OR Today - May 2015 by MD Publishing

CLOROX

EXPERT ADVICE PAGE 15

CONTINUING EDUCATION

ALARM FATIGUE PAGE 36

TAKE GOOD CARE

• NURSES • SURGICAL TECHS • NURSE MANAGERS

SPOTLIGHT ON

BETH COHEN PAGE 58

MAY 2015

www.ortoday.com

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INDUSTRY FOCUSES ON

ENDOSCOPE

REPROCESSING

…

… EDUCATION, TRAINING VITAL FOR INFECTION PREVENTION

…

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TAKE CONTROL OF INFECTIONS AND YOUR BOTTOM LINE Interchangeable disposable lead wires let you decide how to manage HAIs, reduce complications, and avoid costly penalties. These days, with financial penalties based on HAIs and hospital cleanliness, you can’t afford not to use disposables. And OnePatient lead wires from Curbell are a scalable, cost-effective, disposable solution. Interchangeable design lets you balance cost vs. risk ' Use disposables on all patients, only within specific departments, or only on at-risk patients Disposable lead wires work with existing monitor ' cables, so you can choose to use a disposable or reusable based on individual patient need Eliminate cross-contamination ' Reusable ECG lead wires are a known risk factor for HAIs ' Helps you comply with recommended standards from the CDC and others* * Siegel, JD et al (20060). “Management of Multidrug-Resistant Organisms In Healthcare Settings”. Centers for Disease Control and Prevention; the Healthcare Infection Control Advisor Committee (HIPAC); 1-74

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CONTENTS

features

OR TODAY | May 2015

CINCINNATI SUB-ZERO

Cincinnati Sub-Zero has delivered patient temperature management systems to healthcare professionals since it opened its doors in 1963. The company’s line of hyperhypothermia products includes therapeutic heat and cold therapy units. CSZ also offers warming and cooling blankets for healthcare providers.

…

INDUSTRY FOCUSES ON

ENDOSCOPE

REPROCESSING

…

NURSING LAW

INDUSTRY FOCUSES ON ENDOSCOPE REPROCESSING

The proper cleaning and reprocessing of endoscopes and other semi-critical reusable medical equipment (RME) has taken on added urgency after recent news reports that contaminated endoscopes may have led to the spread of deadly infections within health care facilities. We ask experts for their guidance regarding this devices.

SPOTLIGHT ON: BETH COHEN Having already been accepted to law school, Cohen started to have second thoughts, which were only amplified as her grandparents on both sides of the family started to fall ill, one after another. As she became more involved with their care, she met a nurse who told her, “You can do this.”

OR Today (Vol. 15, Issue #4) May 2015 is published monthly by MD Publishing, 18 Eastbrook Bend, Peachtree City, GA 302691530. 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. © 2015

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MAY 2015 | OR TODAY

CONTENTS

departments

PUBLISHER

John M. Krieg | john@mdpublishing.com

VICE PRESIDENT

Kristin Leavoy | kristin@mdpublishing.com

EDITOR

John Wallace | jwallace@mdpublishing.com

ART DEPARTMENT Jonathan Riley Yareia Frazier Jessica Laurain

ACCOUNT EXECUTIVES

Mike Venezia | mike@mdpublishing.com Jayme McKelvey | jayme@mdpublishing.com

30 INDUSTRY INSIGHTS 10 15 18 20 25

News & Notes Clorox Advice AAAHC Update AORN Conference wrap-up OR Today Webinars

Andrew Parker | andrew@mdpublishing.com

CIRCULATION Bethany Williams

ACCOUNTING Kim Callahan

WEB SERVICES Betsy Popinga Taylor Martin

IN THE OR 26 29 30 36

Suite Talk Market Analysis Product Showroom CE Article

OUT OF THE OR 64 Health 66 Fitness 70 Nutrition 72 Recipe 76 Pinboard

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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82 Index

OR TODAY | MAY 2015

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INDUSTRY INSIGHTS NEWS & NOTES

STAFF REPORTS

MEDLINE PINK GLOVE DANCE VIDEO COMPETITION TURNS FIVE

Some people walk for breast cancer. Others race. Medline believes in dancing while wearing pink gloves. On March 9, nearly 1,000 operating room nurses from across the country danced to their hearts’ content to kick off the 2015 Medline Pink Glove Dance Video Competition. The dance took place at Medline’s 10th annual Breast Cancer Awareness Breakfast in Denver, in conjunction with the annual Association of periOperative Registered Nurses (AORN) Surgical Conference & Expo. Breast cancer survivor and former “Dancing with the Stars” host Samantha Harris, danced side-by-side with the nurses and shared her personal breast cancer 10

OR TODAY | MAY 2015

journey as the keynote speaker. Last year, Harris found a lump in her breast days after a clear mammogram. Shortly after, she was diagnosed with breast cancer at the age of 40. “I knew I was in the right place when I walked into the Breast Center at St. John’s Hospital in Santa Monica. Nurses held my hand, listened to me and I never felt alone,” says Harris. “Cancer had a chance to break me down, but I was determined to fight back with strength and positivity.” This is the fifth year of the competition, which includes the United States, Canada and Panama. Separate competitions are held in Europe, Australia and New Zea-

land. To register for the competition, go to www.pinkglovedance. com. Results will be announced Oct. 1 with the winning team receiving a $15,000 donation in their name to the breast cancer charity of their choice. Other prizes will also be awarded. Also at the event, Medline presented the National Breast Cancer Foundation (NBCF) with a check for more than $200,000 to help fund mammograms and educational services for underserved women. To date, Medline has donated $1.6 million to NBCF as part of Medline’s campaign to promote breast cancer prevention and education. •

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NEWS & NOTES

PRIMUS STERILIZER NAMES JIM FRY AS CEO PRIMUS Sterilizer Board of Directors has appointed Jim Fry as Chief Executive Officer and a member of the Board of Directors. Fry brings with him experience in the life science and health care industry. He has led and been a member of executive teams that developed global solutions for customers in the key segments that PRIMUS operates in. Prior to joining PRIMUS, Fry held multiple roles within Getinge including President of LANCER USA, SVP Getinge North America, and a member of Getinge’s Portfolio Decision Board that was responsible for all product life cycle decisions inside the Infection Control Division of the Getinge Group. His last position with Getinge was head of its newly formed Life Science business unit with P&L responsibility for the Americas region as well as a member of the global Life Science Management team. Former CEO Michael Douglas is stepping down after six years with PRIMUS. During his tenure at PRIMUS, he successfully led the company through numerous facility consolidation initiatives and greatly expanded the operating margins of the business. Douglas will assist Fry during a transition period. PRIMUS is a portfolio company of Blue Sage Capital, an Austin, Texas-based private equity firm with $250 million of assets under management. “We are very appreciative of Michael’s leadership at PRIMUS and thank him for his hard work,” said Blue Sage co-founding partner Peter Huff. “We are thrilled to have Jim join the PRIMUS family and believe his extensive background in the industry will serve him well as he leads the company. Jim is a proven leader with a vision for PRIMUS. Both Blue Sage and Jim believe PRIMUS is a market leader in the steam sterilizer industry and we look forward to a successful partnership with Jim.”•

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BIOCONNECT HELPS REDUCE ELECTRICAL INTERFERENCE Medical devices are bombarded with electrical interference within the hospital environment. The explosion of wireless connectivity is one of the biggest contributors to unwanted signal interference. A lesser-known factor is interference caused by the difference in potential between the patient and the medical device. A medical device company developed a mapping catheter system that improved the diagnosis and treatment of atrial fibrillation, one of the most common heart rhythm disorders in the world. Noise created by the potential difference can interfere with the amplified waveforms obtained when using a mapping catheter for treatment of this disorder. Working with the device company, Bioconnect engineers designed a cable that creates a circuit between the patient and data collection box that dampens or eliminates the unwanted electrical noise. A clearer signal allows the doctor or clinician to better interpret the data being collected from within the patient’s heart during the mapping procedure. • FOR MORE INFORMATION and product specifications, visit www.biocables.com.

MAY 2015 | OR TODAY

INDUSTRY INSIGHTS NEWS & NOTES

STAFF REPORTS

ENCOMPASS GROUP OFFERS INNOVATIONS IN REUSABLE OR TEXTILES

Through a partnership with Canadian based Lac-Mac, Encompass Group LLC is offering significant innovations in reusable OR gowns and drapes in the U.S. Paragon Style Level 4 Surgical Gowns are uniquely designed and incorporate R-MOR-Tex LiquidProof Barrier Fabric in critical zones and features a distinct neckline that wicks away moisture and eliminates chafing. Lac-Mac has an Industrial Design Patent in Canada and the U.S. for this gown. The Lac-Mac reusable pouch drape is the only reusable drape pouch system on the market and the liquid-proof pouch can be incorporated into any of the Lac-Mac fenestrated drape products. Another new product is the 12

OR TODAY | MAY 2015

reusable drape with disposable insert. This drape offers an opportunity for facilities currently using disposable drapes an easy way to transition into reusables. The concept means only one drape can be used as a multi-purpose procedural drape simply by changing the insert. The OR is the biggest user of medical supplies in any facility. The decision to use disposable or reusable gowns, drapes and mayo covers can impact cost, infection control and staff comfort. “In selecting drapes and gowns for a facility’s OR, there are four major considerations: safety, comfort, control of health careacquired infections and cost,” said Janice Larson, managing director

for Clinical Resources and Consulting at Encompass Group LLC. “All OR drapes and gowns are considered by the U.S. Food and Drug Administration to be medical devices, and as such are held to AAMI and ANSI standards for protection against fluids and pathogens.” “There are four Levels of barrier performance, from Level 1 (the lowest) to Level 4 (the highest). OSHA and CDC also have requirements for protective barriers,” she adds. “Disposable items must meet these performance standards for a single use. Reusable items must pass the tests to the end of its reuse cycle, typically 50 to 75 uses.” •

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NEWS & NOTES

RF SURGICAL UNVEILS SOLUTION FOR THE PREVENTION OF RETAINED SURGICAL SPONGES RF Surgical Systems Inc. has announced the availability of the RF Assure Detection System X, an integrated solution for the problem of retained surgical sponges. The product is the first in the adjunct detection technology category to incorporate essential compliance support functions as well as improved scanning coverage that extends beyond general surgery to an application-specific approach by surgical specialty. RFS began shipping units in April. Enhancements to the RF Assure Detection System X include a new compliance-driven interface designed to provide “real-time” feedback to guide the OR staff through an effective sponge management protocol. The redesigned interface improves accessibility and data visibility during procedures and automatically stores case and scan records for convenient review and compliance. In addition, RFS introduces a new scanning component for the RF Assure Detection System X, the ArQ•Sphere. This new handheld, stationary scanning device leverages dual-3D scan fields to address the positioning challenges specific to extremity, head, neck, spine and other specialty procedures. The ArQ•Sphere offers motion-free scanning with overlapping scan fields, creating an optimal detection zone for orthopedic and specialty procedures. “The premium digital patient WWW.ORTODAY.COM

safety platform of the RF Assure Detection System X represents our next generation in market-leading detection technology and innovation from RF Surgical,” said John Buhler, CEO of RF Surgical Inc. “The integration of a workflowcomplementary interface with surgical specialty scanning capabilities significantly advances our efforts to eliminate the risks associated with retained surgical sponges for improved OR patient safety.” RF Assure technology minimizes the incidence of retained surgical

sponges, allowing hospitals to optimize the safety and quality of care for surgical as well as labor and delivery patients. RF Assure uses a reliable, low-energy radio frequency signal specifically designed for the detection of misplaced surgical sponges through blood, dense tissue and bone. Additional patient-centric benefits realized by the use of adjunct detection technology include reduction in incremental time under anesthesia and the use of X-rays associated with rectifying sponge miscounts. MAY 2015 | OR TODAY

Empower patient compliance TM with the Clorox Healthcare 4% CHG Skin Cleansing Kit. Provide patients with everything they need in one kit, and you’ve helped them enormously. And you’ve taken another important step in your SSI prevention strategy. 4 oz. 4% CHG Bottle: Evidenced-based literature shows 4% CHG bottles are equally effective for infection prevention as 2% CHG pre-saturated cloths – when patients receive standardized instructions.1

WAIT.

Are A Ar re yo you co onfi nfid den ent you ourr pa pati tien ti nts hav avee fo ollllow owed owed ow d your yo our ur preeop oper errat ativ tivve skkin n cle lean an nsiingg pro oto t co cols? lss?

*While supplies last. Limit one per customer. Business or institutional customers only. 1. Edmiston CE, Medical College of Wisconsin, Milwaukee, WI. “Evidence for using Chlorhexidine Gluconate Preoperative Cleansing to Reduce the Risk of Surgical Site Infection.” AORN Journal. Vol 92. No 5. (2010): 509-518. 2. Edmiston CE, et al. “Empowering the Surgical Patient: A Randomized, Prospective Analysis of an Innovative Strategy for Improving Patient Compliance to the Preadmission Showering Protocol.” Journal of the American College of Surgeons 219.2(2014): 256-264. 3. Hibbing, A., “A Picture Is Worth A Thousand Words,” The Reading Teacher; 2003. ©2015 Clorox Professional Products Company. 1221 Broadway, Oakland, CA 94612. NI-28111

Patient Reminder Systems: Offer multiple contact points shown to enhance compliance for preoperative skin cleansing.2 Waterproof Instructions Card: Includes large text and visual icons, which studies show are effective for promoting understanding.3 Online Video Instructions: Easy to follow and drive correct product use.

Learn more and get a free sample* at www.CloroxHealthcare.com/CHGKit

INDUSTRY INSIGHTS CLOROX ADVICE

BY ROSIE D. LYLES, MD, MHA, MSc

PARTNERING WITH PATIENTS TO COMBAT KEY INFECTION RISK FACTORS

urgical site infections (SSIs) are among the most common and costly healthcare-associated infection (HAI) in the United States.1 However, recent estimates suggest that as many as 55 percent of SSIs could be prevented with current evidencebased strategies2 designed to reduce the risk of infection. The incidence of infection varies from facility to facility, surgeon to surgeon, from one surgical procedure to another and from one patient to another, so it is important to be aware of key risk factors for infection and how best to mitigate them. UNDERSTAND THE RISKS SSIs occur when surgical sites encounter microbial contamination, therefore prevention methods should focus on reducing the presence and limiting the spread of microorganisms. With this in mind, it is helpful to consider three general types of risk factors for SSIs: • Host factors - Patient characteristics such as length of preoperative stay, comorbidities, nutritional status and colonization with microorganisms • Microbial factors - Characteristics such as virulence, antibiotic resistance and adherence • Surgical/Environmental factors - Operation characteristics, such as perioperative care, surgical technique, patient temperature,

ROSIE D. LYLES, MD, MHA, MSc, HEAD OF CLINICAL AFFAIRS

duration of surgery and intraoperative contamination Certain factors like microbial virulence, comorbidities and wound class cannot be helped. However, both healthcare providers and patients have roles to play in modifying several key host and surgical/environmental factors to help reduce the risk of infection. CURTAIL CONTAMINATION Contaminants can be introduced to the operating suite through a variety of sources. The patient, healthcare professionals, surgical instruments and other inanimate objects can all introduce infectious material to the surgical field. However, for the vast majority of SSIs, the primary source of bacterial contamination is the patient’s skin.

As a result, a growing body of scientific and clinical studies support preoperative skin cleansing as part of a comprehensive strategy to prevent SSIs.3,4,5 Many outpatient and acutecare facilities ask patients to bathe using chlorhexidine gluconate (CHG), a fast-acting and persistent antiseptic, prior to surgery, but the benefits of these protocols are reduced if the prescribed bathing regimen is not followed or if the product is not used correctly. One of the best ways to combat this important risk factor is to support patients at home as they prepare for surgery by making sure they have the information and tools they need to cleanse correctly. The Clorox Healthcare™4% CHG Skin Cleansing Kit gives patients everything they need in one convenient, easy-to-use package to reduce bacteria on the skin prior to surgery. Clear instructions are also very important, which is why each kit includes a bilingual, waterproof instruction card with illustrations and easy-to-read text that can be taken into the shower for reference. Both frontline healthcare professionals and patients have the potential to make a big difference and improve patient safety using evidence-based strategies to reduce the risk of SSIs. FOR MORE INFORMATION about strategies to reduce the risk of SSIs, visit www.CloroxHealthcare.com/CHGKit.

[1] Zimlichman E, Henderson D, Tamir O, et al. “Health care–associated infections: a meta-analysis of costs and financial impact on the U.S. health care system.” JAMA Intern Medicine 173.22 (2013):2039–2046. [2] Umscheid CA, Mitchell MD, Doshi JA, Agarwal R, Williams K, Brennan PJ. “Estimating the proportion of healthcareassociated infections that are reasonably preventable and the related mortality and costs.” Infection Control and Hospital Epidemiology 32.2 (2011):101–114. [3] Association of periOperative Registered Nurses (AORN). “Recommended Practices for Preoperative Patient Skin Antisepsis.” Perioperative Standards and Recommended Practices (2012): 445-463. [4] Edmiston CE, et al. “Evidence for Using Chlorhexidine Gluconate Preoperative Cleansing to Reduce the Risk of Surgical Site Infection.” AORN Journal 92.5 (2010): 509-518. [5] “The Joint Commission’s Implementation Guide for NPSG.07.05.01 on Surgical Site Infections: The SSI Change Project” (2013): 1-48.

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MAY 2015 | OR TODAY

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Provides automated tracking and documentation for endoscopes that will help you meet regulatory standards. Upload videos, PDFs, Word documents and have connectivity to oneSOURCE™. ScopeTrac Helps: • Save time and increase OR efficiency • Validate inventory data for all endoscopes • Ensure compliance with guidelines from the FDA, CDC, Joint Commission and AAMI • Reduce reprocessing errors and damage to your endoscope inventory • Provide complete information for audits, trend analysis and benchmarking for process improvement • Provide the ultimate patient safety/infection control for endoscope inventory • Create the foundation for Patient Safety in the OR Scan this tag to learn more about Censitrac®.

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MAY 2015 | OR TODAY

INDUSTRY INSIGHTS AAAHC NEWS &UPDATE NOTES

BY JACK EGNATINSKY, MD

THE OFT FORGOTTEN “DEPARTMENT” Y

ou will notice that I put the word “department” in quotes in the headline, because what constitutes a department responsible for sterilization and disinfection of instruments and other devices is often an enigma to me when I do accreditation surveys.

In a hospital OPD or a large ASC there is usually a Central Sterile Department with a well-trained staff. In a typical ASC, this can vary from a dedicated “tech” – often an OR tech who has had limited formal training – to “whoever brings the instruments to the workroom” having the responsibility for cleaning and packaging for sterilization. As part of the AAAHC infection control and prevention review during an accreditation survey, we will be looking closely at your sterilization and high-level disinfection practices. I expect that the person showing me the cleaning and 18

OR TODAY | May 2015

sterilization area(s) to be able to answer and/or demonstrate, at a minimum, the following: • How do you know if any particular item has been cleaned or disinfected or sterilized? • Can you tell me the difference between critical and non-critical instruments/devices? • What kind of high-level disinfection and sterilization do you have in your center? • Is it all overseen by one person? • What training and demonstration of competence does the person (or persons) in charge undergo? • Are you doing high-level disinfection? If yes, what chemicals do you use? Do you monitor their temperature? How often? • Do you monitor their end of use date? Are you using test strips? How often? Do you record these? • If you are not using closed systems, do you have an exhaust hood over the disinfection area? If not, are your employees wearing glutaraldehyde monitoring badges or something similar?

• Are you doing EO sterilization? Is your system completely closed and in a well-ventilated area? Do you assure that all three phases, pre-conditioning, gas dwell or continuous exposure phase and aeration, are all carried out according to the manufacturers recommended time? How do you assure that aeration is complete before you use the instruments? What BI (biological indicator) and CI (chemical indicator) are you using? • Are you using a hydrogen peroxide gas plasma based unit or a peracetic acid unit? How do you know what instruments are safe to sterilize in your unit? Do you know the requirements for dry, damp, wet? • Dry heat sterilizers? Steam sterilization – do you have gravity or vacuum assist units, or both? Do you do any immediate use sterilization? How much? How do you wrap or otherwise place your instruments in the autoclaves? Where do you place them? What CI or BI are you using? WWW.ORTODAY.COM

AAAHC UPDATE

• CIs and BIs – are you using integrator strips? What class? Why? Do you use instant, rapid, slow BIs? • Logs: What logs are you keeping? Can you identify which instruments were sterilized or disinfected in a specific load by checking your records? • PM – how often is your disinfection and sterilization equipment undergoing preventive maintenance? • What is your procedure if a CI or BI indicates that sterilization was not complete?

WWW.ORTODAY.COM

The functions noted above are critical to your operations. Make sure that you have properly trained, preferably certified, individuals who undergo regular continuing education in infection control and prevention. This is a vitally important field that changes frequently. Your staff must keep up to date if your organization is determined to maintain quality care.

ambulatory surgery arena, both HOPD and ASC. He is a Past-President of the Board of FASA, a predecessor to the ASC Association, and Past-President of AAAHC. He is also on the board of the Accreditation Association for Hospital and Health Systems (AAHHS) and is a representative of Acreditas Global, the international arm of AAAHC. He remains extremely active as a Medical Director for AAAHC, in addition to being a welltraveled AAAHC accreditation surveyor in the USA and internationally.

ABOUT THE AUTHOR Dr. Jack Egnatinsky is an anesthesiologist with extensive experience in the

May 2015 | OR TODAY

INDUSTRY INSIGHTS AORN NEWS CONFERENCE & NOTES WRAP-UP

STAFF REPORT

AORN REACHES THOUSANDS IN DENVER

he annual AORN Surgical Conference & Expo was a huge success in Denver with more than 4,000 perioperative registered nurses in attendance and more than 4,000 exhibitor personnel on hand representing 481 exhibitors. The OR Executive Summit and Leadership Development Summit, alone, had 625 attendees.

AORN, the Association of periOperative Registered Nurses, represents approximately 41,000 Registered Nurses in the U.S. and abroad who facilitate the management, teaching and practice of perioperative nursing, or who are enrolled in nursing education or engaged in perioperative research. The annual conference is designed for these medical professionals and to meet their specific needs concerning educational opportunities, exhibit hall vendors as well as a robust schedule of events and activities. OR Today was among the exhibitors at the expo as they promoted the magazine and the brand new OR Today Live! Surgical Conference set for Las Vegas later this year. The OR Today booth was manned by MD Publishing executives, including President and Founder John Krieg, Vice President Kristin Leavoy and Trade Show Coordinator Bethany Williams. MD Publishing 20

OR TODAY | May 2015

produces three magazines, including OR Today. Denver was a popular destination with a packed exhibit hall each day of the conference. Attendees swarmed the OR Today booth where readers praised the magazine and newcomers quickly signed up for a free subscription. The magnitude of the AORN Surgical Conference & Expo never ceases to amaze. Leavoy described it as an important journey for AORN members and health care professionals. “I think of AORN as being a mecca for OR professionals,” she explained. “It is a pilgrimage taken each year to learn and improve their skill set.” “We think the attendee base at AORN is by far one of the most dedicated in the industry,” she added. “When you interact with the attendees, you get a sense of how passionate they are about their careers.” Williams was amazed by the turnout at the annual conference and said she is “excited” about attending the 2016 event in Anaheim, California. “AORN was fantastic,” Williams said. “We had the opportunity to meet a lot of new readers and we received a lot of great feedback from our existing readers. They told us what they love about the magazine.” Williams said OR Today added 600 new subscribers and the “Nurse Pill” stress ball given away to attendees at the OR Today booth “was the hit of the show.” “It is definitely something we want to participate in next year,” Williams

said about the 2016 AORN Surgical Conference & Expo. Leavoy said the conference provided great interaction with the readers of OR Today. “It was very heartwarming to have the readers come up and say, ‘I know your magazine. I’ve been reading it for 10 years,’ ” Leavoy said. “It was also nice to share the magazine with others and attract new readers.” Individuals are able to improve their knowledge and expand their understanding of the OR setting as well as examine the latest high-tech devices available for perioperative nurses, surgeons and technicians at the annual AORN conference. The House of Delegates of AORN also elected its Board of Directors and Nominating and Leadership Development Committee for the 2015-2016 term. The board of directors was inducted into office during the AORN annual Congress at the Surgical Conference & Expo. The election also marked the beginning of the term for Renae N. Battié, MN, RN, CNOR, as Association president replacing Victoria Steelman, PhD, RN, CNOR, FAAN. Battié, associate vice president, Perioperative Services for CHI Franciscan Health in Tacoma, Washington, has been a perioperative nurse for 28 years and a member of AORN since 1980. The results of the board election also included that of Treasurer Stephanie S. Davis, MSHA, RN, CNOR. Davis is vice president, WWW.ORTODAY.COM

AORN CONFERENCE WRAP-UP

AORN President Renae Battié, MN, RN, CNOR began her term at the end of the conference. Battié will serve for a year until Martha Stratton, MSN, MHSA, RN, CNOR, NEA-BC takes over at next year’s event.

Many of the sessions run concurrently which makes the Educational Hub, where attendees can listen to recordings, a popular spot for catching up.

Smaller sessions are intentionally arranged in a roundtable setting. It gives the nurses a chance to compare notes and network with their peers.

Keynote speakers inspire and entertain the audience of 4,000 nurses who enjoy the break between education sessions.

The exhibit floor at the Surgical Conference & Expo is open throughout the conference to give device representatives and nurses plenty of time to get to know each other. Nurses can learn more on the floor in 20 minutes than they do in weeks of in-services. WWW.ORTODAY.COM

May 2015 | OR TODAY

INDUSTRY INSIGHTS AORN NEWS CONFERENCE & NOTES WRAP-UP

Attendees pose for a quick photo of the packed exhibit hall.

Attendees network and enjoy a snack at the annual event.

The AORN Foundation Gold Rush Party was a hit.

Runners participate in the AORN Foundation Race for Patient Safety 5K Run/3K Walk. 22

OR TODAY | May 2015

surgical services, at Hospital Corporation of America (HCA), Nashville, Tennessee. The newest members of the board also include Sandy Albright, MSHM, BSN, RN, CNOR; George Allen, PhD, MS, BSN, RN, CNOR, CIC; James (Jay) Bowers, BSN, RN, CNOR, TNCC; and Jane Flowers, MSN, RN, CNOR. AORN continuing board members for 2015-2016 are: Vice President Callie S. Craig, MS, BSN, RN, CNOR, clinical director for surgical services at INTEGRIS Baptist Medical Center in Oklahoma City; Secretary Nathalie Walker, MBA, BS, RN, CNOR, a member of the Louisiana Nursing Supply and Demand Commission, a subcommittee of the Health Works Commission of Louisiana; Sandy Albright, MSHM, BSN, RN, CNOR; Holly Ervine, MSN, RN, CNOR; Donna Ford, MSN, RN-BC, CNOR, CRCST; and Missi Merlino, MHA, RN-BC, CNOR. Newly elected to the Nominating and Leadership Development Committee (NLDC) are Kristy Simmons, MSN, RN, CNOR, and Kristy Wheeler, BSN, RN, CNOR, CST. AORN continuing NLDC members for 2015-2016 are Vangie Dennis, BSN, RN, CMLSO, CNOR, as chair; Steve Balog, MSN, BSN, RN, CNOR; and Merideth Lewis-Cooney, BSN, RN, CNOR. WWW.ORTODAY.COM

BY JOHN WALLACE

OR TODAY LIVE! POPULAR AT AORN AORN Surgical Conference & Expo attendees and exhibitors are “intrigued” about a brand new, smaller and more intimate surgical conference. OR Today Live! will be held August 30 to September 1 at Red Rock Resort and Casino in Las Vegas.

OR Today Live! Surgical Conference, presented by the publisher of OR Today magazine, offers a unique new venue for members of the perioperative and surgical communities. The goal is to bring the magazine to life and give readers and newcomers to the publication everything that they find inside each issue – life in and out of the OR. John Krieg, president and owner of MD Publishing, said the new OR Today Live! Surgical Conference is an exciting venture that will benefit a variety of health care professionals. “OR Today Live! was created because of a need in the surgical services community for a smaller, more intimate conference,” Krieg explained. “Our experienced editorial board for OR Today brought to our attention that no such meeting existed.” “What we are doing, essentially, is making the OR Today magazine live – thus the name,” Krieg added. “We are giving the attendees, our readers, an opportunity to engage with leaders at a three-day conference that is a gathering place and a community for the surgical services professional.” MD Publishing executives are even more excited about the new conference after exhibiting at the 2015 AORN

Surgical Conference & Expo in Denver. Readers of OR Today and other attendees expressed interest and excitement in a conference without the sometimes suffocating crowds found at larger expos. “AORN attendees were very excited about a show geared toward them,” MD Publishing Trade Show Coordinator Bethany Williams said about conversations she had with AORN attendees about the new OR Today Live! Surgical Conference. “People are excited about a show that is more intimate with a relaxed atmosphere. The schedule will not be as jammed packed. There will be breaks and dedicated networking opportunities built into the schedule of events.” “A schedule that allows for recharging with more one-on-one time,” Williams added. She was quick to praise the annual AORN conference for its magnitude and all that it offers. OR Today Live! will be on a different scale, but will still offer educational opportunities and an exhibit hall. MD Publishing Vice President Kristin Leavoy said interest is high for the OR Today Live! Surgical Conference. “Most (of the people at the AORN conference) were intrigued about a new and

OR Today was represented by, from left, Sales Representative Jayme McKelvey, Trade Show Coordinator Bethany Williams and Vice President Kristin Leavoy.

smaller show, and they liked that the venue is Las Vegas,” Leavoy said. “They were interested and said they are hopeful that their budget and schedule will allow them to attend.” OR Today Live! is also expected to draw attendees from the many perioperative and surgical professionals who had to remain at health care facilities and work during the AORN conference while their coworkers and colleagues descended on Denver. “Not every OR professional has the opportunity to attend AORN because of budget constraints and the length of the conference,” Leavoy said. “I feel like that is where OR Today Live! offers an excellent alternative.” “OR Today Live! is going to be the one-on-one approach for business management, staﬃng and compliance,” she added. “At AORN, these people go from 5:30 in the morning to 9 or 10 at night. From the time their plane touches down to the time they leave they are going nonstop. OR

Today Live! is a slower pace where the attendee’s attention is not diverted between a dozen simultaneous events.” The goal is not to replicate the AORN conference and attendees made some suggestions about what they would like to see at a smaller venue. “A complaint we heard at AORN is that classes are held while the exhibit hall is open,” Leavoy said. “We are not going to hold classes in conjunction with the exhibit hall.” Another advantage of OR Today Live! is that it is scheduled for late August. “It’s a great time for the show because it does not compete with other shows in the industry,” Williams said. The excitement surrounding OR Today Live! was evident as the OR Today executives prepared to leave Denver at the conclusion of the AORN Surgical Conference & Expo. “Several people said they would spread the word and encourage their colleagues to attend,” Williams said. •

FOR MORE INFORMATION about the OR Today Live! Surgical Conference, visit ORTodayLive.com. WWW.ORTODAY.COM

MAY 2015 | OR TODAY

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INDUSTRY INSIGHTS WEBINARS

BY JOHN WALLACE

ATTENDEES PRAISE OR TODAY WEBINARS

ore and more OR Today readers and industry professionals from throughout the United States are jumping online to take advantage of the free OR Today Webinar Series. More than 120 people registered for the webinar presented March 19. It was the first-ever OR Today roundtable webinar with a panel of experts that covered everything OR professionals need to know when it comes to the very important topic of surface disinfection. The webinar, titled “What’s New in Surface Disinfectants,” included experts from Clorox Healthcare,

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Allied BioScience and UMF Corporation. Dr. Katherine Velez, a scientist at the Clorox Professional Products Company where she serves as a technical liaison for the healthcare business, discussed UV-C and manual surface disinfection approaches and how they can be combined. Timothy S. Goedvolk, RN, B.Sc.N., MSN, senior director of clinical solutions at Allied BioScience shared his experiences working in infection control and provided insights into surface disinfection processes and products for the OR setting. George Clarke, CEO and founder of UMF Corporation, is a nationally recognized subject matter expert and spoke about the benefits of multi-

modal intervention — enterprisewide initiatives to reduce hospitalassociated infections. He also shared success stories where these processes have produced positive results. Attendees gave the webinar high marks in a survey and many complimented the webinar on surface disinfection, as well as the webinar series as a whole. The webinar was “well worth attending,” wrote Irene C. “Thank you for great information,” Michele M. stated.

FOR MORE INFORMATION about upcoming webinars or to view recordings of previous webinars, visit www.ORToday.com/Webinars. MAY 2015 | OR TODAY

IN THE OR SUITE TALK

SUITE TALK

Conversations from the OR Nation’s Listserv

OR INCENTIVES What are managers and organizations doing to support OR staff to increase staff and physician satisfaction? Are incentives being provided to include monetary or comp time when staff voluntarily stay to complete service line cases? Is overtime pay utilized as an incentive or are their other things that are being offered? A: We had to initiate several things here in order to give the staff a good work life balance. Anyone who stays after, when not scheduled, or anyone who has to take unexpected call due to illness receives a flat rate of $55 per case in addition to their time and a half and their $2/hour call pay. Getting called in on the third shift – if staffing allows, they can go home at 1100 with the remainder of

their shift paid. We can always get them out. Yes, it was an added expense, but in the long run it stabilized staffing and improved employee satisfaction. I should mention that we are not a union hospital. A: We have $75 for anyone taking call if someone calls in sick. After 500 hours of call, the staff get $500. •

BLOCKS Is it common for anesthesia to perform blocks when doing routine shoulder arthroscopies, and other cases? Patients who do receive blocks do much better with post-op pain control. What are some of the contraindications to doing blocks? It can be time consuming and extend turnover times if there is a limited amount of anesthesia staff. A: All of our anesthesiologists do blocks prior to orthopedic cases. If you time things right, you can avoid delays. We bring these patients to holding 30 minutes before the case start time. A: We bring our patients in earlier when they are receiving a block. The block is done in their pre-op room with a nurse and anesthesiologist – preferably not the anesthesiologist for their case. This prevents any delay for the surgeon. •

OR TODAY | MAY 2015

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SUITE TALK

OBSERVERS Sometimes facilities encourage floor nurses to come and observe surgery. Knowing how the patient is positioned, and the different types of manipulation that occurs while under anesthesia, can help with taking care of patients post-op. Is there some type of cheat sheet/ protocol that can be given to the floor nurses prior to entering the OR to help facilitate their experience as well as prevent incidents such as contamination of the sterile field? Should the floor nurse be assigned to a primary individual for the day? Just having them in the room without prior preparation and direction can be a recipe for disaster. A: Have the floor nurses look up the procedure and review the process. Many procedures have videos so that you can actually watch a surgery being performed and some have animated videos. We assign the floor nurse to a circulator who provides direction as to where to stand and explains the sequence of events. •

OR FLOORING A year ago we moved into a new hospital that is wonderful except for one thing … the OR flooring is not holding up! We currently have a product called Bio-Spec (sheet vinyl type) and it is literally coming up. We have since had flooring contractors come in and patch it, but I know this is not the ideal fix. So, my question to you is …. Do any of you know what type, brand, etc., of OR flooring you have? A: Armstrong Medintech Sheet Vinyl. A: Terrazzo floor currently and we are planning the same in our new addition. A: I have had Terrazzo floors in other facilities and loved it – very

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durable with easy care. Terrazzo is a composite material, poured in place or precast, which is used for floor and wall treatments. It consists of marble, quartz, granite, glass, or other suitable chips, sprinkled or unsprinkled, and poured with a binder

that is cementitious (for chemical binding), polymeric (for physical binding), or a combination of both. Terrazzo is cured and then ground and polished to a smooth surface or otherwise finished to produce a uniformly textured surface.

MAY 2015 | OR TODAY

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IN THE OR MARKET ANALYSIS

BY JOHN WALLACE

MARKET ANALYSIS

Growth Expected in Endoscope Reprocessing Sector of Infection Control Market

ealth care-acquired infections (HAIs) continue to be a concern in the medical industry. Recent cases involving endoscopes have brought added attention to the endoscope reprocessing and cleaning sector of the overall infection control market. The popularity of minimally invasive surgery as well as aging populations in the United States and other developed nations are additional reasons market watchers expect growth. Other drivers of the overall market include chronic diseases and the increase in awareness across the globe, especially in Asia. Advances in medical instruments, specifically endoscopes, are another factor pushing the expansion of the market. “Sterilization and disinfection are essential components of infectioncontrol procedures. There has been a surge of cleaning standards and mounting pressure for sterilized medical devices and disinfection in hospitals and clinics, which has triggered the growth of the medical sterilization and disinfection market,” according to a recent report description issued by the global market research and consulting company MarketsAndMarkets. WWW.ORTODAY.COM

com. “With an increase in aging population across the globe and a demand for health care services, change in the health care reimbursement policies is pushing the providers of sterilization and disinfection to improve their operations by providing high-quality service at lower costs. These factors are expected to propel the growth of this market. The overall infection control market will grow at a steady pace of around 6 percent and will reach $14.0 billion by 2017 from $10.5 billion in 2012.” “With the introduction of technically enhanced instruments in the market like endoscopes and analyzers, there has been an increased need for advanced sterilizers that are compatible with the same,” according to MarketsAndMarkets. “This has brought about a drastic shift from steam sterilizers to low temperature sterilizers with its wide range of technologies such as ethylene oxide (EtO), vaporized

hydrogen peroxide (VHP), hydrogen peroxide gas plasma, and ozone gas based sterilization.” Endoscope reprocessing is an important part of the market. “In disinfection market, the endoscope reprocessing segment continues to grow due to an increased importance to diagnostic and therapeutic endoscopy procedures, rising minimally invasive surgeries and concerns regarding patient-to-patient cross infection caused due to improper endoscopes reprocessing,” according to MarketsAndMarkets. “The endoscope reprocessing market is anticipated to show healthy growth in the upcoming years due to continued instrument development, and increasing minimally invasive surgery procedures,” according to the report. MarketsAndMarkets indicates that the major players in the infection control market are Getinge, Steris, Medivators, Advanced Sterilization Product , 3M, Belimed, Cardinal Health, Kimberly-Clark, Sterigenics, Sakura, Synergy Health and Nordion.

MAY 2015 | OR TODAY

IN THE OR PRODUCT SHOWROOM

EVOTECH® ENDOSCOPE® CLEANER AND REPROCESSOR

The EVOTECH® Endoscope Cleaner and Reprocessor is the first commercially available system that both cleans* and high-level disinfects endoscopes. Developed by Advanced Sterilization Products (ASP), a Johnson & Johnson company, the EVOTECH® System makes endoscope reprocessing a highly automated process, eliminating tedious brushing* resulting in confidence that endoscope reprocessing is effective and consistent. This can save valuable time, improve health care professional safety and reduce the risk of infection. *Does not eliminate bedside pre-cleaning. Manual cleaning of qualified medical devices (endoscopes) is not required prior to placement in the EVOTECH® ECR when selecting those cycles that contain a wash stage (for those endoscopes qualified for clean & disinfection only). Not all endoscopes can be automatically cleaned, but may be high-level disinfected. The EVOTECH® ECR will only disinfect an EUS scope. The customer will be responsible for the manual leak testing and manual cleaning of the scope per the manufacturer’s instructions for use. Please refer to the EVOTECH® ECR User’s Guide and specific connection diagrams for more detailed information regarding cycle capabilities. •

OR TODAY | MAY 2015

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PRODUCT PRODUCT SHOWROOM FOCUS

OLYMPUS OER-PRO AUTOMATED ENDOSCOPE REPROCESSOR The Olympus OER-Pro Automated Endoscope Reprocessor is designed to comply with the most rigorous industry standards while simplifying and expediting proper cleaning and reprocessing between procedures. Up to two flexible endoscopes can be simultaneously cleaned and disinfected in 26 minutes. The OER-Pro is FDA cleared to automate seven of the 11 manual endoscope cleaning steps, including the most labor-intensive and variable parts of the process: manual flushing of the endoscope channels with detergent, water and air. Its built-in Radio Frequency Identification (RFID) management system automatically traces the endoscope serial and model numbers, operator and time of reprocessing for additional time savings and improved accountability, eliminating cumbersome manual input from a keypad or barcode. â&#x20AC;˘

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MAY 2015 | OR TODAY

IN THE OR PRODUCT SHOWROOM

RUHOF

SCOPEVALET™ INSTRUFLUSH™ ScopeValet™ InstruFlush™ is an effective instrument and scope channel/lumen pre-cleaning and flushing device that increases the productivity of syringe flushing by 74.9 percent. The InstruFlush™ provides a pulse feature for hardto dislodge soils and works very well with lowfoaming enzymatic chemistries, detergents and alcohols. The pump can be used with or without the ScopeValet™ InstruStation™. FOR MORE INFORMATION about the ScopeValet™ InstruFlush™, the ScopeValet™ InstruStation™ and additional Ruhof solutions, visit www.ruhof.com.

OR TODAY | MAY 2015

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PRODUCT PRODUCT SHOWROOM FOCUS

KEY SURGICAL速 SCOPE CLEANING BRUSHES

Scope reprocessing is often challenging due to the complex nature of the instrument. Effective manual cleaning includes choosing the right brush. Key Surgical速 Scope Cleaning brushes are ready for the tough job ahead. Key Surgical offers a wide selection including single-use, reusable, single- or double-ended, tapered and even conveniently pre-packaged brush assortments. Lengths range from 75cm to 240cm and Key Surgical now carries three different styles of brushes designed specifically for shorter channels such as suction wells. CHECK OUT AT KEYSURGICAL.COM or call place your order today at 800-541-7995.

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MAY 2015 | OR TODAY

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IN THE OR CONTINUING EDUCATION 704

OR TODAY | MAY 2015

BY ANNA VER HAGE, RN, MSN, CCRN, CNRN

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CONTINUING EDUCATION 704

ALARM FATIGUE CAN ENDANGER PATIENTS Although medical device alarms are intended to promote patient safety, a growing concern exists that instead these alarms are contributing to patient harm.

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 45 to learn how to earn CE credit for this module.

The goal of this program is to provide nurses with information about safety concerns associated with alarm fatigue. After studying the information presented here, you will be able to: • Identify the patient safety issues associated with alarm fatigue • Describe The Joint Commission National Patient Safety Goal on alarm management • Discuss evidence-based strategies to reduce alarm fatigue

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60-year-old-man was admitted to the ICU after a traumatic brain injury. He was agitated and constantly removed his pulse oximetry device, which caused a shrilling alarm to ring continuously throughout the day. The patient received lorazepam (Ativan) to calm his restlessness, and a few minutes later his alarms began to sound, warning that the patient was experiencing a drop in oxygenation, tachycardia and tachypnea. Reports state that no one responded to these alarms, most likely thinking they were erroneous alarms as they had been all day. About one hour later, a high-alert alarm rang warning of respiratory arrest. A CT scan later showed an anoxic brain injury, and the family withdrew life support a few days later.1

Beeps, bells and soft, loud and ear-piercing alarms are all associated with patient care areas, but what if all this noise is not helping patients but actually harming them? The above scenario portrays a true clinical situation that has become more frequent across the nation. As hospitals continue to become more technologically advanced, the problems associated with technology grow. Alarm fatigue is among these problems and has led to sentinel events, unexpected events in healthcare that lead to death or serious physical or psychological injury or the risk of them. This sentinel event in 2010 prompted a nationwide focus on medical device alarm safety in hospitals, shedding light on the fatal consequences associated with alarm fatigue.2 Although medical device alarms are intended to promote patient safety, a growing concern exists that instead these alarms MAY 2015 | OR TODAY

IN THE OR CONTINUING EDUCATION 704

are contributing to patient harm. With more than 350 alarms ringing per patient in a 24-hour period, equating to thousands of alarms in a single critical care unit and tens of thousands alarms throughout the hospital in one day, there is little doubt that alarm fatigue is prevalent in busy hospital units throughout the United States.2,3 Many medical devices in hospitals have audible alarms and alerts. (Alarms indicate a clinical intervention may be necessary while alerts inform the user that an infusion is complete or the battery is low.) These devices include electronic blood pressure cuffs, pulse oximetry, telemetry, infusion pumps, mechanical ventilators, temperature probes and central station monitors. Over time, clinicians become accustomed to hearing the multitude of alarms and tend to become desensitized, which may lead to a lack of or a delay in response.2 This phenomenon has been termed “alarm fatigue.”2 Alarm fatigue is receiving national attention because of reports of sentinel events related to clinicians’ becoming desensitized by the high number of device alarms. Desensitization leads to delayed response times, and this practice can harm patients. Alarm fatigue has been associated with staff frustration, a delay in response to alarms and poor patient outcomes.2 In 2012, The Joint Commission (TJC) issued a sentinel event alert for 98 alarm-related incidents between January 2009 and June 2012.2,3 Of these reported incidents, death occurred in 80.2,3 Since reporting of most sentinel events to TJC is voluntary, the organization estimates these 98 alarm-related incidents 38

OR TODAY | MAY 2015

account for just about 10% of the actual cases in the United States.2 TJC is not the only organization concerned with this patient safety issue. ECRI Institute, the Association for the Advancement of Medical Instrumentation (AAMI) and the U.S. Food and Drug Administration have also voiced concerns. The FDA’s Manufacturer and User Facility Device Experience reported 566 alarm-related patient deaths between January 2005 and June 2010.4 Each year ECRI, a nonprofit organization that uses research to establish best practices for improving safe patient care, releases a top 10 list of technology safety hazards. Over the past few years, ECRI has named “alarm hazards” the No. 1 health technology safety hazard, and it continues to remain at the top of the list for 2014.5 This is not a new phenomenon. For many years, studies have reported problems with excessive alarms, leading to both a delay in response time and inappropriate disabling of alarms.4 Monitoring devices are an essential part of providing optimal patient care. These devices provide the data to drive treatment and guide clinical decision making. An alarm is intended to get the attention of clinicians and alert them to a change in patient status, a life-threatening event, a potential malfunction or an unsafe situation.6 An alarm may be classified as a crisis alarm, warning alarm, system failure or advisory alarm and depending on the severity levels may be associated with a specific noise or volume. For example, a crisis alarm may be louder and higher pitched than an advisory alarm or alert indicating a low battery on an

infusion pump. “Nuisance alarms” and “false alarms” are terms used to describe alarms that do not require an intervention. Nuisance alarms or alerts are not necessarily related to a patient condition but may indicate a low battery or a machine that needs to be plugged in. False alarms are related to a patient condition and would indicate a need for a response if they were real. Most false alarms are related to artifact, tight setting of parameters or a sensor that fell off. Unfortunately, with the many nuisance and false alarms daily, those high-priority alarms may elicit the same clinician response as a lowpriority alarm. The next time you are at work, listen carefully to the alarms in your unit and see if you can identify the sound that each machine is making. Attention must focus on how to minimize and optimally prevent alarm fatigue. Research has shown that most alarms have no clinical significance. Reports estimate as many as 85% to 99% of alarm signals are false or not clinically significant and, therefore, do not require any medical interventions.2 This means that as few as 1% of all alarms ringing daily actually require an intervention. THE ‘CRY WOLF SYNDROME’ Many factors contribute to alarm fatigue, including alarm limits that are set too tight, false or nuisance alarms, default settings that are not adjusted for an individual patient or patient population and electrodes that have lost conductivity or electrodes that are inappropriately placed.2 Over time, these false alarms reduce the credibility of the alarm and increase response time, leading WWW.ORTODAY.COM

CONTINUING EDUCATION 704

to a potentially catastrophic event. A majority of the reported events occurred in telemetry, critical care, general medicine and EDs.2 The main contributing factors in these areas include:2 • Absent or inadequate alarm systems • Improper alarm settings • Alarms signals not audible in the appropriate areas • Alarm signals inappropriately turned off TJC expects all its certified hospitals to address alarm safety and develop a plan to improve this patient safety issue. The 2014 TJC National Patient Safety Goal (NPSG) on alarm management is in a twophase rollout with Phase 1 having begun in January 2014 and Phase 2 beginning in January 2016.7 Phase 1 requires hospitals to make alarm management a priority, look at their alarm-related incidents and determine alarm management needs. Phase 1 involves gathering data and asking questions of the clinical staff. Discussions should include the alarms that are clinically necessary, the alarms that may be contributing to fatigue among clinicians and an assessment of the potential for patient harm.7 Questions to discuss include whether patients are at risk from erroneous alarms contributing to a delay in response times. This institutionwide approach is best done by creating an interprofessional taskforce representing major stakeholders, such as management, nursing and device manufacturers. During Phase 2, hospitals assess the data collected in Phase 1 and based on the institutions’ individual patient safety concerns develop and WWW.ORTODAY.COM

implement policies and procedures that address alarm management.7 These concerns may include the management of inappropriate settings based on the individual patient or patient populations.7 This may also require defining clinical situations in which it is appropriate to disable alarms and who is qualified to disable or adjust parameters.7 Policies should address recommendations for checking that accurate settings have been set and how and when to monitor the device alarms to ensure proper functioning.2,7 A key to the success of Phase 2 involves educating healthcare clinicians about the monitoring devices and alarms in their clinical arenas and setting expectations for the management of alarms for which they are responsible.7 A task force should be formed to carry out solutions to the issues that were collected in Phase 1. In addition to education and policy revision, solutions should include updating outdated or malfunctioning equipment.7 Roundtable discussions, such as the one held at the 2013 AAMI annual meeting, focus on what actions should be taken to minimize insignificant alarms and improve response time to the clinically significant alarms. The American Association of Critical-Care Nurses’ Practice Alert on Alarm Management was an essential resource during this roundtable discussion as AACN has offered strategies to approach alarm management. AACN emphasizes the need for staff education on ECG monitoring, customization of alarm parameters and a determination of who meets eligibility criteria for monitoring and

recommends these strategies be implemented through an interdisciplinary approach.8 TJC, AAMI, ECRI and AACN offer the following recommendations to minimize alarm fatigue: ECG MONITORING The epidermis is a poor conductor of electricity; therefore, the evidence supports performing a skin preparation before placing the ECG electrodes.8 Simple interventions that will enhance electrode conductivity include washing the area with soap and water to rid the skin of oils that may interfere with conductivity, roughening the epidermal surface by wiping with an abrasive surface (gauze or a dry washcloth) and cutting excess body hair.8,9 These interventions may take only a few seconds, but evidence suggests that by preparing the skin, artifact is reduced, equating to less time spent on managing false alarms.8 • Daily maintenance: Evidence also suggests that changing electrodes daily in addition to when they appear damaged or are no longer intact optimizes conductivity and enhances electrode contact with the skin.8 The outer layer of the epidermis, the stratum corneum, can regenerate within 24 hours, so best practice is to change and repeat skin preparation daily.8,9 • Get it right the first time: Proper placement of ECG electrodes is essential for an accurate signal. Placing electrodes on the fleshy parts of the arms and legs and avoiding bony areas or muscle groups minimize the artifact that commonly occurs during moveMAY 2015 | OR TODAY

IN THE OR CONTINUING EDUCATION 704

5 ELECTRODE SYSTEM COURTESY OF THE AUTHOR

LA = BLACK 2ND ICS

RA = WHITE 2ND ICS

LL = RED

RL = GREEN

CHEST = BROWN

40 OR TODAY | MAY 2015

ment.9 By pressing firmly around the outer area of the electrode during application, the gel center remains intact. This practice will reduce the pockets of air that can develop if the gel center is disrupted and could cause artifact.9 ALARM SETTINGS One quality-improvement project in a medical progressive care unit made slight adjustments in the alarm parameter settings so that when an alarm sounded, it was because action was required or the alarm was clinically significant.10 High heart rate alarms normally set at 120 were increased to 150 bpm and low heart rate parameters were lowered from 60 bpm to 50 bpm.10 Oxygen saturation percentage parameters were adjusted from a low SpO2 of 90% to 88%.10 Education was provided to the nursing staff. Nurses were taught to be proactive when setting alarm parameters instead of reacting to the alarms’ being triggered. Rationales for individualizing patient alarms were provided.10 These simple changes resulted in a 43% reduction in critical alarms over an 18-day period.10 After the interventions were put into place, the number of critical alarms was 9,647, significantly less than the 16,953 alarms preintervention.10 The low oxygen saturation alarm sounded 1,685 times before the inventions, and 623 afterward.10 Recommendations from this qualityimprovement project included:10 • Staff should be trained to appropriately set alarm parameters based on their patients’ needs. • Duplicate alarms should be avoided, such as setting both a WWW.ORTODAY.COM

CONTINUING EDUCATION 704

high heart rate and a tachycardia alarm. • Alarm parameters should be set to limits that require a clinical intervention. To each his own: Each patient is unique with specific medical needs depending on a variety of factors, including diagnosis, medical history and plan of care. Default parameters may not be appropriate for each patient and, in fact, may vary greatly from one patient to the next. Alarms need to be customized to meet the individual needs of the patient. AACN recommends customizing the alarms within the first hour of taking care of a patient and then individualizing these alarms as needed and when changes occur.8 Tailoring alarm parameters to the individual patient or to the specific patient population will minimize alarms. Turn it down … or up: Alarm noises must be audible, and monitors should be seen throughout the patient care areas.8 Alarms must be heard over the other noises on the hospital unit, and monitor screens must be accessible to staff when staff are away from the patient’s room. This encompasses all high-alert alarms, including the mechanical ventilator and fall-risk alarms. PULSE OXIMETRY Studies have demonstrated that most alarms are related to pulse oximetry (Sp02) monitoring.8 SpO2 sensors are typically placed on the fingertips, so patients who are moving can create artifact and noise. Using adhesive sensors will minimize some of this artifact; they are considered more WWW.ORTODAY.COM

accurate in patients with decreased perfusion or who are moving.8 AACN recommends using disposable adhesive sensors and replacing them as needed.8 Turning the high SpO2 alarm off is clinically indicated in most patients as an oxygen saturation of 100% does not require an intervention. Customizing the delay and threshold settings to the patient can significantly reduce erroneous alarms.8 This may require communicating with biomedical engineering to help make these changes. A PLAN FOR ACTION Implementing interventions to reduce alarm fatigue requires proper education about the monitors. Training should include the organization’s own policies and procedures for managing alarms and should be performed with all new staff and then on a regular basis.2 AACN recommends educating nurses on the importance of suspending alarms before performing care, such as drawing labs from an arterial line, suctioning, performing chest physiotherapy or turning a patient.8 Patients may trigger an irregular heart rate alarm just by moving around in bed. Movements such as scratching an electrode can trigger a ventricular tachycardia alarm. Therefore, education is necessary to teach nurses how to differentiate true alarms from false alarms. One retrospective study reviewed data stored in the central monitor data base to analyze what factors contributed to the high number of false and nuisance alarms. The pulse oximetry alarm appeared to be a main offender. Reducing the low

SpO2 alarm from 90% to 88% and instituting a 15-second alarm delay led to a decrease in the number of low SpO2 alarms by more than 80%.11 REALLY? IS IT NECESSARY? Patients for whom monitoring is indicated should be monitored. If no clinical indication exists for monitoring, monitoring is unnecessary and would only contribute to the number of alarm noises.8 For example, a patient with bradycardia at baseline should not have the low heart rate alarm limit set to 60 beats per minute if the baseline heart rate is usually less than 60 bpm. If the patient has an irregular heart rate due to atrial fibrillation, neither the irregular heart rate nor the atrial fibrillation alarm should be enabled as it will not require any clinical intervention. If the patient is having frequent premature ventricular contractions at baseline, increasing the number of PVCs per minute will be an effective alarm reducer. Monitor only what needs monitoring and don’t turn off alarms that are clinically necessary. Patient safety is the priority. THE P&PS Policies and procedures should be developed to address alarm management, establish guidelines for alarm settings and offer suggestions for how to tailor alarms to individual patient needs.2 In addition, an institution’s expectations for performing maintenance on device monitors should be addressed.2,8 Policies should include:2 • Proper skin preparation before electrode placement • Proper placement of electrodes MAY 2015 | OR TODAY

IN THE OR CONTINUING EDUCATION 704

• Recommendations for changing electrodes • Individualization of patient alarms each shift • Assessment of alarm audibility • Proper documentation of alarm settings • Maintenance of the device monitors The American Heart Association (AHA) 2004 Practice Standards for ECG Monitoring in Hospital Settings offers indications, clinical situations and time frames for when ECG monitoring is necessary and outlines best practices for hospital-based ECG monitoring.12 Recommendations include strategies to improve diagnostic accuracy when monitoring for cardiac dysrhythmia, ischemia and QT intervals.12 Hospitals should use these practice standards when developing policies and procedures on alarm management. BACK TO THE EVIDENCE High-quality control trials continue to be needed on alarm fatigue. At this time, randomized control trials and meta-analysis are lacking. The recommendations available are based mostly on expert opinion; qualityimprovement initiatives; recommendations for best practice from safety organizations, such as TJC, ECRI and AAMI; and a few small-scale observational studies in critical care areas and progressive care units. Although there is a lack of quality data to support the recommended interventions, the literature does support the need to have recommendations in place and to further evaluate practice and standards for care. The Healthcare Technology Foundation (HTF) conducted a 42

OR TODAY | MAY 2015

national survey on clinical alarm issues, first in 2005 and then in 2011, to discover changes in perceptions and reassess the problem after improvements were made. There was little difference between survey results from 2011 and 2005. In 2005, 95% of respondents agreed that alarm sounds and visual displays should differentiate the priority of an alarm while in 2011 96% agreed.13 In both surveys, 78% of respondents felt that nuisance alarms reduce trust in alarms and cause caregivers to inappropriately turn alarms off.13 A high percentage reported that nuisance alarms disrupt patient care.13 Twenty percent of respondents reported adverse events related to alarm issues.13 (These events may or may not have been reported to the FDA, which stresses the importance of alarm management reform.13) One recommendation from the study focused on the need for improved central alarm management, with many hospitals reporting they have designated monitor watchers.13 The HTF recommends hospitals consider using monitor watchers for managing alarm fatigue.13 The HTF surveys have many recommendations for alarm management. One implication from the studies revealed the need to use a systems approach: opening lines of communication and developing solutions related to alarm management issues.13 Other strategies focus on the need for placing a high priority on ways to reduce nuisance alarms so desensitization to the noise will be minimized, improving response times to alarms and

correcting the practice of ignoring or inappropriately disabling alarms.13 The Practical Use of the Latest Standards for Electrocardiography (PULSE) Trial is a five-year multisite randomized clinical trial under way to evaluate nurses’ knowledge about ECG monitoring and the effect of implementing AHA Practice Standards for ECG Monitoring.14 The focus is to improve the training of nurses who work with ECG monitoring and improve quality of care and patient outcomes when detecting and diagnosing dysrhythmias, ischemia and QT analysis.14 The first phase of the PULSE Trial assessed patients in cardiac units at 17 hospitals with 4,678 patients enrolled. Of those enrolled, only 295 patients were not on ECG monitors, and 26% of the patients being monitored lacked any indication to support the need for ECG monitoring.14 The preliminary data gathered indicated there was a lack of knowledge among nurses and demonstrated a need for further education on ECG monitoring, specifically ischemia monitoring.14 Of patients with an indication for ischemia monitoring, only 35% were being monitored.14 The PULSE Trial also will assess the benefits of using an online ECG monitoring education program.14 Continued research and the use of evidence-based practices to develop standards of care are main priorities in finding solutions to this crucial problem. Individual organizations need to reflect on their own issues and develop practical solutions to deal with their needs. Alarm fatigue is receiving national attention. This multifactorial WWW.ORTODAY.COM

CONTINUING EDUCATION 704

problem with numerous dimensions has a huge impact on patient safety and patient outcomes. Nurses are the key to suggesting strategies, conducting trials of interventions and discovering solutions to the problem, all to help reduce the negative consequences associated with alarm fatigue and provide safe, quality patient care. ANNA VER HAGE, RN, MSN, CCRN, CNRN, has authored numerous articles along with coauthoring national guidelines on the care of neuroscience patients. She is an RN case manager and a clinical nurse in the neurosurgical critical care unit at University of Colorado Hospital in Aurora. REFERENCES 1. Kowalczyk L. Alarm fatigue: a factor in 2d death. Boston.com Web site. (http://www.boston.com/lifestyle/ health/articles/2011/09/21/umass_hospital_has_second_death_involving_alarm_fatigue/?page=2)1) http:// www.boston.com/lifestyle/health/ articles/2011/09/21/umass_hospital_ has_second_death_involving_alarm_fatigue/. Published September 21, 2011. Accessed January 8, 2015. 2. Medical device alarm safety in hospitals. Joint Commission Web site. http:// www.jointcommission.org/assets/1/18/ sea_50_alarms_4_5_13_final1.pdf. Published April 8, 2013. Accessed January 8, 2014. 3. Mitka M. Joint Commission warns of alarm fatigue: multitude of alarms from monitoring fevices problematic. JAMA. 2013;309(22):2315-2316.

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4. Cvach M. Monitor alarm fatigue: an

alarm fatigue. Biomedical Instrumen-

integrative review. Biomed Instrum

tation & Technology Web site. http://

Technol. July/August 2012; 268-277.

www.visimobile.com/wp-content/

5. ECRI Institute releases top 10 health

uploads/2013/02/Horizons_Alarms-

technology hazards report for 2014.

Article_Welch_Spring-2011.pdf.

ECRI Web site. https://www.ecri.org/

12. Drew BJ, Califf RM, Funk M, et al.

Press/Pages/2014_Top_Ten_Hazards.

American Heart Associationâ&#x20AC;&#x2122;s practice

aspx. Published November 4, 2013. Ac-

standards for ECG monitoring in hos-

cessed January 8, 2014.

pital settings: executive summary and

6. Imhoff M, Kuhls S. Alarm algorithms

guide for implementation. Circulation.

in critical care monitoring. Anesth

2004; 110(17):2721-2746.

Analg. 2006;102(5):1525-1537.

13. 2011 national clinical alarms survey:

7. Prepublication requirements: national

perceptions, issues, improvements

patient safety goal on alarm manage-

and priorities of healthcare profes-

ment. Joint Commission Website.

sionals. Association for the Advance-

http://www.jointcommission.org/

ment of Medical Instrumentation Web

assets/1/18/PREPUB-06-25-2013-

site. http://www.aami.org/hottopics/

NPSG060101.pdf. Published June 25,

alarms/2011_HTFAlarmsSurveyAAMIS-

2013. Accessed January 8, 2014.

ummit.pdf. Accessed January 9, 2014.

8. Alarm management. AACN website.

14. Funk M, Winkler CG, May JL, et

http://www.aacn.org/wd/practice/con-

al. Unnecessary arrhythmia monitor-

tent/practicealerts/alarm-management-

ing and underutilization of ischemia

practice-alert.pcms. Accessed January

and QT interval monitoring in current

8, 2014.

clinical practice: baseline results of the

9. Koninklijke Philips Electronic. Improv-

practical use of the latest standards for

ing ECG quality. http://incenter.medical.

electrocardiography trial. J Electrocar-

philips.com/doclib/enc/feth/2000/4

diol. 2010; 43(6):542-547.doi:10.1016/j.

504/577242/577243/577245/577817/

jelectrocard.2010.07.018.

577869/Improving_ECG_Quality_Application_Note_(ENG).pdf%3fnodeid% 3d1557273%26vernum%3d3. Published September 2008. Accessed November 17, 2013. 10. Graham KC, Cvach M. Monitor alarm fatigue, standardizing use of physiological monitors and decreasing nuisance alarms. Am J Crit Care. 2010;19(1):2834. 11. Welch J. An evidence-based approach to reduce nuisance alarms and MAY 2015 | OR TODAY

IN THE OR CONTINUING EDUCATION 476D

CLINICAL VIGNETTE Mr. Smith arrives to the ED after falling down and hitting his head. He is confused and refusing to stay. He keeps pulling off his ECG leads and pulse oximetry sensor. The alarms keep ringing, causing the nurse to leave her other patients to go answer his alarms. After rehooking the patient up to the monitor numerous times, the nurse becomes frustrated and simply turns the alarms off, thinking she will go back and check on him periodically. The nurse soon becomes busy with another patient, and when she finally has a moment to go back and check on Mr. Smith, he is unresponsive, and she calls a code. He cannot be resuscitated and dies a few hours later.

What does this situation demonstrate? A. Alarm fatigue B. Alarm management C. Alarm malpractice D. Alarm weariness

What organization issues sentinel event alerts concerning incidents such as this? A. AACN B. PULSE C. HTF D. TJC

What should the nurse have done instead of turning off the alarms? A. Intubate and sedate the patient B. Have the charge nurse check in on the patient every hour C. Use redirection techniques to divert the patient’s attention D. Nothing. Turning off the alarms was an appropriate intervention.

This patient’s health was compromised and he ultimately died because of: A. Inappropriate management of the alarm system B. A monitor malfunction C. Improperly placed ECG electrodes D. Delayed response time by the nurse to the alarms

4. Correct answer: A — This patient was compromised because of inappropriate management by the nurse of the clinical alarms. The monitor did not malfunction, nor were the electrodes improperly placed. There was not a delay in response to the alarms as the alarms were turned off. Recommendations and alarm management strategies to prevent sentinel events such as this one include staff education on alarm management and implementation of policies and procedures and best practice guidelines. 3. Correct answer: C — Using redirection techniques may help divert the patient’s attention from the monitoring devices and help the patient to focus on something else. These patients may require a sitter or behavioral restraints. Patient safety is the priority. 2. Correct answer: D — In 2012, The Joint Commission (TJC) issued a sentinel event alert for 98 alarm-related incidents between January 2009 and June 2012. Of these reported incidents, death occurred in 80. 1. Correct answer: A — Alarm fatigue is a phenomenon that occurs when clinicians become desensitized by the vast number of alarms, which can lead to a slower response time or turning the alarms off. 44 OR TODAY | MAY 2015

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CONTINUING EDUCATION 476D

HOW TO EARN CONTINUING EDUCATION CREDIT 1. 2.

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DEADLINE Courses must be completed by 2/10/2016. 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.

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CORPORATE PROFILE

CINCINNATI SUB-ZERO

Please share a little bit about your company’s history and how you achieve success.

Cincinnati Sub-Zero (CSZ), a leading provider of temperature management equipment for over 70 years, serves medical and industrial industries with high quality temperature management products and services worldwide. Although our products are specific to each of our three divisions, Medical, Industrial and Testing, each division leverages and builds upon the successes of the others. The Medical Division designs products with both the caregiver and patient in mind. Products are designed for patient comfort and ease of use with innovation and one of a kind products used to manage patient body temperature in the operating room, recovery room, intensive care units, and other areas of hospitals throughout the world. CSZ has delivered patient temperature management

OR TODAY | MAY 2015

systems to healthcare professionals since 1963. Our complete line of hyper-hypothermia products include therapeutic heat therapy and cold therapy units along with a complete line of warming blankets and cooling blankets for body temperature regulation and hyper-hypothermia treatment. Cincinnati Sub-Zero understands the pressure faced by healthcare professionals today to reduce costs without sacrificing patient safety, comfort, and quality of care. CSZ provides solutions to help meet your needs with a full line of temperature management products.

What are some advantages that your company has over the competition?

At Cincinnati Sub-Zero we put the needs of people first. All of our products are built at our Cincinnati, Ohio facility. You’ll notice the difference in every aspect of our work, from the quality of each product straight through to the variety of products and services that we offer. You’ll be at an advantage when you work with CSZ. We are proud of the quality, design and engineering of each of our products. When you work with Cincinnati Sub-Zero you can

be assured that you will get exactly what you need to deliver top-rate care. We are positively known throughout the healthcare community and our certifications show our commitment to topquality total patient temperature management.

What product or service that your company offers are you most excited about right now?

Right now we are focused on promoting our Hyperthermia system called the Norm-O-Temp along with our Gelli-Roll blanket. The revolutionary and simpleto-use Gelli-Roll® combines patient temperature management and comfort. It can be used for patient warming or cooling (with the Blanketrol), before, during and after surgery. It is a reusable water blanket encapsulated in Akton® polymer. The Norm-O-Temp® is a whole body hyperthermia system that allows conductive warming therapy to be administered. It can be used in the operating room, pre-op, recovery, emergency department or any department in need of patient warming therapy. Here is what one user has to say about the Norm-O-Temp and Gelli-Roll system.

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“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.”— Charles E. Smith M.D., MetroHealth Medical Center, ASA Poster, November 2009.

What is on the horizon for your company? How will it evolve in the coming years?

Cincinnati Sub-Zero is a leader in Temperature Management and we are always looking toward the future. We believe it is vital to our business to listen to the wants and needs of our customers. The feedback our customers provide helps us to improve our product designs and continuous improvement efforts. We will continue to introduce cutting edge temperature management products to improve patient outcomes.

Please share some company success stories with our readers — one time that you “saved the day” for a customer.

Cincinnati Sub-Zero is very proud of its products and the lives that can be WWW.ORTODAY.COM

saved when using them. Two stories that can be found on our website (www.cszmedical.com) are about 2 little girls whose lives were saved with our products. Mia Ordway and Avery Fitzgerald were both born with HIE (Hypoxic Ischemic Encephalopathy). Both babies were treated with induced hypothermia and cooled with our Blanketrol III. The treatment was able to help them heal and give them a normal life. Both are healthy toddlers now. Another story about a life that has been saved with our products is about soccer player, Fabrice Muamba who suffered an on-field cardiac arrest. The 23-year-old midfielder’s heart stopped for 78 minutes follow-

ing his collapse and he was rushed to London Chest Hospital for induced hypothermia treatment. Cincinnati Sub-Zero’s products were used to treat Fabrice, he has been blessed with a positive outcome.

What is your company’s mission statement, or if you don’t have a specific one, what is most important to you about the way you do business?

Cincinnati Sub-Zero’s Mission: Our mission is to deliver worldclass temperature management solutions to our customers right the first time.

MAY 2015 | OR TODAY

Z’s WarmAi S C h t i w e r Sy e r F stem Be Stress Recent studies have proven that warming patients before, during and after surgery and other specialty procedures can markedly improve clinical outcomes.1 With CSZ’s WarmAir® warming system and FilteredFlo® blankets, all air is filtered twice before being distributed to the air blanket.

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Competitor blankets can create air currents. Phone: 513-772-8810 Toll-Free: 800-989-7373 Fax: 513-772-9119 www.cszmedical.com

1. Sessler DI, Kurz A, Lenhardt R. “Perioperative Normothermia to Reduce the Incidence of Surgical Wound Infection and Shorten Hospitalization.” NE Journal of Medicine.1996; 334 (19): 1209-1215.

h with our Filt t m r a W e e h r t 速 e d l F e l o e And F FilteredFlo速 Blankets: Provide therapy before, during and after surgery Offer uniform warm air distribution Built in flaps tuck around the patient providing superior therapy & eliminating the need for additional cover sheets or blankets Easy to manage and will not fly away Can be folded back for easy access to your patient

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“ “Ultimately, Meticulous OR leadership adherence is to the responsible for manufacturer’s making sure for instructions that endoscopes cleaning and used in the OR reprocessing is are safe” essential.” — Nancy Chobin

…

INDUSTRY FOCUSES

ON ENDOSCOPE REPROCESSING …

BY DON SADLER

… EDUCATION, TRAINING VITAL FOR INFECTION PREVENTION …

he proper cleaning and reprocessing of endoscopes and other semi-critical reusable medical equipment (RME) has taken on added urgency after recent news reports that contaminated endoscopes may have led to the spread of deadly infections within health care facilities.

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For example, it is suspected that a superbug outbreak that killed two hospital patients in Los Angeles earlier this year was spread by two contaminated endoscopic retrograde cholangiopancreatography (ERCP) duodenoscopes. In addition, infections of antibiotic resistant bacteria like carbapenem-resistant Enterobacteriaceae (CRE) have also been reported at some hospitals, and some of these infections have been linked to ERCP duodenoscopes. “As we’ve unfortunately seen by recent news reports, patients can be at risk of serious infections if these tools are not properly disinfected,” says Tejal Gandhi, MD, MPH, CPPS, the president and CEO of the National Patient Safety Foundation.

MAY 2015 | OR TODAY

…

INDUSTRY FOCUSES

ON ENDOSCOPE REPROCESSING …

“ As we’ve unfortunately seen by recent news reports, patients can be at risk of serious infections if these tools are not properly disinfected.” — Tejal Gandhi, MD, MPH, CPPS

FDA ADVISORY WARNING According to the Food and Drug Administration (FDA), ERCP endoscopes are used on more than half-a-million patients each year to diagnose and treat pancreatic and bile-duct problems. While the FDA has issued an advisory warning to doctors about carefully following manufacturers’ reprocessing instructions, it notes that germs could still linger on endoscopes even if these instructions are followed correctly. “Meticulously cleaning duodenoscopes prior to high-level disinfection should reduce the risk of transmitting infection, but may not entirely eliminate it,” the agency stated in an FDA Safety Communication in February. However, the FDA does not favor pulling ERCP duodenoscopes from the market, as this would deprive hundreds of thousands of patients of what it calls a “beneficial and often life-saving procedure.” The FDA acknowledges that the ERCP duodenoscope’s complex design and tiny parts 54

OR TODAY | MAY 2015

make complete disinfection extremely difficult. “You can very easily do everything right and still have some contamination,” said Dr. Deverick Anderson, an infectious-disease expert at Duke University, in an article published by the New York Daily News in February. However, none of this means that properly cleaning and reprocessing endoscopes is impossible, says Nancy Chobin, RN, CSPM, vice president, Sterile Processing Services at Barnabas Health System in West Orange, N.J. Chobin is the co-chair of the Association of Advancement for Medical Instrumentation’s (AAMI) committee that is drafting the Flexible and Semi Rigid Endoscope Processing in Healthcare Facilities document that will provide a national standard for endoscope cleaning and reprocessing. “Today’s endoscopes aren’t like the basic medical and surgical instruments that were used 30 years ago,” Chobin says. “They are extremely intricate

and sophisticated and require special cleaning protocols. For example, there are more than 100 steps involved in cleaning an ERCP duodenoscope.” ADEQUATE TRAINING IS CRUCIAL Chobin believes that one of the biggest problems when it comes to proper cleaning and reprocessing of endoscopes is a lack of adequate training. “Only employees who are dedicated to endoscope cleaning and reprocessing and have received the right kind of training should handle this responsibility,” she says. “You can’t just assign this task to anyone.” Another problem, Chobin believes, is failure to follow cleaning and reprocessing policies and procedures. “I walk into facilities all the time that have policies and procedures that aren’t being followed,” she says. “Someone needs to monitor the cleaning process to ensure compliance — missing just one step can be disastrous.” WWW.ORTODAY.COM

“Ultimately, OR leadership is responsible for making sure that endoscopes used in the OR are safe,” Chobin adds. Teresa Wells, director, National Program Office Sterile Processing, Nursing and Patient Care for the U.S. Department of Veteran’s Affairs, emphasizes the importance of following the endoscope manufacturer’s instructions for use to the letter. “This must be done with precise detail, making sure to adhere to every step the instructions require,” she says. “Meticulous adherence to the manufacturer’s instructions for cleaning and reprocessing is essential,” adds Ramona Conner, MSN, RN, CNOR, editor-in-chief, Guidelines for Perioperative Practice, for the Association of periOperative Registered Nurses (AORN). She also stresses the importance of adhering to current nationally recognized guidelines such as the AORN Guideline for Cleaning of Flexible Endoscopes. Conner adds that the Centers for Disease Control and Prevention has recently issued an Interim Protocol for Healthcare Facilities Regarding Surveillance for Bacterial Contamination of Duodenoscopes after Reprocessing. “All health care facilities should review this protocol and determine the appropriate action for their organization to take,” she says. In a statement, the manufacturer of the ERCP duodenoscope said it emphasizes the importance of meticulous manual sterilization of its instruments, and that it is now WWW.ORTODAY.COM

giving new supplemental instructions to users of the ERCP duodenoscope. VISUAL INSPECTION … AND BEYOND According to Conner, OR nurses should visually inspect the end of the endoscope — especially the elevator mechanism, if it has one, to make sure it is clean and free of all debris.

“Although visual inspection before use is a good idea, bacterial and other contamination on endoscopes often cannot be detected visually. Additional methods of surveillance are necessary, such as process monitoring, culturing and testing for retained organic material — for example, adenosine triphosphate (ATP) bioluminescence assays.” — Ramona Conner, MSN, RN, CNOR

“When the endoscope has an elevator channel, it should be visually inspected, preferably under magnification, with the elevator in the ‘open/raised’ position and the ‘closed/ lowered’ position to ensure there is no visible debris above or below the elevator mechanism,” says Conner.

However, all of the experts stress that visually inspecting endoscopes is an inadequate method of making sure they are clean and safe. “Although visual inspection before use is a good idea, bacterial and other contamination on endoscopes often cannot be detected visually,” says MAY 2015 | OR TODAY

…

INDUSTRY FOCUSES

ON ENDOSCOPE REPROCESSING …

“Today’s endoscopes aren’t like the basic medical and surgical instruments that were used 30 years ago,” Chobin says. “They are extremely intricate and sophisticated and require special cleaning protocols. For example, there are more than 100 steps involved in cleaning an ERCP duodenoscope.” — Nancy Chobin, RN, CSPM

Conner. “Additional methods of surveillance are necessary, such as process monitoring, culturing and testing for retained organic material — for example, adenosine triphosphate (ATP) bioluminescence assays.” “There can be bioburden inside the endoscope that you can’t see — that’s where the biggest vulnerability is,” says Chobin. Wells agrees. “You can’t see bacteria and other byproducts that could contaminate the endoscope,” she says. The experts are also unanimous in terms of what OR nurses should do if they suspect that an endoscope has not been properly cleaned before a procedure begins. “If there is any doubt that the device may not be clean, it should not be used — period,” says Conner. “In any instance where an unsafe practice is about to 56

OR TODAY | MAY 2015

occur, it is imperative that OR staff speak up on behalf of the patient’s safety,” says Gandhi. “The leadership of the organization must foster a culture where staff members are encouraged and expected to speak up.” “If you have even the slightest inkling that an endoscope may not be clean enough for use, then you should send it back to be cleaned and reprocessed again,” adds Wells. “The rule should be: When in doubt, send it back.” This points to the importance of a good relationship between the OR and the sterile processing department. “The OR and sterile processing should be a collaborative unit and feel free to talk to each other about how endoscopes have been cleaned and reprocessed,” says Wells. “OR leaders should feel free to inquire about what quality measures are in

place during reprocessing to ensure patient safety.” ONE IS ONE TOO MANY Chobin strongly believes that one patient infection due to an improperly cleaned endoscope is one too many. However, she notes that of the half-a-million procedures performed last year using the ERCP duodenoscope, there were only about 130 infections. “If these endoscopes were impossible to clean like some are suggesting, we would have much higher infection rates than this,” she says. “The bottom line is that no patient should ever undergo a procedure that uses an endoscope that hasn’t been properly cleaned and reprocessed,” says Chobin. “This is the patient’s expectation, and it’s a realistic one.”

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MAY 2015 | OR TODAY

NURSING LAW

OR TODAY | MAY 2015

“

I was always interested in helping professions. [I was] thinking of law, police work; somehow I fell into nursing and it ended up being the perfect fit for me.” — Beth Cohen

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SPOTLIGHT ON: BETH COHEN

Matthew N. Skoufalos

DESIRE

TO HELP OTHERS

LEADS TO SUCCESSFUL CAREER

ooking back on it, Beth Cohen remembers that she entered the field of nursing “kind of by accident.”

Having already been accepted to law school, Cohen started to have second thoughts, which were only amplified as her grandparents on both sides of the family started to fall ill, one after another. As she became more involved with their care, she met a nurse who told her, “You can do this.” “I was always interested in helping professions,” Cohen said, “[I was] thinking of law, police work; somehow I fell into nursing and it ended up being the perfect fit for me.” Today, Cohen is an adult registered nurse practitioner and clinical specialist at Broward Health North in Pompano Beach, Florida. After working in multiple areas of the hospital, she’s realized that being a bedside generalist “and seeing more of everything” has fulfilled her love of helping patients and people. “There’s always something new coming down the pike,” Cohen said. “I get called in when they need education on something; when there’s a particularly difficult case.”

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MAY 2015 | OR TODAY

ork with r family w Effort) e h d n a n ue Beth Cohe lp and Resc epherd He . a id r lo SHARE(Sh in South F

Beth Cohen visits with a very sick dog that SHARE rescued showing “Sassy” that not all people will hurt her.

Cohen also assists with clinical education in the Broward Health virtual hospital, a realistic human patient simulator that runs a variety of life-threatening health scenarios in a classroom setting. She describes it as an effective teaching tool that

system with giving her ample opportunity to change her circumstances as well. “[When] I felt that way, I applied for a different position in a different area of the hospital,” she said. “If you’re feeling crispy or burnt out and

willing to work as a team. You also have to be able to fly on your own.” At least part of the reason Cohen has maintained her path in clinical education and professional training is because the severity of patient need has escalated across the

“If you’re feeling crispy or burnt out and you allow that to continue, that’s your fault. You can go back to school and take classes and become certified. You can apply for positions in different areas of the hospital and learn new things. There’s really not a good reason to say that you’re in a rut unless you choose to be in one.”

helps build clinical skills and practice critical thinking. “We can do everything from have [the virtual patient] stop breathing to have a heart attack to have the nurses practice how to handle that,” she said. Education and one-on-one engagement are the elements of her day-today experience that allow Cohen to remain fresh and interested in her career. She speaks of how the professional burnout that often dogs nurses in the field is something to which she hasn’t been immune, either, but that by switching up assignments, she’s been able to overcome it. Cohen credits the multi-facility Broward Health 60

OR TODAY | MAY 2015

you allow that to continue, that’s your fault. You can go back to school and take classes and become certified. You can apply for positions in different areas of the hospital and learn new things. There’s really not a good reason to say that you’re in a rut unless you choose to be in one.” The necessity of enthusiasm is an attitude that Cohen said has kept her focused on the outcomes of her work; she describes it as being couched in an ability to view her work as part of “a career, not a job. “It’s not a nine-to-five thing and you wash your hands and you’re done,” she said. “You need to maintain your skills. You need to be

board in hospitalization settings, she said. “You need to actually critically think [because] you have to realize that you have people’s lives in your hands,” Cohen said. “Now when you’re hospitalized, you are very sick, and the skill level of the nurse really needs to be built up and stay up. If you’re not willing to take on those responsibilities, it’s probably not the position for you.” Just as Cohen entered the nursing profession “accidentally,” she’s also built up a depth of volunteer work with SHARE (Shepherd Help And Rescue Effort), a South Florida German WWW.ORTODAY.COM

SHARE volunteers pose for a group photo at the Parkland Farmers Market.

Shepherd rescue, in much the same way. “All the best things in my life have been accidental,” she laughed. “My daughter needed a bat mitzvah product; my husband and my daughter volunteered. Now my whole family is involved. It’s one of the few volunteer organizations that I’m aware of that actually gives every single dime to the charity itself.” Just like her work in the nursing field, Cohen dove into the effort headfirst, and brought her family with her. Today her husband and nephew maintain the SHARE website, and she brings SHARE adoptable pets to the Parkland Farmers Market. Of course, she also adopted a shepherd as well, a two-year-old named Abby, whom Cohen describes as a “failed foster” because the family ended up keeping her. WWW.ORTODAY.COM

“When we first met her, she was 10 months old [and] from a kill shelter in Miami-Dade,” Cohen said. “At 10 months old, she had been abused. She only weighed 30 pounds. You could see every bone in her body. She already needed hip surgery; SHARE raised the money and paid for the hip surgery.” “We felt so bad [that] we kept visiting her at the vet,” Cohen said, so they brought Abby home to live with their dogs during her rehabilitation — and she stuck. Abby “did beautifully after surgery,” Cohen said, gained necessary weight to fill out, and is a weekly “example dog” of the work that SHARE does at the Parkland market. “My family’s always loved animals,” Cohen said; “we’re all animalcrazy. The stories [of SHARE rescue animals] are just so awful, animals that have been starved … put in

SHARE volunteer s wear T-shirts encouraging people to ad opt one of their animals.

plastic bags in the garbage and were found because they were making noise.” “I work in a caring profession and I love it,” she said. “I love restoring health to people and easing their pain and helping them be more comfortable. [Volunteering with SHARE] is an extension of that, and a chance to use my brain and connect with the general public and let them hear our story.” MAY 2015 | OR TODAY

OR TODAY | MAY 2015

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MAY 2015 | OR TODAY

OUT OF THE OR HEALTH

BY KAREN COLLINS, M.S., R.D.N., C.D.N., F.A.N.D.,

EXPERTS SHARE THE LATEST DIET STRATEGIES FOR HEART HEALTH

fter three-and-a-half days of presentations on nutrition research at the recent American Heart Association (AHA) conference, here’s the takeaway on today’s big questions on heart health: SATURATED AND TRANS FATS These are still targets. Despite questions raised by headlines, limiting saturated fat remains important for heart health, according to Robert Eckel, M.D., director of the Lipid Clinic at University of Colorado Hospital. The average American needs to cut saturated fat in half to meet the new American Heart Association recommendation of no more than 5 to 6 percent of calories daily, which would reduce LDL (“bad”) cholesterol by up to 11 mg/dL. If you eat about 2,000 calories a day, that’s 11 to 13 grams (g) of saturated fat a day. A regular fast food cheeseburger has 5-12 g of saturated fat, for example. While this goal may be challenging for some, fortunately, it’s not

OR TODAY | MAY 2015

all-or-nothing: Any drop in saturated fat reduces risk. Trans fat, from partially hydrogenated oils in many processed snack and convenience foods, poses the greatest heart risk. Amounts are dropping, but it still warrants checking nutrition labels to avoid trans fat as much as possible. Evidence no longer supports foods’ cholesterol content as an important influence on blood cholesterol or heart risk, except possibly for people with diabetes or extremely high LDL levels. The biggest implication is that you may not need to limit eggs as much as advised in years past, although unlimited use won’t fit with tight recommendations on saturated fat, either. How to replace saturated fat? What do you include in your diet in exchange for saturated fat? Here are multiple strategies:

POLYUNSATURATED FAT (found in nuts, seeds, and canola, soybean and other vegetable oils) brings the biggest drop in LDL cholesterol.

Action examples: Replace cheese in a salad with almonds or walnuts. Switch one meal a week from red meat to fish; you’ll get more of both omega-6 and the especially hearthealthy omega-3 fats.

MONOUNSATURATED FAT (found in olives, olive oil, avocado, and peanuts) brings a smaller, but still strong, decrease in LDL. Action example: Replace sour cream with sliced or mashed avocado.

PROTEIN CONSUMPTION is another way to reduce saturated fat – if added primarily from plant sources, with smaller increases in egg whites and fish. Action example: Modify your usual casseroles, pasta dishes and stews, replacing all or some of the meat with tofu, lentils or beans.

CARBOHYDRATE as a replacement for saturated fat doesn’t lower LDL quite as much as the options above, but WWW.ORTODAY.COM

HEALTH

choices high in fiber and nutrients can bring multiple benefits. Highcarb foods protect heart health when they supply dietary fiber and healthprotective phytochemicals and nutrients. Action example: Have fruit with breakfast instead of bacon. Eat nutrient- and fiber-rich fruit instead of cookies, sweet rolls, donuts and ice cream (desserts are one of the top contributors to saturated fat in the average American diet). Let whole grains and vegetables star in mixed dishes. TOTAL NUTRITIONAL QUALITY MATTERS MOST Effects on heart health seem most closely tied to the total nutritional quality of the diet, rather than a focus on individual nutrients, such as total fat or carbohydrate intake. The Mediterranean diet’s focus on plant foods, nuts, olive oils and vegetable consumption is a common thread tied to a lower risk of cardiovascular disease. In contrast, the long-term use of low-carbohydrate, high-protein diets can threaten heart health, emphasized Linda Van Horn, Ph.D., R.D., a cardiovascular nutrition expert from Northwestern University in Chicago. WEIGHT AND WAIST Excess body fat, mainly around the waist, triggers inflammation and insulin resistance, posing serious heart disease risk. Whatever your weight, make smart food swaps and add physical activity into your everyday life to prevent unwanted weight gain. Contrary to popular opinion, after six months, neither low-fat nor WWW.ORTODAY.COM

low-carbohydrate diets show any better weight loss or reduction in the visceral fat deep in the abdomen that poses most risk, says Frank Sacks, M.D., professor of cardiovascular disease prevention at Harvard School of Public Health. Most important is creating new habits for the longterm. According to guidelines from the AHA in collaboration with other organizations, health risks decrease with a 3 to 5 percent weight loss – 10 to 20 pounds or less for most people. A lifestyle approach to losing and maintaining weight that provides support – such as counseling and support groups – for at least six

months is important; short-term efforts don’t bring long-term results, emphasizes Sacks. A CULTURE OF HEALTH Major studies show that people who eat a healthy diet, don’t smoke, get regular physical activity throughout the week, and maintain a healthy weight and waist size prevent about 80 percent of heart attacks and 93 percent of type 2 diabetes, as well as substantially reducing their risk of stroke and cancer.

Reprinted with permission from Environmental Nutrition

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OUT OF THE OR FITNESS

BY HOWARD LEWINE, M.D.

SITTING TOO MUCH? GRADUALLY BOOST YOUR ACTIVITY LEVEL EACH DAY

I sit at a desk all day at work. My doctor tells me I need to exercise for 30 minutes at least five times per week. I don’t exercise at all now. That seems an impossible goal for me. Any suggestions?

Similar to your doctor, that’s just what I’ve been saying to my patients for years. That is, strive for at least 150 minutes of moderate intensity exercise spread out over a week. But the reality is that fewer than 20 percent of adults actually do that much exercise. It’s time we change the message, especially for people like you who lead very sedentary lives. Doing any amount of physical activity during the day is better than sitting or lying in bed. In fact, there’s no proof that 150 minutes of exercise per week is the ideal amount for an average adult.

OR TODAY | May 2015

But we do know that the more time we spend on our feet and moving improves our health. It’s a dose-response relationship. The more time we spend not sitting, the greater our chance of maintaining good health. That includes lower risk of type 2 diabetes, high blood pressure, heart disease, stroke and certain types of cancer. In addition, our muscles and bones will stay stronger just by standing and walking slowly often throughout the day. Ask yourself: “How much time do I spend sitting and lying down during the day?” Include the time you sleep. Subtract the total from 24 hours. That’s the number of minutes or hours you have left for doing “light activity,” such as standing, walking and climbing stairs. Here’s an even more accurate way to compute the number. Starting tomorrow morning:

Write down the time that you get out of bed and write, “UP” next to the time.

2 3

Every moment you sit or lie down during the day, write down the time and next to it write, “DOWN.” Each time you get up, write the time again and next to it write, “UP.” Do this on two different days – one day at work or school, and one day at home. Instead of reaching a specific goal, try to gradually increase the number of minutes per day you are “UP” over the next several weeks. Another option: Consider buying a fitness tracker that you wear like a watch. Or download a fitness-tracker app for your smartphone. It can keep track of your physical activity. Some will vibrate or beep if you’ve been sitting too long. HOWARD LEWINE, M.D., is a practicing internist at Brigham and Women’s Hospital in Boston and Chief Medical Editor of Internet Publishing at Harvard Health Publications, Harvard Medical School. WWW.ORTODAY.COM

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OUT OF THE OR NUTRITION

BY MCKENZIE HALL, RDN AND MATT RUSCIGNO, MPH, RD

SAFETY CONCERNS ADDRESSED FOR ELDERBERRY AND KOMBUCHA

IS ELDERBERRY SAFE AND BENEFICIAL TO CONSUME?

A. Elderberry has been treasured for centuries as traditional medicine to treat skin conditions and respiratory illnesses, such as colds and flu. However, unripe elderberries and other parts of the elder tree, such as the fresh leaves, flowers, young buds and roots, should not be eaten as they contain a bitter alkaloid and a glucoside that can be toxic, resulting in nausea and vomiting and, potentially, more serious side effects. The ripe blue or purple berries are edible (cooking is highly recommended) and are often used in pies, jams or wine. The berries are an excellent source of fiber, providing 10 grams per cup, and flavonoids, which exhibit antioxidant and anti-inflammatory properties. A few small studies have shown that elderberry eases flu symptoms, but further research needs to be performed to confirm these findings. There are several different types of

OR TODAY | MAY 2015

elder trees, but European elder (Sambucus nigra) is the type most often used to produce berry extracts for supplements. Currently, there is not a recommended dosage for elderberry supplements. If you’re considering taking elderberry supplements, consult your primary care provider, as elderberry may interact with immunosuppressant drugs, laxatives or diuretics. – McKenzie Hall, RDN

I SEE KOMBUCHA EVERYWHERE, BUT IS IT HEALTHFUL?

A. Kombucha is a fermented, slightly effervescent drink made from tea, sugar, bacteria and yeast. The fermentation process uses a symbiotic culture of bacteria and yeast known among aficionados as SCOBY (symbiotic colony of bacteria and yeast). The taste can be vinegary and it resembles a cloudy apple cider. Due to the popularity of fermented foods, interest in kombucha has risen

significantly, despite costing about $4 for a 12-ounce bottle. Is it worth it? Unfortunately, there’s not much scientific evidence that shows the drink and its bacteria promote health. Additionally, it contains caffeine, though less than an equivalent serving of tea, and, despite claims of being a source of B vitamins, total amounts are very low. Because of the fermentation process, kombucha can have very low levels of alcohol; the established limit is 0.5 percent, but in 2013 bottles were pulled from store shelves because some contained significantly more. Though there’s no evidence for increasing immunity or preventing cancer, anecdotal claims of helping digestion abound. Trying this unique drink doesn’t appear to cause any health problems, so if fermented foods please your palate, give kombucha a try.

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OUT OF THE OR RECIPE

BY DIANE ROSSEN WORTHINGTON

ONION AND FENNEL SOUP WARMS YOU UP

OR TODAY | MAY 2015

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RECIPE

’ve made lots of stews, soups and gratins in the last few months, but if I had to pick my favorite cozy dish it would be soup.

Onion soup ranks right up there for its pure deliciousness and comfort. Au Pied du Cochon in Paris may be the most famous brasserie for serving French onion soup, but this version will make you sit up and take notice.

Fennel, naturally compatible in flavor and texture, is added to the onions for an interesting taste combination. The easiest way to slice the onions and fennel is with the food processor, using the slicing blade, or on a mandoline. Slowly caramelizing the onions and fennel takes a long time, so be patient. The longer they cook, the more layered flavors you will experience. I like to make this over the weekend for lunch and serve whatever is left over on a weeknight since it just takes a few minutes to

reheat it. Serve this with a simple Belgian endive salad and a crusty loaf of country bread. Try a robust red Rhone wine to accompany. You can vary the crouton topping with different melting cheeses like fresh goat cheese, Teleme or Italian fontina. These little cheese croutons are easy to make and lighter than the usual fondue style onion soups. You’ll save a step since you don’t have to put the soup under the broiler, because you broil the cheesy croutons and place them on the soup just before serving.

ONION AND FENNEL SOUP WITH PARMESAN-GRUYERE CROUTONS Serves 6 3 tablespoons olive oil 8 large yellow onions, thinly sliced 1 teaspoon sugar 3 fennel bulbs, about 1 1/2 pounds, cleaned, trimmed and fronds removed, thinly sliced 4 garlic cloves, minced 10 cups chicken or beef broth 1/2 cup dry white wine 1 bay leaf 1/2 teaspoon minced fresh thyme or 1/4 teaspoon dried • Salt and freshly ground black pepper 12 (1/4 inch) slices French bread, baguette style 1/2 cup shredded Gruyere cheese (just under 2 ounces) 1/4 cup freshly grated Parmesan cheese 2 tablespoons finely chopped parsley, for garnish In a large, non-aluminum saucepan heat the oil over medium low heat. Add the onions and sweat them by WWW.ORTODAY.COM

covering them with a top until wilted, about 15 minutes, stirring occasionally. Remove the top and add the sugar and fennel and continue cooking, stirring frequently, until dark golden and caramelized, about 30 to 45 more minutes. You may need to turn up the heat to medium to reach the desired color. Add the garlic and sauté another minute. Add the stock, white wine, bay leaf and thyme. Partially cover and simmer for an additional half hour or until the flavors are nicely blended. Add the salt and pepper and taste for seasoning. Discard the bay leaf. While the soup is cooking, under a preheated broiler, broil the bread slices until golden, watching carefully to prevent burning, about 1 1/2-2 minutes. Sprinkle each slice of bread with an equal amount of Gruyere and Parmesan cheese and reserve. Just before serving, broil the croutons for 1 to 2 minutes more, or until the cheese is just melted.

To serve, ladle soup in individual deep soup bowls and float two or three croutons on the top of each bowl of soup. Sprinkle remaining cheese mixture and a little chopped parsley over each soup bowl for garnish. Serve immediately. Advance Preparation: The soup can be prepared completely three days ahead, covered and refrigerated. Reheat gently. This soup also freezes well. Adjust the seasonings when you reheat the frozen soup. Make the croutons up to 4 hours ahead and broil them just before serving.

Diane Rossen Worthington is the author of 18 cookbooks, including “Seriously Simple Parties,” and a James Beard Award-winning radio show host. You can contact her at seriouslysimple.com.

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OR TODAY

CONTESTS • MAY • OR Today celebrates nurses everywhere. May is a time for graduation and we applaud all those who have completed nursing school. Share a funny or interesting story from your time at nursing school and you could win FREE lunch for your department. Better yet, email us a photo from your nursing school graduation! Email your name, title and contact information (along with your graduation photo if possible) to Social@MDPublishing.com. Every entry will win a $5 gift card, but remember that the best entry wins a pizza party!

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SUMMER MOVIE SEASON

The summer movie season is about to kick off. Here are some films that look promising. Plan a day at the movies and escape reality for about two hours. Be sure to grab your favorite box oﬃce snack at the concession stand!

Let’s go to the movies

Here are some suggestions for May and June: • “Avengers: Age of Ultron” • “Pitch Perfect 2” • “Mad Max: Fury Road” • “Jurassic World” • “Terminator: Genisys” • “Magic Mike XXL” • “Minions” • “Poltergeist” • “Mission: Impossible V”

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Cool Stops

WHAT IS AMERICA’S COOLEST SMALL TOWN? Budget Travel recently announced that Grand Marais, Minnesota, has been voted this year’s “Coolest Small Town in America.” Chincoteague, Virginia, claimed the runner-up spot in the annual contest celebrating small town America. Each year Budget Travel (BudgetTravel.com) encourages its readers to discover travel beyond the big cities and experience something different: America’s Coolest Small Towns. Last fall, readers nominated 385 small towns across the country (each with a population under 10,000) for the America’s Coolest Small Town contest. Budget Travel’s editorial team then narrowed the list to 15 great locales they believed embodied cool, small town America. At the end of January, the public began voting with options that stretched from Hawaii to Maine. The online poll tallied 103,961 votes in five weeks. Budget Travel’s Top 5 list of the Coolest Small Towns in America for 2015: 1. Grand Marais, Minnesota (Population: 1,351) 2. Chincoteague, Virginia (Population: 2,941) 3. Hillsborough, North Carolina (Population: 6,087) 4. Allegan, Wisconsin (Population: 4,998) 5. Washington, North Carolina (Population: 9,744)

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INFUSION PUMPS AIV, Inc……………………………………………………………… 65

STERILIZATION Clorox Professional Products……………………………14 Key Surgical, Inc.………………………………………………… 6 TBJ, Inc.……………………………………………………………… 75 Tru-D…………………………………………………………………… 69

INDEX CATEGORICAL ACCREDITATION AAAHC…………………………………………………………………19 ANESTHESIA SMD Wynne Corp.…………………………………………… 67 Sharn Anesthesia……………………………………………… 74 APPAREL Healthmark Industries…………………………………… 80 ASSOCIATIONS AAAHC…………………………………………………………………19 AUCTIONS Government Liquidation…………………………………IBC MedWrench……………………………………………………… 78 BEDS Innovative Medical Products, Inc………………… BC CARDIAC SURGERY C Change Surgical……………………………………………… 9 CARTS Suburban Surgical Company, Inc………………… 68 CABLES/LEADS Sage Services…………………………………………………… 67 CLEANING SUPPLIES Ruhof Corporation…………………………………………… 2-3 CLAMPS Innovative Medical Products, Inc………………… BC DISPOSABLES Flagship Surgical, LLC…………………………………… 34 Government Liquidation…………………………………IBC Kapp Surgical Instrument, Inc.……………………… 79 Sage Services…………………………………………………… 67 ENDOSCOPY Government Liquidation…………………………………IBC MD Technologies……………………………………………… 28 Ruhof Corporation…………………………………………… 2-3 TBJ, Inc.……………………………………………………………… 75 GEL PADS Innovative Medical Products, Inc………………… BC MAC Medical……………………………………………………… 62 GENERAL GelPro………………………………………………………………… 57 Government Liquidation…………………………………IBC MedWrench……………………………………………………… 78 Surgical Power………………………………………………… 74 HAND/ARM POSITIONERS Innovative Medical Products, Inc………………… BC HIP SYSTEMS Innovative Medical Products, Inc………………… BC

OR TODAY | MAY 2015

INSTRUMENTS Government Liquidation…………………………………IBC INTERNET RESOURCES MedWrench……………………………………………………… 78 KNEE SYSTEMS Innovative Medical Products, Inc………………… BC LAB TBJ, Inc.……………………………………………………………… 75 LEG POSITIONERS Innovative Medical Products, Inc………………… BC MONITORS Eizo, Inc……………………………………………………………… 46 Jet Medical Electronics………………………………………16 OR TABLES/ ACCESSORIES Bryton Corporation…………………………………… 17, 67 Dabir Surfaces………………………………………………… 57 Innovative Medical Products, Inc………………… BC ORTHOPEDIC Surgical Power………………………………………………… 74 PATIENT AIDS Innovative Medical Products, Inc………………… BC PATIENT MONITORING Bio-Medical Equipment Service Co.…………… 63 Pacific Medical LLC………………………………………… 35 POSITIONING AIDS Innovative Medical Products, Inc………………… BC POSITIONERS/IMMOBILIZERS Innovative Medical Products, Inc………………… BC PROCESSING TBJ, Inc.……………………………………………………………… 75

SIDE RAIL SOCKETS Innovative Medical Products, Inc………………… BC SOCIAL MEDIA MedWrench……………………………………………………… 78

SURGICAL AAAHC…………………………………………………………………19 Censis Technologies, Inc.……………………………………17 Clorox Professional Products……………………………14 Eizo, Inc……………………………………………………………… 46 Flagship Surgical, LLC…………………………………… 34 MAC Medical……………………………………………………… 62 MD Technologies……………………………………………… 28 SMD Wynne Corp.…………………………………………… 67 Surgical Power………………………………………………… 74 SURGICAL SUPPLIES Cincinnati Sub-Zero…………………………………… 48-51 Government Liquidation…………………………………IBC Key Surgical, Inc.………………………………………………… 6 Ruhof Corporation…………………………………………… 2-3 SURPLUS MEDICAL Government Liquidation…………………………………IBC SUPPORTS Innovative Medical Products, Inc………………… BC TEMPERATURE MANAGEMENT C Change Surgical……………………………………………… 9 TRADE ASC Association……………………………………………… 74 VIDEO Eizo, Inc……………………………………………………………… 46 WARMERS Enthermics Medical Systems, Inc.………………… 47 WASTE MANAGEMENT Bemis Health Care…………………………………………… 24

RADIOLOGY Eizo, Inc……………………………………………………………… 46 REPAIR SERVICES Bio-Medical Equipment Service Co.…………… 63 Pacific Medical LLC………………………………………… 35

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A Complete System for Your Sports Medicine Needs

Distraction with precision in shoulder surgery Shoulder distraction with safety and control Now you have an option with precise positioning, maximum flexibility and controlled distraction, without compromising the sterile field. Ideal for shoulder or elbow arthroscopies.

> Stops on vertical plane for additional patient protection

> Featuring the patented Reznik Universal Shoulder Positioner™ with three planes of adjustment

> De Mayo RoTractor® holds the patient’s arm in rotation while maintaining distraction of the shoulder. Patent applied for.

> De Mayo RoTractor® adapts to most pole style shoulder positioners.

> Phase 4 Gel™ Splint adheres to arm for secure positioning and features a natural wrist contour for increased comfort and patient safety.

Tri-Pull™ Secure Shoulder Solution combines three proven systems to secure and distract the shoulder precisely. Innovation from patient to positioner • Phase-4 Gel™ Splint increases comfort, protects skin, controls internal and external rotation while adhesion holds the arm securely in place • De Mayo RoTractor® delivers complete patient control in the sterile field, holding fixed positions of rotation and allowing distraction of shoulder or elbow • Reznik Universal Shoulder Positioner™ provides controlled shoulder distraction with three planes of adjustment, and patented safety stops for patient protection Learn more about the unique features of the Tri-PullTM Secure Shoulder Solution at www.ismmedical.com or call 800-467-4944 for more information or to speak with a representative.

The operative word in patient positioning. www.ismmedical.com US Patent No. 7,569,024