The Independent Source of News for Operating Room Managers, Supply Chain Professionals & C-Suite Volume 11 • Spring 2020
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TABLE OF CONT ENTS
BULLETIN BOARD
4 Anaphylaxis From Chlorhexidine Considerably Underestimated
6 Surgical Stapler Safety Took Center Stage in 2019
8 Physician Involvement in Value Analysis Improves Outcomes, Saves Millions
10 Could Underbody Blankets Be the Better Option?
12 Navigating the Transition:
What It’s Like to Be Acquired
14 Nursing Shortage, Gender Gap Are Standouts in AORN Salary Survey
18 AI and the Future of Surgery 20 Should I Hire a Consultant? 21 Spring Buyer’s Guide 22 Coronavirus: To Mask or Not to Mask? EDITORIAL STAFF Paul Bufano Managing Editor pbufano@mcmahonmed.com Kevin Horty Group Publication Editor khorty@mcmahonmed.com
James Prudden Group Editorial Director Elizabeth Zhong Senior Copy Editor Kristin Jannacone Copy Editor
Trending Articles Online Read the most-viewed articles last month on ormanagement.net.
1. Keeping Your Cool in the OR. 2. Surgeons Share Tips for Robotic Hernia, Acute Care Surgery 3. The ‘IDEAL’ Framework for Evaluating New Surgical Techniques
Next Issue Preview Study Quantifies Time Spent On Electronic Health Records “For the first time, researchers have looked at how many hours per day that general surgeons spend dealing with their hospital’s EHR. The number is an average of 1.95 hours every day of the week, with some surgeons regularly spending nearly five hours daily.”
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OR Ma n a gement N ews • S p ring 2020
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Anaphylaxis From Chlorhexidine Considerably Underestimated By MICHAEL VLESSIDES
Calgary, Alberta—Medical professionals might be underestimating the anaphylactic potential of chlorhexidine, one of the most common antimicrobial agents in the OR, according to a recent study in Canada. Although the study found that the majority of clinicians were aware of chlorhexidine’s allergic potential, the frequency with which the agent causes anaphylaxis was markedly underestimated. The researchers also found that almost one in 10 patients who identified as having a reaction to chlorhexidine were subsequently given the products. “Chlorhexidine is a ubiquitous antiseptic that is used in the operating room every day,” said Julena Foglia, MD, a resident at the University of British Columbia, in Vancouver. “However, it is also known to commonly cause anaphylaxis.” Indeed, a recent study (Br J Anaesth 2018;121[1]:159-171) showed that chlorhexidine is one of the top three agents causing perioperative anaphylaxis throughout the United Kingdom, with an incidence of 9%. Moreover, one-third of diagnosed patients have had subsequent anaphylactic episodes from repeated exposure to chlorhexidine. “I started this project because I realized when I started my residency that not many of my colleagues fully appreciated the allergic potential of chlorhexidine, even though it was everywhere in my institution,” Dr. Foglia said. To help determine the level of awareness at the academic tertiary care center, the researchers distributed a 10-question survey to all relevant perioperative personnel over a 30-day period. Six of the questions collected data, while four distractor questions were included to increase the survey’s validity. Low Awareness As Dr. Foglia reported at the 2019 annual meeting of the Canadian Anesthesiologists’ Society (abstract 636763), although 83% of the 98 respondents were aware that chlorhexidine causes perioperative anaphylaxis, only 31% were aware that chlorhexidine is one of its top three causes (P<0.0001). The researchers also performed subgroup analysis, which revealed that although physicians trended toward more awareness than nonphysicians (87% vs. 74%), these differences were not statistically significant (P=0.129). Nevertheless, only 36% of physicians were aware that chlorhexidine is one of the top three causes of perioperative anaphylaxis. The survey also found that whereas 53% of physicians encountered patients with skin reactions to chlorhexidine, only 25% referred the patient to an allergist. “That’s a significant percentage of patients that physicians have come in contact with who are allergic to chlorhexidine but were not sent on for perioperative testing,” Dr. Foglia commented. 4
OR M a n a gem ent News • Sp r i ng 2 02 0
Perhaps most alarming was the finding that 8.7% of perioperative staff had exposed a patient to chlorhexidine, even though the patient had identified himself/herself as previously reacting to the antimicrobial agent. “This figure is quite concerning to us,” Dr. Foglia said. “Yet it correlates very well with published data that show that up to 30% of patients who come to allergists have had multiple exposures to chlorhexidine, which increases morbidity and mortality within the hospital system.” Given these findings, the researchers stressed the need for widespread education regarding chlorhexidine’s role in perioperative anaphylaxis, an undertaking they hope will reduce reexposures to the agent. “The second thing I pulled from this is there’s a need for an established allergy clinic where these patients can be seen,” she added. Streamlined patient referrals for allergy testing will help diagnose cases of chlorhexidine anaphylaxis and increase patient safety in the perioperative period. As Dr. Foglia reported, the results of the survey have opened the doors to her realizing her educational efforts. She has since led two grand rounds on the subject and helped spur the creation of a perioperative anaphylaxis clinic at the institution. “We need to have safety nets for these patients when they come into the operating room,” she added. “We need bundles and equipment that are chlorhexidine-free that you can grab at 3 o’clock in the morning. And these should be available in all centers, not just the large urban centers.” “Do you have a sense of people’s awareness of what contains chlorhexidine?” asked session moderator Lucie Filteau, MD, an assistant professor of anesthesiology at the University of Ottawa, in Ontario. “Because people call them alcohol swabs, but when you actually look at the packaging, it’s chlorhexidine,” Dr. Filteau added. “And I’ve noticed that people don’t seem to realize that it’s not alcohol.” “Unfortunately, I didn’t assess that as part of this study,” Dr. Foglia replied. “However, I’ve worked on another project that showed that most do not know where chlorhexidine is found.” ■
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Surgical Stapler Safety Took Center Stage in 2019 Webinar Offers Advice on Avoiding Stapler Misuse ECRI has conducted investigations on about three to five accidents per year involving staplers, said Scott Lucas, PhD, ECRI’s he FDA, professional medical societies and the media had director of accident and forensic investigation, during a recent their sights set on a common topic in 2019: surgical staplers. webinar on avoiding stapler misuse sponsored by the organizaLast March, the FDA issued a letter to physicians expressing tion. From 2009 to 2019, his group reviewed six cases resulting concern over increasing adverse events associated with surgical in a fatal injury, 15 resulting in a nonfatal injury, and five close staplers and staples for internal use, offering recommendations calls with no injury. for providers to promote safe use. The agency published an anal“In most of our cases, our testing resulted in normal operation ysis of nearly 110,000 stapler incidents of the incident stapler on since 2011, resulting in 412 deaths, 11,181 ‘In most of our cases, our testing resulted in surrogate tissue,” he said, serious injuries and 98,404 malfunctions. “so we think there are Some of the most commonly reported normal operation of the incident stapler many possible contributing problems in these reports included failure on surrogate tissue. So we think factors.” These include to fire or misfire, failure to form a staple, the jaws clamping onto there are many possible and difficulty opening or closing. another instrument, the The agency then kicked things up a notch. contributing factors.’ surgeon selecting too thick tissue or In April, the FDA issued a draft guidance to incorrect staple size, using the wrong vessel, and —Scott Lucas, PhD manufacturers of surgical staplers and statissue disease or necrosis that can cause a staple line to ples about information they should include unravel, or the tissue to pull out the staple. in product labeling, such as procedures for Julie Miller, a senior project engineer of health devices for determining that a tissue is appropriate for staECRI, offered the following suggestions during the webinar to pling. In May, the agency held an open public meeting of the Med- help avoid misuse of staplers: ical Devices Advisory Committee’s General and Plastic Surgery 1. During procurement, materials management staff should Devices Panel to discuss whether surgical staplers for internal use communicate with clinicians so that when possible, surgeons should be reclassified, from Class I to II devices. The panel recomcan work with their preferred devices. mended a reclassification, which would subject staplers to premar- 2. Surgery chiefs and OR directors should arrange for handsket notification, and allow the FDA to establish mandatory special on device training for all surgical team members. Training controls to help mitigate known risks of the device. should be conducted by the manufacturer or a superuser at Meanwhile, in April, Ethicon recalled a number of circular stathe institution, and should be scheduled before the device is plers for insufficient firing and failure to completely form staples, used for the first time. and in May, Medtronic recalled some of its Covidien Endo GIA 3. Before a procedure, surgeons and surgical staff should have staplers over possible missing components. In October, Ethicon an appropriate range of stapler cartridge sizes available; have recalled its Echelon Flex Endopath staplers for failure to form additional staplers and other means of closure available, such as complete staples. manual sutures; and inspect the stapler for damage before use. Also in October, the nonprofit ECRI Institute placed misuse 4. During a procedure, surgeons and staff should not use a staof surgical staplers No. 1 on its top 10 technology hazards list for pler if they are unable to visually confirm a secure closure, 2020, up from the No. 8 spot in 2010. and pause before firing to ensure there are appropriately “This is a legitimate concern,” said pediatric surgeon Romeo sized staples for the intended tissue. If there are any unusuIgnacio Jr., MD, FACS, FAAP, the trauma medical director at al sounds or difficulty squeezing the stapler handle, proceed Rady Children’s Hospital–San Diego, and a co-author of a recent with caution or use another closure method. paper on the history of surgical staplers (Am Surg 2019;85[6]:563As the designs continue to advance, however, surgeons and 566). “Anecdotally in surgery we see stapler errors like bowel industry should work together to present training courses on anastomotic leaks, and sometimes we consider it a technical error, proper use of staplers, and to improve dissemination of informabut at times it is the device itself.” tion about recalls, Dr. Ignacio said. But other surgeons say this could be blown out of proportion. While there are rare occasions where the instruments don’t “I think staplers get a bad rap because they’re easy targets,” said work, surgical judgment remains imperative, Dr. Goldberg said: Ross Goldberg, MD, FACS, the vice chair of surgery at Valley- “You can’t blame the tool for what you did. If the surgeon doesn’t wise Health in Phoenix. “There are a lot of staplers, and we aren’t know what they’re doing with the stapler, they shouldn’t be using seeing that many complications compared to the number of sta- it. You need to have the technical background to understand how plers being sold.” to use it, but applying it appropriately is the bigger issue.” ■ By KAREN BLUM
T
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OR M a n a gem ent News • S p r i ng 2 02 0
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BUSIN E SS M A NAG E M E N T
Physician Involvement in Value Analysis Improves Outcomes, Saves Millions A Surgeon-Led Committee Saved One Hospital More Than $2 Million on OR Purchases in 2018 By VICTORIA STERN
New Orleans—Over the past decade, hospitals across the United States have been working to cut costs and simultaneously deliver high-quality care to patients. However, when it comes to health care, the United States continues to vastly outspend other countries. Last year, U.S. health care costs ballooned to an estimated $3.65 trillion, translating to close to $11,000 per person—numbers that far outstrip spending in other developed countries. To counter skyrocketing costs, some hospitals are piloting value analysis efforts. Many of these initiatives focus on streamlining the purchase of pricey surgical tools—or preference items—which include knee and hip implants, pacemakers and hernia mesh, and make up a significant portion of a hospital’s expenses. But the success of such efforts may hinge on a factor that can be easily overlooked: physician participation. “Historically, surgery and business have not gone hand in hand,” said Brendan MacKay, MD, an orthopedic surgeon at the University Medical Center (UMC) 8
OR Ma n a gem ent News • S p r i ng 2 02 0
Health System, in Lubbock, Texas. “The reality, however, is that if surgeons don’t become involved in the business of medicine, they lose their say. Being involved also forces surgeons to critically evaluate what tools they’re using and whether the tools really improve patient care.”
‘If we can save money on certain things while providing equal or better care, we can invest that saved money into other ventures that can further improve patient health and make life better for physicians.’ —Brendan MacKay, MD At the 2019 OR Manager Conference, Dr. MacKay and his colleagues discussed how the value analysis program at UMC was transformed after physicians were brought on board in 2018. “We started a hospital-wide value analysis initiative in 2012, but weren’t seeing
the savings we had hoped,” said Adonica Dugger, DNP, RN, CNOR, an administrator of surgical services at UMC, who took over the surgery value analysis program in 2014. “The missing piece, we found, was that the people leading the effort were not clinicians.” The first hint that surgeon buy-in might be critical to the success of this effort came in 2015, Dr. Dugger explained. UMC had hired an orthopedic surgeon who preferred to use total joints from one vendor, which charged significantly more than its competitors. When Dr. Dugger took a closer look, she found that patient outcomes were not better and their costs were higher. After Dr. Dugger discussed these issues with the surgeon, he agreed it was time to switch vendors. “That year, we saved $1.2 million from changing one vendor,” Dr. Dugger said. “That’s also when we saw how important it was for surgeons to be part of the value analysis process from the beginning.” In 2018, UMC introduced a physicianled committee to the value analysis process. For requested items costing more than $2,500 annually, the physician council continued on page 10
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CLIN IC A L NE WS
Could Underbody Blankets Be the Better Option? By NAVEED SALEH, MD, MS
Vienna—Underbody-type blankets may outperform other types of warming blankets starting around 100 minutes after induction of anesthesia, according to one study. “Underbody blankets, together with surgical draping, enable efficient convection of airflow over the body,” said study author Shigekazu Sugino, MD, PhD, a research associate in the Department of Anesthesiology and Perioperative Medicine at Tohoku University School of Medicine, in Sendai, Japan. “This warmed tent produces a larger body surface area that can be warmed by the blanket.” In the current study, Dr. Sugino and his team prospectively reviewed data from 20,644 patients who underwent surgery under general anesthesia during 2018. They included 10,105 patients in their final analysis, with 3,829 assigned to the underbody blanket group and 6,276 assigned to a control group. Clinical data were taken from electronic health and anesthesia records. Data were collected for each type of blanket every five minutes for a period of four hours after the induction of anesthesia. The lead author of the study was Kunie Sato, MD, who presented the poster during the 2019 annual meeting of the European Society of Anaesthesiology. At 100 minutes after anesthesia induction, the regression coefficient was statistically significant in favor of underbody warming blankets. Anesthetics result in vasodilation by means of direct peripheral action. This process yields an initial rapid decrease in core temperature, and produces core-to-peripheral heat redistribution. Forcedair warming is necessary during the first three hours after anesthesia induction due to core-to-peripheral redistribution of body heat, which causes a rapid drop in temperature immediately after the start of anesthesia. Although underbody-type blankets have recently come to market, their current utility is unclear. “Gaining a deeper understanding of temperature redistribution
Value Analysis continued from page 8
conducts peer reviews to determine whether the new products are clinically necessary. “Initially, I wondered whether the physician council was just going to rubberstamp everything,” Dr. Dugger said. “But surprisingly, I find that our physician committee denies stuff all the time.” Surgeon buy-in also has made the approval process work more efficiently. “Involving surgeons in the process made them more aware of the cost implications and clinical importance of their requests,” Dr. Dugger said. “Physicians were able to 10
OR M a n a gem ent News • S p r i ng 2 02 0
Kunie Sato, MD, presents on benefits of underbody warming blankets during the 2019 annual meeting of the European Society of Anaesthesiology.
and how to maintain normothermia during surgery and anesthesia is an important subject, as there are clinical implications for patient outcomes tied to this metric,” said Scott Falk, MD, an associate professor of anesthesiology and critical care at Penn Medicine, in Philadelphia. “Given the data presented, underbody forced-air warming devices may have some advantage over overbody forced-air devices for prolonged procedures—those procedures lasting over 100 minutes. This study is unique in that it uses mathematical modeling on a large population to determine warmer effectiveness. It would have been beneficial to also relate the findings to significant outcomes, such as temperature postoperatively, patient length of stay and infection rates. Hopefully in the future, we will be able to delineate exactly which populations would benefit from this technology so it can be applied in a directed way.” Drs. Sugino and Sato are looking forward to performing a prospective study in the near future. “We shall verify the usefulness of the underblanket in a prospective study. Actually, we are conducting it now,” Dr. Sugino said. ■
weed out requests, so by the time an item reaches the executive value analysis team, it is almost always approved.” Dr. MacKay, who is part of the physician committee, added: “The physician-led committee turned into a kind of self-policing. We can always have a newer, shinier thing, but we are also asking ourselves and each other, ‘Is it helping the patient?’” So far, the addition of a physician-led committee has had a big impact on savings. The hospital saved over $2 million on OR purchases in 2018. As of September 2019, savings have already reached $2.5 million. “The idea is if we can save money on certain things while providing equal
or better care, we can invest that saved money into other ventures that can further improve patient health and make life better for physicians,” Dr. MacKay said. Drs. Dugger and MacKay agreed that such initiatives need to remain a work in progress, Dr. Dugger said. For instance, scheduling and communication can be a challenge, given everyone’s busy schedules. Dr. MacKay noted he initially found it difficult to get his colleagues excited about value analysis. “After a while, though, most physicians saw that the project wasn’t hurting them; it was just making everyone think more critically about how their choices impacted costs and outcomes.” ■
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FE ATURE
Navigating the Transition: What It’s Like to Be Acquired How to Make a ‘Good’ Merger By VICTORIA STERN
O
ver the past decade, health systems have been scooping up hospitals and physician practices at a growing pace. Analyses show that more than 750 hospitals were acquired or merged between 2008 and 2014, with 115 deals made in 2017 alone. As of 2017, almost 30% of hospitals in the United States (1,749/6,210) were part of a network, and more than half operated within a system of multiple hospitals or alongside organizations providing pre- or post-acute care, according to the American Hospital Association. The pressure for hospitals to consolidate has amplified over the past decade. “When you’re independent and out there on your own, it’s harder and harder to survive,” Dana M. Kopera, MBA, BSN, RN, CNOR, the clinical director of surgical services at UPMC (University of Pittsburgh Medical Center) Altoona, in Pa., and Bedford Memorial, in Everett, Pa., told OR Management News. “Although Altoona was profitable at the time of the acquisition, we saw that over the years we probably wouldn’t be able to stay that way unless we formed a relationship with someone bigger.” After being acquired in July 2013 by the UPMC Health System, an expansive network of hospitals spanning across Pennsylvania and New York, Altoona Regional ultimately adapted despite various challenges, explained Barbara E. Nosek, MHA. “When you join a large health system, you have to adopt new systemwide policies,” said Ms. Nosek, UPMC’s supply chain director. “Every policy and procedure needed to change.” Altoona Regional had to update its surgical documentation system, switch many of its vendors and adapt to a different supply chain process. Transitioning to
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UPMC’s electronic health record system was a particularly difficult initiative, Ms. Nosek said. Some systems allow for cutting and pasting existing preference cards into the new system. But, in this case, Altoona Regional staff had to manually recreate more than 1,000 preference cards. Despite the sweeping changes required, the transition came with notable perks. As part of the deal, UPMC Health System guaranteed a $250 million investment in Altoona Regional over 10 years to upgrade
facilities and physician recruitment efforts. With these resources, Altoona Regional built a cancer center, purchased a surgical robot and began telemedicine services. “We never had the capabilities to do video visits with patients, but now we are able to provide more coordinated care,” Ms. Kopera said. Efficiency improved, as well. After becoming part of UPMC, Altoona Regional saw how poorly it measured up to other hospitals in the health system with regard to OR start times. “We
reached out to our new peers at UPMC and adopted their OR processes,” Ms. Nosek said. “In a short period of time, we went from 19% of OR cases with on-time starts to 60%.” Still, not everyone was on board with the acquisition. “We had to overcome resistance and gain support from employees,” Ms. Kopera said. What helped, she said, is that “the leadership at Altoona was very transparent with us about the pros and cons of being acquired, and kept us informed. It’s important to recognize how hard an acquisition can be on the institution being acquired, but it’s also important to be open to the changes to come.” Making the Most of a Merger For Altoona Regional, the merger promoted greater efficiency and advances in patient care. But, on a larger scale, does consolidation lead to improvements in health care? Health care executives typically argue that it does—namely, that mergers and acquisitions help standardize clinical protocols and allow organizations to gain more clout in the health care marketplace. These advantages, they say, can improve efficiency, quality of care and costs. But research indicates that health care consolidation has not lived up to its promise of higher quality at lower costs. A 2018 analysis, which examined financial disclosures from 104 health systems in the United States between 2015 and 2017, revealed that two-thirds experienced an average decline in operating income of close to 40%, which translated to $6.8 billion in potential lost earnings. These declines were largely driven by expenses growing faster than revenue. Patients may pay more as well. “Overall, studies show that hospital mergers— both horizontal and vertical—tend to continued on page 16
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BUSIN E SS M A NAG E M E N T
Nursing Shortage, Gender Gap Are Standouts in AORN Salary Survey By CHASE DOYLE
N
urses seeking higher wages might consider a return to school, a change of scenery or “leaning in,” according to a comprehensive study of perioperative nursing compensation in the United States. The 2019 survey conducted by the Association of periOperative Registered Nurses (AORN) identified several important factors that influence salary. Findings showed that nurses with a master’s degree and a doctorate earned $5,300 and $12,800 more in base compensation, respectively. After controlling for a multitude of variables, researchers also reported significant differences in salary related to geographic region and sex, with female nurses earning $3,700 less than their male counterparts. It was the shortage of perioperative nurses, however, that researchers highlighted as the study’s biggest takeaway. “Results of our survey suggest that the nursing shortage is getting worse,” said lead author Donald Bacon, PhD, a professor of marketing at the Daniels College of Business at the University of Denver. “The median percentage of vacant full-time nursing positions was 9%, which is the highest we’ve ever seen, and more than two-thirds of facilities reported at least one open position.” Based on 5,708 unique responses from staff nurses and highlevel managers, data from the 2019 survey showed a threefold increase in open nursing positions, which was just 3% in 2013. More importantly, the nursing shortage may be harming the quality of patient care, with 48% of survey respondents reporting having to cancel or delay procedures. “We’re starting to see canceled and delayed procedures, which costs facilities money if patients decide to go to another hospital,” said Dr. Bacon, who cited insufficient compensation (45%), workload (40%), and lack of qualified nurses (40%) as reasons for the nursing shortage. Table. Nurses’ Level of Education by Job Title Education
Staff Nurse, %
Diploma
14
Nurse Manager, %
Higher Education Linked to Higher Salary and Quality Analysis of survey responses also identified a correlation between educational level and compensation (Table). Using nurses with a diploma as a baseline compensation, those with an associate degree earned $700 more; nurses with a bachelor’s degree earned $3,800 more; those with a master’s degree in any field earned $5,300 more; and nurses with a doctorate earned $12,800 more in base compensation. According to Dr. Bacon, however, it was “surprising” that the level of education did not have a more profound effect on salary. “As an educator, I was hoping to see a $20,000 per year improvement with a bachelor’s degree, but that is not what our data suggest,” Dr. Bacon noted. “Nevertheless, the analysis has already controlled for job title, and a nurse’s education level may well affect the level of responsibility attained.” Although lack of a degree does not necessarily hinder achieving a higher-paid position in nursing, approximately 30% of nurse managers and directors had a master’s degree. Nevertheless, researchers could not determine whether the position itself or the degree was the factor affecting salary. “It’s possible that facilities are using higher levels of education as a screen for upper management positions or it could be that nurses who obtain [a] master’s degree are more ambitious,” Dr. Bacon said. “It’s hard to say what the causal relationship is.” Janet Weiner, PhD, MPH, the co-director for health policy at Leonard Davis Institute of Health Economics, University of Pennsylvania, in Philadelphia, said that while there are many market forces that shape nursing compensation, there is clear evidence that a better nurse work environment in hospitals and advanced degrees in nursing are associated with increased quality of patient care. “Obviously, if you have more nurses, you have a higher payroll, but research by Dr. Linda Aiken has shown that having nurses care for fewer patients with mandated minimum staffing ratios in California, for example, leads Director/ to lower mortality rates,” Dr. Weiner said. Asst. Director Of Nursing, %
3.2
2.8
1.6
Associate degree
22.5
17.9
11.4
Bachelor’s degree in nursing
59.9
51.3
32.6
Bachelor’s degree in another field
5.0
3.7
3.2
Master’s degree in nursing
5.0
17.9
30.7
Master’s degree in another field
1.8
1.3
2.9
Master’s in business administration
0.7
3.1
11.7
Doctorate in any field
0.3
0.9
3.8
OR M a n a gem ent News • Sp r i ng 2 02 0
Pay Gap Between Sexes As Dr. Bacon reported, the AORN survey results also showed a statistically significant correlation between sex and nursing compensation, with men receiving approximately $3,700 more per year. Sex has been a significant factor in eight of the last 10 analyses, said Dr. Bacon, who noted that female nurses earned 92% of the pay of male nurses based on 2019 data. Despite this wage gap, researchers noted that this pay ratio was the continued on page 16
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AORN Salary Survey continued from page 14
highest among 10 professions analyzed by the American Association of University Women. “Although a pay gap exists, women in nursing appear to be treated more fairly concerning compensation than they are in other professions,” Dr. Bacon observed. “At the same time, since this is [a] female-dominated field—approximately 90% of nurses are female—you’d think compensation would be more favorable toward women. Women might not lean into the workplace as much as they could.” Regional Differences in Compensation The survey’s total participant size was large enough to make meaningful estimates of differences in compensation among states. Of the 26 states with sufficient sample sizes, eight states showed significantly different effects from what their regions would suggest, but Dr. Bacon pointed to three outliers: California, Massachusetts and Texas. “Nurses in California made $40,500 more than the model estimate, while nurses in Massachusetts made $28,600 more,” said Dr. Bacon, who added that Texas may be in an even more attractive financial position. “Interestingly, nurses in Texas have an average compensation level $5,400 higher than the base model, but a cost of living eight points below the national average.” Job Satisfaction Rated High After controlling for all the variables in the regression equation, researchers found a small but significant correlation between base compensation and job satisfaction. For each 1-point increase in satisfaction (on a 5-point scale), nurses earned an additional $1,400, but compensation was only the fourth most frequently cited source of job satisfaction, Dr. Bacon said (Figure).
Hospital Acquisition continued from page 12
mean higher prices for patients,” said Jill B. Zorn, a senior policy officer at the Universal Health Care Foundation of Connecticut, in Meriden. A recent analysis in Health Affairs found that an increase in acquisitions between 2013 and 2016— specifically hospitals that purchased physician practices in California—was linked to a 12% spike in marketplace premiums, 9% bump in specialist prices and 5% increase in primary care prices (2018;37[9]:1409-1416). So how can health care leaders ensure mergers promote greater efficiency and 16
OR Ma n a gem ent News • S p r i ng 2 02 0
Survey results showed that 71% of satisfied nurses reported “the job itself ” as the reason for satisfaction, followed by “coworkers” (66%) and “benefits” (53%). On the other hand, among dissatisfied respondents, “management” was cited most frequently as the source of dissatisfaction (71%), followed by “compensation” (48%). The job itself
71%
Coworkers
66%
Benefits
53%
Compensation
49%
Other surgical team members
45%
Job scheduling
39%
Management
26%
Workload
16%
Organization structure 15% 0
10
20
30
40
50
60
70
80
Percent, %
Figure. Reasons reported by nurses for job satisfaction.
“A common thread throughout our qualitative analysis was the passion felt by nurses for their job. These people work incredible hours and they deal with a lot of stress, but they also feel like they’re making a difference every day,” Dr. Bacon concluded. “For many nurses, the job is a calling, and the work environment is a source of great value for their lives.” ■ Drs. Bacon and Weiner reported no relevant financial disclosures. The survey study was sponsored by AORN.
better care at lower costs for hospitals and patients? A 2015 perspective in The New England Journal of Medicine explored what a “good” merger in health care should look like and what institutions need to prioritize (372[22]:2077-2079). Specifically, Leemore S. Dafny, PhD, a professor of business administration at Harvard Business School, in Cambridge, Mass., and Thomas Lee, MD, a professor at the Harvard T.H. Chan School of Public Health, in Boston, focused on how institutions can limit expenditures as well as generate “real and measurable improvements in cost or quality” for patients. A merger can, for instance,
promote cost efficiencies by allowing institutions to reduce the variety of products they purchase and negotiate lower prices from vendors. “Proposed mergers may threaten robust competition—but they could also be moments of opportunity, which, if seized, could help providers make major advances in their ability to compete on outcomes and costs,” Drs. Dafny and Lee wrote. “We believe that clear specification of cognizable efficiencies with explicit accountability for their achievement is a key input to a ‘good’ merger.” But, the authors noted, “higher-value health care will not result from good intentions alone; translating this ideal into reality takes vision, planning, and resolve.” ■
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TEC HN O LO GY
Artificial Intelligence in the OR: Separating the Hype From the Reality
said Sandip Panesar, MD, a postdoctoral research fellow in neurosurgery at Stanford University, in California. But, he caurtificial intelligence in medicine is tioned, “robots and devices that can take here. But it’s still in its infancy. over human dexterity: That’s in the future. The FDA has approved about three Humans will have to hold AI’s hand for a dozen AI algorithms in medicine over long time.” the past few years, many of which aim to But will AI someday replace physihelp physicians diagnose disease: diabet- cians? Judith Pins, RN, MBA, the presiic retinopathy from retinal images, can- dent of the health care education company cerous liver and lung lesions from CT Pfiedler Education, a subsidiary of the and MRI scans, and breast cancer from Association of periOperative Registered mammograms. Nurses, does not think so. Ms. Pins, who Entrepreneurs and health care lead- recently spoke at a Nurse Executive Leaders also have jumped on board. Last year, ership Seminar on the OR of the future, health AI startups brought in $4 billion sees AI as a tool that can assist providers. in funding, and a recent survey found that “AI won’t replace doctors and nurses, about half of hospital executives intend to but it can help make good providers great invest in AI over the next year or two. ones in terms of validating diagnoses and Although some experts predict that AI patient care,” she said. will transform medicine, others worry the Dan Hashimoto, MD, MS, a general buzz may be overblown. A recent headline surgery resident at Massachusetts Generin The Los Angeles Times asked, “Can AI al Hospital, in Boston, has some concerns live up to the hype?” and an article from about the hype surrounding AI in medThe Hill explored the “Dangers of Artifi- icine. Dr. Hashimoto believes that unrecial Intelligence in Medicine.” alistic expectations about AI can “lead to “At the moment, the term AI is very significant disappointment and disilluhyped, but a lot of it is real and already sionment” (Ann Surg 2018;268[1]:70-76). translating into something tangible,” Artificial intelligence experts have seen By VICTORIA STERN
A
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it happen before. In the early 1990s, when advances in expert systems—AI software that can mimic the decision-making ability of a human—did not live up to the media hype, the research fizzled. “Problems arose because we did not have enough computational power several decades ago to develop robust algorithms that could deal with large image data sets,” said Sharmila Majumdar, PhD, a professor and the vice chair of research in the Department of Radiology at the University of California, San Francisco, who launched the Artificial Intelligence Center to Advance Medical Imaging last year. But Dr. Hashimoto—who co-directs the Surgical Artificial Intelligence and Innovation Laboratory at MGH with Ozanan Meireles, MD, an assistant professor of surgery at Harvard Medical School, in Boston—says things are different now. “I think it’s the right time to pursue AI because the hardware is catching up to the concepts,” he said. An AI Algorithm to Guide Surgeons Despite the growing number of medical AI designs, not many products being developed are specific to surgery.
T ECHNOLOGY
Dr. Hashimoto is one of the few researchers working on AI for surgeons, specifically, an algorithm that can predict the risk for complications and readmissions for patients during surgery and warn surgeons in real time. The idea came to Dr. Hashimoto in 2012 after he reread Michael Lewis’s book “Moneyball: The Art of Winning an Unfair Game,” which delved into the statistical world of baseball. The book described, among other things, how a player’s likelihood of getting on base contributed to a team’s chances of winning or losing. Dr. Hashimoto wondered whether he could apply this idea to surgery: Develop an AI algorithm to identify surgical events linked to outcomes and use that information to predict outcomes, complications, even who lives or dies. But unlike hits and walks, what if these are measures humans can’t easily count, such as how a surgeon holds a needle? “We had no way of discovering or tracking that kind of data,” Dr. Hashimoto said. In 2014, the duo teamed up with Guy Rosman, PhD, and Daniela Rus, PhD, from the Computer Science and Artificial Intelligence Laboratory at Massachusetts Institute of Technology, in Cambridge. Drs. Rosman and Rus had already built an algorithm to analyze large-scale streaming data that could segment continuous data. The algorithm, for instance, could identify scene breaks in the 2014 movie “Birdman,” which appeared to be filmed as one continuous shot.
The researchers expanded on this premise and developed an algorithm that could pinpoint the individual steps in a laparoscopic procedure from a video recording about 90% of the time (Ann Surg 2019;270[3]:414-421). The next step: Determine whether the algorithm can do this in real time. “When we tweaked the algorithm, we still got about 90% accuracy in real time,” Dr. Hashimoto said. The final hurdle, Dr. Hashimoto noted, is still ahead. Can AI use realtime data, along with patient records, to predict what will happen during an operation? “Essentially we want to know, will a surgeon’s next move come with a high probability of making an error or resulting in a poor outcome for the patient, and can we develop an AI that predicts this risk and warns the surgeon?” Dr. Hashimoto explained. That phase represents the “holy grail” of what he’s trying to do. The biggest obstacle is the lack of data. He said he will likely need to incorporate data from thousands of surgical videos to build a robust algorithm, but “we currently have no centralized, uniform way to collect and store video data and no standard way to annotate that video,” he said. Dr. Hashimoto sees the technology largely as a support tool that can make medicine and surgery safer. “My hope is that AI can help physicians make better decisions, enhance performance, and eventually augment some more routine aspects of a case,” he said. “With AI, we’re not building ‘The Terminator’; we’re building ‘Ironman.’” ■
‘My hope is that AI can help physicians make better decisions, enhance performance, and eventually augment some more routine aspects of a case. With AI, we’re not building “The Terminator”; we’re building “Ironman.”’
—Dan Hashimoto, MD, MS
Here are a handful of other surgery-specific artificial intelligence designs that show potential to improve patient care: Robotics STAR (Smart Tissue Autonomous Robot), developed by researchers at Children’s National Health System and Johns Hopkins University, can suture two parts of a pig’s intestine together with minimal to no help from humans. XAware The Computational Modeling and Analysis of Medical Activities group at Strasbourg University Hospital, in France, led by Nicolas Padoy, PhD, is designing an AI tool that monitors radiation during image-guided interventions, using augmented reality to detect and visualize radiation scatter patterns and ultimately reduce OR staff’s exposure to the emissions. Context-aware SensorOR Researchers at the National Center for Tumor Diseases in Dresden, Germany, led by Stefanie Speidel, PhD, are developing machine learning technology that can analyze sensor data from the laparoscopic images, surgical devices and other activities in the OR. The goal is to understand, guide and optimize the flow of surgery. Brain Surgery A new technique that combines AI and imaging can help neurosurgeons diagnose tumors in a few minutes without removing brain tissue, which is the current standard approach for diagnosing these tumors. A recent Nature Medicine paper outlined the technique, which uses a deep convolutional neural network algorithm to learn brain tumor characteristics and predict the diagnosis from MRI scans (2020;26:52-58).
OR Ma n a gement N ews • S p ring 2020
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BUSIN E SS M A NAG E M E N T
Should I Hire a Consultant? Why Health Care Organizations Should Make Consultants Part of Their Team By DAVID TAYLOR, MSN, RN, CNOR
T
oday’s health care leaders may ask why they should consider hiring a consultant when there are full-time employees in place to execute initiatives and solve problems. The short answer is consultants bring a wealth of knowledge and experience that may not exist within the organization, and they bring an unbiased third-party perspective that is vested in the success of your organization. Health care organizations occasionally have challenging problems they need to be solved, but doing so can be difficult for several reasons. Day-to-day operations are already consuming your leaders’ time, keeping them from taking on new projects; hospital systems may be experiencing staffing shortages that are stressing business opportunities; and regulatory changes are difficult to keep up with and even harder to incorporate into daily work routines. All of this creates silos and employees become distracted. They stop seeing the problems around them or the opportunities in front of them. This myopic view grows over time and can cost your organization dearly, squeezing your margins. Filling the Void Working diplomatically, consultants provide provocative approaches that challenge the status quo and improve the bottom line. Research conducted by the Management Consultancies Association suggests organizations that employ consultants see returns that are six times their investment.1 20
OR Ma n a gem ent News • S p r i ng 2 02 0
Consultants typically work with the executive team, bringing a clear and objective perspective while contributing fresh ideas that are results oriented. They are not afraid of letting leadership know there is a problem. Consultants can ultimately save organizations time and money by prioritizing capital and resources for both short- and long-term goals, thereby letting employees focus on their areas of expertise. Assessment and Implementation A quality assessment can take a few days (macro view) and as long as a few months (micro view). During an assessment, a consultant will typically evaluate the institutional culture, review staffing models, scheduling practices, educational programs, inventory and supply chain costs, and analyze infection and quality control measures. Most firms then provide a summary of their findings and make recommendations for proposed changes, which could include organizational structure, training and education, and equipment and design options. A consultant can scale the project needs to the organization’s internal capabilities, partnering with leadership to facilitate and coordinate every aspect of the project. Situations to Hire a Consultant If your organization is due for a regulatory agency visit, a consultant can provide a pre-survey visit and help prioritize needs. If your organization has been cited by the Joint Commission, or worse, by CMS, a consultant can help you work toward a
resolution quickly. Other areas that a consultant can help with include: • Performance improvement initiatives that reduce care variations and improve quality outcomes. • Improvement of workforce productivity and effective allocation of scarce resources. • Boosting transformational change and establishing cohesive interdepartmental relationships. • Facilitation of OR, PACU and pre-admission testing standardization. • Preference card standardization, cleanup and ongoing card management. • Supplying design assistance with new construction or facility renovations. • An objective perspective when previous attempts to meet needs were not successful. The Cost of Doing Business Although it may seem the hourly rates and expense of hiring a consultant are high, the true costs may be nominal when an organization considers the median salary of an equivalent executive-level position plus the cost of benefits—such as health insurance, 401(k)/profit sharing and lack of taxes—as well as ease of termination once the job is completed. Consultants can hit the ground running and need very little oversight. They require no training, company orientation or hand-holding. Working long hours is part of their job. It is not uncommon to see consultants working every shift and even on weekends to gain clarity into the issues their clients face. continued on page 22
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Product Description: The Nathanson Hook Liver Retractors are designed to retract the liver during laparoscopic surgery and hold it out of the way. Automated Medical Products offers a full range of Nathanson Hook Liver Retractor sizes: Small, Medium, Large, Long Nose, Pediatric, and 3mm sizes. The Iron Intern® Articulated Arm is the retraction of choice for both open and laparoscopic procedures.
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Product Description:Maquet PowerLED II Surgical Light provides surgeons what they value most – predictable, clear and comfortable illumination for precise tissue visualization that inspires confidence to perform at their best. PowerLED II Lights are designed to eliminate glare, reduce eye fatigue, improve color rendition, enhance shadow control, prevent uneven illumination and eliminate the need for constant adjustments
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O R Ma n a gement N ews • Sp ring 2020 21
PE RSP ECTIVE
Coronavirus: To Mask or Not to Mask? By FREDERICK L. GREENE, MD
T
he recent emergence I, the use of gauze masks in military hosof a deadly mutat- pitals was introduced to protect patients ed strain of coronavi- who were placed in mixed wards with a rus (COVID-19) and high incidence of respiratory infections. its spread across the During the influenza pandemic of world has heightened 1918, wearing of gauze masks became interest in the role commonplace, but sadly in retrospect, of the surgical mask as one possible bar- masks were not protective in trapping rier to a potential pandemic. The media viral particles. Throughout the early 20th has touted the use of surgical masks and century, varieties of masks were introthe types of masks that should be worn duced to prevent bacterial transmission as a barrier to airborne viral spread. The from OR personnel to patients. With the need and desire of entire urban popula- recognition of viral contamination, this tions and travelers for facial barriers have filter concept gained greater importance. literally created a worldwide shortage of surgical masks and viral barrier ‘While the wearing of surgical respirator masks. The largmasks may be beneficial in locales est surgical mask provider, Prestige Ameritech, no with smog or other environmental longer is accepting orders pollutants, they are woefully for masks from individuinadequate for protection against als as it focuses on supplying U.S. hospitals. Not since the mutated coronavirus.’ the SARS epidemic in 2002-2003 has there been such interest in the varieties of mask protection. As we began operating on HIV-infectInitial interest in the use of masks as ed patients with laparoscopic techniques protection against infection, especially in the late 1980s, the release of a “viral tuberculosis, began in the late 19th centu- plume” into the OR from the escape of ry but did not routinely translate to usage the carbon dioxide used for creation of in the OR until the 1920s. It is reported a pneumoperitoneum became a concern. that Paul Berger, a Parisian surgeon, first This led to the development of mask filbegan routinely using a mask during surgi- ters that would lessen transmission of viral cal procedures in 1897. These early masks particles and afford increased protection were made of fine mesh gauze and used to for the operating team. Later improvecover the mouth only. During World War ments would usher in the mask respirator
Hiring a Consultant
concept now designated as the N-95 mask recommended for protection against viral particles and especially COVID-19. While the wearing of surgical masks during seasons of heightened respiratory illness has been commonplace in Asian cultures, this protective strategy remains infrequently used in North America. The current spread of COVID-19 is changing all of this. While the wearing of surgical masks may be beneficial in locales with smog or other environmental pollutants, they are woefully inadequate for protection against the mutated coronavirus. It is both appropriate and beneficial as a public health mandate that surgeons should have proper knowledge regarding mask protection that could be shared with patients, their families and, when asked, the media. The assumption that the wearing of a surgical mask is protective for populations at risk from respiratory-mediated viral epidemics should be dispelled. Adequate hand-washing is a better preventive measure than wearing nonprotective facial barriers. While the spread of COVID-19 has rightly engendered fear, the ultimate antidote against fear is fact, and who is best suited to provide appropriate facts regarding the drawbacks of surgical masks and the benefits of hand-washing? Surgeons— that’s who! ■ —Dr. Greene is a surgeon in Charlotte, N.C.
continued from page 20
important. It is essential that they understand the change that is needed and can work within the culture that exists. ■
Conclusion
References
Challenging problems and/or controversial projects can be hard for organizations to take the necessary steps toward without getting wrapped up in the emotions or politics to make the change that is needed. Workplace culture commonly is a significant barrier to change for any health care organization. Today’s leaders know that overcoming this barrier demands appropriate and thoughtful staff engagement to create the buy-in necessary to support needed changes. When choosing a consultant, cultural compatibility is 22
OR M a n a gem ent News • Sp r i ng 2 02 0
1. Management consultants help achieve enormous cost savings. http://bit.ly/2OpaVTT. Accessed February 3, 2020. 2. Don’t be fooled—the real cost of hiring an employee vs a consultant. http://bit.ly/2UsiixA. Accessed February 3, 2020.
—David Taylor, MSN, RN, CNOR, is an independent hospital and ambulatory surgery center consultant and the principal of Resolute Advisory Group LLC, in San Antonio.
GENERAL SURGERY NEWS The Independent Monthly Newspaper for the General Surgeon
Management News The Independent Source of News for Operating Room Managers, Supply Chain Professionals & C Suite
New International Consensus Guidelines on Orthopedic Infections Recommendation
93% of delegates agree
There is No Evidence to Prove Sealants Reduce Surgical Site Infections Without the Use of a Dressing1
The Guidelines recommend the use of silver, occlusive dressings to help prevent SSIs. THREE OUT OF FOUR of the clinical studies supporting this recommendation used
To find out more,
visit www.convatec.com 1. General Assembly, Prevention, Wound Management: Proceedings of International Consensus on Orthopedic Infections. Al-Hourabi, Reema K. et al. The Journal of Arthoplasty, Volume 34, Issue 2, S157 - S168. ©2019 ConvaTec Inc. ™/® indicates a trademark of ConvaTec Inc. AP-020606-US
