events in health-care 2006 update:
a consensus report. Washington (DC): National Quality Forum; 2007.
is another system they can rely on to account for all sponges
3. Joint Commission. Facts about the sentinel event policy [online]. 2008 Mar 20
• increasing staff productivity, avoiding time spent to [cited 2009 Mar 11].
relocate sponges 4. The Joint Commission. Sentinel event statistics: updated through March 31, 2010.
5. Centers for Medicare & Medicaid Services. CMS fact sheets. CMS proposes
additions to list of hospital-acquired conditions for fiscal year 2009 [online]. 2008
Using ClearCount does not take the place of manually counting Apr 14 [cited 2009 Apr 7].
sponges; however, it serves as reinforcement that the sponges 6. Cima, RR, Kollengode A, Garnatz J, et al. Incidence and characteristics of potential
have all been accounted for. Practitioners should continually and actual retained foreign object events in surgical patients. J Am Coll Surg
2008;207(1):80-7.
check for RFOs before closing body cavities and develop safety
7. The Joint Commission. Foreign Objects retained After Surgery. Patient Safety Link
practices to minimize errors. Hunt Regional is committed to end- e-Zine. 2009; 5(1).
ing retained lab sponges; they created a policy to use ClearCount 8. ERCI. Pressure Ulcers. HRC Risk Analysis. 2006;3(Nursing 4):1-37.
9. OR Manager. Save Our Skin: Periop team rally to prevent pressure ulcers in the
for all open abdominal cases in addition to the nurse counting.
OR. 2008; (24)3.

32 The OR Connection
The benefits of counting
and detection in one
advanced system.

The SmartSponge® System takes the worry


out of finding and counting surgical sponges

There’s no greater relief than getting an accurate surgical


sponge count. The SmartSponge System counts, locates
and recounts each sponge up to 80,000 times during a
single surgery. And because it is the only FDA-approved
system that uses radio-frequency identification, it uniquely
identifies each sponge , so you can use the SmartWand-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.

©2011 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
SmartSponge is a registered trademark and SmartWand-DTX is a trademark of ClearCount
Medical Sloutions.
VA
34 OR Connection
What is the
Perioperative
Nurse’s Role
in Prevention?
By Lorri A. Downs RN, BSN, MS, CIC

Healthcare-acquired ventilator-associated pneumonia (VAP) can be


very costly. According to the available literature, the average cost
associated with this complication can be as high as $40,000 per
patient.1 With all organizations looking to prevent costly complications
and provide evidence-based medicine, it is critical for every nurse to
understand ventilator-associated pneumonia (VAP) and how to prevent it.

The main role for perioperative nurses is awareness. Awareness is


key, as the most concerning aspect of VAP is the high mortality rate.

AP
Data published in February 2011 suggest that catheter-associated
bloodstream infection (CABSI) and VAP cause more than two-thirds
of the deaths resulting from healthcare-acquired infections (HAIs), and

Ventilator- that they are five times as deadly as the other HAIs.2 Certainly, in the
operative arena, the anesthesiologist manages the patient’s airway.

Associated Once the patient is recovering in the PACU the VAP bundle of activi-
ties can be implemented promptly. The current literature suggests that
55 percent of VAP cases are preventable with current evidence-based
Pnemonia strategies.2

The Institute for Healthcare Improvement (IHI) published a “ventilator


bundle” in 2006 and updated this bundle in May 2010. The bundle is
a set of strategies healthcare workers can implement to help
reduce the risk of VAP. The recent update has placed oral care with
a Chlorhexidine (CHG) mouth rinse on the list of activities to help
reduce the risk of developing VAP.

The IHI Ventilator Bundle as of May 20103

➢ Elevation of the head of the bed 30-45 degrees


unless medically contraindicated
➢ Daily “sedation vacations” and assessment of
readiness to extubate
➢ Peptic ulcer disease prophylaxis
➢ Deep venous thrombosis prophylaxis
➢ Daily oral care with Chlorhexidine (CHG)

Aligning practice with policy to improve patient care 35


Joint Commission 2012 National Patient Safety Goal NPSG.07.06.01
Elements of Performance4

Perform daily sedation interruption in accordance


11. During 2012, plan for full implementation of this 6
NPSG January 1, 2013. Note: Planning may with the patient’s medical plan of care. Note:
include a number of activities, such as assigning This requirement is not applicable for patients
responsibility for implementation activities, creating that do not have a medical plan for weaning off
timelines, identifying resources, and pilot testing. the ventilator.
Perform hand hygiene before and after providing Measure and monitor ventilator-associated
2 7
care to ventilated patients. (See also PSG.07.01.01) pneumonia prevention processes and outcomes
Position and maintain ventilated patients by doing the following:
3
(except those with medical contraindications) • Selecting measures using evidence-based
in semirecumbent positions. guidelines or best practices
Provide regular antiseptic oral care to patients in • Monitoring compliance with evidence-based
4
accordance with product guidelines. guidelines or best practices
• Evaluating the effectiveness of prevention efforts
Perform daily assessment of ventilated patients to
5
determine their readiness to wean off the ventilator
or to be extubated. Note: This requirement is not
applicable for patients that do not have a medical
plan for weaning off the ventilator.

36 The OR Connection
“55 percent of VAP cases are preventable
with current evidence-based strategies.

Additional focus on VAP
Other healthcare organizations, including The Joint Commission
and the Centers for Medicare and Medicaid Services, are also
looking to target VAP prevention. The Joint Commission will be
adding VAP to the 2012 National Patient Safety Goals under
NPSG.07.06.01.

“Medicare stopped providing reimbursement for treatment of


eight largely preventable conditions, three of which it deemed
“never events” and five “reasonably preventable.” Three of the
five “reasonably preventable” conditions are HAIs; namely, CBSI,
CAUTI, and SSI. VAP is being considered for inclusion in an
expanded list scheduled for release in 2011.”2

What’s new? Oral care! Oral care! Oral care!


Oral care with 0.12% Chlorhexidine gluconate oral rinse twice a
day has been found to significantly decrease the risk of
acquiring ventilator-associated pneumonia. A 2009 study
published in the Journal of Intensive Care Medicine found that
“simple low cost oral care protocols implemented in the SICU
About the author
can significantly decrease the rate of infection and subsequently Lorri Downs, RN, BSN, MS, CIC is a board-
the costs associated with these infections. The cost savings certified infection preventionist and vice president
were $140,000 – $560,000 savings related to infection of of infection prevention for Medline Industries, Inc.
She has a diverse portfolio of more than 25 years
prevention of VAP. The total cost of the oral care program was
in the nursing professions. Her expertise focuses
$2187.49.”1 on infection prevention surveillance at large acute
care organizations, plus ambulatory and public
So, how do we hardwire the importance of oral care into all health settings. Lorri has developed hospital
patient care providers? Education and competency testing is infection control programs and local emergency preparedness plans,
and she has lectured on various infection prevention topics.
the key to sustainability of clinical practices. Clinical education
programs with these components can help move the needle
References
to hospital wide compliance as opposed to unit-based
1. Sona CS, Zack JE, Schallom ME, McSweeney M, McMullen K, Thomas J, et al.
compliance. Oral care and VAP prevention activities do not stop The impact of a simple, low-cost oral care protocol on ventilator-associated
once the patient leaves the PACU, the SICU or the medical/ pneumonia rates in a surgical intensive care unit. Journal of Intensive Care
Medicine. 2009; 24(1):54-62.
surgical units for ventilated patients. 2. Umscheid CA, Mitchell MD, Doshi JA, Agarwal R, Williams, K, Brennan PJ.
Estimating the proportion of healthcare-associated infections that are reasonably
preventable and the related mortality and costs. Infection Control and Hospital
At the end of the day “it may not be an attainable goal of
Epidemiology. 2011; 32(2):101-114.
preventing 100% of HAIs, but comprehensive implementation 3. Implement the Ventilator Bundle. Institute for Healthcare Improvement (IHI)
of prevention strategies could prevent hundreds of thousands of website. Available at: http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/
Changes/ImplementtheVentilatorBundle.htm. Accessed February 28, 2011.
HAIs and save tens of thousands of lives and billions 4. The Joint Commission 2012 National Patient Safety Goals. Hospital
of dollars.”2 Accreditation Program. NPSG.07.06.01.

Aligning practice with policy to improve patient care 37


Ventilator-Associated Pneumonia
can be deadly.
VAPrevent can be easy.

Convenient,
space-saving
packaging

VAPrevent
follows IHI
Ventilator Bundle
guidelines. With
this checklist,
you can too.

Sequential dispensing
system and thumb grip for
easy, one-at-a-time access
— in the right order
Evidence-based innovation in oral care for ventilator patients

VAPrevent is a comprehensive system to give your staff the tools to deliver excellent oral
care. And for ventilator patients, excellent oral care may be part of the difference between
ventilator-associated pneumonia and staying healthy.

The three parts of the VAPrevent program you’ll want to know:

Product
Only Medline gives you these three options for oral care: IHI-recommended
chlorhexidine gluconate (CHG), the alcohol-free moisturizing of Biotene®,
or the proven antisepsis of hydrogen peroxide. Procedure kits feature
innovative components, like graduated suction catheters and toothbrushes
with integrated gum and tongue scrubbers. Breakthrough package design
communicates and educates, all while leaving less waste behind. And the
intuitive stack-pack design with its one-at-a-time dispenser makes it easy
for caregivers to stay on track with care protocols.

Clear visuals let


you identify the
right kit quickly
for your patient’s
needs

Program
When your staff knows how to use a product appropriately, its effectiveness
increases greatly. That’s why Medline developed the Medline VAP program,
which helps build knowledge and clinical skills with educational modules
for both novice and experienced clinicians, as well as an online interactive
competency for oral care. A program manager helps you implement your
program and stays active as you progress, providing 90-day reports to
help you track your incidence of VAP.

Price
If you expected a VAP program this innovative would come at a price
premium, you’re in for a pleasant surprise. VAPrevent from Medline
comes to you for five to ten percent lower than competitors. In a tough,
pay-for-performance environment, VAPrevent represents a major value.

To schedule your evaluation of the VAPrevent System,


contact your Medline representative or call
1-800-MEDLINE (633-5463).

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.

©2011 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
THE INS
AND OUTS
OF HERNIAS
AND WAYS
TO REPAIR
THEM

40 The OR Connection
OR Issues

By Alecia Cooper, RN, BS, MBA, CNOR

Documentation of hernias goes back to ancient times. Physicians in


Alexandria used tightly-fitting bandages as treatment for a hernia, and a
Phoenician statuette circa 900 BC portrays the bandaging.1 It’s debatable,
however, whether hernia surgeries were performed at that time. Fast forward
to 1884, when Bassini introduced a surgical hernia repair that resulted in a
very low (2.7 percent) recurrence rate. Today, the Lichtenstein procedure con-
tinues to dominate the world of hernia repair.2

What is a hernia? Types of hernias


A hernia is the abnormal protrusion of part of an organ or tis- Each type of hernia has its own descriptive name, and the list
sue through a weak spot or other abnormal opening in a wall of types is quite extensive. The most common types of her-
of muscle or other tissue. The condition can develop in various nias, however, are inguinal (in the groin), umbilical (at the belly
parts of the body, but hernias occur most commonly in the ab- button), and incisional (at the site of a previous operation).
dominal region, where part of the intestines or intra-abdominal
fat bulge through the weak spot in the abdominal muscle. An inguinal hernia occurs in the groin where the abdominal
folds of flesh meet the thighs. It is often the result of increased
Patients with hernias may notice a bulge under the skin and pressure within the abdomen due to lifting, coughing or strain-
feel pain when lifting heavy objects, coughing or during pro- ing. This type of hernia occurs more often in males because it
longed standing or sitting. Any motion or action that increases follows the tract that develops when the testes descend into
intra-abdominal pressure will exacerbate the symptoms of a the scrotum before birth. In females, the inguinal hernia follows
hernia. The pain may be sharp and immediate or a dull ache the course of the round ligament of the uterus.
that gets worse toward the end of the day.
An umbilical hernia occurs with weakness in the umbilicus
Hernias can be congenital, meaning they occur during fetal (belly button). This type of hernia occurs most often in infants
development, or acquired. A hernia can be acquired from and children.
increased intra-abdominal pressure causing by heavy lifting,
prolonged coughing, prostate problems or bowel irregularity. An incisional hernia is a frequent complication of abdominal
A common property of all hernias is that once they are present, surgery, with a reported incidence of up to 20 percent.3 This
they are permanent until surgically repaired. type of hernia that can develop at the site of a surgical incision
that fails to heal properly, causing tissue weakness. This hernia
also can occur when excessive strain is placed on the tissue at
the incision site.

Aligning practice with policy to improve patient care 41


Any type of hernia may become strangulated. This is a very
dangerous condition that can appear suddenly and requires
immediate medical attention. A strangulated hernia is one that
is tightly constricted. As any hernia progresses and bulges out
through the weak point in its containing wall, the opening in the
wall tends to close behind it, forming a narrow neck. If this
neck is pinched tightly enough to cut off the blood supply, the
hernia will quickly swell, becoming strangulated. Severe, con-
tinuous pain, redness, and tenderness are signs that the her-
nia may be entrapped or strangulated. Unless the blood
supply is restored promptly, gangrene can set in and may
cause death.4

Surgical hernia mesh


Surgical repair of a hernia
Although various supports and trusses are available to try to
contain a hernia, the most effective treatment is surgical repair In the United States, as of 2003, more than 90 percent of all
of the weakness in the muscle wall where the hernia pro- inguinal and incisional hernias were repaired with mesh, and
trudes. that number is likely higher today. This method has proven to
be more secure than closing the hernia using only sutures and
Approximately 700,000 hernia repair operations are performed nearly eliminates the possibility of the hernia opening
annually in the United States.5 Many are performed by the up again.7
conventional open surgical method. The rest are performed
using a laparoscope.6 The tension-free hernioplasty with mesh, known as the
Lichtenstein operation, was introduced in the 1980s by Irving
Several different surgical techniques have been developed Lichtenstein and colleagues. The technique is known for its
over the years to repair hernias. Most techniques are based on quickness and simplicity to perform. It is also generically
the simple idea of closing the opening in the muscle wall. In the referred to as the plug and patch technique. It’s nearly pain-
past, the opening was simply sutured closed, however, the free for patients and allows for a prompt return to work. What’s
preferred repair method today is the use of mesh fabric placed more, it is the recommended operation of first choice for
over the area for reinforcement. Outpatient surgery is clinically uncomplicated unilateral inguinal hernia in men.7
feasible for at least 75 percent of adults with primary inguinal
hernias whether the operation is performed using an open or The open hernia repair is performed from the outside through
laparoscopic technique, and most patients can go home the an incision in the groin or the area of the hernia. The incision
same day the operation is performed.7 extends through the skin and subcutaneous fat, allowing the
surgeon to get to the level of the defect. This technique is
Open surgery. Before the introduction of hernia mesh, all her- usually done with a local anesthetic and sedation, but may be
nias were repaired by simply suturing together the opening performed using a spinal or general anesthetic.
where the hernia was protruding. A 2004 follow up of a ran-
domized controlled trial of suture versus mesh repair of an Laparoscopic surgery. Laparoscopic hernia repair uses
incisional hernia concluded that mesh repair results in a lower small incisions, telescopes, a camera and a square of surgical
recurrence rate and less abdominal pain and does not result mesh material that acts as a patch over the opening. Com-
in more complications than suture repair. The researchers who pared to open surgery, laparoscopic hernia repair may offer a
conducted the study even recommended abandoning suture quicker return to work and normal activities with decreased
repair of incisional hernia altogether.3 pain for some patients.

Continued on Page 44

42 The OR Connection
Revolutionary technology
for exceptional results.

ASSURE™ Surgical Mesh – REVIVE™ Surgical Mesh –


for the repair of ventral hernias for the repair of inguinal hernias

Both ASSURE and REVIVE feature our proprietary


polyurethane Biomaterial, which offers the advantages
of both a synthetic and a biologic mesh:
• The architecture and design to mimic
tissue in-growth of a biologic mesh1,2
• The strength and economical price
of a synthetic mesh

For more information, contact your Medline


representative at 1-800-MEDLINE or
References: visit Medline.com.
1. “A Comparative Morphologic Evaluation of Synthetic Surgical Mesh Materials
in a Rat Model of Body Wall Repair” (ASSURE 26W Rat Study).
2. “In-Vivo Evaluation of Biomerix Polypropylene Composite Mesh in a Rat Body
Wall Model” (REVIVE 26W Rat Study).

©2011 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc. Assure and Revive are trademarks of Biomerix Corporation.
On the downside, laparoscopic surgery most often requires
“ The large proportion of mankind who
are afflicted with this complaint; – the
great variety of forms in which it appears;
– the fatality which results from its
general anesthesia, which poses more risks to the patient. It’s improper treatment, and the ample
also more difficult to perform than open surgery, it takes longer
and it costs more. In the United States less than 20 percent of resources of surgery in preventing its
all hernias are treated laparoscopically.5 evil consequences, are circumstances
The first report of hernia repair with laparoscopy was made by which combine to render the investiga-
Ralph Ger in 1982.7 To perform laparoscopic hernia surgery, a tion of hernia peculiarly interesting.
laparoscope connected to a special camera is inserted into
the body after making a small (1/4 inch) hole in the abdomen,
allowing the surgeon to view the hernia and surrounding tissue
on a video screen.

Two other holes are also made, which allow the surgeon to
John Syng Dorsey, 18185

All types of flat mesh are available in a variety of sizes and can

be cut to cover over any size hernia. The main difference
work inside the body. A small piece of surgical mesh is inserted between the materials is the tightness of the weave, the vari-
through the surgical hole and placed either outside or inside ation in the weave, and the thickness, suppleness, pliability
the hernia defect and held in place with sutures, staples or and weight of the mesh.7
surgical tacks.
The other large differentiation for types of mesh is the shape.
Surgical mesh Many mesh products are simple flat mesh. However, there are
An ideal surgical mesh is strong, pliable, non-allergenic and a few techniques like the Lichtenstein repair that incorporate
non-biodegradable. It should also stimulate tissue growth for mesh that with a unique three-dimensional shape. These
optimum assimilation into the body. Although there are more shapes work in concert with the local anatomy. As a result,
than 80 different prosthetic biomaterials that can be used to many surgeons use these products and feel they lead to a
repair inguinal and incisional hernias,7 they are all somewhat lower recurrence rate for their hernia repairs.
similar.

The most significant difference is whether or not the mesh is


designed to be used inside the peritoneum, the body’s natu- References
ral barrier to adhesion formation. This peritoneum is more or 1 Lau WY. History of treatment of groin hernia. World Journal of Surgery. 2002;
26(6):748-759.
less a slippery sack that gives the internal organs position and 2 Read RC. Herniology: past, present, and future. Hernia. 2009; 13(6):577-580.
allows them to move freely past one another. Mesh used 3 Burger JW, Luijendijk RW, Hop WC, Halm JA, Verdaasdonk EG, Jeekel J.
Long-term follow-up of a randomized controlled trial of suture versus mesh repair
inside the peritoneum must have an anti-adhesive nature. This
of incisional hernia. Annuals of Surgery. 2004;240(4):578-585.
is achieved by making the mesh out of materials that are anti- 4 Encyclopedia and Dictionary of Medicine, Nursing and Allied Health. 4th ed.
adhesive themselves (polytetrafluoroethylene [PTFE]) or coat- Benjamin F. Miller and Claire Brackman Keane. W.B. Saunders Company.
Philadelphia. 1987. pp. 570-572.
ing the mesh with an anti-adhesive film (caprolactone-coated 5 Lowenfels AB. Managing inguinal hernias. Medscape General Surgery.
polypropylene [PP] or cellulose-coated polyethylene tereph- 6 Patient Information for Laparoscopic Inguinal Hernia Repair from SAGES. Society
of American Gastrointestinal and Endoscopic Surgeons (SAGES). March 2004.
thalate [PET]). Outside the peritoneum, this factor is less
7 Kingsnorth A & LeBlanc K. Hernias: inguinal and incisional. The Lancet. 2003;
important. Common materials are PP and PET because they 362(9395):1561-1571.
have good mechanical properties at an economic price point.

44 The OR Connection
Medline Suction
Canisters and
Liqui-Loc™
Solidifiers
Easy, convenient fluid
management for the OR

Introducing a fluid management system that saves


time, adds convenience and reduces waste.

Medline Suction Canister with patent


pending all-in-one tank turret lid
• No more elbows to lose or misplace
• Shorter OR setup times (less time
spent looking for lost parts)
• Designed and tested with
help from our customers
• FREE accessory program!
Eligible customers may
receive free suction canister
carriers and holders.

Medline advanced
Liqui-Loc solidifiers
Dissolvable PVA packs are:
• Safer - Add solidifier before
the procedure, maintaining
a closed system
• Environmentally friendly -
Eliminate bottle disposal
• More convenient -
Save time setting
up and cleaning
the OR

To request a sample of the advanced Liqui-Loc


Solidifier in the PVA pack, send an e-mail to
Dynacorsamples@medline.com.
©2011 Medline Industries, Inc. Medline is a registered trademark
and Liqui-Loc is a trademark of Medline Industries, Inc.
The final piece
to complete the
latex-free puzzle
in your OR

SensiCare® Surgical Gloves


The protection, performance and comfort of latex – without the latex.
Most supplies in the OR are latex-free these days, but for • SensiCare® with Aloe – standard thickness,
many operating rooms, surgical gloves remain the last smooth grip
piece of the latex-free puzzle. Transitioning to latex-free • SensiCare® LT with Aloe – standard thickness,
surgical gloves has been challenging because historically, textured grip
the latex-free gloves available have offered inferior fit and
• SensiCare® Green with Aloe – Dark green color,
feel compared to natural rubber latex.
10% thinner for enhanced tactile sensitivity
Medline's SensiCare latex-free surgical gloves are different • SensiCare® Ortho – 40% thicker for
because they are made from Isolex, our self-manufactured extra protection
synthetic polyisoprene. SensiCare is actually softer and • SensiCare® SLT – 5% thinner, textured grip
more elastic than latex. Choose the SensiCare glove
option that best fits your needs.

Participate in a BE FREE Day at your facility. Medline will


provide a day’s worth of SensiCare latex-free surgical
gloves to trial at no cost. Call 1-800-MEDLINE or e-mail
glovedivision@medline.com to get started.

©2011 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
The Quest to Improve
Staff and Patient Safety:
How one health district converted
to latex-free surgical gloves
by Heather Francis RN MBA, Cindy Fulmore RN BN CPN(c), Deborah Garnier RN MN CPN(c)

Who is Capital Health?


Healthcare Group: Capital District Health Authority (CDHA) is the largest integrated academic health dis-
Capital District trict in Atlantic Canada. It provides tertiary health services to Atlantic Canadians and to
Health Authority 40 percent of Nova Scotia’s population. Capital Health consists of nine facilities with
11,000 employees, physicians, learners and volunteers providing medical and surgical
Location: care, mental health care, community health programs, addiction prevention and treat-
Nova Scotia, Canada ment and environmental health services. There are 38 operating rooms across the
district, performing approximately 33,845 operations per year.
Size:
Nine facilities with As an academic district, CDHA helps educate tomorrow's healthcare providers and ad-
11,000 employees ministrators and engages in research on new treatments, cures, processes and prac-
tices. With an operating budget of almost $800 million, CDHA serves the 400,000
Challenge:
residents of the district and provides specialist services to the rest of Nova Scotia and
Move the operating room
Atlantic Canada.
staff, including surgeons, to
latex-free surgical gloves

Aligning practice with policy to improve patient care 47


“For the last several years, CDHA
has implemented a proactive
latex-free glove program aimed at
protecting its staff and patients from
Victoria General Hospital, Halifax, Nova Scotia
the complications caused by allergic
reactions to latex.”
Our Challenge not have the tactile sensitivity of the latex version. This resulted
Capital Health is on a journey to become a world-leading haven in the staff and surgeons having to compromise the fit, feel and
for people-centered health, healing and learning. protection of the latex gloves.

For the last several years, CDHA has implemented a proactive Surgeon preference was expected to be a barrier to overcome,
latex-free glove program aimed at protecting its staff and pa- as gloves can be a very personal item for most doctors. The
tients from the complications caused by allergic reactions to overwhelming choice for many was latex gloves because they
latex. The serious consequence of latex allergies for patients liked the fit and feel of latex. Convincing them to change was
and staff are well-documented, including the costs associated going to be a challenge.
with staff disability, teardown of surgical sets, worker’s com-
pensation claims and adverse events of patients. Cost was also a factor, as latex-free gloves cost more than the
latex version. While the impact to our glove budget was signifi-
Recent technological advancements have enabled most prod- cant, (approximately double the cost), the overall OR supply
ucts previously made with latex to now be manufactured using cost increase was only going to be approximately less than one
non-latex materials that look, feel and perform like the latex ver- half of a percent (0.4%) or about $5.00 per procedure if we to-
sion – only safer. A good example of where this has occurred is tally converted to latex-free gloves.
with exam gloves. As a result of new technologies and materi-
als improving the properties of latex-free exam gloves, by the For us to change, we needed a supply partner who not only
end of 2006, all CDHA sites had converted to the latex-free ver- had the right products, but also the staff to provide education
sion. Staff had shown broad acceptance for this new glove and and clinical resources to execute a successful evaluation – and
continue to do so more than three years after the conversion. ultimately – a conversion to latex-free gloves.

Moving the operating room staff, including surgeons, to latex- The Solution
free surgical gloves – one of the last and most important pieces In 2006, the glove contract with the current supplier was expir-
of the latex-free glove puzzle – would prove to be more chal- ing. This provided an opportunity for further exploration of pow-
lenging. The desire to change existed on the part of the surgi- der-free, latex-free gloves, as a change was going to occur
cal team, but not everyone had the information about the anyway. At that time CDHA joined a group purchasing organi-
improved quality of latex-free gloves. zation. Medline Industries, Inc., a major manufacturer and dis-
tributor of healthcare supplies, had won the surgical gloves
Latex-free gloves, to this point, were used on a limited basis for contract with this purchasing organization. Medline was the
cases known to involve a latex-sensitive patient or OR staff North American market leader in many product categories,
member. There were many reasons for this, including the fact including exam gloves, and was rapidly growing within the sur-
that the fit, feel and performance of latex-free gloves had his- gical glove market.
torically been unacceptable to most clinicians and surgeons.
The initial products tore easily, rolled down in the cuffs and did

48 The OR Connection
Key players at CDHA, including management, clinical educa-
We determined that gaining approval for latex-free tors and supply management, were convinced with education
gloves from the surgical team required the following and existing information regarding latex reactions, that moving
key strategies: to latex-free surgical gloves was the right thing to do. At a min-
imum it was agreed there would be a conversion to powder-
• Have the surgical chief of staff and surgical department free gloves with the goal of moving to a latex-safe environment.
heads support a trial and get them involved in the The initial plan was to convert to powder-free, latex gloves to re-
selection process. Without acceptance by senior duce exposure to latex proteins by staff and to prevent
OR leadership, convincing the rest of the OR staff to aerosolization of the latex proteins in the OR environment while
trial the gloves would be extremely challenging. keeping the look and feel of latex. This would significantly
• Do not dictate the team to go latex free. If there was reduce the risk of a latex reaction for staff and patients. At this
pressure to accept the change, staff may resist the time, 78% of surgical gloves being used were powdered latex
process. It would be key to provide choices, so the and 22% were powder-free latex.
end users feel empowered to choose a glove that
suits them personally. Medline introduced its new powder-free, latex-free surgical
glove manufactured with a state-of-the-art polyisoprene syn-
• Prior to a switch, educate staff on the properties of
thetic formula, which was well-received by the perioperative
latex and latex-free gloves, as well as benefits of
leadership group. This glove appeared to have the look and feel
latex-free, powder-free gloves.
of a latex glove, but contained no latex. They also introduced a
• Share with staff the support of occupational health neoprene latex-free glove. The decision was made by materials
and risk management and share personal examples management, purchasing and OR executives to introduce these
of latex reactions. latex-free options to staff and to have three powder-free latex
gloves as alternatives. This became the idea for a “Be Free Day”
during which latex-free gloves could be evaluated.

Continued on Page 51

Aligning practice with policy to improve patient care 49


FREE
Informational
Webinars

Now Available
On Demand 24/7!
Click on the links below to participate in a webinar any time.

Perioperative Pressure Ulcer Prevention


www.medline.com/PUPP-webinar
Hand Hygiene Compliance Improvement Strategies
www.medline.com/handhygiene
Innovation in the Prevention of CAUTI
www.medline.com/erase/webinar.asp
Prior to the “Be Free Day,” a glove provider representative was brought in clinical support for the day to answer questions and
a constant presence to provide support and education sessions provide information on the latex-free gloves. Tables were set up
and tirelessly meet with many of the surgical staff to talk about near the ORs where clinicians and surgeons could try on the
the differences between latex and latex-free gloves, all in an gloves, test them and ask questions in a casual atmosphere.
effort to garner support for the new gloves. As in any large Staff members who wanted to try the gloves during surgery
hospital group, there were a few surgeons that would be a were encouraged to do so. It was clear to the staff that they
challenge to convert, and convincing this group required were not being forced to go latex-free. There were no pressure
addressing them in a more personalized manner. The glove rep- tactics involved. Each person was asked to complete a simple
resentative met separately with the surgical chief in each spe- form indicating if the new glove was “better than/ equal to/or
cialty to explain the gloves, and the process of changing to worse than” their current latex glove. To encourage participa-
latex-free. She found out from the chiefs who would be the tion, each form was entered into a prize drawing.
‘challenging’ surgeons to convince. She then met with them
individually over several months to ensure as many end users as The results from the “Be Free Day” were very positive:
possible were on board with the move to latex-free. Each chief
also sent emails to the respective surgical specialties to ensure
all end users were reached. Communication and choice would 90% answered “better than” or “equal to”
prove to be key in a successful conversion to latex-free. In ad-
dition, a poster campaign was launched to introduce the 10% answered “worse than”
concept of the “Be Free Day.”

Based on the success of “Be Free Day,” CDHA investigated the


cost implications of a primarily latex-free surgical glove choice.
Cost was going to increase (see page 2), but not enough to pre-
vent the switch, as executives were convinced it was the right
thing for patient and staff safety. The conversion also gave us
the opportunity to standardize the number of different glove
types in the organization, which would reduce our inventory
and costs associated with inventory management. At this

Be Free point, the organization was using nine different glove types
from different glove vendors. The goal was to standardize to

Day three or four glove types.

Phase II – Two-week Evaluation


Based on the acceptance from “Be Free Day,” a two-week eval-
uation period started the week of October 15, 2007. All of the
old gloves were removed from every area during the evaluation
period so staff did not have the option of reverting to the old
gloves. The glove supplier provided a clinical support team at
each site to work with individual staff members to determine the
right glove based on their specialty, glove practices, sensitivi-
ties and other considerations.
Phase I – “Be Free Day”
“Be Free Day,” Phase I of the latex-free surgical glove process, Staff members wore gloves in their surgical cases to determine
took place on June 25, 2007. It was a chance to try/evaluate which glove was most appropriate for them. After wearing the
the latex-free gloves with each surgeon’s group at all OR sites gloves for several days, staff members filled out an evaluation
in CDHA. The purpose of the exercise was to gauge the form indicating if the gloves were “acceptable” or “unaccept-
response of the OR staff toward the gloves. The glove provider able.” If a glove was “unacceptable,” the staff member worked

Aligning practice with policy to improve patient care 51


with the glove provider’s clinical expert to find a glove with an
acceptable fit and feel. Ongoing information-sharing was also
“Based on the acceptance
available from the glove supplier’s on-premise representatives.
Key to the evaluation phase was for the glove supplier to work
rate during the trial and the
closely with materials management to ensure an adequate sup-
ply of all gloves were on hand throughout the entire evaluation
overall cost justification, the
period. If we ran out of gloves, it would negatively impact the OR leadership team and
entire process.
materials management
The results of the evaluation were overwhelmingly
positive. The acceptance rate was 96.4%. decided to officially move
A sampling of staff comments and/or
observations from the evaluations included: forward with a conversion.”
“I love the zero latex concept. Thanks”
“Happy! Happy! Happy!”
“Feels good, fits well”
“The best I’ve ever tried”
“I actually like them”
“I like the fit and feel. Very comfortable”

Phase III - Conversion


Based on the acceptance rate during the trial and the overall
cost justification, the OR leadership team and materials man-
agement decided to officially move forward with a conversion.

The implementation phase was expedited as it was thought a


conversion would go smoother for surgical teams if they began
using the new gloves they tried during the evaluation immedi-
ately, rather than switching back to old gloves while the deci-
sion-making occurred.

This also eliminated stocking challenges for supply staff, as they


did not have to pull evaluation gloves from the stock shelves and
reintroduce them at a later date. The glove provider and our
distributor ensured order numbers were provided to the supply
staff and that the initial implementation order was distributed to
all appropriate areas. Staff responsible for picking case carts
were engaged at this time and introduced to the new product.

Implementation was facilitated by the extensive preliminary


work/education provided by the glove provider, which also
ensured that our OR staff members were engaged in the process.

Continued on Page 54

52 The OR Connection
Finally!
A way to know
when the catheter
was placed

MEDLINE’S FOLEY INSERTAG™


This easy documentation tool lets you know
exactly when your patient’s catheter was placed
Foley
InserTag
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.
To learn more about Medline’s Foley InserTag and
Medline’s Foley InserTag. The one little sticker that can the ERASE CAUTI program, attend an informational
make all the difference. webinar at www. medline.com/erase/webinar.asp.

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.

©2011 Medline Industries, Inc. Medline is a registered trademark and InserTag is a trademark of Medline Industries, Inc.
1
8 Steps to a Successful Glove Conversion

Engage key decision makers

2 Ask risk management and


occupational health to provide
evidence on the hazards of latex

3 Educate, educate, educate

4 Be transparent and facilitate


ongoing communication

5 Provide choices and options

6 Consider cost, but not as the


only deciding factor

7 Make sure product is available


to ensure a successful trial and
evaluation

8 Ask glove supplier to provide


on-site experts to support all
staff, including the supply team,
surgeons, nursing and sterile
processing

54 The OR Connection
Current Status
We are a little more than two years into the conversion to the
latex-free surgeon’s gloves, and the acceptance and satisfac-
tion rates among the OR staff continue to be high. At one site,
“We are a little more
the number of glove types have been reduced to four from nine
at the time of conversion.
than two years into the
conversion to the latex-free
Next steps
There are a still a few staff members from the original conversion surgeon’s gloves, and the
who have not found a glove with the fit or durability they
enjoyed with their latex glove. Since the original conversion, acceptance and satisfaction
Medline has developed four new latex-free gloves, including a
latex-free orthopedic glove. These new options should provide rates among the OR staff
more acceptable choices for those staff members who were not
satisfied with the initial latex-free gloves.
continue to be high.”

About the Authors


Heather Francis, RN BN MBA – Heather was the Health Service Director for Perioperative Services for
eight years until fall 2009. She has 15 years of perioperative experience. She is currently the Health
Services Director of Dartmouth General Hospital. She graduated from St. Rita's School of Nursing
and earned her Bachelor of Nursing and Master of Business from Dalhousie University.

Cynthia Fulmore RN BN CPN(c) – Cindy has been the clinical educator for the operating rooms at
Victoria General Hospital in Halifax for the past seven years. She is a graduate of Dalhousie University
Halifax. She is certified in perioperative nursing (Canada), and has 20 years perioperative experience.

Deborah Garnier RN MN CPN(c) – Deborah has been the Health Service Manager for the operating
rooms at Victoria General Hospital in Halifax for the past four years. Previously she held positions as
OR supervisor, perioperative educator and perioperative staff nurse. She is a graduate of SA Grace
General Hospital School of Nursing, St. Johns NL, St. Francis Xavier University, Antigonish NS and
Athabasca University, Athabasca, Alberta. She is a certified perioperative nurse (Canada) with over
20 years of perioperative experience.

Aligning practice with policy to improve patient care 55


Special Feature

Patient experience is #1
Nurse leaders rank priorities in national survey

According to the newly


released HealthLeaders
Media Industry Survey 73%
of nurse leaders said
2011, nurse leaders are
their organization plans to
most concerned about encourage more nurses
1. Patient experience/ to pursue bachelor’s de-
patient satisfaction grees over the next three
years; 18 percent plan to
2. Quality/patient safety encourage
3. Cost reduction nurses to pursue
master’s degrees.

With the advent of the of nurse leaders


HCAHPs (Hospital Care
Quality Information from the
Consumer Perspective)
survey and more government
39% say that nursing
research is
being effectively
translated into
pay-for-performance practice at the
requirements, nurses are bedside.
making the connection that
reimbursement will be tied
to patient satisfaction and When ranking the most important
quality of care, and patient factors for providing high-quality
safety beginning next year. patient care, nurse leaders reported:

#
Regarding hand 1 MOST IMPORTANT
hygiene compliance, Nurse-to-patient staffing ratio

48%
of nurse leaders agreed that
53%
of nurse leaders confirmed
#

#
2 MOST IMPORTANT
Nurse experience level

that their organization will


3 MOST IMPORTANT
the primary reason behind
be part of an accountable Nurse education/certification level
failure to achieve hand-washing
compliance is lack of spine care organization within
to self-police and report the next five years.
colleagues’ violations.

Source: HealthLeaders Media Industry Survey 2011: Nurse Leaders. Available at: www.healthleadersmedia.com/intelligence

56 The OR Connection
BioCon™- 500
Bladder Scanner
Safely Measures
Bladder Volume
Minimize unnecessary catheterization
Research has shown that 80 percent of urinary tract
infections acquired at healthcare facilities are associated
with an indwelling urethral catheter.1 This type of infection
is known as CAUTI, or catheter-associated urinary tract
infection. What’s more, Medicare no longer reimburses
for treatment of CAUTI if it happens while a patient is
hospitalized, giving hospitals a major incentive to prevent it. But
how?

Avoiding unnecessary catheter use is a primary strategy


for preventing CAUTI, and clinical guidelines recommend
the consideration of alternatives to catheterization.2
Bladder scanners can be used in place of a urinary
catheter to assess bladder volumes, and many
catheterizations can be avoided.3

To learn more about CAUTI


prevention and the BioCon-500, visit
www.erasecauti.com/alternatives.asp
or contact your Medline
sales representative.

1. Lo E, Nicolle L, Classen D, Arias A, Podgorny K, Anderson DJ, et al. SHEA/IDSA


practice recommendation: strategies to prevent catheter-associated urinary tract
infections in acute care hospitals. Infect Control Hosp Epidemiol. 2008;29:S41-S50.
2. Stokowski, LA. Preventing catheter-associated urinary tract infections. Medscape
Nursing Perspectives. February 3, 2009.
3. Stevens E. Bladder ultrasound: avoiding unnecessary catheterizations. Med/Surg
Nursing. 2005; 14(4):249-253.

©2010 Medline Industries, Inc.


Medline is a registered trademark of Medline Industries, Inc.
BioCon-500 is a trademark of Mcube Technology Co., Ltd.
What did we do after
designing a revolutionary
new catheter tray system?

We found THREE more ways


to make it even better.
We’re obsessed with engineering new and better Combined with the previous innovative tray redesign
technology for healthcare workers. So after we and comprehensive ERASE education, these three
revolutionized the outdated Foley catheter tray with new features help to improve patient safety and quality,
a unique, one-layer system design, we immediately while reducing avoidable costs associated with waste
turned our attention to addressing how we could and urinary tract infections.
make it even easier to use. We studied how the
tray was being used in the field. The result was To learn about the ERASE CAUTI system, as well as
three more great improvements. 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.

©2011 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
1 Real photography on the outside –
so you know exactly what’s inside
A photo on the package helps identify the
contents of the kit, serves as an educational
tool for the clinician and can be used to
discuss the procedure with the patient.
Also, the label opens up to a booklet
with step-by-step instructions and
helpful tips for the clinician.

2 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.

3 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.
SAFER CATHETERIZATION
FOR KIDS
Pediatric
Catheter
Tray

Children’s
Introducing Medline’s new Activities
Pediatric Catheter Tray. The
latest addition to the innovative
ERASE CAUTI product line.
ra
Sometimes, you just need a buddy. Buddy
ra mB v
mB v
e
I’
the Brave lion cub is here to help your youngest
e

catheter patients. Along with some serious patient


I’

(and parent) education resources, you’ll find some

dy
Li

upbeat fun and even a bravery award sticker in


ke
Bud
dy

every tray.
Li

ke
But it’s more than just fun. There’s published evidence Bud
that distraction helps children tolerate unpleasant
ra
mB v
Bravery Sticker
procedures better than adult reassurance does.
ra
mB v
e
I’

You trust Medline for clinical innovations, such as our To learn more about Medline’s ERASE CAUTI
e
I’

industry-leading catheter tray design. Now, we can be program and alternatives to catheterization,
dy

your patient’s buddy, too. visit http://erasecauti.com.


Li

ke
Bud
dy
Li

ke
Bud
ra
mB v
©2011 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

Bra
e
I’
OR Issues

Unity Hospital: Utilizing Medline’s ERASE CAUTI®


Program to Reduce Hospital Acquired Infections
in the Delivery of Safe, Quality Care
By Erica Perez BSN, RN, Clinical Educator, Unity Hospital

Quality Improvement Goal


Hospital: Unity Hospital continuously monitors for hospital-acquired infections (HAIs),
Unity Hospital including catheter-associated urinary tract infections (CAUTI). Through data
monitoring of infection markers, Unity Health System has identified areas for
Location: improvement to reduce urine Nosocomial Infection Markers (NIMs), and reduce
Rochester, NY the number of CAUTIs to enhance outcomes. Opportunities identified include:
increasing nurse/provider communication/collaboration; educating nurses
Size: regarding best practice techniques for catheter insertion; empowering nurses to
340-bed actively evaluate clinical indications or need for catheter insertion, along with
early Foley discontinuation; and reinforcing patient education. By focusing on
Challenge: these initiatives, Unity Health System is able to provide safe, quality care and
To develope a proactive approach to infection reduce the risk of HAIs. The reduction of urine NIMs not only enhances patient
prevention and to raise awareness of the outcomes but also promotes organizational efficiency. With the implementation
significance of hospital-acquired infections of the Value Based Purchasing (VBP) program by Centers for Medicare &
on our patients and the facility. Medicaid Services (CMS), reimbursement is directly linked to quality outcomes
and efficiency. Many organizations, including Unity Health System, continue to
Results:
strive for best quality and care outcomes.
Decreased urine NIMs by 32% demonstrating:
Facility Demographics
• Significant cost-avoidance of $3,637 per
Unity Hospital is a 340-bed, nonprofit hospital. It is accredited by The Joint
urine NIM
Commission, and the hospital’s intensive care unit ranks in the Top 100 in the
• Reduced risk of patients developing a
United States. In 2009 Unity Hospital had 14,687 discharges and a total of
catheter-associated urinary tract infection
147,265 patient days.
(CAUTI)
• Improved standard of care for patients
receiving a Foley catheter

Aligning practice with policy to improve patient care 61


“The ERASE CAUTI program ties education, nursing
power and industry product to promote best processes
and decrease the opportunity for a CAUTI to develop.”

Unity Health System offers a wide range of services including: Inconsistencies were observed in the technique nurses used
• Emergency center to insert Foley catheters. This was due to:
• Endoscopy unit
• Family birth place 1. Variance in how nurses were initially taught the procedure;
• Intensive care unit 2. Differing protocols at previous facilities where nurses
• Joint replacement center have practiced;
• Spine center with pain management 3. Different types of Foley trays nurses have used in the past.
• Residency program
• Stroke center Given these challenges, Unity Hospital established the following
• Surgical center new goals:
• Vascular center • Raise awareness of CAUTI prevention;
• Reduce catheter utilization;
Unity Hospital strives to offer the latest advancements in • Provide clinical education for proper Foley
treatment while giving the personal attention patients expect insertion techniques;
and deserve from a community health system. Not only are • Enhance patient education;
the physicians able to provide high quality medical services, • Reduce urine NIMs and overall CAUTI rate.
clinical staff also provides compassionate care to make the
patient feel as comfortable as possible. The Solution
Medline’s ERASE CAUTI Foley catheter management program
The Challenge was introduced to Unity Hospital in April, 2010. The ERASE
Unity closely monitors HAIs, including catheter-associated CAUTI program ties education, nursing power and industry
urinary tract infections (CAUTI). Instances in which a CAUTI product to promote best processes and decrease the
developed, data was evaluated to determine the cause of opportunity for a CAUTI to develop.
the infection. While examining the cause of the infection in
retrospect was valuable, a more proactive approach in The Medline program offered the tools to reduce the
infection prevention was imperative. It was essential to raise inconsistencies identified.
awareness of CAUTI and the significance of HAIs within the
facility, but more importantly the outcomes these have on our 1.The one-layer tray presents the procedure components in an
patients. intuitive manner, guiding the nurse through the procedure from
left to right. It is also more efficient to handle all the
Throughout this process, we identified gaps in standardization components in one layer, making it easier to maintain aseptic
and knowledge regarding the proper insertion technique and technique. The one layer tray is a neatly packaged clinical
clinical indications of a Foley catheter. The decision to insert a solution, not just a supply solution.
Foley involves collaboration between medical and nursing
staff; however, nurses must possess a sense a responsibility 2.The accompanying education program is provided online
for ensuring the appropriate clinical decision. In addition, the through the e-learning site, Medline University. The education
nurses sought to feel more empowered to monitor a patient’s encompasses a video overview, three learning modules, and
ongoing need for a Foley, ensuring its timely removal. an interactive competency that the clinician uses to
demonstrate knowledge of proper foley insertion.

62 The OR Connection
3. Awareness tools are also included in the program to were conducted for two weeks. These online modules have
communicate program goals engaging the nurses in the since been added to clinical orientation as a mandatory core
education process, and to encourage the participation in the competency for new nursing staff. To date, over 500 nurses
facility-wide effort to reduce CAUTI. have completed the education classes online.

4. The patient education card resembles a greeting card, which It’s essential to note that because the education is web-based,
every nurse reviews with their patients before insertion. This it was critical to evaluate the technical standards of the work
allows the patients to become an active participant in their station computers, as well as the facility network capability. When
care. The card, included in the tray, helps to bridge the we experienced initial usability issues, Medline worked with the
knowledge gap for patients caring for their catheter once it information technology (IT) department to make adjustments to
is in place. the facility firewall and other technical concerns.

Awareness tools, education, and the tray design all emphasize Step 3- Trial the Tray
evidence- based techniques that standardize practices for Foley Following the completion of the competency, four units - - (the
catheters. The checklist on the front of the tray also serves as Emergency Department (ED), the Operating Room (OR), and
a useful tool that guides nurse’s practice when a Foley insertion medical surgical units 2300 and 2400) - - trialed the ERASE
is necessary. CAUTI Foley catheter tray for three weeks. As a supplement to
the online education program, Medline support staff was
Execution available to demonstrate the
After learning more about the program and demonstrating its
capabilities to a group of staff members and nurse leaders, components of the tray to all nurses in the participating units.
Unity Hospital decided to trial the program in June 2010. Medline staff was on site throughout the trial process to support
clinical staff, ensure communication and documentation of
Step 1- Process Improvement Plan feedback. The outcomes of the trial were monitored and
The organization’s first step was to create an overall process hospital- wide implementation was discussed.
improvement plan. Team leaders, staff champions, directors and
the Infection Prevention team collaborated to draft the plan. Step 4- Implementation
Meetings were held to discuss all components of the program Following a successful trial period, the program was rolled out
including: steps of implementation, necessary tasks to complete, facility- wide to all acute units in August 2010. Medline provided
delegation of tasks, and the estimated date of completion for product support staff to assist during distribution and rollout.
each task. The plan was communicated to all staff involved in the Educators demonstrated the product design and layout to
project and updated to reflect the current status of each step. familiarize the nursing staff with the new product. The
mandatory online education and interactive competency taught
Step 2- Education the indications and alternatives to catheterization, aseptic
The team worked to educate the end user clinical staff technique and proper insertion of a Foley catheter, care and
regarding the ERASE CAUTI program by utilizing the tools maintenance, signs and symptoms of CAUTI and timely
available on Medline’s e-learning site: Medline University. The removal. Ensuring proper education is a crucial step in the
program was rolled out to nurses and the education classes ongoing sustainability and success of the program.

Aligning practice with policy to improve patient care 63


“This decrease in urine NIMs
demonstrates safe care delivery
and a significant cost-avoidance
for Unity Hospital.”

Results Summary of Clinical Outcomes


Unity Hospital was satisfied with the results experienced within Standardization of Foley insertion technique, increased
one month of implementing Medline’s ERASE CAUTI program. education, nurse/physician communication and collaboration,
Data collected from the same time period one year prior to along with overall awareness of proper indications for use
implementation (August 2009) revealed a marked reduction in contributed to a 32% decrease in urine NIMs. This decrease in
urine NIMs. urine NIMs demonstrates safe care delivery and a significant
cost-avoidance for Unity Hospital. Achieving these outcomes
Reduction in urine NIMs: was possible thanks to Medline University’s online ERASE
Unity Hospital uses a data surveillance system to track NIMs. CAUTI education and competency course that simulates
This data collection system increases efficiency for reporting proper insertion technique. The education combined with a
and internal process improvements by prescreening likely single layer tray design that follows the Center for Disease
causes of HAIs. During the implementation of Medline’s ERASE Control (CDC) Guidelines, plus the dedication and commitment
CAUTI program, the rate of urine NIMs was closely monitored. to clinical excellence demonstrated by the clinical care team at
Compared to the control period of August 2009, Unity Hospital Unity has made this initiative a success.
observed a decrease in urine NIMs of 32% in August 2010. The
data surveillance provider that Unity utilizes calculates a dollar As a result, Unity has improved the standard of care for patients
amount associated with each NIM identified. The associated receiving a Foley catheter and has reduced the risk of CAUTI.
cost for each urine NIM is $3,637, which demonstrates a Through continued use of the online education program for new
significant cost-avoidance based on the reduction in urine NIMs clinical nurses, enhanced patient education and sustained use
after the ERASE CAUTI Program implementation. This reduction of the ERASE CAUTI tray, Unity anticipates continued clinical
in urine NIMs indicates fewer patients may be at risk for excellence and safe patient care delivery to better serve our
developing a CAUTI. Unity Hospital is very proud to share this community and our patients.
demonstration of reduction in urine NIMs.
About the author
Reduction in CAUTI: Erica Perez is the Clinical Educator at Unity Hospital in Rochester,
Although Unity Hospital experienced a very low rate of CAUTI in New York. In this position, Erica has the responsibility of overseeing
clinical education in the acute inpatient areas, developing and
2009, after implementing the ERASE CAUTI Program rates
delivering inservices on new products, communicating updates of
continue to trend downward. Because Unity Hospital had few
hospital policy and procedures and serves as the Infection Control
incidences of CAUTI prior to implementation, success has been
liaison. Erica brings 18 years of nursing experience to this position
measured by demonstrating a decrease in NIMs post
with a specialty in Emergency Medicine and serves as a member of
implementation of this program. the New York State Emergency Nurses Association Genesee Valley
Chapter. Serving the past roles of CNA, LPN, RN and BSN
throughout her career allows Erica to effectively implement education
programs while remaining sensitive to the participation of all roles in
nursing practice. Most recently Erica has earned her Masters of
Science in Nursing from Roberts Wesleyan College.

64 The OR Connection
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68 The OR Connection
Special Feature

12
Ways to
Reduce Hospital
Readmissions
By Cheryl Clark
for HealthLeaders Media
December 27, 2010

Time flies. In just 21 months, the federal government will start We also spoke with Amy Boutwell, MD, an internist at Newton-
penalizing hospitals with higher than expected readmission rates. Wellesley Hospital in Newton, MA and Director of Health Policy
And even though much about the regulations-to come remains Strategy for the Institute for Healthcare Improvement; Timothy
unclear, clinicians along the care continuum are scrambling to Ferris, MD, medical director of the Massachusetts General Physi-
get ready. cians Organization, and Estee Neuhirth, director of field studies
at Kaiser Permanente in California.
Or they should be. It’s not just important for a hospital’s bottom
line. It’s important for the patient. Some of these strategies aren’t yet proven to work in all settings,
of course. And many are still in the demonstrations phase. But
We’ve been talking with some of the nation’s experts on the sub- with national readmission rates as high one in five, and higher for
ject, including Stephen F. Jencks, M.D., whose April 2009 article certain diseases, many providers are trying anything that sounds
in the New England Journal of Medicine set the tone for today’s plausible.
readmission prevention energy. His review of nearly 12 million
beneficiaries discharged from hospitals between 2003 and 2004 Here are some of the prevention strategies that these and other
found that nearly 21 percent, or one in five, were re-hospitalized experts think might be worth a shot. Many involve—to a greater
within 30 days and 34 percent were readmitted within 90 days. or lesser degree —following the patient out of the hospital,

Aligning practice with policy to improve patient care 69


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either in-person, electronically, or by phone, but others involve Jencks adds that “senders and receivers, for example hospital
upside-down introspection and re-evaluation by providers along discharge planners and skilled nursing facility staff and home
the care continuum. health” meet often enough so they can learn about the realities
of the transitions they initiate and receive.
1. Discharge Summaries
Dictate discharge summaries within 24 hours of discharge. 3. Provide Medication on Discharge
Boutwell says that standard practice and policy at most hospi- Send the patient home with a 30-day medication supply,
tals is that discharge summaries are completed within 30 days wrapped in packaging that clearly explains timing, dosage,
of the discharge. “I was trained that the summary is a retro- frequency, etc. Some health centers with Medicaid patients may
spective report of what happened in hospitalization. But what we be trying this strategy, which is difficult for hospitals to do with
need today is anticipatory guidance. Patients get discharged and Medicare patients because of distinctions between Part A and
go home. They can’t fill their meds, insurance doesn’t cover the Part B payment. Still, for some high-risk populations, such as
med or they have questions. They’re nervous and worried. They patients with congestive heart failure and those who have been
call their primary care provider, who didn’t even know they were readmitted before, it might be worth it for the hospital to absorb
admitted. the cost.

Boutwell says that 30-day-discharge summary policies “might 4. Make a Follow-up Plan Before Discharge
have sufficed in a time gone by. But that doesn’t work anymore. Have hospital staff make follow-up appointments with patient’s
Information needs to be available at the time of discharge. physician and don’t discharge patient until this schedule is set
There’s a growing recognition of this need, but staff bylaws up. A key is to make sure the patient has transportation to the
haven’t changed.” physician’s office, understands the importance of meeting that
time frame, and following up with a phone call to the physician
2. Lengthen the Handoff Process to assure that the visit was completed.
At every juncture in patient care process, especially discharge,
have teams talk to each other about the patient. And by the way, 5. Telehealth
don’t call them discharges. Call them “transitions.” Standardize We couldn’t find anyone using video monitors to communicate
them for a variety of providers, from hospital to rehabilitation on a daily basis with the use of such software as Skype, for
facility to skilled nursing facility to home and back. example, but some readmission experts say it’s an interesting
approach to keep up visual as well as verbal communication with
Boutwell says that “taking this person-centered approach shifts patients, especially those that are high risk for readmission.
the concept from discharge, which is a moment in time and
you’re done with it, to a transition—a shared accountability. We On a more practical scale, Home Healthcare Partners in Dallas
need to make sure the receiving providers understand who this uses health coaches, intensive care clinicians, and wireless tech-
patient is, with a 360-degree view. nology to record vital signs on a daily basis for about 2,100
discharged Medicare fee-for-service beneficiaries for between

Aligning practice with policy to improve patient care 71


60 to 120 days. So far, they have done this for about 7,000 7. Understand What's Happening After Discharge
unduplicated patients in the last two years, for several hundred Kaiser Permanente is using video cameras to chronicle home
hospitals in Dallas and Louisiana, says HHP’s CEO, Wayne Bazzle. settings and the entire care process to determine what’s
happening to the patient after discharge that provoked a
The target population for intense monitoring includes those with readmission.
four or five co-morbidities and who have a primary diagnosis of
congestive heart failure, chronic obstructive pulmonary disease, The team is also using video of the care team, from the phar-
diabetes, Alzheimer’s and hypertension. macist, home care providers, nurses, and physicians about their
care of that patient, to highlight wrinkles and cracks in the
Bazzle says that the effort involves phone calls of between five system that brought the patient back to the hospital.
and 15 minutes, and is frequent enough with the same team “so
we have their trust. We can help them stay out of the hospital if So far, Kaiser officials say that the video project has contributed
they'’re more truthful with us about what’s going on, and if we to a reduction in readmission rates at some hospitals where it
see some deterioration, we can help them cope. Normally it’s a has been tried, such as from 15.7 percent to 9 percent at
medication management issue, or they’ve become a little too Kaiser’s South Bay Medical Center near Los Angeles, because
relaxed with their diet.” it gave the team information to streamline care, says Kaiser’s
Neuwirth.
6. Identify Frequent Flyers
Customize your hospita’s admission and re-admission rates for 8. Provide Home Care on Wheels
demographic and disease characteristics to identify those at Just like Meals-on-Wheels can be scheduled in advance, so can
highest risk, and expend extra resources on their care needs. case management, housekeeping services, transportation to the
This may involve special programs for homeless patients, such pharmacy and physician’s office. At Piedmont Hospital in Atlanta,
as the one effort by a cohort of Los Angeles hospitals who grap- in collaboration with the Area Agency on Aging, patients having
pled with how to safely discharge homeless patients without elective knee surgery get coupons and prescheduling, “so that
violating city laws. by the time you get out of the hospital, it’s waiting there for you,”
Boutwell says. She adds that this kind of a pre-arrangement for
The Los Angeles project now discharges homeless patients who post-transition care is “spreading like wildfire” among a number
meet certain criteria to a half-way type of house in nearby Bell, of hospitals, but so far it’s mainly being tried with elective
and saved $3 million for hospitals in its first few months. Expan- patients.
sions in other parts of Southern California are underway.
Continued on Page 74

Many strategies involve—to a greater or lesser


degree —following the patient out of the hospital,
either in-person, electronically, or by phone.

72 The OR Connection
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9. Consider Physician Medication Reconciliation For surgical patients, those with vascular surgery had the high-
A recent paper in the New England Journal of Medicine by Yut- est readmission rate, 23.9 percent, followed by those with hip or
ing Zhang of the University of Pittsburgh noted the wide geo- femur surgery, 17.9 percent. Perhaps these are the places where
graphic variation among physicians’ prescribing practices with readmissions can be most quickly reduced.
medications that should be avoided in patients over age 65. She
also noted variation in prescribing practices for drugs that have States with the Highest Hospital Readmission Rates
a high risk for negative drug-disease interaction. Washington, D.C. 23.2%
Maryland 22%
Jencks says that Zhang and colleagues “are pointing us to a Louisiana 21.9%
rather important gap in the most common thinking about transi-
New Jersey 21.9%
tions—that we are to make sure that patients are able to get and
Illinois 21.7%
take medications, get recommended follow-up, and generally do
West Virginia 21.3%
as they are told. But we know that medication plans can be in
Kentucky 21.2%
life-threatening error, that physicians often recommend a time-to-
Mississippi 21.1%
follow-up that is too long, that discharge plans are often written
in ignorance of the patient’s pre-admission history and experi- Missouri 20.8%
ence. In general, we need to be much more critical of the plans New York 20.7%
patients get.” Massachusetts 20.2%
Oklahoma 20.1%
10. Make Sure Patients Understand
Patients may nod, and say they understand what they’re sup-
posed to do after they leave the hospital. But “teach back,” in 12. Listen to the Patient
which they and their caregivers repeat back those instructions, Involve the emergency room, hospice or home health providers
even to more than one hospital caregiver, needs to be constantly to make sure patients don’t come to the emergency room for
reinforced, readmission experts say. Jencks says that caregivers non-emergent end-of-life care issues. Providing patients and
need to understand that their patients are often heavily med- their family members with informed choices, opportunities for
icated, stressed, groggy and confused. And that their disease advance directives, and counseling in the emergency room setting
state may impair their ability to understand what they are being may avert painful, unnecessary admissions. Look for this to be
told, much less remember it two days later. a major expansion of palliative care professionals inside the ED.

11. Focus on Highest-risk Patients “There really needs to be a care plan that reflects the patient’s
Examine the readmission patterns at your hospital and see which wishes,” Jencks says. “This is quite different from either a med-
patients, with which conditions, diseases or procedures, have ical power of attorney or what is often called a living will because
the most readmissions. If resources are limited as they are at it lays out the goals of treatment.
most hospitals, push them toward a select group of patients in
a more intense way to see if increased effort makes a difference. “Cure? Palliation? Functional independence? Playing dominoes
with friends? Hospice? This kind of plan has little relevance to
For example, in his New England Journal of Medicine paper, persons without substantial chronic conditions, but it is totally
Jencks showed that for certain diseases or conditions, and in relevant to a patient with one or more chronic conditions that
certain parts of the country, readmission rates are even higher have required hospitalization. With such a plan, one can often
than the national average of one in five. For example, for med- avoid readmissions that really do not serve the patient’s needs or
ical patients, the readmission rate for heart failure patients was values. What is, after all, worse than a readmission? Readmission
27 percent; for those with psychoses, 24.6 percent; chronic of a patient who does not want to be readmitted,” Jencks says.
obstructive pulmonary disease, 22.6 percent. Patients with
pneumonia and gastrointestinal problems were re-hospitalized Reprinted with permission from HCPro, Inc. (February 2011) Copyright
at rates of 21 percent and 19.2 percent respectively. HCPro, Marblehead, MA. For more information, call 800/639-7477 or visit
www.HealthLeadersMedia.com.

74 The OR Connection
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Aligning practice with policy to improve patient care 75
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Medline Joins
Greening the
Operating Room
Initiative

Medline has joined a group of corporate sponsors to support The following are the GOR areas for “green” interventions in the
Practice Greenhealth’s Greening the Operating Room (GOR) operating room:
initiative. This initiative to green the nation’s operating rooms was • Single-Use Device (SUD) Reprocessing
launched in 2010 to reduce the environmental footprint of oper- • Reusables v. Disposables: Gowns, Surgical Drapes, Basins
ating rooms in U.S. hospitals. Hospital operating rooms contribute and Other Reusables
between 20 and 30 percent of the hospital’s total waste.1 • OR Kit Formulation
• Waste Anesthetic Gas Scavenging Systems
Medline will join the collaborative effort of hospitals, manufactur- • Fluid Waste Management Systems
ers and related stakeholders to develop guidance documents for • Energy Use/Lighting & Thermal Comfort
helping reduce the environmental impact of the nation’s operating • Regulated Medical Waste (RMW)
rooms and potentially reduce cost, increase quality and improve Minimization/Segregation
worker or patient safety. • 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.
Reference
1. Esaki RK & Macario A. Wastage of supplies and drugs in the operating room. Medscape Anesthesiology.

Aligning practice with policy to improve patient care 77


Medline Launches
Sustainability Program
Healthcare facilities, which generate an estimated 6,600
tons of waste per day, are almost the largest generator of
waste in the country, second only to the food industry.
That translates to the equivalent of 5,110 pounds of waste
per patient bed annually. Medline is addressing this
industry-wide concern through their Sustainability Pro-
gram, which will include hospital management consulting,
staff education, and facility-wide awareness campaigns.
For more information on Medline’s Sustainability Program,
contact Francesca Olivier at 847-643-3821.

Hospital operating rooms contribute between 20 and 30


percent of the hospital’s total waste. Medline is a co-sponsor
of Practice Greenhealth’s Greening the Operating Room™
initiative, a collaborative effort of hospitals, manufacturers
and related stakeholders to develop guidance docu-
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operating rooms.

Practice Greenhealth’s vision for this initiative is to help


every provider in the country offer the best available
patient care in operating rooms that utilize product and
practices that are patient-, worker-, and environmentally
safe while minimizing costs.

Nearly 100 hospitals have already pledged their participa-


tion by completing the Participation Commitment Form,
which is included on the next page. The Commitment
allows hospitals to participate in whichever way is best for
their needs. Resources and educational materials for hos-
pitals can be found at www.practicegreenhealth.org or by
calling 502-727-8658.

78 The OR Connection
Green Facts

Upcoming
Green Events An avera
of
g
percent e of 24
86%
of total hospital
waste is medical
cla
as hazard ssified costs are
CleanMed 2011 ous a
regulate nd attributed to
d
Medline will be an exhibitor at CleanMed 2011, a conference
this waste
that brings together leaders in environmentally sustainable
healthcare and features topics from environmentally preferable
products and purchasing, to green building design. Medline will
exhibiting our greensmart products such as the EcoDrape, Nat- 90% of red bag waste does not actually meet
ural OR Towels and Pigment-Free Plastics. The conference is in criteria for red-bag waste
Phoenix, Arizona April 6-8, 2011.

Webinars By switching to reusable


To register for these events go to surgical gowns, one
http://www.practicegreenhealth.org/tools/webinars/calendar hospital saved $60,000
per year

Apr 12 Climate Change and the Role of the Health Care By switching from blue wrap
Free Professional: Education, Mitigation and Adaptation storage to hard cases, a hospital
saved $26,000 per year
Apr 14 Climate Change and the Role of the Health Care
Free Clinician: Education, Mitigation and Adaptation

40
Percent of red-bagged medical waste
Apr 27 Green Design & Construction Series:
from ORs that is actually just packaging
$150 Regulatory Impact on Healthcare Greening
material (Another 40% is suction
May 05 Introduction to Greenhealth Tracker canister waste)
Free

25
Percent estimated portion of hospital
May 10 Getting Started with PGH - Intro for New Members operating costs that are consumed
Free by energy use

May 11 Green Operations Series: Community Organizing


Source: Kwakye G, Brat GA, Makary, MA Arch Surg.
$150 101: How a Corner Office Can Cultivate a 2011;146(2):131-136.
Sustainable Local Food Program for Patient
Health, Healing and Wellness.

May 19 Greening the OR: Energy Efficiency in the OR 121 ft


Free per day
Amount of material the average
May 25 Green Design & Construction Series:
$150 10-OR Suite could save if they
Greening the Community Hospital:
Re-scaling the Management of Benefits and Costs replaced half of their full-size
vier at 847-643-3821. natural OR towels with the slightly
smaller natural OR hand towel

Medline Industries, Inc. Data on file.

Aligning practice with policy to improve patient care 79


The OR Goes Green
– the only TRULY eco-friendly surgical drape
Medline’s new patent-pending EcoDrape is the only Composition Comparison
dye-free eco-friendly surgical drape available today. EcoDrape SMS

Made of more than 96% wood pulp, EcoDrape will Fibers More than 96% No wood
wood pulp pulp
biodegrade in only two to five months in a landfill –
Petrochemical 0% 100% PP
polypropylene drapes take hundreds of years to break ingredients (plastics)
down. EcoDrape has all the same great features and Additives Bio-based Fluorine
performance as other Medline drapes, including
hook-and-loop line holders, large reinforcement
zones, and premium tape and incise film flush to For a quick online video demonstration,
the fenestration. visit www.medline.com/ecodrape

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level of green!

©2011 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
EcoDrape and greensmart are trademarks of Medline Industries, Inc.
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" # $ $ % & % ' !(! ( ) $ !*
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!
Please feel free to call or write with any questions, comments or suggestions you might have.

Thank you so much for your support and we look forward to working with you as a pioneer in this
extraordinarily important undertaking!

Go to www.practicegreenhealth.org for an electronic copy of this form.

Aligning practice with policy to improve patient care 81


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Study of
Breast Biopsies
Finds Surgery
Used Too
Extensively
Too many women with abnormal mammograms or other breast prob-
lems are undergoing surgical biopsies when they should be having
needle biopsies, which are safer, less invasive and cheaper, new
research shows.

A study in Florida found that 30 percent of the breast biopsies there


from 2003 to 2008 were surgical. The rate should be 10 percent or
less, according to medical guidelines.

The figures in the rest of the country are likely to be similar to


Florida’s, researchers say, which would translate to more than
300,000 women a year having unnecessary surgery, at a cost of hun-
dreds of millions of dollars. Many of these women do not even have
cancer: about 80 percent of breast biopsies are benign. For women
who do have cancer, a surgical biopsy means two operations instead
of one, and may make the cancer surgery more difficult than it
would have been if a needle biopsy had been done.

Dr. Stephen R. Grobmyer, the senior author of the Florida study, said
he and his colleagues started their research because they kept see-
ing patients referred from other hospitals who had undergone surgi-
cal biopsies (also called open biopsies) when a needle should have
been used.

By Denise Grady

84 The OR Connection
OR Issues

Hospitals charge $5,000 to $6,000 for a needle biopsy,


and double that for an open biopsy,

“After a while you keep seeing this, you say something’s About 1.6 million breast biopsies a year are performed in the
going on here,” said Dr. Grobmyer, who is director of the United States. But in 2010, only about 261,000 found can-
breast cancer program at the University of Florida in cer (207,000 women had invasive breast cancer, and another
Gainesville. 54,000 had a condition called ductal carcinoma in situ, in
which cancer cells have not invaded the surrounding tissue).
The reason for the overuse of open biopsies is not known.
Researchers say the problem may occur because not all Hospitals charge $5,000 to $6,000 for a needle biopsy, and
doctors keep up with medical advances and guidelines. But double that for an open biopsy, according to Dr. Grobmyer’s
they also say that some surgeons keep doing open biopsies article. Doctors’ fees for an open biopsy range from $1,500
because needle biopsies are usually performed by radiolo- to $2,500, he said, and $750 to $1,500 for a needle biopsy.
gists. The surgeon would have to refer the patient to a radi-
ologist, and lose the biopsy fee. A surgeon who was not part of Dr. Grobmyer’s study said
she often encountered patients referred from other hospitals
A surgical biopsy requires an inchlong incision, stitches and whose open biopsies should have been done with a needle.
sometimes sedation or general anesthesia. It leaves a scar.
A needle biopsy requires only numbing with a local anes- “I see it all the time,” said the surgeon, Dr. Elisa R. Port, the
thetic, uses a tiny incision and no stitches and carries less chief of breast surgery at Mount Sinai Medical Center in
risk of infection and scarring. Manhattan. “People are causing harm and should be held
accountable.”
If the abnormality in the breast is too small to be felt and has
been detected by a mammogram or other imaging method, Dr. Melvin J. Silverstein, a breast cancer surgeon at Hoag
the needle biopsy must also be guided by imaging — mam- Memorial Hospital Presbyterian in Newport Beach, Calif., and
mography, ultrasound or M.R.I. — and will often have to be a clinical professor of surgery at the University of Southern
performed by a radiologist. If a lump can be felt, imaging is not California, said it was “outrageous” that 30 percent of breast
needed to guide the needle, and a surgeon can perform it. biopsies were done by surgery.

“Surgeons really have to let go of the patient when they have He said some of the unnecessary procedures were being
an image abnormality,” said Dr. I. Michael Leitman, the chief performed by surgeons who did not want to lose biopsy fees
of general surgery at Beth Israel Medical Center in Manhat- by sending patients to a radiologist.
tan. “They are giving away a potential surgery. But the stan-
dards require it. And I’m a surgeon.” “I hate to even say that,” Dr. Silverstein said. “But I don’t
know how else to explain these numbers.”
Dr. Grobmyer’s study, published by The American Journal of
Surgery, is based on 172,342 biopsies entered into a state A study at Beth Israel Medical Center in Manhattan (Dr. Leit-
database in Florida. It is the largest study of open biopsy man was an author), published in 2009, found that the rate
rates in the United States, and the first to include patients of open breast biopsies in 2007 varied with the type of
with and without cancer. surgeon.

Aligning practice with policy to improve patient care 85


One way for hospitals to stop excess open biopsies is to ban
them, Dr. Silverstein said, unless they are truly necessary, as in
uncommon cases in which a needle cannot reach the spot.

Breast surgeons employed by the hospital and involved in One way for hospitals to stop excess open biopsies is to ban
teaching had a 10 percent rate. Breast surgeons in private them, Dr. Silverstein said, unless they are truly necessary, as
practice who operated at Beth Israel had a 35 percent rate. in uncommon cases in which a needle cannot reach the
Among general surgeons, who do not specialize in breast spot.
surgery (some who were on staff at the hospital and some
who were not), the rate was 37 percent. All the doctors earn “We made a rule,” he said. “If it can be done with a needle,
biopsy fees, so they all had the same incentive. it has to be. We embarrass you if you do an open biopsy. We
bring you before a tumor board to explain.”
The lead author of the study, Dr. Susan K. Boolbol, chief of
breast surgery at Beth Israel, said the difference could be Dr. Silverstein says that when he lectures and asks how
explained, in part, by training. She said the academic breast many surgeons in the audience perform open biopsies, no
surgeons on the hospital staff were more likely than the others hands go up. “Nobody will admit it,” he said.
to keep up with new developments in the field and to work
closely with radiologists. As for the idea that the motivation He said there is more to be gained by taking his message
was money, she said, “A huge part of me doesn’t want to straight to the patients. He and other doctors say that any
believe it’s true.” woman who is told that she needs a surgical biopsy should
ask why, and consider a second opinion.
She said that when she asked surgeons in the study why
they were doing open biopsies, many said patients wanted “Maybe we have to get patients to say, ‘This guy took a big
them. “My comeback was, ‘Do you think you had an inher- chunk out of me and I didn’t even have cancer, and now I’m
ent bias in the way you explained it?’ ” In the past seven deformed,’ ” Dr. Silverstein said. “Who just overthrew
years, she said she had only one patient choose an open Mubarak? The people. This is exactly the same thing.”
biopsy over a needle biopsy.

Dr. Boolbol says some patients fear that sticking a needle From The New york Times, February 19, 2011. © 2011 The New york
Times All rights reserved. used by permission and protected by the
into a cancer will cause it to spread, and she spends a lot of Copyright laws of the united States. The printing, copying, redistribution,
time explaining that it is not true. She said that open biopsy or retransmission of the Material without express written permission
rates declined among surgeons at Beth Israel who were told is prohibited.
about her study’s findings, but newcomers still tended to
have higher rates.

“This is a constant education process for surgeons,” she


said.

86 The OR Connection
ARGLAES® IN THE OR
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Use silver to fight bacteria and surgical site infections


Arglaes provides: The Arglaes family of products has something
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• Moist wound healing • Arglaes Film is ideal for managing bacterial penetration
• Fewer dressing changes on post-op incision and line sites.
• Non-attaining assay • Arglaes Island features a calcium alginate pad for fluid
• Transparency for wound monitoring management in addition to controlled-release silver.

To schedule a FREE demonstration of Arglaes


in your OR, contact your Medline representative,
call 1-800-MEDLINE or visit www.medline.com.

©2011 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
Arglaes is a registered trademark of Giltech Limited Corporation.
Special Feature

Celebrating Six Since 2006, Medline has been hosting “Together We Can
Save Lives Through Early Detection” breast cancer awareness
breakfast forums at the Association of PeriOperative Regis-
Years of Spreading tered Nurses (AORN) Annual Congress as part of the com-
pany’s efforts to raise breast cancer awareness and share the

Breast Cancer importance of early detection.

Awareness to Spreading this message to nursing professionals is a key goal


of Medline’s campaign. Nurses are not only caregivers, but

Healthcare major influencers of women when it comes to early detection.

Every year, Medline invites a celebrity breast cancer survivor to


Professionals share her survival story and her own inspirational message
of hope at the breakfast. Past keynote speakers include Ann

Across the Nation Jillian, the late Rue McClanahan, Dr. Marla Shapiro, Linda
Ellerbee and Peggy Fleming.

2011
Breakfast Forum at the AORN 58th Congress – Philadelphia, Pennsylvania

This year, Medline’s 6th annual breakfast, held in conjunction


with the AORN 58th Congress in Philadelphia, Pennsylvania,
features Jill Eikenberry, a breast cancer survivor, and her hus-
band Michael Tucker. Eikenberry and Tucker are veteran
stage, film and television actors, perhaps best known for their
portrayals of Ann Kelsy and Stuart Markowitz on the long-run-
ning hit television series l.A. law.

88 The OR Connection
A look back at the breakfast forums
over the past five years

2010
Breakfast Forum at the AORN 57th Congress – Denver, Colorado

An audience of more than 1,200 operating room nurses, the largest yet, gathered
to hear Olympic gold medalist Peggy Fleming talk about her skating career and battle
with breast cancer. She did not disappoint the early morning crowd, who were
also treated to a surprise appearance by several other celebrities of sorts – the
staff members from Providence St. Vincent Medical Center in Portland, Oregon,
who starred in the “Pink Glove Dance,” a YouTube video sensation that has more
than 13.1 million views to date.

AORN breakfast participants are inspired by Peggy Fleming’s story about her battle with breast cancer

Aligning practice with policy to improve patient care 89


2009
Breakfast Forum at the AORN 56th Congress – Chicago, Illinois

One of the funniest, frankest and most distinctive journalists to ever appear on television,
keynote speaker Linda Ellerbee touched and inspired the crowd of 1,000 with her candid
talk about her treatment and recovery. A 17-year breast cancer survivor, she said she was
lucky because her training as a journalist taught her to ask questions.

Photo by Gordon Munro

2008
Breakfast Forum at the AORN 55th Congress – Anaheim, California

Dr. Marla Shapiro, author of life in the Balance: My Journey with Breast Cancer, a renowned
Canadian on-air medical expert and a physician with a thriving medical practice, delivered
a dynamic presentation on coping with stress, balancing life and battling breast cancer. She
candidly told the audience that on August 13, 2004, she went from being a doctor to a
patient in a matter of moments. And that despite her medical training, she was not fully
prepared for the path her life would take.

2007
Breakfast Forum at the AORN 54th Congress – Orlando, Florida

The late Rue McClanahan, an award-winning actress who played Blanche Devereaux on
the hit TV series Golden Girls, filled the room with laughter as the keynote speaker of
Medline’s 2nd annual breast cancer awareness breakfast forum. She was diagnosed with
breast cancer in 1997 and was treated successfully. Janelle Hail, president of the National
Breast Cancer Foundation (NBCF) also spoke, reminding everyone that each day is a gift.

2006
Breakfast Forum at the AORN 53rd Congress – Washington, D.C.

Medline held its first “Together We Can Save Lives Through Early Detection” breakfast forum
during the AORN 53rd Congress in Washington, D.C. Attendees were inspired by the words
of Ann Jillian, actress, singer and breast cancer survivor. At 35 years old, the actress made
headlines when she was diagnosed with breast cancer and she became a vocal advocate
for cancer research and prevention.

To see more photos from the breakfast forums visit medline.com/breast-cancer-awareness.

90 The OR Connection
Medline started the Generation Pink movement with a single

A World vision: A World Without Breast Cancer Is in Our Hands. It’s


now the largest philanthropic cause in the company, where

Without Breast Medline partners with the National Breast Cancer Foundation
(NBCF) to support free mammograms for underserved women,
build awareness at forums for nurses and other healthcare
Cancer Is in workers, and even spread awareness virally through social
media and events such as The Pink Glove Dance.™

Our Hands™ Pink ribbon products, including pink gloves, help Medline sup-
port the National Breast Cancer Foundation. Medline donates
a portion of the proceeds to the NBCF: more than $800,000
to date. Their mission of awareness, early detection and pre-
vention lines up perfectly with Medline’s: A World Without
Breast Cancer Is in Our Hands.™

Healthcare Sites Appearing in the


Pink Glove Dance Sequel The Dance Goes
Providence St. Vincent Medical Center, Portland, Oregon
University of Minnesota Medical Center, Fairview, Minneapolis, Minnesota
On and On…
Indiana University Melvin and Bren Simon Cancer Center, Indianapolis, Indiana Seen over 13 million times since it went viral in
Tallahassee Memorial Healthcare, Inc., Tallahassee, Florida 2009, the Pink Glove Dance kicked off a huge
wave of awareness, joy and caring. The
Saint Michael’s Medical Center, Newark, New Jersey
2010 sequel features more than 4,000 health-
The Medical Center of Plano, Plano, Texas care workers and breast cancer survivors from
HCA Johnston-Willis Hospital, Richmond, Virginia 14 separate facilities all over the United States
Sky Ridge Medical Center, Lone Tree, Colorado and Canada. Visit pinkglovedance.com

Thibodaux Regional Medical Center, Thibodaux, Louisiana


Capital Health, Halifax, Nova Scotia
Burgess Square Healthcare and Rehab Centre, Westmont, Illinois
Isabella Geriatric Center, New York, New York
Lorien Health Systems, Ellicot City, Maryland
Scripps Memorial Hospital La Jolla,
La Jolla, California
Straight From the Heart
Quotes about the Pink Glove Dance

“ Watching this video is the first time I’ve cried over my


breast cancer. I hadn’t realized how alone I felt, even
though surrounded by caring family and friends. The fact
that so many healthcare workers were donning gloves

and dancing to show that I am not alone touched me
deeply. Thank you from my heart for this video.
Jenny W.
Ft. Collins, Colo.

“ I have just watched these videos for the 5th time. Each
time tears stream down my face. I have shared these
with my family and work family to help them realize just
how important breast cancer awareness is. It saved my
life not once, but twice. Let’s hear it for all those great

people dancing all over the United States … THANKS
from the bottom of my heart.
Louise C.
Haverhill, Mass.

92 The OR Connection
Caring For Yourself

Medline Breast Cancer Awareness By the Numbers

$809,606 Dollars Medline has donated to the


National Breast Cancer Foundation to date.
4,000 Healthcare workers and breast cancer
survivors participated in the Pink Glove
Dance sequel.
6 Number of breast cancer awareness
breakfast forums Medline has hosted in
conjunction with AORN Congress.
13,178,145 Views of the Pink Glove Dance and
Pink Glove Dance Sequel on YouTube.
5,700 Healthcare workers who have attended
Medline breast cancer awareness breakfast
forums since 2006.
14 Facilities that participated in the Pink Glove
Dance Sequel.
4,567 People that like Medline’s Breast Cancer
Awareness Facebook page.

Aligning practice with policy to improve patient care 93


Yes, They’re Genuine.
Only Medline’s Pink Pearl™ gloves combine
aloe, nitrile and breast cancer awareness.

For more information,


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

©2011 Medline Industries, Inc.


Medline is a registered trademark
and Pink Pearl is a trademark of
Medline Industries, Inc.
Special Feature

Beyond a Reasonable Doubt:


Open Communication Helps Jill Eikenberry
Raise the Bar for Breast Cancer Awareness

Aligning practice with policy to improve patient care 95


Most everyone has heard the saying “your life
can change in an instant.” Actress Jill Eikenberry
is one who can definitely appreciate it

After struggling for more than a decade on the New Eikenberry. “I had never checked myself before. I don’t
York City stage, Eikenberry and her husband Michael know what made me do it, but I think somehow we
Tucker finally felt they’d made it when, in 1986, they know. We have some sort of intuitive feelings sometimes.”
landed regular roles on a new television show called L.A.
Law. Their son was starting kindergarten. She was cele- She called her gynecologist, who acknowledged that she
brating her thirteenth wedding anniversary. had felt something during Eikenberry’s last exam and
had, in fact, already scheduled a mammogram without
“We were going to get the fame and fortune we thought telling her. At age 39, it would be her first. The result
we always wanted,” says Eikenberry. wasn’t good: the lump was malignant.

And then in a moment, everything changed. She found a “I was terrified. In those days, no one was talking about
tiny lump in her right breast. It would later test malignant. surviving breast cancer,” she said. “The only person that
The diagnosis was breast cancer. I knew that had had it was the woman that lived upstairs
from us in our New York apartment. She had died the
“I didn’t know anybody who’d survived breast cancer,” year before, leaving three children.”
she recalls. “And I thought I was going to die for sure.”But
while breast cancer is one of society’s common denom- Eikenberry and Tucker consulted a breast surgeon, who
inators, so fortunately, are hope and survival. All it took recommended either a lumpectomy or a mastectomy.
was a chance meeting with a woman who had survived The surgeon leaned toward a mastectomy. Eikenberry’s
– with her breast intact – to provide Eikenberry with a first panicky impulse was to agree.
belief in both.
“I said ‘Whatever you have to do get it out of here – get
Eikenberry’s breast cancer story began as she and it off.’ And we went home in despair.”
Tucker were packing up their lives and children in New
York to move to the West Coast. They had finished It wasn’t until a couple of days later – “I sort of laid on the
shooting the pilot for L.A. Law and were heading to Los bed and cried, didn’t want to tell anybody” – that she
Angeles for the rest of the series. decided to attend a screening of a movie she had
recently completed called The Manhattan Project. The
“I reached up while driving and felt something, and cast included her friends John Lithgow and Cynthia
instantly when I felt this thing I knew that something was Nixon.
wrong. This wasn’t what was supposed to be there,” said

96 The OR Connection
While Eikenberry has a long list of theater,
film and television credits, she is perhaps
best known for her portrayal of L.A.
Law’s Ann Kelsey

She walked into the lobby of the movie theater, deter- at Barnard College in New York. In her second year, how-
mined not to tell anybody about her situation. However, ever, she auditioned for and was accepted into the Yale
“Cynthia took one look at me and said ‘what happened School of Drama in New Haven, Connecticut.
to you?’ And I poured the whole story out.”
She met Tucker while the two of them were performing at
Nixon brought Eikenberry into the audience to see her the Arena Stage in Washington, D.C. They were later cast
mother, Ann. Nixon’s mother then took her hand and in the play Moonchildren, which eventually took them to
dragged her up the aisle into the ladies room. Broadway in 1972. They married the following year.

“Ann hiked up her blouse and said, ‘You see this little scar While Eikenberry has a long list of theater, film and tele-
on my right breast? That’s all I have to remind me of my vision credits, she is perhaps best known for her portrayal
breast cancer 11 years ago.’ And all of a sudden, I felt of L.A. Law’s Ann Kelsey alongside Tucker’s Stuart
hope,” said Eikenberry. Markowitz. Over the course of the series’ long-run, she
received four Emmy nominations, two Golden Globe
That hope persuaded Eikenberry to seek a second opin- nominations and a Golden Globe Award.
ion. The news was better this time as her doctor said she
was a perfect candidate for a lumpectomy. “I saved my One of the most decorated dramas in television history,
breast,” she said. “It was amazing what Ann Nixon did the show followed a group of lawyers at the fictitious law
for me.” firm McKenzie, Brackman, Chaney and Kuzak. In its
prime, blessed with a plumb Thursday time slot behind
Amazing is a descrip- “Cosby” and “Cheers,” the series regularly finished in the
tion that Eikenberry top 15. Its legal cases covered big issues of the day, such
herself has heard over as the outing of prominent gays and the morality of the
the years in reference death penalty, as well as unusual ones like dwarf tossing
to her stellar career and the culpability of a Jewish mohel sued for snipping a
and odds-defying, bit too much at a circumcision ceremony.
long-term Hollywood
marriage to Tucker. The compelling stories would often intermix with the
lawyers’ sexy personal entanglements – including the
Born in New Haven, famous storyline where Tucker employs a secret sexual
Connecticut, she was technique called the “Venus Butterfly” to win the hand of
raised in Madison, Eikenberry. The episode was one of the most talked
Wisconsin before about of the entire season, and although the “V.B.” was
moving to Missouri. a fictional figment of a writer’s fertile imagination, hordes
She began her college of viewers wrote the show asking what the ancient sex-
studying anthropology ual practice was.

Aligning practice with policy to improve patient care 97


The chemistry between Eikenberry and Tucker made
them instantly identifiable as a TV couple, and a hit show
put them squarely in the public eye. The fame would
make it challenging for Eikenberry, who by now had
undergone surgery at Mt. Sinai in New York, to keep her
ensuing radiation therapy treatments a secret. That pri-
vacy was very important to Eikenberry, as she was very
concerned about the word getting out and people think-
ing of her as “the actress with cancer.”

“After the surgery Steven Bochco, who was producing


L.A. Law, called a friend at UCLA who agreed to admin-
ister my radiation therapy in private so nobody would
know,” she recalled. “So every night we would have to
get off the set without anybody noticing and sneak over
to UCLA and have my radiation treatments.”

However, despite being able to keep the treatments from Eikenberry was among the first to be
the public, she wasn’t, by her own admission, dealing installed into the Cancer Survivors Hall
very well with the up-and-down emotions she was expe-
riencing.
of Fame in October 2000.

“On one hand, I think that it was really good for me to


play that character because Ann Kelsey was a fighter.
She could walk into a room filled with men, CEOs, and Things began to change when Eikenberry was
level the room. She was really tough. I think for me it was approached by Linda Otto, a documentary film maker
the most positive thing to play somebody that tough who also had breast cancer. She had an idea for a new
when I was feeling as vulnerable as I was,” she said. “But documentary film based on interviews with women who
I wasn’t really talking to myself about my fears. I was just have survived the disease. Her pitch resonated with
trying to bury them in the character and work the char- Eikenberry: “I don’t think anyone knows you can survive.
acter and be famous instead of being the person with I think that if people know there is a good chance of sur-
cancer.” vival, especially if you catch it early, people would be less
afraid to check themselves and to get their mammograms.”
Tucker was having a hard time as well.
Even so, Eikenberry was very reluctant at first to do it.
“My focus was on Jill – helping her and making her feel
confident. I completely forgot about myself,” said Tucker. “I thought there was going to be a terrible stigma if I went
“Because of that fear of loss, I went into a phase of on television and said I have breast cancer,” she said. “I
denial for two years. It wasn’t until later that the penny was a celebrity now. I had done L.A. Law for a couple of
dropped and I realized that I was going through some- years and I was terrified of what people would think.”
thing too.”

98 The OR Connection
Eikenberry received four
Emmy nominations for
playing lawyer
Ann Kelsey, noting that
“She was a fighter.
I think for me it was
the most positive thing
to play somebody that
tough when I was
feeling as vulnerable
as I was.”

But in her car after meeting with Otto, she thought about anti-cancer bias, and their forthrightness becoming the
her own initial reaction to her diagnosis and her subse- program’s spiny strength as it helps to further lift the
quent encounter with Ann Nixon – and tearfully decided stigma from a disease that was once considered
that it was time to go public. unmentionable.”

“I knew that I had to talk about it because it had been so When the documentary went on the air it was a revelation
important to me when somebody talked about it.” for Eikenberry.

Eikenberry not only agreed to participate, but also “I thought there would be a stigma, when in fact it was
became the interviewer for the project. The result became the beginning for a whole new career for me really be-
the 1988 NBC special Destined to Live: 100 Roads to cause people had felt as alone as I had. When they saw
Recovery, with subjects ranging from Gloria Steinem and the documentary they were given hope. It was just this
Nancy Reagan to a gruff-talking female deputy sheriff and amazing thing to realize that I had friends everywhere
a woman whose supportive husband bought her a Fred- who were so grateful to be able to share their story once
erick’s of Hollywood negligee after her breast surgery. they heard all the stories we told on the show.”

“It was very important for me to do this documentary,” The success of Destined to Live: 100 Roads to Recovery
said Eikenberry in an interview with the Los Angeles led to Eikenberry receiving the Vital Options Vital Spirit
Times. “On a personal level I have a tendency, because Award 1991. At the awards ceremony, emcee Meryl
I’m optimistic, to put it away and pretend it didn’t hap- Streep praised “the ease with which the information was
pen. But being able to face one’s own mortality does give given” within the documentary, noting that Eikenberry “re-
one a new lease on life.” ally got the women to talk about it. It was moving and
heartening. It made you understand what they went
The Los Angeles Times praised the special, noting that through.”
“the candor is remarkable considering society’s lingering

Aligning practice with policy to improve patient care 99


“I think that the most important thing that I have learned “Each of us has changed a lot and grown a lot,” said
is that silence is not golden in this situation,” said Eiken- Eikenberry. “And I think the main thing is that we allowed
berry. “The more that we are able to try and understand the change in the other person and did not try to keep
what we are feeling and communicate it, the better we things in a status quo situation. I think that’s big. We’re
feel and the more we are able to go into the experience very good communicators. We make a point of it.”
and be present and make our own decisions. It’s just so
important to be open with ourselves and other people. It’s also why both Eikenberry and Tucker continue to
It’s a very different environment now. People are not feel- travel the country, telling their story. It’s not only cathartic,
ing the way they were feeling back then.” it makes them stronger and feel more connected.

Eikenberry witnessed the difference first hand, because in “Every time I go out and talk about the cancer, even
February of 2009 she faced what every breast cancer though it is difficult to say the words, it ends up eliciting
survivor fears most – a check-up mammogram that all kinds of responses in people out there in the audience
detected a recurrence. – the nods, the compassionate faces. And I feel suddenly
that I am so not alone. Everyone should know that feeling.”
“My mammogram discovered another tiny tumor in
exactly the same spot as my old one,” she said. “But this
time was so different. There’s a lot more people vocal
about their breast cancer now. My radiologist said to me
on the phone when she gave me the news, ‘you have
nothing to worry about.’ They would have newer said that
to me in 1986.”

Another big change noted by Eikenberry: the communi-


cation between her caregivers and herself.

“I had so much communication with everybody all along


the way this time and last time I felt completely in the
dark,” she says. “This time I didn’t have to have chemo
or radiation; I was able to have a lumpectomy again in
the same spot. But I felt like it was my choice every step
of the way, and that I was being part of the experience
instead of the victim of the experience.”

And like he has for more than four decades, Tucker was
there to help her through it.

“My husband was able to be so present with me because


he wasn’t afraid the same way as last time,” she said.
“We were really able to have our eyes open and talk
about it every step of the way instead of feeling like we Eikenberry originally was very
had to push it all down. And that was just really an eye
opener in many respects. The medical profession has
concerned with word getting out
changed and I have changed a lot for the better.” that she had breast cancer, and
was “terrified that people would
It’s open communication that has kept Eikenberry and think of me as the actress
Tucker – or Tuckerberry as they refer to themselves – to-
gether both personally and professionally since 1970.
with cancer.”

100 The OR Connection


OR Issues

Less Invasive
Surgery Just as
Effective for Some
Breast Cancer Patients
by Allison Bierly, PhD

When breast cancer has spread to nearby lymph nodes, many The team recruited almost 900 patients from 115 different treat-
doctors believe that removing several more nodes provides ment centers. All had tumor cells in 1 or 2 sentinel lymph nodes.
better treatment. But a new study suggests otherwise. The find- Patients were randomly divided into 2 groups. One underwent
ing may change the way early-stage breast cancer is treated in ALND while the other did not. All the patients received radiation
some patients. therapy. The study, which was funded by NIH’s National Cancer
Institute (NCI), appeared in the February 9, 2011, issue of the
Doctors often begin with sentinel lymph node dissection Journal of the American Medical Association.
(SLND)—only removing one or two lymph nodes—to determine
if cancer has spread. If these sentinel nodes don’t contain tumor Overall, an average of 17 lymph nodes per patient was removed
cells, no more surgery is performed. However, if the sentinel from the ALND group, while just 2 were removed from patients
nodes do contain tumor cells, the next step is to perform axillary who underwent SLND alone. Strikingly, 5 years after surgery,
lymph node dissection (ALND)—removing at least 10 nodes. the research team saw no difference between the 2 groups in
the percentage of patients who survived or who remained
ALND can lead to a number of side effects, including seromas disease-free.
(swelling due to clear fluid pockets), tingling sensations and
buildup of lymph fluid called lymphedema. Moreover, studies The team also compared how many patients in each group had
haven’t definitively shown whether ALND improves survival or complications from surgery, including wound infection, seromas
staves off reoccurrence of the disease compared to SLND alone. and tingling sensations. In the group that received SLND alone,
Dr. Armando Giuliano of the St. John’s Health Center in Santa only 25 percent suffered from these complications, while 70
Monica, California, and his colleagues set out to investigate. percent of the ALND group experienced them.

These results show that SLND is no less effective than ALND at


Complication rates following lymph node removal preventing death or reoccurrence of disease after 5 years, while
dramatically reducing the risk of side effects from surgery.
Giuliano notes that several treatment centers—including
St. John’s Health Center and the Memorial Sloan-Kettering
25 %
complications Cancer Center—are already using the findings to make treat-
70 % ment decisions for early metastatic breast cancer. “It’s ready to
complications go for these patients,” he says.

Source: National Institutes of Health http://www.nih.gov/researchmatters/


axillary lymph sentinel lymph february2011/02282011surgery.htm
node dissection node dissection

Aligning practice with policy to improve patient care 101


How to
ENERGIZE
102 The OR Connection
by Wolf J. Rinke, PhD, RD, CSP

YOUR TEAM
Aligning practice with policy to improve patient care 103
...the fastest way to achieve peak
performance is to treat all employees
as if they were volunteers

Let’s face it—health care is a team “sport.” No matter what your


current role, sooner or later you’ll end up being a team leader.
And when that happens, your success depends on your team
members’ willingness to go the extra mile. (Hint: if you are not
yet a team leader, read this anyway because the time to
practice is now.) Here are six strategies to keep your team
members “juiced.”

1. Treat all team members as if they are volunteers. Now, stop and think, what would you say to your team mem-
I refer to this as the most important leadership principle of all bers if indeed they were volunteers? How about: "Please."
time. I discovered it while I was a Board member of one of my "Thank you!" "Can I count on you?" "I need your help." "I really
professional associations and the Chair for the Council on appreciate what you’ve done." "Thanks for being on my team!"
Education. In that role the Board looked to me to implement "Thanks for showing up." And now the one that blows the
new Standards of Education, which had been in limbo for autocratic managers away: "Could you do me a favor?" That
countless years. A team of 12 professionals was on my com- one just doesn’t sit well with lots of managers. Here are some
mittee. All highly educated, all volunteers, all having their own of the things they’ve said to me: "What are you talking about?
agenda. I quickly became aware that all the “crutches” that I You’re paying them; they owe you a good job." Or "You’ve got
relied on during my “day job” did not work. For example, one of to be nuts. They are not doing you any favor, it’s their job," and
my committee members, let’s call her Julie, was really gung-ho. so on. All really good arguments, and all really, really incorrect.
Any time there was a project to be done she was the first one (If you agree with any of these, it’s time to wake up and smell the
to volunteer. There was only one problem—Julie seldom deliv- coffee. Because the only thing pay will do is get team members
ered. Forget delivering on time, she just did not deliver. At work, to show up, and stay with you. (Not bad, but certainly not peak
when any of my team members did that, I could counsel them performance.) And the fastest way to achieve peak perform-
and if that did not work I could use the ultimate “crutch”— ance is to treat all employees as if they are volunteers.
I could fire them. Trying that with Julie, however, produced just
the opposite results. Her response: “Hey I don’t need this; I’m 2. Catch team members doing things almost right!
outta here—more time with the family.” Most of us were taught to supervise team members by catch-
ing them making mistakes. Someone even gave it a name:
After banging my head against the proverbial brick wall several management by exception. Unfortunately most team members
times I finally figured out that my autocratic strategies simply will live up or in this case down, to your expectation. To reverse
did not work with volunteers. I had to develop an entirely different this, you will need to learn to catch team members doing things
skill set to motivate these people. And after I had mastered right. No wait, let me modify that, catch team members doing
them, I transferred these new strategies to my “day job.” For things almost right! The problem is that if you are a perfection-
me this was a defining moment that enabled me to transform ist some of your team members just have a tough time getting
myself from an autocratic manager to a highly effective leader. it right, especially if right is defined as the way you would have
What was that concept? Are you ready for it? This is BIG! Drum done it. Then you must compliment or recognize that positive
roll please! Treat all employees as if they are volunteers. performance in some way. In other words, you must learn to

Continued on page 106


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Center's Commission on Accreditation.
I learned a long
time ago that if it’s
fun, it gets done.

3. Make work fun.


I learned a long time ago that if it’s fun, it gets done. So ask
yourself, are your team members having fun? Better yet ask
them. It’s very hard to be motivated and energized if work is a
big pain. In fact Sigmund Freud got this right when he identified
the Pleasure Principle, which basically says that all human
beings move themselves in the direction of pleasure and move
themselves away from pain. So if you have a high turnover rate,
have team members who abuse sick leave or have trouble get-
ting team members to show up for work on time, you can be
sure that working for you is painful. What to do? Ask five of your
team members to serve on a “Celebration or Fun Team.” Give
them a budget. If you don’t have one, suggest that they con-
tact local merchants who’d love to achieve greater visibility in
your organization. Suggest that they ask those merchants to
practice management by appreciation (MBA). Although difficult make donations to your Celebration Team. Example: movie tick-
to master, this is a more powerful strategy than you will ever ets, a weekend for two at a local resort, etc., etc. Just be sure
learn in any university MBA program. Catching team members to give those who donate lots of visibility. Now ask the Cele-
doing things almost right means you use your abundant men- bration Team to get together to identify specific things they are
tal energy to look for your team members moving in the right di- planning to do each month that make work fun. Tell them any-
rection, instead of using the same amount of energy to catch thing goes, provided that they stay within their allocated budget
them messing up. If you look hard enough, you will find that and it does not violate any laws, rules or regulations.
most team members do several things each day that they feel
really great about. Find it, and then be sure to make a big deal 4. Be positive and energetic
about it, ideally in public. If you still find yourself slipping back Attitudes, just like colds are
into old habits use the 10 penny system. Put 10 pennies in your catching. Positive attitudes are
left pocket or in case you don’t have pockets, the left side of caught just as easily as negative
your desk. Every time you catch one of your team members attitudes. The only problem is
doing something almost right and let them know about it, trans- that negative attitudes suck the
fer one penny from your left pocket to your right pocket. On the energy out of your team mem-
other hand if you provide negative reinforcement to one of your bers like a giant sponge—some-
team members, reverse the process; but this time move three thing your peak performers are
pennies back to the left pocket. Your goal is to have all pennies just not going to put up with. On
in your right pocket at the end of each day. the other hand, positive attitudes
are like the little Energizer bunny.
They will keep your team mem-

Continued on page 108

106 The OR Connection


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Recognize that positive
language energizes you.

bers going, and going, and going (well, you get it.) To build a 6. Get team members to listen to motivational
positive attitude, become aware of your conversations including audio programs.
the ones that you have inside of your head. Recognize that pos- Mary Kay sales associates, or for that matter all highly suc-
itive language energizes you, and negative, cynical, “stinking cessful sales professionals, have this figured out. You must pro-
thinking” conversations de-energize you and your team mem- vide team members with external motivation if you want them
bers. Make it a practice to say positive things, especially about to consistently perform at peak performance. So start building
other people, or say nothing at all. Also recognize that your an audio-program library. Suggest to your team members that
mind can hold only one thought at a time. It can either be pos- they listen to a program every day on their way to work. Meet
itive or negative, it is your choice! So when you catch yourself in brief weekly meetings and have team members share one
thinking positive thoughts, congratulate yourself. On the other powerful principle they learned from each program. That way
hand when you are thinking negative thoughts, catch yourself, everyone can learn from everyone else, and energize each other
change those thoughts, then give yourself credit. Remember at the same time. Supplement these activities by showing a mo-
because of “mirror neurons” your team members take their cue tivational program during your next in-service. (Aren’t your team
from you! You must be the role model for the kind of behaviors members getting tired of the same mandatory training?) Or bet-
you want them to exhibit. (For in-depth strategies of how to ter yet hire a motivational speaker to energize your next "all
make this happen read Make It a Winning Life--Success hands" team meeting. Your team members will be positively
Strategies for Life, Love and Business available at http://wol- surprised, feel honored and energized. And when they are
frinke.com/miwlbook.html.) energized everyone’s job will be much more enjoyable, and to
top it all off, your patients will be less grumpy and may even get
5. Build on team members' strengths. better faster.
Statistics tell us that 25% of the US population hates what they
do, another 56% could take it or leave it, and only 19% love © 2011 Wolf J. Rinke
what they do. Typically team members who love what they do
are in jobs that let them build on their strengths. So find out Dr. Wolf J. Rinke, RD, CSP is a keynote
what your team members love to do and do everything in your speaker, seminar leader, management con-
power to assign them to those projects or place them in those sultant, executive coach and editor of the free
positions. What if you end up losing them? Think about it: would electronic newsletter Read and Grow Rich,
you rather have team members who love what they do and available at www.easyCPEcredits.com. In ad-
hence are peak performers, or those who stick with you dition he has authored numerous CDs, DVDs
because they can’t get a job anywhere? Even your most dedi- and books including Make It a Winning Life:
cated team members are going to get burnt out really fast if Success Strategies for Life, Love and Busi-
they are not building on their strengths. So you would be much ness, Winning Management: 6 Fail-Safe Strategies for Building
better served to get team members in positions or projects that High-Performance Organizations and Don’t Oil the Squeaky Wheel
enable them to build on their strengths even if you lose them. and 19 Other Contrarian Ways to Improve Your Leadership Effec-
Just remember that whoever inherits one of your team mem- tiveness; available at www.WolfRinke.com. His company also pro-
bers will be much more likely to reciprocate in the future. Plus duces a wide variety of quality pre-approved continuing
the team member who has left you will become an "ambas- professional education (CPE) self-study courses, available at
sador of goodwill" for you. And in today's competitive health www.easyCPEcredits.com. Reach him at WolfRinke@aol.com.
care industry, good will is a very valuable commodity when you
need to fill your next vacancy.

108 The OR Connection


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Healthy Eating

Nutrition
Information
Servings: 9
Calories: 166
Fat: 15.6 g
Sodium: 159 mg
Fiber: 0.1 g

Aunt Judy’s
Tortilla Roll-Ups
1 cup finely shredded cheddar cheese
½ cup sour cream
8 oz. cream cheese, softened
1 pkg. taco seasoning
12 green olives or green chiles/pimentos
3 large tortillas

Directions: This recipe is Judy’s favorite appetizer, which she inherited from
Mix ingredients together, and spread onto the tortillas. Roll up her Aunt Judy a year ago. It’s a highly requested dish at the
tortillas. Place into a zip lock bag and chill. When ready to serve, many events Judy attends.
slice and serve with salsa.
Judy was also involved in creating Medline’s first and second
Hint: Healthier alternative ~ low fat cheese and low fat sour edition cookbooks, which feature recipes from Medline employ-
cream and whole wheat tortillas may be used. ees. The latest edition is available for purchase, and the pro-
ceeds go to Medline’s Spirit of Giving fund, which helps support
Judy DeSalvo, Marketing Business Manager – Mundelein Medline employees in times of need.
Judy DeSalvo has been working at Medline for nine years. She
basically “does it all” to keep the Marketing Department running
The Medline employee cookbook
efficiently. Judy sees print projects through to completion, mak-
is $10. To purchase your own
ing sure vendor estimates are correct on
copy, please e-mail Judy at
invoices, all the way down to ensuring
jdesalvo@medline.com.
marketing materials arrive on time and in 

the right location at trade shows and


meetings. She’s often been sighted mov-
ing boxes of brochures and Medline dolls,
and she’s even been known to wield a
screwdriver to repair a piece of office
equipment in a pinch so coworkers can
get their jobs done.

110 The OR Connection


Forms & Tools

The following pages contain


practical tools for implementing
patient-focused care practices
at your facility.

Surgical Attire
Highlights of AORN’s Revised Recommended
Practices for Surgical Attire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .113

Hand Hygiene
CDC Clean Hands Poster . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .120

Pressure Ulcer Prevention


How Well Do You Know Pressure Points? . . . . . . . . . . . . . . . . . .121

Aligning practice with policy to improve patient care 111


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
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tion risk through a combination of disposable products. To sign up for a FREE webinar on perioperative
pressure ulcer prevention, go to
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References
1
Braden Scale for Predicting Pressure Sore Risk. Available at:
www.bradenscale.com/braden.PDF. Accessed November 6, 2008.
2
Recommended practices for positioning the patient in the perioperative practice setting. In:
Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2008.

©2010 Medline Industries, Inc. Medline, QuickSuite and Sahara are registered trademarks of Medline Industries, Inc.
AORN’s Recommended Practices Forms & Tools

Highlights of AORN’s
Revised Recommended Practices
for Surgical Attire

November 2010

Highlights of
AORN’s Revised
Recommended
Practices for
Surgical Attire

The following report includes excerpts from AORN’s “Recommended


Practices for Surgical Attire.” For a complete copy, refer to AORN’s 2011
Perioperative Standards and Recommended Practices.

Aligning practice with policy to improve patient care 113


Forms & Tools AORN’s Recommended Practices

Italicized wording throughout the document represents language quoted


directly from AORN’s Recommended Practices for Surgical Attire.

AORN recently revised its Recommended Practices for Surgical Attire to include stronger
recommendations for donning safe surgical attire, based on emerging evidence showing a
connection between attire and possible risk of infection.

The following are some of the major changes:


• The biggest change: All recommendations for home laundering of
surgical attire have been removed. AORN recommends that surgical
attire should be laundered in a health care-accredited laundry facility
• New information on characteristics of safe surgical attire fabrics, including
recommendations that fabrics should be low linting, tightly woven, stain
resistant and durable, and that 100% cotton fleece should not be worn
• A new recommendation that cover apparel (lab coat, cover gown)
should be laundered daily
• A new recommendation that nonscrubbed personnel in the semirestricted
and restricted areas should wear a freshly laundered or single-use long
sleeve warm-up jacket
• A new recommendation on quality assurance monitoring of laundering processes

Recommendation I
Surgical attire should be made of low-linting material, contain skin
squames, provide comfort, and promote a professional appearance.

Researchers have found that tightly woven and/or synthetic surgical attire helps contain bacterial
shedding and promotes environmental control. The design of the surgical attire is not as important
as the material from which it is made.

I.a. Surgical attire fabrics should be:


• Tightly woven
• Stain resistant
• Durable
• Comfortable in terms of design, fit,
breathability and weight of the fabric

I.b. Surgical attire made of 100% cotton fleece should not be worn. Some fabrics made
of cotton fleece collect and shed lint. Lint may harbor microbial-laden dust, skin squames,
and respiratory droplets.
114 The OR Connection
AORN’s Recommended Practices Forms & Tools

Recommendation II
Clean surgical attire, including shoes, head covering, masks, jackets,
and identification badges should be worn in the semirestricted and
restricted areas of the surgical or invasive procedure setting.

Clean attire minimizes the introduction of microorganisms and lint from health care personnel
to clean items and the environment.

II.a.2. When wearing a two-piece scrub suit, the top of the scrub suit should be secured
at the waist, tucked into the pants, or fit close to the body.

II.a.3 Health care personnel should change into street clothes whenever they leave the health
care facility or when traveling between buildings located on separate campuses.

II.e. Identification badges should be worn by all personnel authorized to enter the
perioperative setting. Health care personnel as well as patients should be able
to identify caregivers.

II.e.1. Identification badges should be secured on the surgical attire top, be visible, and
be cleaned if they become soiled.

II.f.1 Cover apparel should be laundered daily in a health care-approved or accredited


laundry facility (See Recommendation V.)

In one study of cover coats worn by 100 physicians, Staphylococcus aureus was isolated
from 25 of the cover coats. The cuffs and pockets of the coats were the most contaminated.

Aligning practice with policy to improve patient care 115


Forms & Tools AORN’s Recommended Practices

Recommendation III
All individuals who enter the semirestricted and restricted areas
should wear freshly laundered surgical attire that is laundered
at a health care-accredited laundry facility or disposable surgical
attire provided by the facility and intended for use within the
perioperative setting.

III.a. Surgical attire should be changed daily or at the end of the shift.

Surgical attire may have bacterial colony counts that are higher when scrub clothing
is removed, stored in a locker, and used again.

III.a.1. Reusable or single-use contaminated attire should be placed in appropriately


designated containers after use. Worn reusable surgical attire should be left at
the health care facility for laundering.

III.a.2. Surgical attire that has been penetrated by blood or other potentially infectious materials
should be removed immediately or as soon as possible and replaced with freshly
laundered, clean surgical attire. When extensive contamination of the body occurs,
a shower or bath should be taken before donning fresh attire.

III.a.3. Wet or contaminated surgical attire should not be rinsed or sorted in the location of use.

III.a.4. Surgical attire contaminated with visible blood or body fluids must remain at the health
care facility for laundering or be sent to an accredited laundry facility contracted by the
health care organization.

III.b. When in the semirestricted or restricted areas, all nonscrubbed


personnel should wear a freshly laundered or single-use long
sleeved warm-up jacket snapped closed with cuffs down to the wrists.

III.b.1. All personal clothing should be completely covered by the surgical


attire. Undergarments such as T-shirts with a V-neck, which can
be contained underneath the scrub top may be worn; personal
clothing that extends above the scrub top neckline or below the
sleeve of the surgical attire should not be worn.

Personal clothing is not laundered by a health care-accredited laundry.


Appropriate surgical attire,
including warm-up
jacket, for semirestricted
and restricted areas.
116 The OR Connection
AORN’s Recommended Practices Forms & Tools
Recommendation V
Surgical attire should be laundered in a health care-accredited
laundry facility.

Accredited health care laundering facilities provide a monitored laundering process and must
adhere to established standards set forth by the Healthcare Laundry Accreditation Council (HLAC).
These standards require that facilities demonstrate regulated practices for every step of the
laundering process, from transferring soiled laundry, to sorting it, washing with specified wash
formulas, time and temperature according to manufacturer guidelines, drying, pressing, packing and
transporting clean laundry. The new AORN Recommended Practices for Surgical Attire cites many
studies showing the ineffectiveness of home laundering in removing infectious bacteria from fabrics.

Surgical attire; street clothing; PPE; and other hospital textiles (e.g., bed linens, towels, privacy
curtains, washcloths) may become contaminated by bacteria and fungi during wear or use.
In one study, researchers found that microbes can survive on hospital textiles for extended
periods of time. These textiles included:
• 100% cotton clothing
• 60% cotton/40% polyester blends (e.g., scrub suits, lab coats)
• 100% polyester clothing; and
• polyethylene plastic aprons

The shortest time for enterococci survival on textiles was 11 days.1,2 It has been postulated that
these fabrics can become vectors for fungi.2

Health care-accredited laundry facilities are preferred because they follow industry standards.

V.a. Laundered surgical attire should be protected during transport to the practice
setting to prevent contamination.

V.a.1. Surgical attire should be transported in a clean vehicle and enclosed


carts or containers.

V.b. Clean surgical attire should be stored in a clean, enclosed cart or cabinet.

V.b.1 Surgical attire may be stored in a dispensing machine. Dispensing machines


should be routinely emptied and cleaned according to the manufacturer’s directions.

1. Neely AN, Maley MP. Survival of enterococci and staphylococci on hospital fabrics and plastic. J Clin Microbiol. 2001;38(2):724-726.
2. Neely AN, Orloff MM. Survival of some medically important fungi on hospital fabrics and plastics. J Clin Microbiol. 2001;39(9):3360-3361.

Aligning practice with policy to improve patient care 117


Forms & Tools AORN’s Recommended Practices

Recommendation VII
Health care personnel should receive initial and ongoing education
and demonstrate competency on appropriate surgical attire.

Competency assessment verifies that health care personnel have an understanding


of the articles and purpose of surgical attire. This knowledge is essential for reducing
the risk of health care-associated infections.

Recommendation IX
The health care organization’s quality management program
should evaluate compliance with surgical attire policies and
identify and respond to opportunities for improvement.

IX.a.1. Quality indicators for surgical attire may include, but are not limited to,
• head coverings completely cover the hair and scalp;
• warm-up jackets with wrist-length sleeves are worn and are snapped;
• identification badges are worn, visible, and clean;
• shoes are clean and protect health care personnel’s feet;
• visibly soiled or wet surgical attire is removed and cleaned at an
accredited health care laundry facility;
• masks, when worn, are tied securely and are discarded after each
procedure; and
• cover apparel, if worn, is laundered daily at the organization
or an accredited laundry facility.

118 The OR Connection


AORN’s Recommended Practices Forms & Tools

These recommended practices are intended as guidelines adaptable to various practice settings,
including traditional operating rooms (ORs), ambulatory surgery centers, physicians’ offices,
cardiac catheterization laboratories, endoscopy suites, radiology departments and all other areas
where surgery and other invasive procedures may be performed.

GLOSSARY
Restricted Area: Includes the OR and procedure room, the clean core, and scrub sink
areas. People in this area are required to wear full surgical attire and cover all head and
facial hair, including sideburns, beards and necklines.

Semirestricted Areas: Includes the peripheral support areas of the surgical suite and
has storage areas for sterile and clean supplies, work areas for storage and processing
instruments, and corridors leading to the restricted areas of the surgical suite.

Surgical Attire: Nonsterile apparel designated for the OR practice setting that includes
two-piece pantsuits, cover jackets, head coverings, shoes, masks, protective eyewear,
and other protective barriers.

Aligning practice with policy to improve patient care 119


120
CLEAN HANDS SAVE LIVES
Forms & Tools

DEPARTMENT OF HEALTH AND HUMAN SERVICES


CENTERS FOR DISEASE CONTROL AND PREVENTION
Protect patients, protect yourself

The OR Connection
Candida
Staphylococcus

Influenza

RSV
Hand Hygiene Poster

Klebsiella Pseudomonas

Enterococcus
Alcohol-rub or wash
before and after EVERY contact.
www.cdc.gov/handhygiene
Pressure Point Quiz Forms & Tools

How well do you know


Pressure Points?
Feel free to use this quiz for skill 6
fairs, training and in-services. 7
1
Choose from (some may be used twice)
Dorsal thoracic area
Ear
Elbow
5
Foot 2 4
Greater trochanter 3
Heel
Ischial tuberosity 10
Lateral aspect of foot
Lateral aspect of knee
Lateral malleolus
Medial aspect of ankle
Medial malleolus
Occiput 8 12
Posterior knee 9 11 13
Ribs
Sacrum/Coccyx
Shoulder
Shoulder blade
19
1. _____________________
2. _____________________
3. _____________________
14 20
4. _____________________
5. _____________________
6. _____________________
7. _____________________
8. _____________________
9. _____________________ 15
10. _____________________
11. _____________________
12. _____________________
13. _____________________
14. _____________________ Answer key to
16 quiz on page 123
15. _____________________
16. _____________________
17. _____________________
18. _____________________
19. _____________________ 17 18
20. _____________________

Aligning practice with policy to improve patient care 121


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Medline University continues to build its curriculum with
another group of NEW Surgical Tech courses, available at
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Visit today to earn free CE credits with the following courses:


• The Different Types of Wounds
• Debridement
• Using DIMES to Your Advantage
• Infection Prevention
• Wound and Skin Care Education
• Hand Hygiene Improvement Strategies

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©2010 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc. add new courses and content.
* Courses are approved for continuing education credit by the
Association of Surgical Technologists.
Pressure point answers
From page 121

1. Lateral malleolus
2. Lateral aspect of foot
3. Lateral aspect of knee
4. Greater trochanter
5. Ribs
6. Shoulder
7. Ear
8. Occiput
PERIOPERATIVE PRESSURE
9. Ear
ULCER EDUCATION.
10. Elbow
11. Dorsal thoracic area
MORE IMPORTANT
THAN EVER BEFORE
12. Sacrum/Coccyx
13. Heel
14. Shoulder blade
15. Sacrum/Coccyx
16. Ischial tuberosity
17. Posterior knee
18. Foot
“ I have seen an increase in
the number of legal issues
linking facility-acquired pressure
ulcers to post-surgical patients.
A pressure ulcer program for the
OR is more critical than ever.”
Diane Krasner, PhD, RN, CWCN,
19. Medial malleolus CWS, BCLNC, FAAN
20. Lateral malleolus
Medline’s Pressure Ulcer Prevention Program now has a
component designed specifically for the perioperative services.
The easy-to-use interactive CD addresses the following:
• Hospital-acquired conditions
• CMS reimbursement changes
• Best practices for pressure ulcer prevention
• Perioperative assessment tools
• Critical patient and equipment risk factors

To learn more about Medline’s Pressure


Ulcer Prevention Programs for long-term
care, acute care and perioperative
services, call your Medline representative
or visit www.medline.com/pupp-webinar.

©2011 Medline Industries, Inc.


Medline is a registered trademark of Medline Industries, Inc.

Aligning practice with policy to improve patient care 123


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