OR Today - October 2014

IN THE OR

SURGICAL SERVICES SUMMIT

TAKE GOOD CARE

SPOTLIGHT ON

PINBOARD

ASHLEY BROWN, RN LIFE IN THE BIG APPLE

NURSES • SURGICAL TECHS • NURSE MANAGERS

CONTESTS AND WINNERS

www.ortoday.com

OCTOBER 2014

ALARM FATIGUE ZING

BAM

CLANK

PING

CLANG

BEEP

BEEP

PING

POW

WHOOSH

POW

ZAP BEEP

CLINK

POP ZAP

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Experts share solutions that prevent sentinel events

POP

ZING

BZZZ

PING

BOOP

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CONTENTS

features

OR TODAY | October 2014

46

50

ALARM FATIGUE

The ECRI Institute has listed alarm fatigue as the number one health technology hazard for the past three years. Experts share advice and techniques to prevent this problem that can lead to sentinel events.

58

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SPOTLIGHT ON

Ashley Brown left sunny California for the BIg Apple to pursue a career in nursing and she has no plans to leave. She says her work in a neurosurgical unit at NYULangone is a rewarding career.

OR Today (Vol. 14, Issue #10) October 2014 is published monthly by MD Publishing, 18 Eastbrook Bend, Peachtree City, GA 30269-1530. POSTMASTER: Send address changes to OR Today at 18 Eastbrook Bend, Peachtree City, GA 30269-1530.

For subscription information visit www.ortoday.com. The information and opinions expressed in the articles and advertisements herein are those of the writer and/or advertiser, and not necessarily those of the publisher. Reproduction in whole or in part without written permission is prohibited. Š 2014

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October 2014 | OR TODAY

7

CONTENTS

departments

PUBLISHER

John M. Krieg | john@mdpublishing.com

19

VICE PRESIDENT

Kristin Leavoy | kristin@mdpublishing.com

EDITOR

11

John Wallace | jwallace@mdpublishing.com

ART DEPARTMENT Jonathan Riley Yareia Frazier Jessica Laurain

ACCOUNT EXECUTIVES

Sharon Farley | sharon@mdpublishing.com Warren Kaufman | warren@mdpublishing.com

68 INDUSTRY INSIGHTS 11 News & Notes 16 AAAHC Update

IN THE OR 19 22 27 28 36

CIRCULATION Bethany Williams

ACCOUNTING Sue Cinq-Mars

WEB SERVICES Betsy Popinga Taylor Martin

Surgical Services Summit Suite Talk Market Analysis Product Showroom CE Article

OUT OF THE OR 66 Health 68 Fitness 70 Nutrition 72 Recipe 74 Pinboard 78 Index

8

74

Jayme McKelvey | jayme@mdpublishing.com

OR TODAY | October 2014

MD PUBLISHING | OR TODAY MAGAZINE 18 Eastbrook Bend, Peachtree City, GA 30269 800.906.3373 | Fax: 770.632.9090 Email: info@mdpublishing.com www.mdpublishing.com

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INDUSTRY INSIGHTS NEWS & NOTES

STAFF REPORTS

MEDLINE INTRODUCES ITS FIRST COLLOIDAL OATMEAL EXAM GLOVE

H

and hygiene compliance can take a toll on hands. And just because clinicians wear gloves, doesn’t mean their hands are completely protected. Underneath those gloves, many nurses commonly battle dry, irritated skin — complaints often connected to constant washing, scrubbing and sanitizing.

In fact, 88 percent of healthcare professionals believe that following proper protocols can lead to the onset of skin problems.

Medline Industries Inc. has developed an exam glove that helps soothe healthcare professionals’ hands and maintain the skin’s moisture barrier to prevent and protect dry skin. A number of skin studies have examined how clinician hands compare to those who don’t participate in frequent hand washing and conclude that healthcare workers are vulnerable to dry skin, more than any other group. Restore nitrile gloves with colloidal oatmeal incorporate this soothing agent.

Colloidal oatmeal is a USP skin protectant drug and one the Food and Drug Administration has indicated can temporarily protect and help relieve minor skin irritation and itching due to rashes or eczema.

“More needs to be done to highlight the important link between hand hygiene compliance and skin WWW.ORTODAY.COM

care,” said Martie Moore, R.N., MAOM, CPHQ, chief nursing officer for Medline. “Gloves are like a second skin to healthcare workers and this innovative new glove is a simple step facilities can take to help protect its most valuable tools — the hands of staff.”

Restore’s patented technology is designed to protect and nourish the skin. The colloidal oatmeal in the glove temporarily protects and

helps relieve minor skin irritation and itching due to rashes or eczema.

By creating a soothing physical barrier between the glove and skin, the gloves contribute to a more comfortable and moisturizing environment where sweating and irritation can be common. • LEARN MORE about Medline’s new colloidal oatmeal glove at www.medline. com/restore-gloves.

October 2014 | OR TODAY

11

INDUSTRY INSIGHTS NEWS & NOTES

AAAHC CELEBRATES 35 YEARS STRONG In recognition of three and a half decades as the leader in ambulatory healthcare accreditation, the Accreditation Association for Ambulatory Health Care (AAAHC) recently marked its 35th anniversary. It highlighted the evolution of its high-quality standards of care, commemorated long-term partners and celebrated the peer-driven accreditation process it has championed.

An August 2014 survey of AAAHC accredited organizations offers another cause for celebration.

Ninety-one percent of respondents said they place significant value on the well-established foundation and experience that AAAHC offers and 98 percent of respondents said they would return to AAAHC when it comes time to reaccredit.

“For 35 years, AAAHC has been dedicated to developing standards to advance patient safety and quality care, and establish measurements of value and performance for ambulatory healthcare,” said John Burke, PhD, president and CEO, AAAHC. “Through peer-based accreditation processes, education and research, AAAHC continually raises the bar for quality patient care.”

Since its inception, AAAHC has maintained that a voluntary, peer-based, consultative and educational survey process is one of the most powerful ways to demonstrate that an ambulatory health facility is meeting high-quality standards. The AAAHC accreditation process includes an on-site review by expert surveyors who have decades of experience as healthcare professionals – from physicians and nurses to medical directors and administrators.

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OR TODAY | October 2014

Colleen M. Jahnel, Director of Quality Assurance, Compliance, and Health Information at Boynton Health Services, holds a 35-year commemorative plaque outside the University of Minnesota facility.

“Armed with both experience and education, AAAHC surveyors are highly skilled in helping healthcare organizations achieve successful accreditation,” said Burke. “The collaborative, consultative nature of the AAAHC survey process, combined with surveyors’ personal approach and insights, exemplify our passion and commitment to ambulatory healthcare accreditation and high standards.”

Over the past 35 years, AAAHC has demonstrated an ability to access the evolving needs of various healthcare settings, adding new standards in areas such as dentistry, behavioral health and health education and wellness, while annually updating existing standards to reflect cutting-edge ambulatory care knowledge and practice. Such efforts have ranged from offering the most comprehensive Patient-Centered Medical

Home accreditation and certification programs available to streamlining the accreditation process for ambulatory surgery centers.

A key component in the AAAHC accreditation process is the personal commitment of each provider team to welcome peer-based personal and organizational evaluation. As part of the 35th anniversary celebration, AAAHC recently presented commemorative plaques to two ambulatory healthcare organizations that have earned AAAHC accreditation for 35 consecutive years strong.

Boynton Health Service is a primary health care provider serving University of Minnesota students, staff and faculty. In 1979, Boynton was the first college health facility to achieve AAAHC accreditation.

The Banner Health Phoenix Surgicenter, the first free-standing, multi-specialty surgery center in

WWW.ORTODAY.COM

NEWS & NOTES

the country, also has been accredited by AAAHC for the past 35 years.

“Through its wealth of resources, education and training that offer ongoing consultation and professional development, AAAHC will continue to provide organizations the assurance that they will remain at the forefront of optimum ambulatory care,” Burke said. “Our 35th anniversary is a significant milestone, marking a rich history to be followed by a bright future.” • FOR MORE INFORMATION, visit www.aaahc.org.

Surgicenter’s Sharon Shafer, RN, holds a 35-year commemorative plaque presented to the facility by AAAHC.

ENCOMPASS GROUP LLC PARTNERS WITH PERFECTCLEAN FOR INFECTION PREVENTION With the incentives for preventing healthcare-associated infections (HAIs) continuing to escalate, leading hospitals are looking to environmental hygiene solutions from brands like PerfectCLEAN offered by Encompass Group LLC. The PerfectCLEAN Environmental Hygiene System has been designed to exceed the CDC recommendations for blood borne pathogens and has been developed to be laundered in a commercial laundry with the CDC recommended levels of hypochlorite bleach.

The products represent the only true color-coded system supported by a number of training programs including Operating Room processing – practices and procedures which recently received the AORN Seal of Recognition. In this day and age it makes absolutely no sense whatsoever not to isolate the bathroom, the key reservoir for C diff, from the patient care zone. PerfectCLEAN offers excellent ROI through superior durability.

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hand-in-hand with any cleaning solution.

Maintaining a safe and clean patient environment is an essential part of caring for hospitalized patients. Each year, more than 2 million patients are affected by HAIs, resulting in more than 100,000 deaths. The cost to treat HAIs is growing. A report published last year estimates that HAIs arising in U.S. acute care hospitals cost society as much as $147 billion annually.

October 2014 | OR TODAY

13

NEWS & NOTES

NEW DISC SEALS ACCESS SITES AND IS IDEAL FOR TUNNELED DIALYSIS CATHETERS Each year, approximately 80 percent of all hemodialysis patients in the U.S. are treated with a Tunneled Dialysis Catheter (TDC).

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These dressing disruptions are a known risk factor for M-CRI and CR-BSI. To minimize dressing disruptions for large catheters, Biolife has introduced StatSeal Disc in a new 10-14 Fr size. Earlier this year, StatSeal debuted its 1.9-4 Fr extra small size, which is now widely used in children’s hospitals around the country. With the addition of the Large Disc, StatSeal Disc is now available in sizes to fit catheters from 1.9-14 Fr. Using the same FDA-cleared formulation of potassium ferrate and hydrophilic polymer found in StatSeal Powder, StatSeal Disc creates an instant seal to stop the flow of blood and exudates from PICC and central line insertions. The seal 14

OR TODAY | October 2014

IMP INTRODUCES NEW INNOVATIVE SPORTS MEDICINE LINE

keeps access sites dry, intact and protected from contamination.

While traditional access dressings (sponges, gels, gauze) absorb blood and exudates, mandating dressing changes three times in seven days on average, one StatSeal Disc application lasts seven days to dramatically minimize dressing disruption.

Based on feedback from the company’s own testing, the disc requires less training, leads to shorter product evaluation, is less disruptive to the access site and provides patients with greater comfort. • FREE SAMPLES of StatSeal Disc are available by contacting Biolife at customercare@biolife.com.

The new Innovative Sports Medicine line from Innovative Medical Products includes the Reznik Universal Shoulder Positioner that provides surgeons three planes of adjustment when performing arthroscopic shoulder procedures with the patient in the lateral position.

Designed with safety stops on the vertical plane for additional patient protection, the patented solution ensures controlled distraction and rotation of the shoulder. The IMP device can also be used in elbow arthroscopies.

“Designed to solve a wide array of surgical needs with one device, the system represents the most economic solution to the challenge of multi-surgeon and multi-surgical technique traction requirements,” noted Alan Reznik, M.D. “Whether for position, rotation control or flexibility, every surgeon’s ideal set-up is possible with the Reznik Universal Shoulder Positioner because of its simplistic, universal design. The positioner’s patented, lightweight, double-pole, universal flange design also reduces set-up time, yielding more cost saving,” said Reznik.

“Its storage hook allows for zero footprint storage in the operating room and the universal design also reduces complexity in surgical scheduling and last-minute operating schedule changes, making accommodating multiple surgeons easy and efficient, while reducing downtime for the entire arthroscopy operating suite.”

The Reznik Universal Shoulder Positioner can be used in conjunction with IMP’s sterile Phase 4 Gel Splint, a unique forearm traction splint for shoulder or elbow arthroscopies. The Phase 4 Gel Splint protects against skin breakdown, allows greater flexibility in forearm and shoulder rotation and adds stability and anatomical uniformity to patient positioning.

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GEL POSITIONERS

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INDUSTRY INSIGHTS AAAHC UPDATE

BY KATHY WILLIAMS BEYDLER, RN, MBA, CASC, CNOR

ATTRACTING EXCEPTIONAL SURGEONS TO YOUR ASC

Y

our ASC is only as good as your staff – especially your surgeons. Which means that to gain a significant competitive advantage, your surgeons must be exceptional. Here are three key attributes to attracting the best and brightest to help your center stand out from all the rest.

BUILD A RELATIONSHIP WITH THE SURGEON Begin with a one-on-one meeting with the surgeon you’re targeting for your center. Specify that the meeting will be no more than 15 minutes – and hold to that time frame, unless he indicates he’d like the meeting to go longer.

In this first meeting, ask the surgeon what his greatest frustration is in getting his cases done. This will help reveal your competitor’s areas of weakness – knowledge you can turn to your advantage by making sure your center is strong in those areas.

16

OR TODAY | October 2014

Second, ask the surgeon what he likes about where he’s currently working. By asking this question, you gain insight into what is important to the surgeon and can position your center to exceed his expectations.

I have yet to meet a surgeon that time was not his most valued asset.

One of our surgeons had small children and said that every day as he put his garage door down, his goal was to see how quickly he could be back with his family.

Working with the surgeon to make sure his time is spent more effi-

ciently will result in a better partnering relationship.

Check in frequently with him to see how his cases are going and assess any changes that need to be made. Talking with him immediately after his cases, if at all possible, provides the best real time feedback.

At a minimum, chat with the surgeon at least once a week. Once you have built the relationship, the surgeons can be your best recruiters for other physicians.

BUILD A RELATIONSHIP WITH THE SURGEON’S SCHEDULER For most surgeons, the scheduler is the gatekeeper for booking the cases. Establishing a rapport with this key person will provide you with a wealth of information about the physician and help you better understand the surgeon’s needs.

WWW.ORTODAY.COM

AAAHC UPDATE

Identify his preferences and focus on how you can make your center his center of choice.

Visit with the scheduler every two weeks for the first few months, and then check in monthly to answer questions and address any concerns and/or issues that may have arisen.

Building a relationship with the scheduler can help foster the idea that it is easier and more productive to operate at your center than anywhere else. For instance, physicians and their office staff are often frustrated by the myriad chores they are required to perform. Make sure you: Have a clear process for preadmission testing requirements and patient admission criteria.

Reduce any requirements that are not necessary, for regulatory or patient safety issues. This will strengthen loyalty from the surgeon and staff. Some simple things: For paper records, put ‘sign here’ stickers on each page the physician needs to review and sign.

For electronic records, look for ways to make it easier for the physician to quickly and methodically review and complete the records.

Overall, your aim should be to convince the surgeon and scheduler that your center provides the best care for the patients, simplifies the scheduling, and provides WWW.ORTODAY.COM

the professional environment that still meets all the regulatory requirements.

FOCUS ON THE SURGEON’S EXPERIENCE AT YOUR CENTER Involve your staff. Having a consistent team working alongside the surgeon builds confidence in the center and places the surgeon more at ease in the new environment.

Let the surgeon know he will have the same team members as much as possible and that this team will be training others in time.

The surgeon will become more confident and comfortable as he sees the experience and the professionalism of your staff.

As the staff members demonstrate their understanding of the surgeon’s preferences, their critical thinking skills and ability to work through new challenges, the advantages of your center will increase the surgeon’s loyalty.

Involve your anesthesia providers; they can be a good marketing source for physicians. Anesthesia providers frequently service more than one site and may have both personal and professional relationships with other surgeons.

Our anesthesia providers were excellent in talking to physicians about the benefits of our surgery center and getting them to consider coming.

Once the patients and surgeons

come to the center, anesthesia’s part in the process continues with timely assessment of the patients to allow for efficient turnovers.

Anesthesia’s involvement and buy-in is critical to the flow and effectiveness of the center.

No detail is too small for insuring physician loyalty. Surgeon preferences extend beyond the operating room and can involve every aspect of the center experience. If your center provides snacks, for example, find out which ones the physicians prefer and have them available. One surgeon’s preference was for Hot Tamales candy — a simple item we could have on hand for him and something he looked forward to when he did cases at the center.

The ROI for these gestures was incalculable. Remember the surgeon always has a choice – make sure your center is the one he chooses.

ABOUT THE AUTHOR Kathy Williams Beydler is the Director of Surgical Services at Regional One Health, a Level I Trauma Center in Memphis, Tenn. Previously, Kathy was the administrator of a start-up surgery center and transferred five years later to the flagship center in Memphis. She is a surveyor for AAAHC and especially enjoys the opportunities to teach during her surveys and encourage centers to become the best they can be.

October 2014 | OR TODAY

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In 1979 the Steelers won the Super Bowl.

Saturday Night Fever was the album of the year. And AAAHC began accrediting ambulatory health care organizations.

YEARS STRONG

We’ve been raising the bar on ambulatory care through accreditation for 35 years. The secret of our success? Our peer review. AAAHC surveyors are physicians, nurses, anesthesiologists, medical directors and administrators. Which is why organizations routinely heap praise on us for our consultative and educational survey process.

And why we are the leader in ambulatory accreditation.

If you would like to know more about AAAHC accreditation, call us at 847-853-6060. Or email us at info@aaahc.org.

Or you can visit our web site at www.aaahc.org.

Improving Health Care Quality through Accreditation 18

OR TODAY | October 2014

WWW.ORTODAY.COM

IN THE OR SURGICAL SERVICES SUMMIT

BY JOHN WALLACE, EDITOR

EIGHT REASONS TO ATTEND THE SURGICAL SERVICES SUMMIT T

he inaugural Surgical Services Summit, presented by Inside the Joint Commission and OR Today, is a gathering place for leaders in the field. The luxurious Green Valley Ranch Resort and Spa is the site for this brand new industry conference on Dec. 7-9.

Education is always an excellent reason to attend a conference and the Summit is no different, but that is just one of several reasons to attend. Here we take a look at eight reasons why OR nurses and directors should register today.

1

VEGAS

Las Vegas is an ideal destination for various reasons with gaming, shows and its own unique brand of excitement. The Green Valley Ranch Resort and Spa, site of the Surgical Services Summit, is a four-diamond luxury hotel with amenities that exceed even the highest expectations. Attendees are invited to enjoy Vegas at the unbelievable price of just $105 a night thanks to a special rate for Summit attendees.

Reservations can be made online or by calling 866-782-9487. The deadline to acquire accommodations is Nov. 7.

Discounts are also available for flights and rental cars. For additional travel information, visit http://surgicalservicessummit.com/hotel-travel/.

WWW.ORTODAY.COM

2

KEYNOTE

The Surgical Services Summit is thrilled to have Dr. Nancy L. Fisher, RN, MD, MPH, and Chief Medical Officer at the CMS Seattle Regional Office as the keynote speaker. Fisher’s extensive education and experience combine to make her an ideal speaker for the Summit. She will address the sometimesmysterious world of healthcare reform.

As a CMS leader she will share her expert insights regarding valuebased care, cost effectiveness and quality measures.

Fisher will focus on communication, explain the reasoning behind value-based care and discuss the need for data.

“In order to improve, we need information and we have to measure quality,” Fisher said.

“Quality makes the case for cost containment in the healthcare system and is also key now in reimbursement.

Practitioners look at it as a burden.”

— Dr. Nancy L. Fisher, RN, MD, MPH

“What I really want to focus on is quality. Quality makes the case for cost containment in the healthcare system and is also key now in reim-

bursement. Practitioners look at it as a burden.

We’ve listened to them and I want to show them how to make it easier.”

“I will focus on surgical services and provide examples of what they can do to meet the quality measures,” she added.

Carol Brault, Vice President, Acute Care Group, DecisionHealth LLC, explained the unique opportunity attendees have to hear Fisher.

“We are delighted to have Dr. Fisher from the CMS keynote the Surgical Services Summit. She will share key strategies and provide examples so perioperative leaders can be better equipped to meet the required quality measures and take steps toward reaching reimbursement sustainability,” Brault said.

October 2014 | OR TODAY

19

IN THE OR SURGICAL SERVICES SUMMIT

3

EDUCATION

The Surgical Services Summit has been approved for 10 nursing contact hours through the Commonwealth Education Seminars, an approved provider for the American Nurses Credentialing Center and the California board of Nursing, Provider Number CEP15567. To receive a continuing education certificate, participants must complete an evaluation form at the end of the conference. Added educational opportunities are available through two preconference workshops.

For updated articles on speakers at the Summit, visit http://surgicalservicessummit.com/ latest-articles.

20

OR TODAY | October 2014

5

ROUNDTABLES

Michelle Jackson, Scheduling Coordinator

4

PRE-CONFERENCE WORKSHOPS

Two additional educational opportunities are offered the day before the official start of the Summit. “Operational Management and Block Scheduling in the Operating Room” will be presented by Michelle Jackson, Scheduling Coordinator, St. Luke’s Health System, Boise, Idaho, and James X. Stobinski, PhD, RN, CNOR, Director of Credentialing and Education, Competency and Credentialing Institute. This in-depth learning experience includes the second edition of the Surgical Services Management (SSM) Certificate of Mastery program. “Operations Management” is a part of the 7-module program.

Participants will be required to complete written materials after the Surgical Services Summit to receive credits. Course requirements include the completion of an online pre-test and post-test. Once participants have complet-

James X. Stobinski, PhD, RN, CNOR

ed the required work, they will receive 19.5 CE credits and a certificate.

The pre-conference workshop “Right Capacity/Right People and Workforce Management for Peri-Operative Units” will address techniques for budgeting, management of full-time employees and the challenges perioperative leaders face in today’s shifting healthcare landscape. ChrysMarie Suby, president and CEO, Labor Management Institute, will present the three-hour workshop. All RNs interested in earning three continuing education contact hours through the California Board of Registered Nursing are encouraged to attend the workshop.

Moderators will facilitate discussions on a variety of timely topics, such as avoiding readmissions, LEAN practices, patient satisfaction and more. During the hour-long roundtable session, attendees will rotate halfway through so participants can increase their knowledge by discussing two pertinent subjects. The roundtables will be narrowly focused by design and moderators will ensure each participate has an opportunity to share and learn. The topics are listed on the Surgical Services Summit website and may be updated to reflect attendees’ interests.

ChrysMarie Suby, president and CEO WWW.ORTODAY.COM

SURGICAL SERVICES SUMMIT

6

EXHIBIT HALL

There will be 42 booths showcasing industry-leading products and services in the Surgical Services Summit exhibit hall.

Attendees are encouraged to walk the exhibit hall floor and interact with these premier vendors to learn about the latest medical devices, technologies and services. A complete list of exhibitors is available online at surgicalservicessummit.com/exhibitors-sponsors/ floor-plan/.

7

NETWORKING

The Surgical Services Summit schedule includes opportunities to unwind and interact with colleagues from throughout the country. A welcome reception on Sunday, Dec. 7 will be the first opportunity for attendees and exhibitors to connect via a cocktail reception in the lobby bar of the Green Valley Resort.

Networking breakfasts on Monday and Tuesday are another way for attendees to meet colleagues. An exhibit hall reception will be held on Monday evening from 5-6:30 p.m. with complimentary drinks and light hors d’oeuvres.

It serves as an excellent opportunity to re-connect with friends from the industry and make new connections with a peer or mentor.

8

GREAT VALUE

There are three great attendance options for the Surgical Services Summit. Attendees can register for the ultimate experience and attend the pre-conference workshops and the two-day Summit for $745 via Early Bird registration. Registration for the two-day Summit is $495. The cost to attend only the pre-conference workshops is $295. Early registration closes Oct. 24. Brault encourages early registration.

“It’s off to a strong start and there is limited space. Hurry and register to reserve your spot,” she says.

REGISTER now at surgicalservicessummit.com/ register.

WWW.ORTODAY.COM

October 2014 | OR TODAY

21

IN THE OR SUITE TALK

SUITE TALK

Conversations from the OR Nation’s Listserv

Q

TATTOOS Is it OK to put a bovie pad on a tattoo?

A: Tattooing practice is adopted worldwide and represents an important socio-cultural phenomenon, but the injection into the skin of coloring agents as metals might pose a risk for allergies and other skin inflammations as well as for systemic diseases. In this context, 56 inks for tattooing purchased from 4 different supply companies were analyzed for metal concentration. The relative contribution of metals to the tattoo inks was highly variable between brands and colors, even with pigments with the same base color.

Q

A: As a clarification – although often used interchangeably, cautery and electrosurgery are distinctly different modalities and as such, cautery does not require the use of a return electrode (bovie pad). •

COMPUTER CHARTING Sometimes the computer charting is so pre-programed that many limitations exist. If you currently use McKesson Paragon CCS for PACU charting, please share how you go about charting meds.

Many times, even if a medication is not given early, the nurse is prompted to provide an early dose reason. The nurse then has to do additional charting to explain inaccurate charting.

A: We use Meditech.

A: As of yet we do not computer chart in the OR but the rest of the hospital does using the system CPSI. Does anyone else use this system? How user friendly is it to use in the OR? 22

AORN does not recommend placing the cautery pad over a tattoo because of the possibility these metallic dyes may be present and can cause a burn to the patient. AORN does have a link on their website that has a short video on the placement.

OR TODAY | October 2014

A: We are using Meditech at the moment.

not perfect but we are using it quite successfully.

A: We also use Meditech.

A: We use Meditech but a different system for anesthesia. •

A: We use CPSI hospitalwide, including in the OR. Like any other system, it is

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SUITE TALK

Q

NIGHT SHIFT COVERAGE Does anyone staff the 11 p.m.-7 a.m. shift with only a surgical technician? Their duties are to get rooms ready for the next day, stock, do quality checks and call in the rest of the team.

A: We staff our night shift with one RN, who performs those duties and more. Her role is very valuable, particularly in assessing and triaging potential scheduling issues that may need to be resolved before the day shift charge RN comes in.

A: We do. They are actually very busy at night. They have to recheck all the cases that have been picked, get the ambulatory ready for the next

Q

day, stock preference cards and they assist as needed throughout the building as sitters, runners, etc.

A: We staff with a OR RN and a surg tech. These positions were added about 5-6 years ago as a retention strategy as we were losing staff due to the amount of call required. In addition to doing cases, they pick cases for next day, set rooms up, review expiration

dates, etc. It has been challenging to continue to find valued work for them. Given our night shift volume, the additional duties are important for staffing this shift.

A: That is the same reason we added night coverage – to retain staff.

A: It is a huge satisfier to our RNs not to cover first call during the week. •

SHOULD I WAIT? Often times surgeons and anestheologist order tests and then want to proceed to the OR without the results of the test, because it is taking too long for the results. Why order the test if you are not willing to wait for the results? If this occurs, should the patient be charged for the test? Where is the best place to chart that the surgeon preceded without waiting on results? It is one thing to proceed in an emergency situation, it is another when it is a scheduled case.

A: I think we all have encountered this a few times in our careers and I agree it is ridiculous to order a test when you’re not willing to wait for the results when it isn’t a emergency situation.

Why run the test then? When this situation arises we document it in the Intraoperative Report (under notes) that a certain test was performed on patient but surgeon/anesthesia refused to wait for results. My philosophy is that it is always good to cover our butts as circulating nurses.

A: Our policy states all ordered tests and procedures will be on the chart before being brought to the OR. This actually went to the surgery committee and fortunately I had administration backing for this. It is for patient safety and as you stated, “Why would the test be ordered if not needed?” •

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October 2014 | OR TODAY

23

IN THE OR SUITE TALK

Q

CHEWING GUM

THESE POSTS ARE FROM OR NATION’S LISTSERV

A question has come up on gum chewing in the OR suite. We all know there are days when we just can’t control a tickle in our throat and have had a cough drop still in our mouth as we roll the patient to the OR suite. I’m asking about chewing gum or any other food or drink in the OR suites. I’m interested in hearing what others are doing.

A: We don’t consider gum a food and allow it.

snapping gum, etc.) and is disallowed.

A: Absolutely no food or drink beyond the designated break area. If gum or a cough drop becomes a “distraction,” then it falls under our “distractions” policy (phones, radio, chatter,

A: Chewing gum is appropriate as long as it does not disrupt cases. No food or drinks allowed.

These are kept in the lounge.

FOR MORE INFORMATION or to join the conversation, visit www.theornation.com

A: We do not allow it.

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The Gelli-Roll® is a reusable water blanket that provides patient warming and comfort. It allows for the caregiver to have complete access and is easy to clean with disinfectants.

“Gel pad water blanket warming was more effective in maintaining normothermia after cardiac anesthesia compared with convective warming. This can be considered an advantage as the gel pad system is easy to use and quiet. Gel pad warming has replaced underbody convective warming during cardiac anesthesia at our institution.”

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IN THE OR MARKET ANALYSIS

STAFF REPORTS

MARKET ANALYSIS

Temperature Management

P

atient temperature management is a vital element in many instances of healthcare. Medical devices to lower or increase body temperature are valuable tools, especially when it comes to surgical settings.

Temperature management can be used for patient comfort and can also improve health outcomes.

Therapeutic cooling can reduce fevers and serve a vital role in preserving the functionality of the brain and the nervous system.

Devices used to warm patients can provide assistance when treating sports injuries, patients suffering from trauma and is an important element of neonatal care.

A recent report by TechNavio indicates that this market of medical devices is on the rise. The analysts predict that the global patient temperature management market will grow at a compound annual growth rate of 7.4 percent from 2013 through 2018.

“The global patient temperature management market has also been witnessing an increase in mergers and acquisitions among the leading vendors to increase their global presence and to achieve economies of scale,” according to ResearchAndMarkets. “However, the unavailability of adequate scientific WWW.ORTODAY.COM

support for the systematic and protocol-driven application of these devices could pose a challenge to the growth of this market.”

“The global patient temperature management market is witnessing an increase in the number of mergers and acquisitions among the leading vendors in the market,” an analyst said. “Vendors opt for the mergers and acquisitions strategy to gain more market share, increase their global presence, and to achieve high economies of scale.

For instance, GE Healthcare acquired Vital Signs Inc. in 2008; Philips Healthcare acquired InnerCool Therapies Inc., and ZOLL Medical Corp. acquired Alsius Corp. in 2009; Stryker Corp. acquired Gaymar Industries Inc. and 3M Health Care acquired Arizant Inc. in 2010; and C.R. Bard Inc. acquired Medivance Inc. in 2011. These acquisitions by the leading vendors have enabled them to maintain their position in the global patient temperature management market and develop a variety

of offerings, which will boost their revenue during the forecast period.

According to the report, one of the major drivers is the increasing prevalence of cardiac and CNS disorders. The rise in cardiac, brain, and spinal surgery is leading to the growth of the market as hot and cold therapy products are used in these surgeries to provide patient comfort and improve outcomes.

Further, the report states that one of the major challenges faced by the market is the unavailability of adequate scientific support for the systematic and protocol-driven application of these devices.

The United States traditionally leads the worldwide market with Europe a close second.

Key vendors dominating this space include 3M Health Care, Cincinnati Sub-Zero Products Inc., Covidien plc, Smiths Medical, and Stryker Corp.

Other vendors mentioned in the report are Augustine Temperature Management LLC, Belmont Instrument Corp., C. R. Bard Inc., Ecolab Inc., EMIT Corp., Enthermics Medical Systems Inc., GE Healthcare Ltd., Geratherm Medical AG, Philips Healthcare, Pintler Medical LLC, The 37 Co., WElkins LLC, ZOLL Medical Corp.

October 2014 | OR TODAY

27

IN THE OR PRODUCT SHOWROOM

3M™ SpotOn™ The 3M™ SpotOn™ system is a non-invasive, accurate core temperature monitoring system that continuously measures patient temperature with an affordable single-use sensor. Designed by the creators of 3M™ Bair Hugger™ therapy, the SpotOn system delivers temperature monitoring accuracy normally associated with more invasive systems like esophageal, bladder, rectal or PA catheters. In addition, the SpotOn system provides clinicians with a single temperature monitoring method that can be used through each phase of the perioperative journey, improving clinical efficiency while improving consistency, reducing opportunity for error and eliminating the duplication of effort required to purchase and carry multiple products.

For more information, visit www.spotontemperature.com. • 28

OR TODAY | October 2014

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PRODUCT SHOWROOM

C CHANGE SURGI SLUSH™ Surgical teams use sterile slush therapeutically during complex surgical procedures to reduce an organ’s need for oxygen, slow cellular damage and provide doctors more time for treatment. The SurgiSLUSH™ system lowers costs, simplifies slush production, saves space and reduces the risk of unintended contamination. SurgiSLUSH™ users reduce direct costs by producing soft, smooth sterile slush inside C Change Surgical’s innovative, re-sterilizable slush containers. The re-sterilizable containers save money whenever slush must be on hand. SurgiSlush™ simplifies slush production and increases sterile field efficiency by moving slush out of the sterile field. Just insert re-usable bottles, press a button and perfect slush is ready when needed. SurgiSLUSH™ units save space and are mobile.

SurgiSLUSH™ users reduce the risks of unintended contaminations by eliminating the use of vulnerable slush drapes. •

WWW.ORTODAY.COM

October 2014 | OR TODAY

29

IN THE OR PRODUCT SHOWROOM

CINCINNATI SUB ZERO KOOL-KIT® AND BLANKETROL® The Kool-Kit® when combined with the Blanketrol® III is a whole body cooling system for induced hypothermia and other patient temperature applications. It contains three high-quality cooling blankets and wraps; the heap wrap, vest, and lower body blanket. The self-sealing hoses keep water from spilling when disconnecting the blankets. The random flow design of the blankets/wraps ensures that the therapy will be constantly delivered regardless of the patient’s positioning. This high-quality coverage is not matched by any other and allows for therapy to be provided to all of the major vasculature. •

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OR TODAY | October 2014

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PRODUCT SHOWROOM

THERMOFLECT HEAT REFLECTIVE TECHNOLOGY PRODUCTS Attaining and maintaining normothermia before, during and after surgery can be a matter of life and death.

Thermoflect products provide an easy addition to any facility’s warming protocol, using no wires or external heat source, just proven reflective warming that works immediately for the patient. Thermoflect Heat Reflective Technology banks the patient’s heat by capturing and reflecting it back to the skin, as well as preventing windchill. Thermoflect Heat Reflective Technology products are available in a wide range of products, including blankets, caps, patient gowns, pediatric products, and staff apparel. For more information visit www.thermoflect.com. • WWW.ORTODAY.COM

October 2014 | OR TODAY

31

IN THE OR PRODUCT SHOWROOM

ZOLL INTRAVASCULAR TEMPERATURE MANAGEMENT ZOLL’s Intravascular Temperature Management (IVTM™) system provides cooling and warming from a catheter inserted into a patient’s vein. This provides rapid and precise control of the core body temperature by directly cooling or warming the patient’s blood as it flows through the body. This catheter is connected to the Thermogard XP® console, which circulates ice-cold saline solution inside a multi-balloon catheter. The Thermogard XP precisely maintains target temperature within 0.2C and can slowly rewarm the patient to normal body temperature. Since the saline flows only within the catheter, no fluid is infused into the patient.

The ZOLL IVTM system is efficient, precise and easy to use, and enables unhindered access to the patient.

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OR TODAY | October 2014

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October 2014 | OR TODAY

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IN THE OR CONTINUING EDUCATION 379-60D

BY KATHLEEN DUFFETT, RN, JD MARGI J. SCHULTZ, RN, PHD, CNE

EMERGENCY CARE IS A PATIENT’S RIGHT: Insured or Not

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OR TODAY | October 2014

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CONTINUING EDUCATION 379-60D

“B

ack in five,” Joe Smith, RN, a 15-year veteran of the ED at an urban medical center, says as he takes a break in the middle of his night shift. Joe walks out to the ambulance bay for a breath of fresh air. A car comes screeching down the driveway of the ED. A young man jumps out and yells, “My girlfriend, Maria, is having a baby!” Joe hears a woman’s scream come from inside the car. Knowing that the medical center doesn’t have a labor and delivery unit, he yells back, “Quick, drive around the block to the other hospital — they do deliveries there.” “Thanks!” yells the young man, who jumps back in the car and tears out of the driveway. Joe goes back inside, thinking he has done a good deed, when in fact he has violated the Emergency Medical Treatment and Labor Act.

ContinuingEducation.com guarantees this educational activity is free from bias. The planners and authors have declared no relevant conflicts of interest that relate to this educational activity. See page 43 to learn how to earn CE credit for this module.

The goal of this program is to educate nurses, EMTs and paramedics about the fundamental requirements of the Emergency Medical Treatment and Labor Act. After studying the information presented here, you will be able to: • Describe the history of EMTALA and its goals • Discuss three fundamental requirements of the EMTALA • Explain the legal and regulatory consequences of violations of EMTALA

WWW.ORTODAY.COM

WHAT IS EMTALA? The Emergency Medical Treatment and Labor Act is a federal law enacted in 1986.1 Congress passed EMTALA, also known as the Patient Anti-Dumping Statute, to stop hospital EDs from refusing to treat poor or uninsured patients or from transferring patients to other facilities before their medical conditions are stabilized for transfer. EMTALA is intended to ensure that all people have equal access to emergency treatment regardless of their ability to pay. The law applies to hospitals that participate in Medicare (most do) and to all patients who seek emergency treatment at such hospitals regardless of their insurance status.

Some states have their own EMTALA-like statutes. In such cases, EMTALA preempts the state law if a state requirement conflicts with a requirement of EMTALA. Healthcare professionals who work in clinical areas in which EMTALA applies need to be aware of its fundamental requirements. Supervisors in such areas need to ensure that their staff members are properly educated about EMTALA and that policies are in place to address EMTALA. To ensure adherence, healthcare professionals responsible for regulatory compliance should be aware of the laws, regulations and other resources that govern EMTALA, and should be able to respond to a violation.

EMTALA ACRONYMS

CMP — Civil monetary penalties (fines) CMS — Centers for Medicare

& Medicaid Services EMC —Emergency medical condition MSE — Medical screening exam TAG — Technical Advisory Group

WHO’S RESPONSIBLE FOR ENFORCEMENT? The Centers for Medicare & Medicaid Services is primarily responsible for enforcing EMTALA. While state survey agencies, typically state departments of health, receive and investigate EMTALA complaints, it is the CMS that retains the authority to determine whether there has been a violation and to initiate termination of a hospital’s Medicare provider agreement.

Also important in enforcement is the Office of the Inspector General of the Department of Health and Human Services.

The inspector general has the authority to impose fines for EMTALA violations.2 EMTALA and its role in the healthcare system continue to be fine-tuned. In 2005, October 2014 | OR TODAY

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IN THE OR CONTINUING EDUCATION 379-60D

for example, the inspector general reiterated the need for hospitals to address EMTALA as part of their compliance programs.2 In 2006, the CMS made changes to EMTALA, including permission for certified nurse-midwives and certain other nonphysician healthcare professionals to certify that a woman is in false labor. At that time, the CMS also clarified that all hospitals participating in Medicare, including specialty hospitals, must accept appropriate transfers of unstable people whether such hospitals have an ED or not.3 In 2006 and 2007, the CMS issued guidance on three topics that relate to EMTALA. They are: • Parking of EMS patients in hospital (i.e., hospitals that prevent the transfer of a patient from an ambulance or a stretcher to a hospital gurney or bed by its EMS personnel)4 • The provision of emergency services and compliance with Medicare conditions of participation for hospitals5 • EMTALA issues for emergency transport services1 DOES EMTALA APPLY ONLY TO EDS? EMTALA applies to hospitals with a dedicated ED. A dedicated ED is a department or facility of a hospital on or off the main hospital campus that meets at least one of the requirements below:6 • It is licensed by the state as an ED or department.

• It is held out to the public — by name, signs, advertising or other means — as a place that provides care for emergency medical conditions (EMCs) on an urgent basis without the requirement of an appointment; for example, urgent care or fast-track centers are included.

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OR TODAY | October 2014

• Based on a representative sample of patient visits in the previous calendar year, it provides at least one-third of all its outpatient visits for the treatment of EMCs on an urgent basis without the requirement of an appointment.

(Labor and delivery and psychiatric units often meet the definition of a dedicated ED on this basis.)

For hospitals subject to EMTALA, its reach applies not only to patients who come to the dedicated ED, but also to patients who seek emergency treatment who are on hospital property. Hospital property is the main hospital campus, including parking lots, sidewalks and driveways, but excludes other areas or structures of the hospital’s main building that are not part of the hospital, such as physician offices, rural health centers and skilled nursing facilities, that participate separately under Medicare. Hospital property does not include restaurants, shops or other nonmedical facilities. Nonetheless, hospitals should have procedures for emergencies that occur in areas that EMTALA does not cover.

EMTALA applies to ambulances, but exceptions exist. It does not apply to hospital-owned air or ground ambulances that operate under one of the conditions below:6 • Under communitywide EMS protocols that direct the ambulance to transport a person to a hospital other than the hospital that owns the ambulance • At the direction of a physician who is not employed or otherwise affiliated with the hospital that owns the ambulance Even when a hospital is on diversionary status, if a person is trans-

ported by ambulance or otherwise shows up in a dedicated ED or on hospital property for treatment for what could be an emergency condition, a medical screening exam (MSE) must be provided.

WHAT ARE A HOSPITAL’S OBLIGATIONS? EMTALA obligations for a hospital include the following:6 1. Patients who present to a dedicated ED and ask for medical treatment must receive an MSE. The purpose of an MSE is to determine whether the patient has an EMC, a condition in which the absence of immediate medical attention would likely lead to a serious threat to life or limb. An MSE may range from simple (e.g., a brief history and physical exam) to complex (e.g., blood work and CT scan). The MSE should be the same for any patient with the same presenting signs and symptoms regardless of his or her ability to pay for care. Triage is not the equivalent of a medical screening exam.

If a person comes to a hospital’s dedicated ED and a request is made on his or her behalf for an examination or treatment for a nonemergency medical condition, the hospital must perform only such screening as would be appropriate for any person who presents in that manner to determine that the person does not have an EMC. 2. Patients who present on hospital property and request emergency medical treatment must receive an MSE. EMTALA takes into account that people who seek emergency treatment may try to reach a dedicated ED, but for various reasons they may present for such treatment somewhere else on hospital property. If a person presents on hospital property and WWW.ORTODAY.COM

CONTINUING EDUCATION 379-60D

requests treatment for what may be an EMC, an MSE must be provided.

A person will be deemed to have made such a request if a prudent layperson observer — a person who is not medically trained — would believe, based on the person’s appearance or behavior, that he or she needs an emergency examination or treatment.

In a separate but related matter, a 2007 CMS memorandum pointed out that all Medicare-participating hospitals are required to appraise medical emergencies and to provide initial treatment and referral (when appropriate) regardless of whether the hospital has a dedicated ED.5 This requirement is under the Medicare conditions of participation for hospitals,1 which are independent of EMTALA regulations. CMS also discusses the propriety of hospitals’ use of 911 services to handle emergencies.

3. The medical screening exam cannot be delayed to inquire about insurance. A hospital may develop reasonable registration practices, but the Office of the Attorney General and the CMS make it clear that a hospital should not seek authorization from managed care plans until after the hospital provides an MSE and any medical treatment required to stabilize an EMC.7 Typically, federal and state laws that govern managed care plans prohibit the plans from requiring preapproval for emergency care. Also, managed care organizations and participating hospitals often negotiate tiered rates for ED services such that, consistent with EMTALA, authorization is not required before services can be performed.

4. The presence or absence of an EMC determines the hospital’s obligations under EMTALA. Whether an EMC exists is the WWW.ORTODAY.COM

responsibility of the qualified medical personnel of the hospital to determine.

The hospital’s governing board determines which providers (physicians, physician assistants, nurses, etc.) are qualified to perform medical screening exams.

In the past, to determine the medical personnel who could certify false labor was an issue for hospitals.

Until October 2006, only a physician could certify that a woman was in false labor. As a result of the 2006 changes to EMTALA, certified nurse-midwives and certain other nonphysician healthcare providers may now certify that a woman is in false labor. This change provides hospitals with great flexibility in the types of healthcare professionals that can assess women in labor.

If no EMC exists, the hospital has fulfilled its obligations under EMTALA. If an EMC exists, the hospital has two options: One is to stabilize the patient (treat and discharge or treat and admit), and the other is to transfer the patient appropriately.

EMTALA obligations end for a hospital when a patient is admitted in good faith for inpatient care.

5. A patient with an EMC who has not been stabilized must be appropriately transferred. When a patient’s EMC cannot be stabilized at the facility (e.g., a patient has major head trauma, and the facility does not offer neurosurgical services), the patient may be transferred if the patient requests it, the examining physician certifies that the medical benefits of the transfer outweigh the risks, and the transfer is appropriate.

An appropriate transfer means that: • The sending hospital provides treatment to minimize the risks to the patient.

• The receiving hospital has agreed to accept the transfer and has space and personnel available.

• The medical record is forwarded to the receiving hospital.

• The sending hospital ensures that transfer is undertaken with qualified personnel and an appropriate transportation method.

For an appropriate transportation method, the CMS makes it clear that a receiving hospital must accept an appropriate transfer even if the sending hospital refuses to use the transport service designated by the receiving hospital, such as an air medical service owned by the receiving hospital.1 Receiving hospitals that condition acceptance of an appropriate transfer on the use of a particular transport service will be cited for violating EMTALA. As one would expect, the medical record must show compliance with the above criteria.

If a physician is not physically present in the ED at the time of a patient’s transfer but agrees with the qualified medical person who performed the medical screening exam that a transfer is appropriate, that qualified medical person can fill out and sign the certification.

Thereafter, the physician must cosign the order.

A hospital that participates in Medicare must accept a transfer of a patient with an EMC if the hospital has specialized capabilities and the capacity to treat the patient. A recipient facility has specialized capabilities if: 1. It offers services that are not available at the sending facility (e.g., burn units or other specialized units) or 2. The transfer is between comparable facilities, but the receiving facility would offer enhanced care benefits to the patient (e.g., when the sending facility does not have the October 2014 | OR TODAY

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IN THE OR CONTINUING EDUCATION 379-60D

equipment to perform a procedure or the sending facility’s equipment has malfunctioned) Capacity refers to the recipient hospital’s ability to accommodate the needs of the patient who requests transfer and includes an assessment of the number and types of beds available, the number of staff on duty and the equipment available. Hospitals that offer specialty services, such as burn units and trauma centers, should have policies that address the circumstances under which they will accept patients with EMCs. Of note, as part of the 2006 changes to EMTALA, all hospitals with specialized capabilities that participate in Medicare, including specialty hospitals, must accept appropriate transfers of unstable people regardless of whether the hospital operates a dedicated ED.1 EMTALA requires that a receiving hospital notify the CMS or the state survey agency of any inappropriate transfers, i.e., dumping.

Dumping includes the transfer of patients who arrive in an ED without notification from the sending facility. It also includes the transfer of patients who arrive in an ED in an unanticipated deteriorated condition or without appropriate documentation. A recipient hospital that suspects it received an improperly transferred patient must report the incident to the CMS or the state survey agency within 72 hours. Failure to report can result in termination of the recipient hospital’s Medicare provider agreement.

Whistle-blower protections exist for physicians and other qualified medical personnel who refuse to authorize the transfer of patients with EMCs who have not been stabilized and for hospital employees 40 OR TODAY | October 2014

who report violations of EMTALA. Hospitals are prohibited from taking any action against physicians or other qualified medical personnel who refuse to authorize the transfer of patients with EMCs who have not been stabilized. Hospital employees who report violations of EMTALA are also protected.

An excellent resource for more comprehensive information about EMTALA obligations for hospitals is Appendix V of the Medicare State Operations Manual. Appendix V is commonly called the Surveyor Interpretive Guidelines; surveyors use Appendix V when investigating a violation of EMTALA. OTHER KEY POINTS FOR HEALTHCARE PROFESSIONALS Healthcare professionals should also be familiar with the following aspects of EMTALA:1 • Signage: Hospitals must post signs in the ED and other conspicuous places that explain a person’s right to a medical screening exam and state whether the hospital participates in Medicaid, a government health insurance program for low-income people.

• Record retention: A hospital must maintain medical and other records for people transferred to and from the hospital for five years from the date of transfer.

• On-call lists: Hospitals must maintain a list of physicians on call to provide further evaluation and treatment necessary to stabilize a patient with an EMC. Hospitals and physicians have been critical of the lack of concrete guidance from the CMS on this requirement, and it remains an unsettled issue for most EDs. • Logs: Hospitals must maintain a central log of people who come to the dedicated ED for treatment and

indicate their disposition (i.e., refused treatment, admitted, discharged).

• The EMTALA Technical Advisory Group (EMTALA TAG): This group is responsible for reviewing EMTALA regulations and may make recommendations to the secretary of Health & Human Services (HHS). The group also solicits comments and recommendations from hospitals, physicians, nurses and the public on the implementation of EMTALA and can disseminate information about the regulations to hospitals, physicians and the public. The EMTALA TAG has been influential since its first meeting, in 2005, resulting in regulatory changes as well as more frequent guidance letters from the CMS on aspects of EMTALA compliance.

EMTALA VIOLATIONS If the CMS determines a violation has occurred, it immediately starts the process to terminate the hospital’s Medicare provider agreement. If patient health and safety are in immediate jeopardy, termination will occur within 23 days. If the violation is not considered to result in immediate jeopardy, the termination schedule is 90 days.

Termination of the Medicare provider agreement is the remedy hospitals dread most. The remedy that is less of a threat (but more likely to occur) is a monetary fine (called a civil monetary penalty).

Hospitals and physicians can be fined up to $50,000 per violation.

Physicians who violate EMTALA can be excluded from the Medicare program.

In terms of lawsuits, EMTALA provides that a person who suffers personal harm as a direct result of a hospital’s violation of EMTALA may WWW.ORTODAY.COM

CONTINUING EDUCATION 379-60D

institute a civil action against the hospital to recover damages. However, a lawsuit under EMTALA is not the same as a lawsuit for malpractice.

If a patient seen in an ED is erroneously diagnosed, most courts have held that EMTALA does not apply. As long as the hospital provided an MSE of the type that it would provide to all patients who presented with the same symptoms regardless of their insurance status, the hospital has met its EMTALA obligations. This is so even if the MSE did not meet the standard of care or the provider failed to diagnose the patient’s condition correctly. In such cases, patients can sue the hospital and the qualified medical person who conducted the MSE in state court for malpractice.

FOR MORE INFORMATION on the EMTALA statute, go to http://www. medlaw.com/category/emtala/.

So what should Joe Smith have done to avoid a violation of EMTALA? Instead of sending away a person seeking emergency treatment (Maria) who was on hospital property (the ED driveway), he should have taken Maria directly into the ED for an MSE. If it revealed that Maria had an EMC (active labor), the hospital would have been obligated to stabilize her (deliver her baby) or appropriately transfer her to a facility that had labor and delivery services.

EDITOR’S NOTE: This module is intended to provide accurate and substantive information about EMTALA. It is not a substitute for specific legal advice.

KATHLEEN DUFFETT, RN, JD, advises healthcare organizations and providers on how to meet their regulatory obligaWWW.ORTODAY.COM

tions. Her practice areas include EMTALA, HIPAA and managed care. She can be reached at kduffett@optonline.net.

MARGI J. SCHULTZ, RN, PHD, CNE, is the director of the nursing division at GateWay Community College in Phoenix, Ariz., and the administrator for MaricopaNursing, part of the Maricopa Community College District, also in Phoenix. Her PhD studies focused on adult education and distance education in nursing.

REFERENCES 1. Emergency Medical Treatment and Labor Act. Examination and treatment for emergency medical conditions and women in labor. 42 USC §1395dd. (2008). Government Printing Office Web site. http://www. gpo.gov/fdsys/pkg/USCODE-2008-title42/ pdf/USCODE-2008-title42-chap7-subchapXVIII-partE-sec1395dd.pdf. Accessed February 1, 2013.

2. Office of Inspector General supplemental compliance program guidance for hospitals. Office of Inspector General Web site. https://oig.hhs.gov/fraud/docs/complianc eguidance/012705HospSupplementalGuid ance.pdf. Published January 31, 2005. Accessed February 1, 2013.

3. Certification and compliance for the Emergency Medical Treatment and Labor Act. Centers for Medicare & Medicaid Services Web site. http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/ CertificationandComplianc/downloads/ EMTALA.pdf. Accessed February 1, 2013.

4. EMTALA: ‘parking’ of emergency medical service patients in hospitals. Centers for Medicare & Medicaid Services Web site. http://www.cms.hhs.gov/SurveyCertificationGenInfo/downloads/SCLetter06-21.pdf.

Published July 13, 2006. Accessed February 1, 2013.

5. Provision of emergency services — important requirements for hospitals. Centers for Medicare & Medicaid Services Web site. http://www.cms.gov/Medicare/ProviderEnrollment-and-Certification/SurveyCerti-

ficationGenInfo/downloads/SCLetter07-19. pdf. Published April 26, 2007. Accessed February 1, 2013.

6. Special responsibilities of Medicare hospitals in emergency cases. 42 CFR. §489.24.

(2008). Government Printing Office Web site. http://www.gpo.gov/fdsys/search/ pagedetails.action?browsePath=Title+42% 2FChapter+IV%2FSubchapter+G%2FPart +489%2FSubpart+B%2FSection+489.24& granuleId=CFR-2010-title42-vol5-sec48924&packageId=CFR-2010-title42-vol5&col lapse=true&fromBrowse=true&bread=true.

Accessed February 1, 2013.

7. OIG/HCFA special advisory bulletin on the patient anti-dumping statute. Office of Inspector General Web site. https://oig.hhs. gov/fraud/docs/alertsandbulletins/frdump. pdf. Published November 10, 1999. Accessed February 1, 2013.

October 2014 | OR TODAY

41

IN THE OR CONTINUING EDUCATION 379-60D

CLINICAL VIGNETTE Mrs. Smith, age 79, is a nursing home resident with diabetes who recently had a right hip replacement. Typically alert and oriented, Mrs. Smith has become increasingly confused over the past several days. She has become argumentative with the nursing home staff and with other residents, sometimes trying to hit them. Finally, a nursing home staff member calls an ambulance to transport Mrs. Smith to the ED of Medical Center A, a large academic medical center. The documentation sent with Mrs. Smith indicates that she has received psychiatric care in the past year. The ambulance personnel report that Mrs. Smith required sedation before the transport.

Dr. Jones, an ED physician, speaks to Mrs. Smith after she is triaged. He notes that she knows her name and knows that she is in Medical Center A. He also notes that she is not in any physical distress.

Medical Center A’s ED is very busy when Mrs. Smith arrives. No beds are available for patients who may need an inpatient admission. Dr. Jones, recognizing that Mrs. Smith will need to be fully assessed before returning to the nursing home, contacts Hospital B, a community hospital, to arrange a transfer. Hospital B accepts Mrs. Smith, who is placed back in the same ambulance and transported to Hospital B. No formal medical record is created for Mrs. Smith at Medical Center A, nor is she logged in or registered as an ED patient there.

1

EMTALA applies to Medical Center A because: A. Mrs. Smith arrives by ambulance.

B. Medical Center A clearly

operates a dedicated ED. C. Mrs. Smith is seeking

treatment for an emergency.

D. Medical Center A has an

ED physician on duty.

2

After triaging Mrs. Smith, Hospital A should have: A. Provided Mrs. Smith with

a medical screening exam B. Arranged for an

appropriate transfer to

another facility C. Called the nursing home

for more information D. Called a new ambulance

company to transport

Mrs. Smith to another facility

3

To comply with EMTALA, Medical Center A should have: A. Used its own ambulance

to transport Mrs. Smith to

Hospital B B. Gone on diversion

because it did not have

any inpatient beds available C. Documented Mrs. Smith’s

presentation to the ED

and her transfer to

Hospital B D. None of the above

3. Correct Answer: C — Under EMTALA, a hospital must maintain a central log of people who present to its dedicated ED seeking treatment and the disposition of each one (refused treatment, admitted, etc.).

2. Correct Answer: A — Under EMTALA, a patient who presents to a dedicated ED seeking medical care must receive a medical screening exam to determine whether the patient has an EMC. CMS has stated that triage is not the equivalent of a medical screening exam.

1. Correct Answer: B — EMTALA applies to hospitals with dedicated EDs as defined by EMTALA 42

OR TODAY | October 2014

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CONTINUING EDUCATION 379-60D

HOW TO EARN CONTINUING EDUCATION CREDIT 1.

2.

Read the Continuing Education article.

Go online to ce.nurse.com to take the test for $10. If you are an Unlimited CE subscriber, you can take this test at no additional charge. You can sign up for an Unlimited CE membership at www.nurse.com/unlimitedCE for $44.95 per year.

DEADLINE Courses must be completed by February 28, 2015.

3. If the course you have chosen to take includes a clinical vignette, you will be asked to review the

vignette and answer 3 or 4 questions. You must answer all questions correctly to proceed. If you answer a

question incorrectly, we will provide a clue to the correct answer.

4.

Once you successfully complete the short test associated with the clinical vignette (if there is one), proceed to the course posttest. To earn contact hours, you must achieve a score of 75%. You may retake the test as many times as necessary to pass the test.

5.

All users must complete the check out process to complete the process. You will be able to view a certificate on screen and print or save it for your records.

ACCREDITED ContinuingEducation.com is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

Accredited status does not imply endorsement by the provider or ANCC of any commercial products displayed in conjunction with this activity.

ContinuingEducation.com is also accredited by the Florida Board of Nursing (provider no. FBN 50-1489) and the California Board of Registered Nursing (provider no. CEP13213).

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October 2014 | OR TODAY

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October 2014 | OR TODAY

45

CORPORATE PROFILE

EIZO INC.

Eye pleasing, work achieving.

When you focus on something and continue to work on it for decades you will without a doubt become one of the best, if not the best, ever.

EIZO Inc. is known for the high-quality monitors it crafts after almost half a century of perfecting its process while staying abreast of the latest technologies available in the competitive arena of display performance.

46

OR TODAY | October 2014

EIZO Corporation factory campus in Hakusan, Ishikawa, Japan houses Manufacturing, R&D, and quality assurance within close proximity.

EIZO’s facility is ISO certified and adheres to the strictest guidelines in order to ensure all its displays confirm to medical standards for quality. The campus is made up of over 1,500 employees in Hakusan, Ishikawa, Japan and every person’s goal there is to ensure the continuous quality manufacturing clients have come to expect.

“EIZO has been manufacturing display technology for over 45 years out of our factory in Japan,” says Joey Sanchez, Brand Development Manager. “EIZO, pronounced ‘ay-zo,’ which means image in

Japanese, is one of the last true monitor manufacturers that takes great pride in making all of the high-quality components that go into their displays.”

The company dates back to a time when there wasn’t a computer in most U.S. households. There were many households that didn’t even have a TV when EIZO got its start.

Today, monitors are everywhere.

EIZO is able to deliver monitor products, not just for medical imaging, but also for some of the most demanding professional environments including high-end WWW.ORTODAY.COM

SPECIAL ADVERTISING SECTION

EIZO RadiForce surgical monitor solutions provide flexible imaging capabilities during delicate procedures.

graphics, air traffic control, gaming, and industrial applications where accuracy of display is vital.

“Having started way back in the black-and-white television days, their imaging expertise has migrated into very niche markets that still demand high reliability and stability over time,” Sanchez says. “Color accuracy is always goal one and EIZO delivers some of the best monitors available for the graphics, corporate, industrial, and medical imaging markets – including operating room specific displays.”

EIZO is well known for the quality of its products and prides itself on manufacturing not just the finished monitor but also the crucial parts that are the key to the world-class displays it provides to its customers.

“Since EIZO is able to control every component of its production line and has research and developWWW.ORTODAY.COM

ment and manufacturing all on one campus, EIZO maximizes product quality in a very efficient manner,” Sanchez says. “Most of the display innovations are thought up, manufactured, and quality tested in the same facility by display experts.”

Sanchez points out that EIZO is a leader in monitors and also in peace of mind when you consider how the company stands behind its products.

“Since EIZO’s components are already of better quality from the start, EIZO is able to deliver the most reliable monitors available on the market,” Sanchez says.

“They offer the lowest failure rates in all of their industries and the longest warranties when compared to like products.”

Healthcare professionals are familiar with EIZO, especially those who deal with medical imaging equipment.

“EIZO has a long-standing background in diagnostic medical imaging displays for all high-resolution PACS applications including mammography,” Sanchez says.

“Much of the expertise the company has accumulated in making quality monitors for diagnosis, they have implemented into their larger format displays for the surgical market.”

Surgeons and the members of OR staffs in hospitals and medical centers around the world are becoming more and more familiar with the company thanks to its selection of world-class products.

“EIZO delivers large-format displays that are able to take the place of multiple monitor configurations in an OR/interventional suite setting. These large monitors allow the display of several windows from various inputs all on one screen without distracting bezels seen in multiple monitor October 2014 | OR TODAY

47

SPECIAL ADVERTISING SECTION

The EIZO RadiForce line-up offers solutions for every medical imaging modality and environment.

set-ups,” Sanchez says. “The large monitor’s inputs are controlled by a Large Monitor Manager which can take various signal types and optimize them on the large monitor for viewing during procedures.”

One example of the high-tech, high-quality monitor solutions offered

by EIZO is the RadiForce LS580.

“There are a couple of exciting display offerings right now from EIZO,” Sanchez says. “The first is the 58-inch, FDA-compliant large monitor – the RadiForce LS580. This monitor allows for the replacement of several monitors in OR environments giving a more uniform look without the usual distracting bezels that multiple monitors can have. The large screen can be split into 27 separate input windows that allow for various signals to all appear on one screen at the same time. Inputs are controlled by a large monitor manager that allows for easy configuration of that screen from those various inputs.”

“Secondly, their line-up of multi48

OR TODAY | October 2014

modality diagnostic displays, RadiForce Multi-Series, is perfect for users who want flexibility at a workstation to view several different types of modalities. Images are optimized on one screen, whether in color or grayscale,” he adds.

“Our success lies in some of the inherent technologies of our large format displays,” Sanchez points out.

“EIZO has redundant capabilities built into their displays so that if a power supply or backlights fail for any reason, the entire monitor is not lost. Therefore, there are no interruptions during critical care and physicians and surgeons are able to carry on through their procedure without fear of losing sight.”

A storied past is only part of the story. EIZO also has a bright future.

“We are seeing the implementation of more network-based solutions within a facility for easier administration and control as well as smarter and smarter monitors,” Sanchez says.

“Whether that means they are ready to go with built-in smart capabilities

in the monitor or additional network calibration features, EIZO wants to remain on the forefront delivering the most exceptionally accurate imaging available.”

EIZO continues to build on its tradition of great display solutions and every member of the company is focused on quality and customer satisfaction. It is a leader in the medical field that remains dedicated to providing a positive impact on patient care.

“EIZO offers the most versatile line-up of medical imaging monitors on the market and was the first to offer an all LED line-up of diagnostic displays,” Sanchez says. “We are always on the forefront of innovation and our reliability is unmatched by any other manufacturer. EIZO goes above and beyond to pay extra attention to the strictest of medical certifications to ensure physicians are always able to make the proper diagnosis every time.”

FOR MORE INFORMATION about EIZO Inc., visit EIZO.com.

WWW.ORTODAY.COM

Surgical Monitor Solutions

58

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A Complete Solution for all O.R. Environments.

The EIZO Large Display System is complete turnkey solution that upgrades multiple standard size displays to one large format Quad HD 8MP display without obtrusive bezels. The Large Monitor Manager formats configurations from multiple video sources and displays them to a physician’s preference. This solution maximizes the flexibility of image layouts and allows users better concentration on surgical and minimally invasive procedures.

Be sure to ask about our full range of Multi-Modality displays available in 4MP, 6MP, and 8MP solutions.

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October 2014

800-800-5202 | OR TODAY 49 www.eizo.com

ALARM FATIGUE Experts share solutions that prevent sentinel events

By Don Sadler

WHOOSH PING

BE

BEEP

BEEP

P

POP

ZAP BEEP

PING DING

BOOP

PING

ZAP PING

BOING

EEP

ALARM FATIGUE

E

veryone is familiar with the fable of “the boy who cried wolf.” A shepherd boy shouted to the villagers twice that a

wolf was attacking their sheep just to amuse himself. When a wolf really did attack, nobody

BEEP

from the town responded, and the sheep were PING

BOOP

scattered.

Unfortunately, the “cry wolf” syndrome is starting to take effect in many operating rooms around the country when it comes to clinically non-significant alarms.

These are alarms that sound from the many different monitors present in the OR that do not drive an actionable response by OR personnel. The result is what is now commonly referred to as “alarm fatigue.”

ZING

ALARM FATIGUE

ZAP

PING

PO P

BOOP

BEEP THE ‘CRY WOLF’ EFFECT “There’s no question that clinically non-significant alarms have led to a ‘cry wolf’ effect,” says Dr. Maria Cvach DNP, RN, Assistant Director of Nursing, Clinical Standards, at the Johns Hopkins Hospital in Baltimore, Md. “When an alarm is viewed as insignificant most of the time, staff will eventually begin to ignore the warning. The problem is that staff could potentially miss a clinically actionable alarm.”

Alarm fatigue may occur “when the sheer number of monitor alarms overwhelms clinicians, possibly leading to alarms being disabled, silenced or ignored,” Cvach adds.

The ECRI Institute has listed alarm fatigue as the number one health technology hazard for the past three years.

Every type of medical device and monitor has some kind of alarm: EKG, pulse oximeter, end tidal CO2, cardiac output, respiration, and so forth.

“So the OR can just become a cacophony of alarms,” says Dr. Purna Prasad, BE., M.S., Ph.D., C.C.E., Director, Clinical Technology and Biomedical Engineering, Information Technology/ Information Services, Stanford University Medical Center.

“At first, nurses want to respond to every alarm,” Prasad adds. “But as time goes on, they build up a tolerance and become desensitized to them. Their minds are becoming conditioned to unresponsiveness, which is very dangerous in the OR.” “We have seen hospital staff completely overwhelmed by

52

OR TODAY | October 2014

alarms, unable to distinguish between alarms that are clinically non-significant and those that require action on their part,” adds Rikin Shah, Senior Associate, Applied Solution Group, at the ECRI Institute.

According to Cvach, clinicians are exposed to as many as 700 physiologic monitor alarms per patient day. And research indicates that between 85 percent and 99 percent of all alarms are either false or clinically nonsignificant, not requiring clinical intervention.

These clinically non-significant alarms disrupt patient care 71 percent of the time, and clinicians disable alarms 78 percent of the time according to a 2011 survey conducted by the Healthcare Technology Foundation.

Cvach gives several examples of clinically non-significant alarms that often sound: » An alarm that occurs when a threshold setting is breached momentarily. For example, the pulse oximeter drops momentarily when the blood pressure cuff inflates. » Alarms that sound due to incorrect monitor programming or inappropriate patient individualization. For example, the pulse oximeter alarm is programmed too high for a patient who has a chronically low saturation concentration. » Alarms that sound due to system or technical issues.

For example, the pulse oximeter alarm sounds because the probe cannot read the patient’s pulse correctly.

RIKIN SHAH, Senior Associate, Applied Solution Group, at the ECRI Institute

“We have seen hospital staff completely overwhelmed by alarms, unable to distinguish between alarms that are clinically non-significant and those that require action on their part” WWW.ORTODAY.COM

When an alarm is viewed as insignificant most of the time, staff will eventually begin to ignore the warning. The problem is that staff could potentially miss a clinically actionable alarm.

DR. MARIA CVACH DNP, RN, Assistant Director of Nursing, Clinical Standards, at the Johns Hopkins Hospital in Baltimore, Md.

There are many potentially negative consequences of alarm fatigue, both for patients and OR personnel. In a worst-case scenario, it can result in serious patient complications and even death.

“Non-detection of changes in a patient’s condition can result in a failure to rescue, the results of which can be fatal,” says Prasad.

Meanwhile, many OR nurses are suffering from impaired hearing and concentration, elevated blood pressure and stress levels, disorientation and distraction, and sleep disruption and loss due to the cacophony of alarms sounding in the OR. Alarm volumes inside hospital ORs can reach 120 decibels, which is as loud as a chain saw. The World Health Organization (WHO) recommends that OR noise levels not exceed 30 to 40 decibels.

WWW.ORTODAY.COM

SENTINEL EVENT Clinically non-significant alarms have resulted in sentinel events.

The Joint Commission’s Sentinel Event database includes reports of 98 alarm-related events between January 2009 and June 2012, with 80 of these resulting in death, 13 in permanent loss of function, and five in unexpected additional care or extended stay.

In an effort to help deal with the problem of clinically nonsignificant alarms and alarm fatigue, the Joint Commission has included this in its 2014 Critical Access Hospital National Patient Safety Goals.

In 2014, hospital leaders should be identifying the most important alarm signals to manage, based on such factors as whether specific alarm signals are needed or unnecessarily contribute to alarm noise and alarm fatigue. By 2016,

hospital leaders should establish policies and procedures for managing alarms that address the following: » Clinically appropriate settings for alarm signals » When alarm signals can be disabled » When alarm parameters can be changed » Who in the organization has the authority to set alarm parameters » Who in the organization has the authority to change alarm parameters » Who in the organization has the authority to set alarm parameters to “off ” » Monitoring and responding to alarm signals » Checking individual alarm signals for accurate settings, proper operation and detectability October 2014 | OR TODAY

53

1

ALARM FATIGUE

IMPROVED MEDICAL DEVICE ALARM FEATURES

PROPER ALARM CONFIGURATION

2

IMPROVED ALARM ALGORITHMS

By this date, hospital leaders should also educate staff and licensed independent practitioners about the purpose and proper operation of alarm systems for which they are responsible, notes the Joint Commission.

DR. PURNA PRASAD, BE., M.S., Ph.D., C.C.E., Director, Clinical Technology and Biomedical Engineering, Information Technology/ Information Services, Stanford University Medical Center.

“At first, nurses want to respond to every alarm,” Prasad adds. “But as time goes on, they build up a tolerance and become desensitized to them. Their minds are becoming conditioned to unresponsiveness, which is very dangerous in the OR.” 54

OR TODAY | October 2014

MEETING THE CHALLENGE Prasad sums up the challenge of reducing clinically non-significant alarms and alarm fatigue as follows: “Selecting the right monitoring parameters with the right setting for the right patient, at the right time and by the right clinicians, to obtain actionable clinical data to promote patient safety.”

He breaks solutions into three broad categories:

1

PROPER ALARM CONFIGURATION AND THRESHOLD SETTINGS

This includes eliminating redundant alarms, clinically irrelevant alarms, and multiple devices monitoring the same physiological signals, as well as optimizing the alarm to the individual patient’s condition and range of values.

2

IMPROVED ALARM ALGORITHMS

This involves balancing sensitivity and specificity. Algorithms should be developed that accommodate technical and artifact detection and decrease false alarms and fatigue. For example, research indicates that a 19-second alarm delay would reduce false-positive alarms by 67 percent, according to Prasad.

3

IMPROVED MEDICAL DEVICE ALARM FEATURES

These might include nonauditory means for presenting alarms, like color-coded displays or vibrations on smartphones and tablets that are ported to alarms.

In addition, Shah encourages routine replacement of electrodes, proper patient skin prep and electrode interface/placement, and replacing device batteries at a set time every day or every shift.

“Steps like these have been shown to reduce alarm burden and create an environment where alarms that do sound are alarms that require action,” says Shah.

In an effort to raise awareness of clinically non-significant alarms and alarm fatigue, ECRI Institute has created an Alarm Safety Resource website at https://www.ecri.org/ forms/pages/Alarm_Safety_Resource.aspx.

The site includes a wide range of free resources to help nurses and clinicians better understand the problem and minimize alarm fatigue. This includes some free sample content from ECRI Institute’s new publication, The Alarm Safety Handbook: Strategies, Tools and Guidance.

“Determining and implementing strategies to improve alarm safety and reduce alarm fatigue will allow alarm management policies and procedures to be improved across the organization,” says Shah. “This will increase the quality of care delivered and improve patient safety across all units of the hospital.”

WWW.ORTODAY.COM

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57

LIFE IN THE

BIG APPLE Nurse Leaves California for Neurosurgical Unit at NYU-Langone NYU - Langone

A

fter two years at New York University’s Langone Medical Center, Senior Staff Operating Room Nurse Ashley Brown still gets questions about why she would choose to relocate from sunny Marin County, Calif., to the Big Apple (particularly in winter).

n, RN ey Brow HT ON: TLIG n, RN ey Brow AshlAshl HT ON: TLIG SPOSPO falosfalos SkouSkou MattMatt BY: BY:

SPOTLIGHT ON

Brown’s career began in New Orleans, where she pursued a degree in graphic design. When Hurricane Katrina leveled the city during her junior year of college, Brown was displaced, and returned home to California.

From there, an internship at an urgent care clinic moved her to shift her focus to nursing. When she was accepted at New York University, Brown said she “immediately jumped in.”

“This was going to be my way to see New York and follow this new career that I’m excited about,” she said. “I’ve been here five years now, between school and my first job and this job. I don’t have any plans to leave.”

From working in a private practice that focused on dermatology and cosmetic cancer surgeries to the neurosurgical unit at NYU-Langone, Brown said that the change in assignments 60

OR TODAY | October 2014

Ashley Brown is pictured in an operating room at NYU-Langone’s Tisch Hospital

has been rewarding as well as challenging.

“I did my internship on a step-down unit and wanted that job,” she said. “When I got to do a quick rotation around the OR a few times in the beginning of my orientation, I remember being in this brain tumor removal case, [and] everything about the surgery was exciting and thrilling to me.”

Brown said that neurosurgery is so compelling to her because she finds fascinating the adaptive qualities of brains and bodies to deal with trauma and pain. Equally intriguing, she said, is the variety of skill sets required to work on the brain as opposed to the spine: brain

tissue requires atomically precise movements and an incredibly delicate touch, whereas spinal surgeries often can have a jarring impact related to cutting into bone.

But the outcomes have never left her mind of the “two different worlds” in which a patient lives before and after the surgeries.

“These poor patients are in so much pain,” Brown said, and sometimes removing a piece of tissue can make “a whole new person.”

Consistent from procedure to procedure, whatever the specialty, Brown said, is the feeling of responsibility that she shares as part of the surgical team to make the experience a smooth one.

WWW.ORTODAY.COM

Members of the surgical team from NYU-Langone’s Tisch Hospital Operating Room - (from left to right) Tim Cilente, Ashley Brown, Kali Bassingwaithe, Gina Adlawan

“When you stay positive and stay calm and keep the atmosphere as least stressful as possible, you’re not only benefiting yourself, but the attitude is contagious. I feel that you might not be able to see it in the current moment, but it has lasting effects that are beneficial to everyone.”

“It’s a very high-demanding, stressful job at points, and I definitely have my own tools to make sure I’m going into work at the top of my game, and I’m focused and energized,” she said.

To prepare for the demands of the operating room, Brown WWW.ORTODAY.COM

practices a daily meditation that she said helps to clarify her perspective, her intentions, and focus on the patient. Even after three or four years, she said, “being present with everything that you do is a daily practice” that doesn’t come easily in the

fast-paced world of New York City, let alone the high-intensity operating room.

“When you stay positive and stay calm and keep the atmosphere as least stressful as possible, you’re not only benefiting yourself, but the attitude is contagious,” Brown said. “I feel that you might not be able to see it in the current moment, but it has lasting effects that are beneficial to everyone.”

“We have a lot on our plate,” she said. “We have a ton of things to do. Making sure that everything the surgeon needs is there, it’s still super-important to not lose being in that moment and making sure that you know why you’re doing October 2014 | OR TODAY

61

SPOTLIGHT ON

Ashley Brown poses for a group photo at the Sgt. Keith A. Ferguson 5K Run/Walk, which is organized in his memory to provide scholarships to Criminal Justice students each year.

what you’re doing, and that the patient is always a priority.”

Ultimately, Brown said, everything in the surgical suite is about the patient, including her meditative practices. Her coworkers — who are “incredible, super-intelligent, driven people” — have the common goal of patient safety.

Keeping herself “happy and centered and balanced” enables Brown to be a better, more supportive role player on that team.

“Literally, our entire OR will drop anything at any given moment to come help you if 62

OR TODAY | October 2014

they’re able to,” Brown said.

“That’s a rare environment.”

Because turnover times are “the number one money-maker for the hospital,” surgical teams can feel pressured to move as quickly as possible, Brown said. Meditation helps her to anchor her focus on the job for the best outcome possible for the patient.

“You just have such a clearer perspective on why you’re there, what your intention is, and you’re able to focus on the patient when you come into work with that mindset,” Brown said.

Gaining greater acceptance for such an inwardly focused practice can be exceptionally difficult in such a high-stress environment, Brown said. She was excited to learn that NYU Langone has an in-house meditation center, and hopes it can be a jumping-off point for others to explore the practice.

“I know that they have a good spiritual support team [here],” she said, “but that’s another great option for patients and their healing and for all of us to decompress throughout the day.”

WWW.ORTODAY.COM

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OUT OF THE OR HEALTH

GINA SHAW, EATINGWELL

DON’T LET DIABETES STOP YOU

FROM EXERCISING

I

t’s a message you hear everywhere: Exercise is one of the most important things you can do to control your diabetes. It’s also a catch-22: Controlling diabetes can be so exhausting that some days just leaving the house feels like climbing a mountain.

Why is lack of energy such a big issue? One big cause is an imbalance in blood sugar.

“If your blood sugar is out of control in either direction – too high or too low – you can feel tired and drained,” says Aaron Vinik, M.D., Ph.D., research director at the Strelitz Diabetes Center at Eastern Virginia Medical School in Norfolk.

Other health factors, such as high blood pressure and excess weight, can also make you feel as if there’s a giant hole in the tank of your energy reserves. But you can find the energy you need to exercise – you just need to know where to look.

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TIPS TIME IT RIGHT

START SMALL

Stop watching extreme workouts on TV weightloss shows and thinking that’s what you should aspire to.

“That will turn you right away from exercising,” says Camille Eroy-Reveles, M.P.H., a fitness instructor and exercise consultant in New York City.

“Do what you can, right at this moment. If that means five minutes of walking, then that’s what you can do.

You have to start somewhere.”

GIVE YOURSELF PERMISSION TO STOP

Sometimes the best way to get started is to

start small.

“If you’re feeling horrible, tell yourself that you’re just going to walk for a few minutes. After that, if you’re still feeling horrible, you can quit,” says Eroy-Reveles. “Exercise is going to be hard for the first few days. Give yourself two weeks for it to feel better. You can do anything for two weeks!”

For a couple of days, pay close attention to your energy levels and try to figure out what time of day you have the most energy. Is it first thing in the morning or later in the afternoon? What time of day do you usually feel most productive?

That’s often the best time to schedule your exercise.

TRACK YOUR BLOOD SUGAR

Uncontrolled blood sugar can cause a lot of fatigue with diabetes. Keeping your blood sugar levels on target is key, and the best way to monitor that is to test regularly with your meter.

PLAY DETECTIVE

Blood sugar numbers aren’t the only pertinent data to record. Keep a journal, “and on the days when you’re really fatigued WWW.ORTODAY.COM

HEALTH

and experiencing pain, look at what you’ve been doing,” says Julie Silver, M.D., a rehabilitation physician and assistant professor at Harvard Medical School. For three days, write down what you’re doing every half hour, and rate your pain and fatigue level on a 0-5 scale (0: feeling great; 5: a lot of pain and fatigue). Then review the data.

“On bad days, did you use coffee as a pick-me-up, skip a meal or drink alcohol? On days when you felt really good, what did you do?”

Silver asks. Identifying your fatigue triggers can help you eliminate them and restore your energy.

CONSIDER INSULIN

If you’ve had type 2 diabetes for a while and fatigue is a major issue, talk to your doctor about adding insulin to your therapy toolbox. It’s not a treatment of last resort, Vinik says. He recommends early, aggressive use of insulin as the boost some people need to get up and get moving.

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CALL IT FUN

Whatever you do to move more, don’t call it exercise, suggests Vinik.

“That sounds like a punishment, a prescription. Choose something that’s fun for you.”

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October 2014 | OR TODAY

67

OUT OF THE OR FITNESS

HARVARD HEALTH LETTERS

MAKE THE MOST OF YOUR DIGITAL FITNESS MONITOR

T

he latest trend in high-tech health puts control in the palm of your hand. It’s called digital fitness monitoring, and it comes in the form of tiny gadgets that you wear or place in your pocket.

“If you’re already motivated to exercise or eat differently, the monitor is a great tool to track your progress and help you understand where you need to make changes,” says Dr. Anne Thorndike, a preventive medicine researcher and assistant professor of medicine at Harvard Medical School.

TYPES AND FEATURES Digital fitness monitors (DFMs) come in wearable styles such as wristbands, watches, and pendants, as well as hand-held pieces you can clip onto a sleeve or slip into a pocket.

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OR TODAY | October 2014

DFM features may be simple, such as sensors that track the number of steps you take or how many calories you burn. Or they may be more sophisticated, with sensors that capture your heart rate, perspiration, skin temperature and sleep patterns.

Some DFMs have longer-lasting batteries, light-up screens, and alarms that vibrate or flash to remind you to be more active or announce that you’ve reached a goal. Others have satellite navigation, speed and pace sensors, and even weather gauges. Most have programs for a computer or smartphone that allow you to chart your progress.

WHAT TO LOOK FOR DFM prices increase with the number of bells and whistles available. You may see one gadget for $25 and another for $750. The majority, however, are in the $50-$200 range.

How much you spend is a matter of personal preference.

“Sophisticated monitors can be fun, but all you really need to know is how many steps you’re taking,” says Thorndike.

She advises that you first determine what kind of information will help you reach your fitness goals, then consider if you’re going to wear a DFM on your wrist or clip it onto your clothes.

“And look for something that’s easy to use and can be charged quickly,” she says.

MAKING THE MOST OF A DFM Before you set your fitness goals, wear the DFM to get a sense of how many steps you already take.

“We tell people to shoot for 10,000 steps a day, but if you only take 2,000, you can set your first goal at 3,000,” says Thorndike.

Then use the DFM to see how you’re doing throughout the day: if you’re low on steps by dinner, take a walk afterward.

And consider fitness competitions WWW.ORTODAY.COM

FITNESS

with others using DFMs. Thorndike recently completed a study that found young adults who used DFMs and engaged in competitions had a small but statistically significant increase in activity levels.

Visiting museums, taking up a sport, or getting a dog can help.

Sometimes the best way to fit more walking into your life is to trick yourself into moving.

“I don’t think people always associate exercise with fun,” says Dr. Richard Ginsburg, a psychologist with Harvard-affiliated Massachusetts General Hospital.

“If you engage in an activity you enjoy, then it’s something you’ll want to do, and you won’t mind the workout.”

WWW.ORTODAY.COM

TRY SOME OF THESE IDEAS TO SNEAK MORE STEPS INTO YOUR DAY: • GET A DOG You’ll have to walk the animal, and you’ll likely enjoy your time with your fuzzy friend.

• CONSIDER SPORTS Take up golf, which involves a lot of walking. Or go to a grandchild’s or friend’s outdoor sporting event.

Most playing fields are a good distance from the parking area, so you’ll get some extra walking on the way to the bleachers. After the game, do a lap around the field for some extra steps.

• VISIT WALKING-ONLY DESTINATIONS Museums, botanical gardens, and amusement parks are for pedestrians

only. You may wind up logging a few miles, depending on where you go.

• WINDOW SHOP AT A BIG BOX STORE OR MALL You’ll definitely have to walk to check out the merchandise. One lap around an average mall’s upper level ranges from a quarter to a half of a mile. Exact distances are available at mall management offices.

• VOLUNTEER FOR A BEAUTIFICATION PROJECT Join a group that collects trash along a roadside, or join a neighborhood cleanup crew. Both these activities require lots of walking.

October 2014 | OR TODAY

69

OUT OF THE OR NUTRITION

NICCI MICCO

REPLACE REFINED CARBS WITH THESE GRAINS FOR A HEALTHIER DIET

O

ur bodies and our brains need carbohydrates to work effectively. But not all carbohydrates are equal. Some, like white breads and starchy sweets, offer little to no nutrition; others, like fruits, vegetables and whole grains, are packed with goodness. Here are 6 healthy carbs you should consider incorporating into your diet:

2

Quinoa: A delicately flavored whole

grain, quinoa provides some fiber (about 2 grams per half cup) and a good amount of protein (4 grams). Rinsing quinoa removes any residue of saponin, its bitter natural protective coating.

To cook: Bring 2 cups water or broth to a boil; add 1 cup quinoa. Reduce heat to a simmer, cover and cook until the liquid has been absorbed, 15 to 20 minutes. Fluff with a fork.

1

Whole-wheat pasta. Because sometimes you just need pasta, and whole-wheat varieties offer two to three times more fiber than refined white brands, but they’re just as versatile and delicious. (Similarly, whole-wheat bread and brown rice are healthier choices than their “white” counterparts.)

To cook: Follow the package directions.

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OR TODAY | October 2014

WWW.ORTODAY.COM

NUTRITION

3

Barley is available “pearled” (the bran has been removed) or “quick-cooking” (parboiled). While both contain soluble fiber that may help keep blood cholesterol levels healthy, pearl barley has a little more. (Note: Barley is not technically classified as a whole grain but it’s often considered one nutritionally because of its healthy nutrient profile.)

To cook: Pearled barley – Bring 1 cup barley and 2 1/2 cups water or broth to a boil. Reduce heat to a simmer; cook, covered, until tender and most of the liquid has been absorbed, 40 to 50 minutes. Let stand 5 minutes. Quick-cooking barley – Bring 1 3/4 cups water or broth to a boil; add 1 cup barley. Reduce heat to a simmer; cook, covered, until tender, 10 to 12 minutes.

4

Bulgur is cracked wheat that’s been parboiled so it simply needs to soak in hot water for most uses – a perfect low-maintenance grain. It’s also a good source of feel-full fiber: just 1/2 cup delivers about 5 grams.

To cook: Pour 1 1/2 cups boiling water or broth over 1 cup bulgur. Let stand, covered, until light and fluffy, about 30 minutes. If all the water is not absorbed, let the bulgur stand longer or press it in a strainer to remove excess liquid.

6

Popcorn. Reach for popcorn when you’re craving pretzels or potato chips; it may satisfy a snack craving and it’s a whole grain. Three cups of popped popcorn (what you get by popping 1 heaping tablespoon of kernels) equals one of your three recommended daily servings of whole grains and contains 3 grams of fiber.

To cook: Toss a heaping tablespoon into an air popper.

5

Wheat berries are whole, unprocessed kernels of wheat. They’re terrific sources of B vitamins, iron, magnesium, zinc and fiber.

To cook: Sort through wheat berries carefully, discarding any stones, and rinse with water. Bring 4 cups water or broth and 1 cup wheat berries to a boil. Reduce heat to a simmer, cover and cook, stirring occasionally, until tender, but still a little chewy, about 1 hour. Drain.

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October 2014 | OR TODAY

71

OUT OF THE OR RECIPE

BY DIANE ROSSEN WORTHINGTON

SCRAMBLED EGGS TURKISH STYLE

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OR TODAY | October 2014

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RECIPE

I

t must have been the Turks who discovered that breakfast is the most important meal of the day.

On a recent visit to Turkey, I reveled in the morning repast. At every hotel and inn we enjoyed a feast of delicious offerings.

The breads alone took my breath away. Of course, classic croissants and Danish pastry graced every bread arrangement, but there was so much more.

I fell in love with simit, a kind of sesame Turkish bagel that was sold on street corners and ferries and, of course, in bakeries. These sesame nuggets of goodness are hard to find in the United States, but if you are in New York City or New Jersey look for them at the East Coast Turkish bakery Simit and Smith. I imagine they will soon be available across the country.

One of my favorite dishes to get the morning going was scrambled eggs, Turkish style. Menemen is a dish of sauteed onions, peppers and tomatoes with scrambled eggs, enriched with crumbled feta cheese.

I had many versions throughout my Turkish culinary visit. Sometimes the dish had the vegetable mixture on the bottom of the pan and steamed (not scrambled) eggs on top. I prefer the scrambled tangle of sweet tomatoes, mild peppers, golden onion and creamy eggs. I have added a yogurt drizzle spiced with sumac that has a tart, lemony flavor for a touch of Turkish flavor.

My most memorable breakfast was at the Kempinski Hotel Barbaros Bay. Sitting outside on a private bay overlooking the Aegean Sea, menemen was presented in copper casseroles. The hotel setting was magical. We also visited the Ciragan Palace Kempinski in Istanbul that was situated right on the Bosphorus. The breakfasts, served on the patio, were a sight to behold, occupying an entire room of possibilities. Menemen, of course, was served there as well.

Turkey may seem far away but you can certainly experience this breakfast pleasure in your own kitchen. Start with fresh juices of your choice, a basket of fresh baked breads and croissants, great fruit preserves and a casserole of menemen with the yogurt drizzle as a tasty garnish. No need for Turkish coffee – cups of steaming tea seem to be the way the Turks end the meal. Enjoy.

WWW.ORTODAY.COM

MENEMEN

Serves 4 1 tablespoon olive oil 1 tablespoon unsalted butter 1 onion, finely chopped 2 banana peppers, seeded and thinly sliced or diced (you can use a yellow or red pepper instead) 4 medium tomatoes, peeled and finely chopped • salt and freshly ground black pepper 1/2 teaspoon red pepper flakes 8 eggs 1/3 cup crumbled feta cheese • Sumac yogurt sauce (see below) 2 tablespoons finely chopped parsley

DIRECTIONS: Heat the oil and butter in a medium skillet

on medium-high heat. Sauté the onion for 5 minutes or until soft and translucent. Add the peppers and continue cooking until the onions are golden and the peppers are softened, about 5 more minutes.

Add the tomatoes and cook for another 5 to 7 minutes or until the tomatoes are softened and much of the juice has evaporated. Add the salt, pepper and chili flakes, and cook another minute. Lower heat to medium.

Meanwhile, combine the eggs in a bowl and whisk to blend. Season with salt and pepper and add the feta cheese.

Stir the egg mixture into the cooked vegetables and scramble the eggs until they are just done, 5 to 6 minutes. Do not overcook.

Transfer to plates or shallow bowls or serve right from the pan. Drizzle with sumac yogurt sauce and garnish with parsley. Serve the remaining yogurt sauce on the side.

SUMAC YOGURT SAUCE 1/2 teaspoon sumac 1 tablespoon olive oil 1 minced garlic clove 1/3 cup plain Greek yogurt • Salt DIRECTIONS: Combine all ingredients in small bowl and mix to combine. Season to taste.

DIANE ROSSEN WORTHINGTON is an authority on new American cooking. She is the author of 18 cookbooks, including “Seriously Simple Holidays,” and also a James Beard award-winning radio show host.

You can contact her at www.seriouslysimple.com.

October 2014 | OR TODAY

73

OUT OF THE OR PINBOARD

PINBOARD

The News and Photos That Caught Our Eye This Month

OR TODAY

2014 SURGICAL SERVICES SUMMIT From our “Daily News and Notes” Board

Happy Halloween!

ORToday is everywhere you are!

Tell us about your favorite healthy snack or the candy you can never get enough of! Each submission gets a $5 Starbucks gift card! Plus, the most creative entry receives lunch for their team! Send entries to social@mdpublishing.com or post on our ORToday Facebook page!

{

EACH SUBMISSION WINS A STARBUCKS GIFTCARD THE WINNER GETS LUNCH FOR THE ENTIRE TEAM!

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PIN OF THE MONTH

CONTESTS • OCTOBER •

Follow us on Pinterest: www.pinterest.com/ortoday

OR TODAY IS NOW ON LINKEDIN Join our group!

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OR TODAY | October 2014

$5 Starbucks gift card

Win Lunch!

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OR TODAY

CONTEST WINNERS JULY

Catching waves!

Karely Deal, RN, Center Director at Airport Endoscopy Center in Los Angeles enjoyed a little rest and relaxation at the beach with her copy of OR Today.

AUGUST

Johns’ Angels!

Ma Lourdes “Sheila” Balderosa and her crew make up the dedicated and energetic Pediatric Orthopedic Team at Johns Hopkins Hospital in Baltimore!

They include OR Today among the tools they need to be successful. They are Johns’ Angels!

Thank you to all who submitted!

Look for your chance to win in our OR Today Magazine monthly contests!

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October 2014 | OR TODAY

75

OUT OF THE OR PINBOARD

Join the community!

WOMEN TAKING TOO MUCH CALCIUM CREATE HEALTH RISK

Kevin Tilley and the team at Wayne County Hospital in Corydon, Iowa, sent in this photo of their free lunch after winning a contest earlier this year.

“The trained nurse has become one of the great blessings of humanity, taking a place beside the physician and the priest, and not inferior to either in her mission.” – William Osler, M.D. 76

OR TODAY | October 2014

Researchers from the North American Menopause Society found that supplementing with calcium elevates calcium levels too high, putting women at risk for kidney stones, among other health problems.

Women close to menopause are commonly told to take supplements containing calcium and vitamin D to prevent diseases such as osteoporosis, to which they are particularly prone.

“I would recommend that women determine how much calcium they typically get through their food sources before taking a hefty calcium supplement. They may not need as much as they think,” says NAMS executive director, Margery Gass, M.D. A free 32-page guide to the benefits of magnesium, and its deficiency symptoms, is available at www.nutritionalmagnesium.org.

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October 2014 | OR TODAY

77

INDEX

ALPHABETICAL

AAAHC…………………………………………………………………18 AIV……………………………………………………………………… 67 Ansell Healthcare………………………………………………… 4 Artho Plastics Inc.………………………………………………18 BEMIS Healthcare…………………………………………… 65 Bryton Corporation……………………………………………15 C Change Surgical…………………………………………… 33 Cincinnati Sub-Zero………………………………………… 26 Cygnus Medical………………………………………………… 55 Didage Sales Company, Inc.…………………………… 45 Ecolab Inc, Professional Products Div.………… 44 Ezio, Inc.……………………………………………………… 46-49

INDEX

Palmero Health Care……………………………………… 57 Polar Products………………………………………………… 33 Ruhof Corporation…………………………………………… 2-3 Sage Services…………………………………………………… 69 SIPS Consults, Corp.………………………………………… 77 SMD Wynne Corp.…………………………………………… 77 Soma Technology, Inc.…………………………………… 45 Stryker Sustainablility Solutions…………………… 25 Summit Medical Inc.…………………………………………… 6 Surgical Power………………………………………………… 57 Surgical Services Summit……………………………… 35 TBJ, Inc.……………………………………………………………… 56

Surgical Power………………………………………………… 57

REPAIR SERVICES AIV……………………………………………………………………… 67

CATEGORICAL

ACCREDITATION AAAHC…………………………………………………………………18 ANESTHESIA SMD Wynne Corp.…………………………………………… 77 APPAREL Healthmark Industries……………………………… 34,63 ASSOCIATIONS AAAHC…………………………………………………………………18 AUCTIONS Government Liquidation…………………………………IBC MedWrench……………………………………………………… 64 BEDS Innovative Medical Products, Inc………………… BC CARDIAC SURGERY C Change Surgical…………………………………………… 33 CABLES/LEADS Sage Services…………………………………………………… 69 CLEANING SUPPLIES Cygnus Medical………………………………………………… 55 Ruhof Corporation…………………………………………… 2-3 CLAMPS Innovative Medical Products, Inc………………… BC DISPOSABLES Ansell Healthcare………………………………………………… 4 Government Liquidation…………………………………IBC Sage Services…………………………………………………… 69 ENDOSCOPY Ecolab Inc, Professional Products Div.………… 44 Government Liquidation…………………………………IBC MD Technologies……………………………………………… 34 Mobile Instrument Service & Repair…………… 10 OR Specific……………………………………………………… 67 Ruhof Corporation…………………………………………… 2-3 SIPS Consults, Corp.………………………………………… 77 Summit Medical Inc.…………………………………………… 6 TBJ, Inc.……………………………………………………………… 56 EMPLOYMENT SIPS Consults, Corp.………………………………………… 77 EQUIPMENT/REFERBISHED EQIUPMENT Artho Plastics Inc.………………………………………………18 Soma Technology, Inc.…………………………………… 45 FALL PREVENTION Encompass Group, LLC…………………………………… 34 FLUID CONTROL Artho Plastics Inc.………………………………………………18 GEL PADS Innovative Medical Products, Inc………………… BC GENERAL Didage Sales Company, Inc.…………………………… 45 GelPro………………………………………………………………… 24 Government Liquidation…………………………………IBC Lumalier Corporation………………………………………… 5 MedWrench……………………………………………………… 64 SIPS Consults, Corp.………………………………………… 77 Summit Medical Inc.…………………………………………… 6 78

Encompass Group, LLC…………………………………… 34 GelPro………………………………………………………………… 24 Government Liquidation…………………………………IBC Healthmark Industries……………………………… 34,63 Innovative Medical Products, Inc………………… BC Jet Medical Electronics…………………………………… 33 Lumalier Corporation………………………………………… 5 MAQUET, Inc.……………………………………………………… 9 MD Technologies……………………………………………… 34 MedWrench……………………………………………………… 64 Mobile Instrument Service & Repair…………… 10 OR Specific……………………………………………………… 67

OR TODAY | October 2014

HAND/ARM POSITIONERS Innovative Medical Products, Inc………………… BC HIP SYSTEMS Innovative Medical Products, Inc………………… BC INFECTION CONTROL/PREVENTION Ansell Healthcare………………………………………………… 4 BEMIS Healthcare…………………………………………… 65 Cygnus Medical………………………………………………… 55 Ecolab Inc, Professional Products Div.………… 44 Encompass Group, LLC…………………………………… 34 Government Liquidation…………………………………IBC MAQUET, Inc.……………………………………………………… 9 Palmero Health Care……………………………………… 57 Ruhof Corporation…………………………………………… 2-3 SMD Wynne Corp.…………………………………………… 77 INFUSION PUMPS AIV……………………………………………………………………… 67 INSTRUMENTS Government Liquidation…………………………………IBC Mobile Instrument Service & Repair…………… 10 INTERNET RESOURCES MedWrench……………………………………………………… 64 KNEE SYSTEMS Innovative Medical Products, Inc………………… BC LAB TBJ, Inc.……………………………………………………………… 56 LEG POSITIONERS Innovative Medical Products, Inc………………… BC MONITORS Ezio, Inc.……………………………………………………… 46-49 Jet Medical Electronics…………………………………… 33 OTHER TBJ, Inc.……………………………………………………………… 56 OPHTHALMICS Ecolab Inc, Professional Products Div.………… 44 OR TABLE ACCESSORIES Bryton Corporation……………………………………………15 Innovative Medical Products, Inc………………… BC ORTHOPEDIC OR Specific……………………………………………………… 67 Surgical Power………………………………………………… 57 PATIENT AIDS Innovative Medical Products, Inc………………… BC PATIENT WARMING Encompass Group, LLC…………………………………… 34 POSITIONING AIDS Innovative Medical Products, Inc………………… BC

SHOULDER RECONSTRUCTION Innovative Medical Products, Inc………………… BC SIDE RAIL SOCKETS Innovative Medical Products, Inc………………… BC SOCIAL MEDIA MedWrench……………………………………………………… 64 SPINE OR Specific……………………………………………………… 67 STERILE PROCESSING TBJ, Inc.……………………………………………………………… 56 STERILIZATION Lumalier Corporation………………………………………… 5 SIPS Consults, Corp.………………………………………… 77 Summit Medical Inc.…………………………………………… 6 SURGEON COOLING Polar Products………………………………………………… 33 SURGICAL AAAHC…………………………………………………………………18 Artho Plastics Inc.………………………………………………18 Ecolab Inc, Professional Products Div.………… 44 Ezio, Inc.……………………………………………………… 46-49 Lumalier Corporation………………………………………… 5 MD Technologies……………………………………………… 34 Mobile Instrument Service & Repair…………… 10 SMD Wynne Corp.…………………………………………… 77 Stryker Sustainablility Solutions…………………… 25 Summit Medical Inc.…………………………………………… 6 Surgical Power………………………………………………… 57 SURGICAL EQUIPMENT Mobile Instrument Service & Repair…………… 10 SURGICAL SUPPLIES Cincinnati Sub-Zero………………………………………… 26 Cygnus Medical………………………………………………… 55 Government Liquidation…………………………………IBC Ruhof Corporation…………………………………………… 2-3 SURPLUS MEDICAL Government Liquidation…………………………………IBC SUPPORTS Innovative Medical Products, Inc………………… BC TEMPERATURE MANAGEMENT C Change Surgical…………………………………………… 33 TRADE SHOWS Surgical Services Summit……………………………… 35 ULTRASOUND AIV……………………………………………………………………… 67 Ecolab Inc, Professional Products Div.………… 44

POSITIONERS/IMMOBILIZERS Innovative Medical Products, Inc………………… BC

VIDEO Ecolab Inc, Professional Products Div.………… 44 Ezio, Inc.……………………………………………………… 46-49

RADIOLOGY Ecolab Inc, Professional Products Div.………… 44 Ezio, Inc.……………………………………………………… 46-49

WASTE MANAGEMENT BEMIS Healthcare…………………………………………… 65

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