OR Today - July/August 2015 by MD Publishing

NUTRITION BUDGET ORGANICS PAGE 62

TAKE GOOD CARE

CONTINUING EDUCATION BUILDING RELATIONSHIPS PAGE 34

NURSES • SURGICAL TECHS • NURSE MANAGERS

SPOTLIGHT ON PAMELA MOSS PAGE 54

JULY/AUGUST 2015

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CONTENTS

features

OR TODAY | July/August 2015

CORPORATE PROFILE: LET’S GEL INC.

SPOTLIGHT ON: PAMELA MOSS, RNC, BA

Let’s Gel Inc. continues to be an innovator in comfort for health care professionals. Building on the success of its shock-absorbing polymer gel mats the company has expanded its operations and is excited about its new Comfort Cushion Insoles and upcoming product lines in the operating room positional aid category.

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STAFF SHORTAGES AND STAFFING STRATEGIES

A looming shortage of registered nurses in the U.S. has been attributed to a number of different factors, including the retirement of many baby boomers and the need for more health care services as the U.S. population ages. We look at the consequences of this shortage in the operating room and how facilities can prepare with different scheduling strategies.

Pamela Moss graduated college with a psychology degree, but has since traded it in for a career as a nurse. She enjoys being an active part of a health care team and being able to care for patients.

OR Today (Vol. 15, Issue #6) July/August 2015 is published monthly by MD Publishing, 18 Eastbrook Bend, Peachtree City, GA 30269-1530. POSTMASTER: Send address changes to OR Today at 18 Eastbrook Bend, Peachtree City, GA 30269-1530. For subscription information visit www.ortoday.com. The information and opinions expressed in the articles and advertisements herein are those of the writer and/or advertiser, and not necessarily those of the publisher. Reproduction in whole or in part without written permission is prohibited. © 2015

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July/August 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

60 INDUSTRY INSIGHTS 10 News & Notes 16 AAAHC Update 18 CCI 20 OR Today Webinars

Andrew Parker | andrew@mdpublishing.com

CIRCULATION Bethany Williams

ACCOUNTING Kim Callahan

WEB SERVICES Betsy Popinga Taylor Martin

IN THE OR 24 27 28 34

Suite Talk Market Analysis Talk Product Showroom CE Article

OUT OF THE OR 59 Health 60 Fitness 62 Nutrition 64 Recipe 66 Pinboard 70 Index

OR TODAY | July/August 2015

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

PROUD SUPPORTERS OF

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INDUSTRY INSIGHTS NEWS & NOTES

STAFF REPORTS

AAAHC ANNOUNCES NEW CEO The Accreditation Association for Ambulatory Health Care (AAAHC) has appointed Stephen A. Martin Jr., Ph.D., M.P.H., as chief executive officer. Martin brings health care administration, delivery and accrediting experience to AAAHC as he replaces retiring CEO John Burke. “Dr. Martin has the energy and enthusiasm to help us improve health care quality through accreditation, and the ability to embrace and drive change for the betterment of AAAHC,” said AAAHC Board Chairman W. Patrick Davey, M.D., MBA. “His branding and marketing expertise will help us take the profile of the organization to the next level.” Martin has more than 18 combined years of governmental and non-governmental experience in the health care and public health arenas. Most recently he was the executive

OR TODAY | July/August 2015

director of the Association for Community Health Improvement at the American Hospital Association (AHA). He also has served as the chief program officer for the Health Research and Educational Trust/AHA, the health commissioner and

chief operating officer for the Cook County Department of Public Health and a senior executive with the Cook County Health and Hospitals System, the third-largest U.S. public health care system. Martin’s responsibilities at AAAHC will include leading the Institute for Quality Improvement, the organization’s nonprofit subsidiary founded to address the quality improvement requirements of AAAHC accreditation; overseeing the success of the Accreditation Association for Hospitals/ Health Systems Inc. (AAHHS), a sister organization to AAAHC dedicated to offering a nationally recognized, consultative accreditation program customized for rural hospitals, critical access hospitals (CAH) and small hospitals with less than 200 beds; and growing the AAAHC International division Acreditas Global. •

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NEWS & NOTES

ADVANCED COOLING THERAPY’S ESOPHAGEAL COOLING DEVICE SHOWS BENEFITS IN HEAT CONDUCTION TO WARM PATIENTS Advanced Cooling Therapy’s first product, the Esophageal Cooling Device (ECD), is showing benefits in the conduction of heat for warming of patients in a controlled manner in new clinical settings. A site in the European Union has used the ECD to keep challenging patients, such as burn patients, warm while undergoing complex skin procedures in the operating room, which allows clinicians to accomplish more in one setting than they ordinarily could without the ECD. Clinical studies reporting these results are in progress. Warming patients in the operating room is important to prevent infection, wound complications, excessive blood loss, and prolonged recovery time. Guidelines developed by the Surgical Care Improvement Project (SCIP) specifically focus on maintaining optimal temperature in patients during surgery. In addition, preventing inadvertent perioperative hypothermia is recommended by major organizations, including the Centers for Medicare and Medicaid Services via the Surgical Care Improvement Project, and the American Society of Anesthesiologists. The ECD is

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also being used to effectively control temperature in challenging patients with central fever and ischemic injuries. The ECD is designed to modulate and control patient temperature when clinically indicated through a single use, fully enclosed triple lumen system that is inserted into the esophagus. Two lumens attach to existing temperature modulation equipment while a third lumen simultaneously allows gastric decompression and drainage. The ECD can be rapidly inserted by most trained health care professionals, in similar fashion to a standard gastric tube, and can be used to control patient temperature in the operating room, recovery room, emergency room or ICU. The ECD is CE marked; Health Canada approved; sold in Europe and Canada; and cleared for marketing in Australia. The device is pending clearance from the FDA for use in the U.S. •

INOVA HEALTH SYSTEM IMPLEMENTS EXCEL MEDICAL’S BEDMASTEREX SOLUTION Excel Medical has announced that Inova Health System has implemented Excel Medical’s BedMasterEx solution to integrate with Inova’s Epic EHR to optimize cardiac monitoring and improve patient safety across the health system. This is part of an ongoing rollout of the platform, which will ultimately span all five Inova hospitals, representing more than 825 monitored beds. Like many hospitals and medical centers, Inova was facing a multitude of challenges related to effective capture, retention, utilization, and communication of high-value patient data. Inova identified the need for a solution that would integrate bedside monitoring data from telemetry and ICU areas into its EHR. BedMasterEx turned out to be the solution that provided this functionality. The BedMasterEx solution is fully secure, HIPAA-compliant and can be deployed on Windows workstation or within client technologies such as Citrix for remote access and management. The platform provides the means for Inova to continue to achieve its goal to “Build a Culture of Safety.” Toward that end, Excel Medical’s software integration with Epic ensures that the right strip is matched to the right patient by eliminating the manual steps for data collection. Electronic maintenance of the cardiac waveforms also means that nurses and clinicians can view patient data throughout the hospital enterprise from available workstations, including computerson-wheels. July/August 2015 | OR TODAY

INDUSTRY INSIGHTS NEWS & NOTES

MEDLINE UNVEILS HOLISTIC APPROACH TO SKIN HEALTH According to 2014 data from the Centers for Medicare and Medicaid Services (CMS), more than 2,000 of 16,000 long-term care facilities across the U.S. were cited for failure to properly treat a resident to prevent new bedsores or heal existing ones. If such issues are not corrected and skin breakdown occurs, facilities are subject to penalties. More than 17,000 lawsuits are filed annually due to pressure ulcers, second only to wrongful death in health lawsuits filed. An estimated 1.5 million skin tears occur annually in older institutionalized adults in the U.S. Clinicians need a solution that speaks not only to prevention, but one that also is designed to address the treatment of varying skin breakdown. Protocols exist but oftentimes lack context, consistency and versatility. Medline Industries’ holistic skin health initiative Skintegrity recognizes healthy skin is as important as a healthy heart, brain or lungs. It represents a long-term, sustainable approach that encourages attention to the health of a patient’s skin during all key points of care and at every life stage. Because every person’s skin is unique and may react differently to conditions like friction and shear, Skintegrity is designed to meet a patient’s individual needs. The program features personalized clinical education for assessing skin changes, a portfolio of evidencebased products for care and treatment, and easy-to-use outcomes management tools that pinpoint where gaps in skin care occur. • LEARN MORE about Skintegrity at: http://www.medline.com/clinical-solutions/skin-health/skintegrity. 12

OR TODAY | July/August 2015

STAFF REPORTS

BLACK DIAMOND VIDEO RECEIVES CERTIFICATION FOR EHR INTEGRATION

Black Diamond Video has been awarded certification by a leading electronic health record provider, certifying that Black Diamond Video’s BDV Clarity solution is fully capable of integrating BDV OR video system data with the EHR provider’s electronic health record solution. For each leading EHR provider, Black Diamond Video has developed a simple, secure BDV Clarity interface that imports patient record and schedule HL7 information from the EHR system to Black Diamond Video’s Integrated Digital Surgical Suite system in the operating room. Import of this HL7 information supports simplified and accurate patient recordkeeping. High-defini-

tion images and recordings captured by the IDSS system during surgical procedures are then exported to the EHR provider’s media storage for later clinical access. Black Diamond Video’s certification by an EHR provider verifies effective interaction between BDV’s integrated OR solution and the EHR provider’s electronic health record system. In addition to interfacing with EHR solutions, Black Diamond Video’s BDV Clarity solution also offers BDV Nurse Core View, BDV Physician Remote View, and other tools to increase clinical workflow visibility, communication and collaboration. •

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NEWS & NOTES

HALYARD HEALTH CROWNS SMART-FOLD WRAP RACE CHAMPION Halyard Health crowned the champion of the second annual Smart-Fold Wrap Race at the 2015 International Association of Healthcare Central Service Material Management (IAHCSMM) 50th Annual Conference and Expo in Ft. Lauderdale, Florida. Darreona McDowell from Children’s Healthcare of Atlanta Scottish Rite was declared the fastest sterilization wrapper, beating out Central Service (CS) professionals from across the United States and Canada. The 2015 Smart-Fold Wrap Race competition was designed to test the wrapping skills and speed of CS professionals using Smart-Fold Sterilization Wrap. More than 150 wrappers entered the contest and after several rounds of competition, the wrappers with the four fastest times traveled to IAHCSMM to determine the victor. In the final round, McDowell was named the SmartFold Wrap Race Champion, wrapping three surgical instrument trays consecutively in just 36 seconds. •

AETHON PRESENTS MEDWEX TRAYSAFE Aethon Inc. introduces MedEx TraySafe, the next-generation automated kit replenishment solution, which was featured at the American Society of Health Systems Pharmacists (ASHP) Summer Meetings & Exhibition 2015 HELD June 6-10 at the Colorado Convention Center in Denver. TraySafe automates the process and improves the safety of replenishing kits and trays. TraySafe tracks all medications distributed throughout the hospital as well. These capabilities reduce the time to process a kit while providing the tools to respond instantly to recalls, expired medications or audits. TraySafe improves on current automated medication replenishment solutions by replacing the WWW.ORTODAY.COM

costly RFID tags normally added to each dose with a system that uses an industry-standard and data-rich 2D bar code. Recently passed legislation as part of the Drug Supply Chain Security Act mandates the use of 2D bar codes that include NDC number, lot number and expiration date on unit dose medications, and will be required in 2017. Since it also creates an ultra-high resolution image of the tray that shows which medications are present and automatically detects if medication is in its proper place within the tray, TraySafe delivers a patient safety enhancement that is particularly critical in the emergent situations in which the trays are used. • July/August 2015 | OR TODAY

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INDUSTRY INSIGHTS AAAHC UPDATE

BY SARAH MARTIN, MBA, RN, CASC

GETTING YOUR ASC INVOLVED IN LEGISLATIVE ISSUES WHY SHOULD MY ASC GET INVOLVED? There are many legislative changes that have taken place in recent years that impact ASCs financial performance, with more in the works both at the state and federal level. The effective way to manage these changes, as opposed to having these changes manage your facility, is to have a voice in what happens through active involvement in your state ASC association and the national Ambulatory Surgery Center Association (ASCA). Today’s ASC managers must now include awareness of proposed legislative changes to their list of tasks necessary to run their ASC. It also is imperative to share this knowledge and possible actions with your ASC staff and physicians to maximize the impact of grass roots initiatives. Before identifying these opportunities, however, one must first understand the current issues facing ASCs. CURRENT ISSUES FACING ASCS The Affordable Care Act (ACA) continues to be a concern as to the impact it will have on ASCs. Accountable Care Organizations (ACOs) have been established and, for the most part, ASCs have not participated in these networks. 16

OR TODAY | July/August 2015

While the increased access to care by the newly insured could potentially bring additional cases to ASCs, ACOs may direct those new patients elsewhere. The ASC Quality and Access Act of 2013 requires ASCs to provide data on quality outcomes to CMS, and ASCs need to anticipate implementation of value-based purchasing platforms, similar to what hospitals experienced several years ago. Like ASCs, hospitals reported quality outcomes and were then moved to reimbursement from CMS based on the results of their quality outcomes. The continued disparity in Medicare payment between ASCs and HOPDs, negatively impacts freestanding facilities. HOPDs currently receive 81 percent more than ASCs for the same services. Managed care payers are forcing out-of-network strategies to be eliminated: it is becoming more difficult for ASCs to negotiate significant payment increases, implants are no longer being carved-out, and payment on percentage of charges is rare. There exist procedures that cannot be covered for payment in ASCs, but are paid for in HOPDs. Managed care companies are incentivizing physicians to perform procedures in their offices, which impacts high-volume, low-supply cost cases such as GI and pain

SARAH MARTIN, MBA, RN, CASC

management. Add to this, the push for pricing transparency; while ASCs are still a lower cost provider, overpriced outlier ASCs reflect poorly on the industry overall and consumers are “shopping” pricing for their care. Hospitals are buying ASCs, and joint ventures with ASCs and hospital partners have declined. Hospitals are also hiring physicians, which often deters physicians from using or having ownership in ASCs. This elimination of competition and control of referrals not only negatively impacts the ASC, but can also WWW.ORTODAY.COM

AAAHC UPDATE

Educating the Surgical Suite & Professionals

be to the detriment of the consumer, since market control can equal decreased competitive pricing. In addition, national drug shortages hit ASCs harder, as access to these limited supplies tends to be provided to hospitals first, or the ASC is allocated minimal quantities. For assistance in managing these challenges, it is important for ASCs to reach out to state and federal leaders representing them in their respective areas of the country. WHAT YOU CAN DO THROUGH GRASSROOTS INITIATIVES By definition, grassroots means at the local level and not waiting for leaders at the top to effect changes. ASC managers, staff and physicians can participate in grassroots initiatives such as writing letters to Congress, hosting a facility tour for state legislators at your ASC, or hosting an open house on National ASC Day. The ASC Association hosts Capitol fly-ins several times a year in Washington, D.C. which puts ASC personnel face to face with their legislators to discuss important issues. You can find a whole armory of resources at http://www.ascassociation.org/ govtadvocacy/grassrootsadvocacy. YOU CAN MAKE A DIFFERENCE Grassroots efforts do make a difference, as evidenced by the recent revision to CMS Conditions for Coverage for radiology services in ASCs. Letters to Congress, Capitol Fly-ins and lobbying efforts by ASCA were the driving forces behind the change. WWW.ORTODAY.COM

Membership and participation in state ASC associations is another avenue for effecting change on the state level since many bills that evolve into national issues start in the state. You can support political action committees (PACs), by writing a check, regardless of the amount given. It is expensive for candidates to run for office; consequently contributing to a candidate or an incumbent through a PAC or directly is an important piece of advocacy. ASCA has a PAC, as do most state associations. It is important for all ASC managers to participate in some manner of grassroots advocacy and to educate staff and physicians on issues facing the ASC both locally and nationally. This collective effort is necessary to ensure the continued success and viability of the ASC industry as a whole. Make sure you play your part. SARAH MARTIN has over 34 years experience in health care, focusing on ambulatory services for the past 15 years. A registered nurse with an MBA, she holds the CASC credential and has served on the boards of ASCA, AAASC, Tennessee Ambulatory Surgery Center Association (TASCA), and the ASC Quality Collaboration. She is a frequent speaker at national ASC meetings; has held SVP and VP positions in both operational and clinical/quality roles with national ASC companies; and is a surveyor for AAAHC.

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INDUSTRY INSIGHTS COMPETENCY & CREDENTIALING INSTITUTE

BY JAMES X. STOBINSKI, PH.D., RN, CNOR

MAKING THE CASE FOR ONGOING PROFESSIONAL DEVELOPMENT IN PERIOPERATIVE NURSING LEADERS

he operating room is a fast-paced, complex and ever-evolving environment. Nursing leaders must engage in continuous professional development (CPD), or ongoing education, just to stay even with the pace of change. This need for lifelong learning, or CPD, was clearly stated in the Institute of Medicine’s 2011 “Report on the Future of Nursing,” and practical experience in our workplace reinforces this necessity.

The career progression of perioperative nurse leaders has changed markedly over the last three to four decades. It was previously assumed that perioperative leaders must have extensive clinical experience to be successful in a management role. As a result of rigorous scientific studies using job analysis methods performed by the Competency & Credentialing Institute (CCI), we now know that managing an operating room is a distinct and separate skill set. Since clinical skills in perioperative nursing do not guarantee success 18

OR TODAY | July/August 2015

as a manager, there should be separate education to set management candidates up for success. Until recently, there was no such education available. Being acutely aware of the challenges its perioperative nurses faced as they transitioned to management roles, CCI recently instituted programs to address this knowledge gap. To meet the need for specialized education, CCI has offered a Certificate of Mastery in Surgical Services Management. This educational program may be done in self-directed, asynchronous learning or in conjunction with live instruction as will be offered at the OR Today Live! Surgical Conference in Las Vegas beginning August 30. As defined by the American Speech-Hearing Association certificate courses are “… a training program on a specialized topic for which participants receive a certificate after completing the course and passing an assessment instrument.” We eventually found that the body of knowledge required to be successful in surgical services management was even sufficient enough to support a certification exam. In July of 2015, CCI will offer the first testing period for the CSSM (Certi-

JAMES X. STOBINSKI, PH.D., RN, CNOR, DIRECTOR OF CREDENTIALING & EDUCATION AT CCI

fied Surgical Services Manager) certification exam. A certification exam is differentiated from a certificate program in that it is a “… voluntary process by which a non-governmental entity grants a time-limited recognition and use of a credential to an individual after verifying that he or she has met predetermined and standardized criteria.” The CSSM certification exam allows successful test takers to use WWW.ORTODAY.COM

COMPETENCY & CREDENTIALING INSTITUTE

Entertaining the Surgical Suite & Professionals

“The nursing profession must adopt a framework of continuous lifelong learning that includes basic education, academic progression, and continuing competencies.” the CSSM designation as part of their credentials. As the larger group of perioperative nurses has the CNOR certification, perioperative nurse managers now will have the CSSM certification to represent their specialized knowledge. With these two programs, aspiring perioperative nurse leaders may now chart an educational and professional development path that will culminate in the CSSM certification. The CSSM credential has a distinct recertification mechanism which will delineate a program of CPD for the period the credential is active. This progressive approach to recertification is designed to maintain and advance the competency level of the perioperative nurse leader by addressing their knowledge levels as demonstrated on the initial certification exam. The IOM “Report on the Future of Nursing” (2011, p 213) clearly speaks to the need for CPD, stating, “The nursing profession must adopt a framework of continuous lifelong learning that includes basic education, academic progression, and continuing competencies.” This need is prominent for perioperative nursing leaders but there is now a clear career path with standardized educational materials and also a certification process geared to support lifelong learning. WWW.ORTODAY.COM

It is the hope of CCI that in working with our partners, such as OR Today or your membership organization, we can assist you in your perioperative nursing career and facilitate your success. JAMES X. STOBINSKI, Ph.D., RN, CNOR, is the Director of Credentialing & Education at CCI in Denver, Colorado, and has over 25 years of experience in the operating room.

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REFERENCES American Nurses Association and National Nursing Staff Development Organization. (2010). Nursing professional development: Scope and standards of practice. Silver Spring, MD: Nursesbook.org. American Speech-Language-Hearing

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Association. Professional Certification vs. Certificate Program. Accessed 12 JUN 2015 at: sha.org/CE/CEUs/ProfessionalCertification-vs-Certificate-Program/

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The Competency and Credentialing Institute. (2015). CSSM Candidate Handbook. Retrieved 11 JUN 2015 from: http://cc-institute.org/cssm/applicationand-candidate-handbook IOM (Institute of Medicine). 2011. The Future of Nursing: Leading Change, Advancing Health. Washington, D.C.: The National Academies Press.

8.30 - 9.1 2015 RED ROCK RESORT LAS VEGAS WWW.ORTODAYLIVE.COM

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INDUSTRY INSIGHTS NEWS WEBINARS & NOTES

STAFF REPORTS

OR TODAY WEBINARS CONTINUE TO GROW

he most recent OR Today webinar “Mind the Gap: Raising the Bar with Patient-Focused Warming Strategies” was a hit with health care professionals.

Fifty-seven people attended the webinar presented by Carol Stamas, RN, and sponsored by Encompass Group. The session addressed the prevalence of unplanned perioperative hypothermia in surgical patients. The webinar was designed to help attendees identify patient-focused warming strategies to bank heat, prevent cutaneous heat loss, and maintain normothermia throughout a patient’s perioperative journey. National statistics on prevalence of unplanned hypothermia in postoperative environment and establishing the gap in patient population that needs improved warming strategies were addressed. Stamas discussed typical warming measures and their contribution to cutaneous warming and prevention of hypothermia. She also discussed how professionals can determine the most-effective tools for patient-focused warming strategies. The webinar was well received earning a rating of 4.0 via a survey sent to each attendee. “Great webinar on the importance of patient warming no matter what setting you’re in. The presenter also pointed out that warming starts in the pre-op setting. Most think it is only an OR issue,” Sherry W. wrote in her webinar survey. Another recent OR Today webinar “Novel Techniques for Changing the Paradigm in Spine and Orthopaedic Procedures: Strategies for the 20

OR TODAY | July/August 2015

Hospital and Ambulatory Surgery Center Settings” presented by John Malara, PA, and sponsored by Pacira Pharmaceuticals, explored a nonopioid option for the management of postsurgical pain. About 50 people attended the

The webinar “Back To The Future: New Innovations in Reusable OR Textiles” presented by Angie O’Connor on May 7 received a 4.1 rating. “This webinar brought to the light so much of what has been known for years, but has been derided by the disposable textile industry,” John S. wrote in his webinar survey. “That is, reusable textiles have so many advantages, on so many levels, over

“This webinar brought to the light so much of what has been known for years, but has been derided by the disposable textile industry. that is, reusable textiles have so many advantages, on so many levels, over disposables. Angie did a great job!” session that received a 4.1 rating. “(It was) very informative to hear how other facilities currently use the medication,” Kelly B. wrote in her survey. Malara discussed issues surrounding the current use of opioids for the management of post-surgical pain. He said the U.S. government and health care professionals have strongly pushed to avoid the use of narcotics for post-operative pain management. He said the focus is on the use of a multimodal pathway. He highlighted the ways his institution has implemented opioid reducing strategies, specifically how EXPAREL (bupivacaine liposome injectable suspension) has impacted its pain management strategy; enhanced recovery after surgical protocols; quality initiatives; and best practices to achieve optimal results with EXPAREL.

disposables. Angie did a great job!” In the presentation, which was sponsored by Encompass Group, O’Connor compared the safety and comfort features between reusable drapes, gowns, and mayo stand covers and disposable items. She identified specific requirements and performance standards for barrier protection in the OR. Also, she differentiated the costs associated with the use of reusable drapes, gowns, and mayo stand covers versus disposable items. Recordings of every OR Today webinar are available at www.ortoday.com/webinars. The OR Today webinar is available online at ortoday.com/webinars.

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INDUSTRY INSIGHTS OR NEWS TODAY & NOTES LIVE!

BY JOHN WALLACE

OR TODAY LIVE! PARTNERS WITH CCI FOR INAUGURAL CONFERENCE CCI Offers Surgical Services Management Certificate of Mastery Program

R Today Live! has partnered with the Competency and Credentialing Institute (CCI) to provide valuable CE education in Las Vegas this summer. The educational program for the brand new OR Today Live! Surgical Conference (www.ORTodayLive.com), to be held Aug. 30-Sept. 1 at the Red Rock Resort, includes classes and workshops presented by CCI experts. “This conference promises to be one of the most exciting and innovative in-person opportunities for OR leaders,” said Shannon Carter, chief executive officer and executive director of Competency & Credentialing Institute. “We are proud to be part of delivering exceptional educational content to the best-in-class perioperative managers and RNs.” Along with its partnership with CCI, the conference is a certified state of California Board of Registered Nursing Continuing Education Provider. “We are thrilled to be collaborating with CCI for our inaugural OR Today Live! Surgical Conference, “ said John Krieg, president of MD Publishing Inc., parent company of OR Today. “This is a tremendous opportunity to partner with such a prestigious credentialing leader for our industry. Their standard of excellence will only enhance an

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already stellar OR Today Live! educational program.” EMPOWERING THE SURGICAL SERVICES COMMUNITY Perioperative leaders from throughout North America are invited to attend this exciting new conference that offers a unique blend of topnotch educational sessions and entertaining networking events. OR Today Live! presents a dynamic environment for perioperative leaders to engage with industry leaders, advance their education, further develop management skills, discover the latest services and products and ultimately deliver solutions to improve their health care facility’s performance. OR Today Live! will address common challenges, regulations and culture changes facing the surgical suite and the professionals called on

to manage the business decisions and patient care within the OR. The conference will follows a three-day format beginning with workshops and a welcome reception on Sunday, Aug. 30. In addition to the education, attendees will also find unique networking events at OR Today Live! Some of the festive events include the Poolside Welcome Reception in Cherry Lounge, Cocktails and Cash and the Red Rock Lanes Bowling Party. MD Publishing has more than a decade of experience with successful conferences, including the popular MD Expo. Find out more about OR Today Live! and register to attend online at ORTodayLive. com or call Bethany Williams at 800-906-3373.

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July/August 2015 | OR TODAY

IN THE OR SUITE TALK

SUITE TALK

Conversations from the OR Nation’s Listserv

DISCHARGE INSTRUCTIONS When discharging patients from the hospital after same-day surgery, a set of discharge instructions is sent home with the patient. Is it acceptable to have the patient (not a minor) sign the discharge instruction paperwork if they are alert and able to?

A: Not unless they have only had a local anesthetic. We have the person who is with them sign the paperwork and advise our patients not to sign any paperwork for 24 hours. A: I agree (to the above) completely!

OR DISTRACTIONS POLICY I am in the process of developing an OR Distraction Policy. The purpose of having such a policy in place would ensure that the primary focus of all providers and care team members remains on patient care and focuses on communication of patient care. Does anyone currently have a policy in place that they would be willing to share? How does your organization deal with/ address anesthesiologists, nursing team members, other members of the care team Facebooking, surfing the web, texting, etc. in the OR? Is it allowed? A: Absolutely not! I have zero tolerance – automatic corrective action. A: I would also love to see the same type of policy. Our safe surgery committee is trying to develop something and we want to use the model

A: We review the discharge instructions with the patient before surgery (at the same time they sign consents) and have them sign at that time. They also get a copy at the time of discharge. •

OR TODAY | July/August 2015

from Council on Surgical and Perioperative Safety (CSPS) to encompass all electronic distractions. A: Would love to hear what other organizations are doing. This is such a huge issue. Very difficult to enforce with nursing

when surgeons and anesthesia providers do it. A: We keep it simple – no cellphones in the OR! Any of that is completely unacceptable. If they are on call or awaiting an “urgent” text, etc. They can leave their

phone with support staff outside of the OR and the staff can communicate any messages. We found anesthesia to be the worst offenders so we made our policy very simple and universal. A: Absolutely zero tolerance! • WWW.ORTODAY.COM

SUITE TALK

FIRST ASSIST

What are your minimal requirements to allow a surgeon to bring along his own first assistant? A: Must be credentialed as either medical staff or allied health. A: Our surgeons must have the staff member cleared through the credentialing department. A: We would require that person to either be an employee of ours or a contracted provider. We would have them complete an application. I would verify their education and certification. They must have proof of immunizations (as required by the state). We would do a background check and HIPAA form. We require a liability waiver form (for

e Th nal igi r O

non-employee – stating if they slip and fall in OR, they won’t sue us, etc. – same form I use for sales reps or other visitors to the OR) and malpractice insurance (with us as a certificate holder) if applicable. I can get this for the PA or CFA, both typically hold that. I’ve had surgeons want to bring a first assist and they use that term loosely – it could mean a P.A., it could mean a CFA or it could be their favorite surgical tech. I have had several times over the years where doctors just “show up” with an assistant of sorts and I can’t allow just anyone into the OR without

this information. They usually get angry (stating that they’ve known this person or worked with them for years). Now, unfortunately, we can cite the example of Joan Rivers’ doctor as a prime example of why we can’t just let anyone into the OR. We are a Joint Commission accredited facility. A: They must be credentialed through Med Staff. A: If they are not employees of the organization, all licensed assistants would be credentialed through the medical staff office.

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IN THE OR MARKET ANALYSIS

MARKET ANALYSIS

BY JOHN WALLACE, EDITOR

Hand Hygiene

and hygiene is a major concern in the health care industry. One reason for the increased awareness revolves around a heightened awareness of healthcareacquired infections. The Centers for Disease Control and Prevention is one of many government and regulatory agencies promoting hand hygiene awareness and practices to promote patient and clinician safety. “In the United States, hospital patients get an estimated 722,000 infections each year. That’s about 1 infection for every 25 patients. Infections that patients get in the hospital can be life threatening and hard to treat. Hand hygiene is one of the most important ways to prevent the spread of infections,” according to the CDC website. “Health care providers should practice hand hygiene at key points in time to disrupt the transmission of microorganisms to patients including: before patient contact; after contact with blood, body fluids, or contaminated surfaces (even if gloves are worn); before invasive procedures; and after removing gloves (wearing gloves is not enough to prevent the transmission of pathogens in health care settings).”

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“Patients and their loved ones can play a role in helping to prevent infections by practicing hand hygiene themselves as well as asking or reminding their health care providers to perform hand hygiene,” the CDC adds.

Yet, some analysts see obstacles that the market will have to overcome to reach that mark. “The requirement to prevent and manage healthcare-acquired infections affecting millions of people every year in the world is driving the hand hygiene market all across the globe,” according to a report from Transparency Market Research. The report from Transparency Market Research indicates that major outbreaks of various infectious

The report from Transparency Market Research indicates that major outbreaks of various infectious diseases in many countries will have an impact on the hand hygiene market. An increased awareness of hand hygiene is among the factors sending this specific market to new heights, according to a market report. New technology and devices are also cited as reasons for continued growth. “Integration of hand hygiene compliance monitoring technologies, with the use of automated and manual dispensers, is expected to help the hand hygiene market grow to $446.9 million in 2017,” according to an analysis from Frost & Sullivan.

diseases in many countries will have an impact on the hand hygiene market. However, the potential for the hand hygiene market fluctuates across regions, the report states. Poor awareness, lack of education, and training on hand hygiene, along with the lack of a standard procedure for hand hygiene is hindering the growth potential of the market in many nations and could have a negative impact on the global market, according to Transparency Market Research. July/August 2015 | OR TODAY

IN THE OR PRODUCT SHOWROOM

MEDLINE STERILLIUM® RUB Medline’s Sterillium® Rub supports hand hygiene efforts to help reduce surgical site infections. The rapid, antiseptic is gentle on a surgeon’s skin but tough on germs. With 85 percent ethyl alcohol, Sterillium Rub® (85% w/w) ensures rapid yet extensive and thorough efficacy. Sterillium Rub meets the United States and international efficacy specifications for surgical hand antisepsis. It is non-drying and formulated with emollients that leave hands feeling soft and smooth. With a 90-second application time, the Sterillium Rub leaves hands less sticky and quick-rub to glove donning. It kills over 99.999% of clinically relevant germs. It is compatible with many surgical gloves, including latex, nitrile and vinyl. •

OR TODAY | July/August 2015

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PRODUCT PRODUCT SHOWROOM FOCUS

BIOVIGIL HEALTHCARE SYSTEMS BIOVIGIL SYSTEM BIOVIGIL is an automated hand hygiene compliance and awareness system that promotes safety at every patient interaction by intervening at the point of care to provide situationspecific hand hygiene reminders. Healthcare workers wear small, personal badges with on-board chemical sensors, so the system works with existing dispensers and sanitizers. After the badge validates hand hygiene, a green light is displayed, providing reassurance to patients and their families. Hospitals that use the BIOVIGIL system regularly achieve hand hygiene compliance rates well over 95 percent, compared to a national average of 45 percent. • TO DOWNLOAD A FREE WHITE PAPER: http://www. biovigilsystems.com/white-papers/.

PURELL® WATERLESS SURGICAL SCRUB PURELL® Waterless Surgical Scrub provides instant germ kill and persistent activity critical to the surgical environment. PURELL Waterless Surgical Scrub’s advanced alcohol formulation is designed to meet and exceed FDA requirements and AORN guidelines for surgical scrubs without harsh ingredients that cause skin damage. Requiring only two applications and drying quickly, PURELL Waterless Surgical Scrub creates a pH-balanced environment that helps inhibit germ recovery and regrowth, and, as a result, is able to provide six-hour persistence without the need for a secondary active. PURELL Waterless Surgical Scrub can be used in operating rooms or other high-risk areas. • WWW.ORTODAY.COM

July/August 2015 | OR TODAY

IN THE OR PRODUCT SHOWROOM

ECOLAB EQUI-SOFT™ FOAM HAND SOAP

Ecolab has launched Equi-Soft™ Foam – a new mild antimicrobial hand soap for the healthcare environment. Using benzalkonium chloride as the active ingredient, Equi-Soft™ Foam delivers the efficacy of a medicated soap with the mildness of the market leading non-medicated soap.1,2 This Triclosan-free formula empowers healthcare workers with an alternative for diverse antimicrobial hand soap needs. Unlike harsh soaps that can impede hand-washing compliance, Equi-Soft™ Foam is formulated to be gentle to skin and is also paraben-free and dye-free to reduce risk of irritation. It kills standard healthcare micro-organisms as well as MDR Acinetobacter, VRE, CRE and multiple strains of MRSA. It is also compatible with chlorhexidine gluconate (CHG) products and is available in multiple dispensing options including Ecolab’s Nexa platform. •

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OR TODAY | July/August 2015

SwipeSense transforms the way health care organizations manage infection control with a unique integrated system that combines point-of-care hand hygiene dispensers, a sensor reporting network for new and existing wall-mounted dispensers, and state-of-the-art informatics so caregivers get timely self-monitoring feedback. Additionally, all hygiene events as well as staff entry and exit movements at patient rooms and other care areas are automatically logged, so that risk and infection prevention professionals receive the compliance data needed to effectively administer their organization’s quality initiatives. •

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PRODUCT PRODUCT SHOWROOM FOCUS

3M AVAGARDTM For more than 10 years, 3M has offered hand hygiene formulations to reduce the risk of health care-associated infections. Our goal is simple: to provide the effective products and support you need for this persistent challenge, which is why 3M™ Avagard™ hand antiseptics make hand hygiene a snap. 3M™ Avagard™ (Chlorhexidine Gluconate 1% Solution and Ethyl Alcohol 61% w/w) Surgical and Healthcare Personnel Hand Antiseptic with Moisturizers is the first and only FDA NDA-approved waterless, brushless surgical hand antiseptic that combines two active ingredients plus a lotion for effective antimicrobial activity and skin conditioning. •

HALYARD HEALTH AIRISTA HAND HYGIENE COMPLIANCE MONITORING Halyard Health has spent years researching and piloting hand hygiene monitoring technologies to understand what works for hospital staff and facility teams. Halyard has learned several factors are critical to a successful implementation – the badge must be easy to wear and fit normal workflow, data must be

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accurate, and the system must be easy to install. Now a system has arrived that meets these requirements. Halyard offers AiRISTA Hand Hygiene Compliance Monitoring coupled with Halyard Compliance Clinical Services to comprehensively improve hand-hygiene compliance.

July/August 2015 | OR TODAY

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IN THE OR CONTINUING EDUCATION 662B

OR TODAY | July/August 2015

BY MAUREEN HABEL, RN, MA

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CONTINUING EDUCATION 662B

BUILDING COLLEGIAL NURSE-PHYSICIAN RELATIONSHIPS O

lder nurses can remember a time that when a physician came to a patient unit, nurses who were charting or on the phone relinquished their chairs and gathered charts to help the physician during patient rounds. In previous eras, nurses were expected to function in a subordinate role to physicians. In fact, critical thinking and problem-solving on their own were discouraged. Nursing developed in a time when men were viewed as superior to women.1 The traditional cultural assignment of power roles to males contributed to the caste-like relationship between primarily male physicians and predominately female nurses. This problem has been compounded by media portrayals of nurses, in which nurses are often cast roles in which they appear less scholarly and less able to make effective clinical judgments than physicians.2 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 49 to learn how to earn CE credit for this module.

The goal of this program is to educate nurses about the importance of nurse-physician relationships and to propose ways in which building effective nursephysician partnerships can improve patient care. After studying the information presented here, you will be able to: • Describe the impact of effective nurse-physician communication on patient safety • Discuss five types of relationships between nurses and physicians • State four strategies nurses can use to develop collegial relationships with physicians WWW.ORTODAY.COM

GOOD COMMUNICATION = SAFETY + QUALITY Healthcare has changed dramatically. Medical and nursing knowledge has increased exponentially, and a wealth of research now drives evidence-based practice. The patient care environment is also more complex than ever. Both nurses and physicians must provide patient care at a rapid and efficient rate while at the same time reducing costs and improving outcomes. Providing safe and effective care increasingly depends on nurses and physicians working closely together to achieve optimum patient outcomes. Agencies such as the Centers for Medicare & Medicaid Services, The Joint Commission and the Institute for Healthcare Improvement emphasize the critical need for healthcare professionals to communicate in a way that prevents errors and improves quality.3 The Institute of Medicine’s 1999 “To Err Is Human”

report was a wake-up call, documenting about 98,000 patient deaths each year in the U.S., with communication breakdowns being the cause of a substantial number of preventable errors. The report served as an impetus for studies about nursephysician collaboration and their impact on patient safety. Increasingly, the patient safety literature emphasizes the importance of creating a culture of safety, one that expects all staff to speak up when a patient may be harmed. A classic study done in intensive care settings found that communication between physicians and nurses was the most significant factor associated with patient mortality.4 More recent studies have confirmed these findings.5,6 Healthcare organizations that participate in the American Nurses Credentialing Center’s Magnet Recognition Program are recognized by providing nursing excellence. Some authors propose July/August 2015 | OR TODAY

IN THE OR CONTINUING EDUCATION 662B

that outstanding nurse-physician collaboration may account for the lower patient mortality seen in Magnet hospitals.5,6 One study documented that specific characteristics of Magnet hospitals (e.g., nursing involvement in hospital affairs, a professional nursing practice model and adequate staffing) were all important factors that enhanced nurse-physician communication.6 RELATIONSHIPS MATTER Faced with the need to attract and retain nurses, a large healthcare network conducted a nurse-physician relationship survey in 2002 that solicited the opinions of 1,200 participants, including nurses, physicians and administrators. This study verified that nurse-physician relationships strongly affect nurses’ morale and job satisfaction.7 The findings also documented that physicians viewed nurse-physician relationships as less important than did nurses and administrators.7 The journal Nursing conducted a major survey of nurse-physician relationships in 1991 that was repeated in 2007. In the more recent survey, a majority of nurses reported that they were basically satisfied with their relationships with physicians, indicating improvement from 1991, when only 43% of nurses reported satisfactory relationships.8 However, the 2007 survey found that 43% of nurses continue to have unsatisfactory relationships with physicians.8 Nurses mentioned several factors that influenced optimal nurse-physician relationships, including male physicians’ perceptions of traditional gender roles, physicians’ feelings of superiority combined with nurses’ feelings of inferiority and a hospital culture in which nurses were seen as subordinate to physicians.8 The 36

OR TODAY | July/August 2015

majority of the nurses responding to the 2007 survey reported they had been treated disrespectfully, experienced a sense of being inferior to physicians and believed their opinions were sometimes misunderstood or ignored.8 They also believed that healthcare organizations did not enforce sanctions for physicians who demonstrated disruptive behavior.8 Some of those surveyed also reported that older physicians and those from cultures characterized by male/female inequality were more likely to view nurses as subordinates.8 A literature review of physician-nurse collaboration proposed assessing collaboration in more depth, conducting studies to evaluate the effectiveness of communication improvement strategies and examining how senior physicians and nurses can affect interprofessional collaboration.9 The impact of gender and cultural differences in Mexico and the U.S. on nurse-physician relationships was the subject of a recent study. Results indicated that U.S. physicians and nurses expressed more positive attitudes about the value of collaboration than did their Mexican counterparts.10 In both countries, nurses had more positive attitudes toward collaboration than did physicians. There was no difference among female physicians in either country regarding nurse-physician collaboration.10 In a survey of 14 Magnet hospitals, power was the most important factor driving nurse-physician relationships.5 In this survey, five types of relationships were described, ranging from collegial to negative:5 • Collegial — “different but equal” — a true partnership • Collaborative: Mutual trust and respect produce willing cooperation • Student-teacher: Physicians and

nurses teach and explain. Power is unequal but patient outcomes benefit. • Neutral: A near absence of relationship • Negative: Avoidance of communication. Patient outcomes are compromised. The “different but equal” style characterizing collegial relationships benefits everyone: physicians, nurses and, most important, patients. Working as colleagues, nurses and physicians plan the most appropriate care for individual patients. Collegial relationships represent a true partnership in which nurses feel equal to physicians in caring for patients and both disciplines value the positive effect that medical expertise and nursing expertise combined have on patient care.5 In a collaborative relationship, willing cooperation results from mutual trust and respect. Nurses are afforded some power because of their close contact with patients and their experience in recognizing and solving patient care problems. However, power is not distributed equally.5 Nurses who describe their relationships with physicians as collegial or collaborative rank patient care quality significantly higher than do nurses in situations where power is less equally shared.5 In a studentteacher relationship, both physicians and nurses share information and are willing to explain and teach one another, although the physician member retains power. A neutral relationship is characterized by information exchange only; as a result, there is essentially no relationship.5 In a negative relationship, characterized as one of frustration and hostility, nurses communicate only what is essential. As a result, valuable nursing input necessary for WWW.ORTODAY.COM

CONTINUING EDUCATION 662B

positive patient outcomes is lost.5 In all 14 hospitals surveyed, a positive relationship was found between the quality of nurse-physician relationships and the perceived quality of patient care.5 All of these hospitals surveyed also had developed formal collaborative practice structures that provided a foundation for excellent collaborative practice.5 A SCALE OF ATTITUDES Responding to the need for increased emphasis on interprofessional teamwork, the Thomas Jefferson Medical College Center for Research in Medical Education and Health Care developed the Jefferson Scale of Attitudes Toward Nurse-Physician Collaboration.11 The following are some of the statements posed in this 15-item Likert-type rating questionnaire:11 • Physicians should be the authority in all healthcare matters. • A nurse should be viewed as a collaborator and colleague with a physician rather than an assistant. • Interpersonal relationships between physicians and nurses should be included in their educational programs. • Nurses are qualified to assess and respond to psychological aspects of patients’ needs. Negative nurse-physician relations jeopardize the ability of nurses to provide optimum patient care. One study reported that daily interactions between nurses and physicians strongly influenced nursing morale.7 Although this survey indicated that only between 2% and 3% of medical staff exhibit disruptive behavior, both nurses and physicians agreed that such behavior negatively affects nurses’ attitudes and is a barrier to the effective teamwork that is essential WWW.ORTODAY.COM

for safe and effective care. More than 92% of respondents in this study reported witnessing disruptive physician behavior, including yelling, acting in a condescending way, insulting or demeaning staff and using abusive language.7 Nurses reported that disruptive physician behavior was most likely to be associated with calls to physicians, questioning or trying to clarify orders and physician perceptions that orders were delayed. Physicians reported that not having orders carried out promptly and being called inappropriately were their major causes of concern. They also said that being contacted by nurses who lacked relevant patient information was a source of frustration.7 Nurses in this survey also documented barriers that prevented them from reporting abusive physician behavior, including fear of retribution, a perception that “nothing ever changes,” a lack of administrative support and an unwillingness to change on the part of some physicians. Fear of retribution or retaliation was cited as the most important reporting barrier.7 Physicians who avoid communicating with nurses can create an additional source of disruption, forcing nurses to provide care without the benefit of medical collaboration.12 Sixty-seven percent of nurses participating in both the Nursing 1991 and Nursing 2007 surveys reported they had witnessed disruptive physician behavior, confirming that this remains a major workplace problem. Physicians have learned certain behaviors that reinforce their dominant role in healthcare, such as expecting orders to be carried out immediately. Nurses have also learned a set of behaviors that are often reinforced in work settings, such as unassertive communication

and conflict avoidance. In addition to apologizing for interrupting a physician’s work, many nurses would rather avoid conflict than confront a problem head on. Many nurses also find it difficult to directly approach other nurses whose behavior is inappropriate.1 In addition, nurses often avoid communicating with physicians who demonstrate unpleasant behaviors.1 The good news is that learned behaviors can be replaced by new behaviors that can build professionally satisfying work relationships. WAITING FOR EMPOWERMENT Every nurse has the ability for self-empowerment. Rather than waiting for empowerment to be bestowed externally, individual nurses can take a leadership role in achieving collaborative practice relationships. The basis of professional partnerships is clinical competence. Nurse leaders can emphasize the importance of a “different but equal” relationship model by communicating that nursing knowledge is different from physician knowledge but as important to patient care.5 Nurse managers can promote a collegial working environment by supporting educational opportunities that continually enhance clinical competence.5 The literature on Magnet organizations describes the positive effect between nursing staff with higher education and improved patient outcomes.12 Encouraging nurses to obtain more nursing education and specialty certification is an important way to support nurses in becoming intellectual peers with physicians.12 Nurse leaders have a key role in this effort by implementing clinical ladders that emphasize professional development, designing flexible work schedules and providing tuition July/August 2015 | OR TODAY

IN THE OR CONTINUING EDUCATION 662B

and certification reimbursement.12 Nurses can continue to expand their clinical expertise through participation in continuing education programs and by being knowledgeable about research and evidence-based practice guidelines. Participation in nursing professional organizations is another way to be on the cutting edge of new developments. Participating on interprofessional committees provides nurses with the opportunity to have not only an important voice in organizational policies but also the opportunity for others to view nurses as professionals with excellent problem-solving abilities.3 Nurses who have served in leadership roles on hospital committees can role model to other nurses how to represent nursing in a positive way. Encouraging physician participation in nursing continuing education is a good opportunity for physicians to be exposed to the breadth of nursing knowledge. For example, a physician who is concerned about the quality of postoperative care for his or her patients could be invited to provide a program about specific surgical procedures and the critical importance of postoperative care. By encouraging physician involvement in educational activities, a nurse manager helps improve clinical knowledge and at the same time establishes a climate in which physicians and nurses can interact without the stress of solving immediate clinical problems.12 ZERO TOLERANCE Administrators should take the lead in establishing zero-tolerance policies for disruptive behavior from any staff member, including having physicians sign a code of conduct describing expectations for interprofessional collaboration when they 38

OR TODAY | July/August 2015

join the staff or are recredentialed.7 Physicians can also be encouraged to participate in nursing recruitment activities to let them gain an understanding of factors that matter to nurses seeking employment.7 Nurses can also learn more effective ways to communicate with physicians. Nurses and physicians use different communication styles. In general, nurses are narrative and descriptive as compared with physicians, who are listening for the bottom line.13 Thousands of times a day, a nurse calls a patient’s physician, often describing a broad narrative picture while the physician is waiting to hear what the problem is so it can be fixed.13 In addition, physicians consistently report frustration with nurses when they perceive a nurse has not gathered enough information or cannot appropriately express why a changing patient situation demands the physician’s attention. Obviously, nurses should be able to clearly articulate the reason for a call and should provide the data the physician needs to make a decision about diagnostic or treatment interventions. Nurses should also refrain from apologizing for making a call and should avoid making statements such as “I do not know this patient very well” or “This is not really my patient.” Kaiser Permanente has developed a communication tool known as SBAR (Situation, Background, Assessment and Recommendation) that provides a practical framework for organizing and communicating patient information.14 In the Situation section, the nurse states that he or she is calling about a specific patient and defines the problem (e.g., “the patient has developed a sudden change in mental status; he is disoriented and anxious”). The Background section prompts the

nurse to provide information about relevant assessment data (e.g., the patient’s prior mental status, vital signs and neurological status). In the Assessment section, the nurse clearly states what he or she thinks is the problem. In the final section, Recommendation, the nurse requests what he or she wants done, such as transferring the patient to intensive care, having the physician come in to see the patient or asking an on-call resident to see the patient promptly. The nurse also asks about whether the physician wants any additional diagnostic tests; if a change in treatment is ordered, the nurse also finds out what treatment outcomes are expected and the parameters for calling the physician again.14 SBAR can be an effective tool for nurse-physician communication, especially when a change in a patient’s conditions warrants close collaboration.13 A recent study of after-hours communication using SBAR reported that simply using an SBAR format didn’t ensure complete communication of vital information. In this study, nurses often did not communicate significant background information and physicians didn’t follow up by asking for necessary information.15 When a nurse advocates for a plan of action for a patient and the patient’s physician disagrees or ignores a recommendation, the nurse is put in a position of participating in an action that she or he believes is wrong.1 This is why it is vital for nurses to have managerial and administrative support for advocating for a patient’s best interests. Nurse managers can reward critical thinking about patient care issues and coach nurses about the most effective ways to advocate and communicate.12 Nurses consistently report that their work environment is the most significant problem underlying the nursing shortage; at the core of a rewarding and meaningful work environment is WWW.ORTODAY.COM

CONTINUING EDUCATION 662B

the quality of interpersonal relationships. The hectic pace of many patient care settings can reduce the quality of working relationships and in turn can negatively affect the work environment.1 In response to the need to do more and do it faster, the time healthcare professionals spend getting to know one another as individuals with a shared humanitarian purpose has eroded. By learning more about one another as people with families, pets, hobbies, aspirations and challenges, nurses and physicians can help create a working environment in which people are respected and valued.1 When was the last time you had the chance to talk with a physician about anything besides patient care — or he or she with you? If there is not time to build basic social relationships on a patient care unit, innovative ways to do so should be explored. Strategies such as teaching educational programs collaboratively or inviting physicians to unit social events can build the kind of down-to-earth relationships that are the basis for communicating about ways to care for patients.

Nurses might also consider the stresses on their physician colleagues, especially in today’s healthcare environment. Besides being expected to have expert and comprehensive knowledge and working harder and longer, physicians are faced with both reduced reimbursement for their services and skyrocketing malpractice rates. Creating open communication structures is a responsibility that nurses, physicians and administrators share. Outstanding nurse-physician relationships offer hospitals a competitive advantage. A healthy work climate saves money by lowering recruitment and turnover costs, and an organization gains market share when consumers and insurance providers see it as a safe environment with high-quality outcomes.12

7. Rosenstein AH. Nurse-physician relation-

MAUREEN HABEL, RN, MA, is an award-winning nurse author living in Seal Beach, Calif.

physician-nurse collaboration. Eval Health

VALUABLE STRATEGIES Nurses can take responsibility for improving nurse-physician collaboration and initiate strategies that free the profession from the subservient role that persists in some organizations.2 Valuable strategies include being assertive, approaching conflict directly rather than avoiding it and using a clear and persistent approach when communicating with physicians and other members of the healthcare team. Nurses can also benefit by role modeling their expertise in caring for patients holistically rather than focusing on tasks.2 Nurses who have excellent relations with their physician colleagues can be enlisted to coach and mentor younger nurses or those who wish to improve their collaboration skills.

Communication. Marblehead, MA: HC Pro

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REFERENCES 1. Bartholomew K. Speak Your Truth: Proven Strategies for Effective Nurse-Physician Inc.; 2005:8-9,32-33,42-45. 2. Danis S, Forman H, Simek PP. The nursephysician relationship: can it be saved? J Nurs Admin. 1998;28(7/8):3-53. 3. Sirota T. Nurse-physician relationships: improving or not? Nursing 2007;37(1):52-55. 4. Knaus WA, Draper EA, Wagner DP, Zimmerman JE. An evaluation of outcome from intensive care in a major medical centers. Ann Intern Med. 1986;104:410-418. 5. Kramer M, Schmalenberg C. Securing ‘good’ nurse physician relationships. Nurs Manage. 2003;34(7):34-38. 6. Manojlovich M, De Cicco B. Healthy work environments, nurse-physician communication and patients’ outcomes. Am J Crit Care. 2007;16(6):536-543.

ships: impact on nurse satisfaction and retention. Am J Nurs. 2002;102(6):26-34. 8. Sirota T. Nursing 2008 nurse/physician relationships survey report. Nurs. 2008;38(7):28-31. 9. Tang CJ, Chan SW, Zhou WT, Liaw SY. Collaboration between hospital physicians and nurses: an integrated literature review. Int Nurs Rev. 2013;60(3):291-302. 10. Hojat M, Nasca TJ, Cohen MJM, et al. Attitudes toward physician-nurse collaboration: a cross-cultural study of male and female physicians and nurses in the United States and Mexico. Nurs Res. 200l;50(2):123-128. 11. Hojat M, Fields SK, Rattner SL, Griffiths M, Cohen MJM, Plumb KM. Psychometric properties of an attitude scale measuring Prof. 1999;22(2):208-220. 12. Smith AP. Partners at the bedside: the importance of nurse-physician relationships. Nurs Econ. 2004;22(3):161-165. 13. Groff H, Augello T. From theory to practice: an interview with Dr. Michael Leonard. Docstock Web site. http://www.docstoc. com/docs/99481788/From-Theory-toPractice-An-Interview-with-Dr-MichaelLeonard. Published 2003. Accessed April 19, 2014. 14. SBAR technique for communication: a situational briefing model. Institute for Healthcare Improvement Web site. http:// www.ihi.org/explore/SBARCommunicationTechnique/Pages/default.aspx. Accessed April 19, 2014. 15. Joffe E, Turley JP, Hwang KO, et al. Evaluation of a problem-specific SBAR tool to improve after-hours nurse-physician phone communication: a randomized trial. Jt Comm J Qual Patient Saf. 2013;39(11):495-501.

July/August 2015 | OR TODAY

IN THE OR CONTINUING EDUCATION 662B

CLINICAL VIGNETTE Mrs. Sanchez, a 71-year-old who had a cystectomy three days ago, suddenly develops acute dyspnea. Her respiratory rate is 26 per minute, her pulse is 102 and regular, and her blood pressure has dropped from 122/72 to 104/66. Mrs. Sanchez also appears anxious. Suspecting a potential pulmonary embolus, the nurse calls the patient’s physician.

1. A. B. C. D.

What information is least relevant to have in preparation for the call? Vital signs Patient history of previous surgeries Onset and quality of dyspnea Patient history of previous PE or DVT

2. A. B. C. D.

When using the SBAR communication technique, the nurse’s initial statement should be: “One of your patients seems to have a problem.” “I’m sorry to bother you about this patient.” “I’m concerned about Mrs. Sanchez; she has suddenly developed acute dyspnea.” “Mrs. Sanchez is a postoperative patient on the following medications.”

3. A. B. C. D.

In this situation, what patient data should be reported first? Current medications and mental status Characteristics of the dyspnea, intake and output, current medications IV flow rate, oxygen saturation, intake and output Oxygen saturation, onset and quality of the dyspnea, changes in vital signs

4. A. B. C. D.

Before completing her conversation with Mrs. Sanchez’s physician, the nurse should ask about: The need for any diagnostic tests Treatment orders and what treatment outcomes are expected Parameters for reporting back to the physician All of the above

4. Correct answer: D — The last part of the nurse’s communication should include the items listed above, including clarification of diagnostic tests to be ordered, treatment orders and expected outcomes, and when and under what conditions the nurse should call the physician again. 3. Correct answer: D — Because this is a respiratory problem, information related to respiratory status, such as oxygen saturation, characteristics of the dyspnea and changes in vital signs, should be the information presented first. 2. Correct answer: C — The first part of the SBAR technique is to clearly state the situation. Giving the patient’s name, the clinical problem and the nurse’s concern alerts the physician to the problem. 1. Correct answer: B — The patient’s surgical history is not as relevant in this situation as is information about the patient’s change in vital signs, the onset and quality of dyspnea, and any history of PE or DVT. 40 OR TODAY | July/August 2015

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CONTINUING EDUCATION 662B

HOW TO EARN CONTINUING EDUCATION CREDIT 1. Read the Continuing Education article. 2. Go online to ce.nurse.com to take the test for $12. If you are an Unlimited CE subscriber, you can take this test at no additional charge. You can sign up for an Unlimited CE membership at www.nurse.com/unlimitedCE for $49.95 per year.

DEADLINE Courses must be completed by 5/15/2016. 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. Once you successfully complete the short test associated with the clinical vignette (if there is one), proceed to the course posttest. To earn contact hours, you must achieve a score of 75%. You may retake the test as many times as necessary to pass the test. 5. All users must complete the evaluation process to complete course. You will be able to view a certificate on screen and print or save it for your records.

ACCREDITED ContinuingEducation.com is accredited as a provider of continuing nursing education by the American Nurses Credentialing Centerâ&#x20AC;&#x2122;s Commission on Accreditation. Accredited status does not imply endorsement by the provider or ANCC of any commercial products displayed in conjunction with this activity. ContinuingEducation.com is also accredited by the Florida Board of Nursing (provider no. FBN 50-1489) and the California Board of Registered Nursing (provider no. CEP13213).

ONLINE Nurse.com/CE You can take this test online or select from the list of courses available. Prices subject to change.

QUESTIONS Questions or for a complete listing of our courses Phone: 800-866-0919 Email: ce@nurse.com

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July/August 2015 | OR TODAY

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CORPORATE PROFILE

LET’S GEL INC. Let’s Gel Inc. has a lot to be thankful for in 2015 and it all started on Thanksgiving day in 2002.

obb McMahan completed the tile floor in the kitchen of the home where he and his wife, Lisa, were hosting a family feast. Lisa had spent the day preparing the meal and everything appeared to be great, except for the leg and back pain she was having after standing on the hard tile floor for hours. Lisa ventured to a home improvement store where she bought some foam mats that helped with the pain, but they were not durable and did not last. Robb, an engineer, decided he could solve the dilemma himself. After countless late nights and hundreds of prototypes, he developed a mat design utilizing soft, shock-absorbing polymer gel as the cushioning element. Fast-forward 13 years and Robb is the founder and CEO of Let’s Gel Inc. Let’s Gel Inc., an Austin, Texasbased privately held corporation, is the leading manufacturer and provider of innovative ergonomic flooring products in the home, medical, and commercial flooring categories.

44 OR TODAY | July/August 2015

Robb explains how the company expanded from the residential market into the medical industry. “The way we got into this business wasn’t some genius move on my part. We constantly had hospitals contacting us about buying mats,” Robb says. “We had a surgeon, Dr. Jamie Landman, MD, contact us and he basically said ‘I absolutely love your product. It is wonderful. I won’t do a surgery without it. I want to do a study on your mat. Will you guys supply me with mats to do a study?’ We said, ‘Yes, absolutely.’ ” “We did the study with him and through feedback from Jamie we actually made some modifications to the mat,” Robb says. “We are the first and only manufacturer of ergonomic flooring with gel,” he adds. “Our mats have antimicrobial and anti-bacterial properties. The top surface provides the necessary friction level for use with damp or dry surgical booties. They are compatible with hospital grade quaternary cleaners and are NFPA 260 and Cal 117 compliant. GelPro mats are also certified by the National Floor Safety Institute for high-traction.” “The medical mat is a little more cushioned. It is 50 percent thicker than our standard mat that we sell in the residential marketplace,” Robb WWW.ORTODAY.COM

SPECIAL ADVERTISING SECTION

STAND IN COMFORT

The company is expanding its GelPro medical workplace offerings with its new Comfort Cushion Insoles to provide all-day anti-fatigue comfort to medical workers who walk and stand for prolonged periods of time.

says. “It’s a little more cushioned because what we found is that a lot of the surgeons and a lot of the surgeries, particularly the orthopedic surgeries, tend to go for a pretty long time. Some of these surgeries go four to eight hours. With feedback through this study, we actually modified the product and made the product better.” According to the randomized control study conducted by Columbia University’s School of Medicine, and led by Dr. Landman, it was concluded that the Let’s Gel products improved surgeons’ comfort and ergonomics during minimally invasive procedures, reducing the number of stretches and postural changes. Robb says it is easy for people to understand how the mats benefit people in health care facilities. He compares it to a shopping trip to the mall. After walking on the hard floor in the mall and then stepping onto a carpet or padded surface relief can be felt almost instantly. WWW.ORTODAY.COM

“Basically, the mat allows surgeons to stand in a more comfortable position for a longer period of time and have their focus on the work that they are doing as opposed to focusing on the pain they are experiencing from standing,” Robb explains. “As someone who has had knee surgery, and other surgeries in my life, I certainly want my surgeon to be pain free and focused on treating me.” The entry into operating rooms was a big success, but the need for Let’s Gel products did not stop there. Nurses and other hospital personnel soon began to contact the company for comfort solutions. Soon mats were placed at nurse stations and pharmacies as well as other areas of the hospital. These mats are the NewLife Eco-Pro Anti-Fatigue Mats. They are ergonomically designed to provide comfort and support. The company’s proprietary Cellulon Polyurethane Technology stands up to the tough demands of commercial environments while providing lasting

comfort that won’t bottom out over time. Manufactured in the USA, this eco-friendly line of anti-fatigue mats is certified by the National Floor Safety Institute for its high-traction bottom surface. “It is extremely durable, but the great thing about the polyurethane mats is that they have what we call a very high-energy return factor,” he adds. “They are very springy and very bouncy. So, they are super comfortable to stand on and they are great for walking back and forth on.” July/August 2015 | OR TODAY

CORPORATE PROFILE

THE SUCCESS OF THE MATS LED TO GROWTH AND NEW PRODUCTS Let’s Gel Inc. purchased a 64,000-square foot manufacturing facility in Waco, Texas in 2014. The facility, named Area 51 Manufacturing, is a wholly owned subsidiary of Let’s Gel Inc. The purchase of Area 51 Manufacturing was driven in-part by an increase in demand for the company’s mats. Additionally, the facility will support production of upcoming product lines in the operating room positional aid category, as well as other gel-based products, with plans to begin production in those categories in 2015. “Waco will be the exclusive manufacturing site of our premium line of comfort mats, GelPro Elite. Waco was chosen for its central location, skilled workforce and a commitment from the area city business leaders in driving the local economy,” Robb said. Area 51 Manufacturing currently employs about 40 people, with plans to expand in 2016. 46

OR TODAY | July/August 2015

THE COMPANY HAS ADDED A MEDICAL SALES VETERAN TO ITS LEADERSHIP TEAM To support the growing medical demand for comfort products, GelPro has named Will Jones as vice president of medical sales. Jones brings 31 years of experience in medical sales, most recently at Barton Medical where he sold and promoted a comprehensive portfolio of safe patient handling equipment and services. Jones will be responsible for expanding GelPro’s health care division. Also, the company is expanding its GelPro medical workplace offerings with its new Comfort Cushion Insoles to provide all-day anti-fatigue comfort to medical workers who walk and stand for prolonged periods of time. The new comfort insoles complement the GelPro Medical Mats used in operating rooms and NewLife Eco-Pro commercial mats used in nursing stations, radiology/imaging and pharmacies. The patented Comfort Cushion Insoles, made with half-inch thick, closed-cell foam, are placed under

shoes and into medical shoe covers to reduce discomfort and fatigue. The insoles, available by the case in small, medium and large sizes, are designed to be used for about 30 days or replaced as needed. “The foam in the Comfort Cushion Insoles cradles your shoes for all-day comfort and support, absorbing harmful impact while helping to prevent joint and muscle discomfort,” Jones said. “These insoles provide the extra support and relief that medical professionals need when they walk or stand all day in operating rooms, radiology, procedure areas, nurses’ stations, labs and pharmacies.” MORE MEDICAL PRODUCTS ARE ON THE WAY With GelPro’s extensive knowledge of foam and gel the company will begin offering operating room positional aides by the end of 2015.

FOR ADDITIONAL INFORMATION about these products, email Will Jones at willj@letsgel.com. WWW.ORTODAY.COM

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July/August 2015 | OR TODAY

could be e g a rt o sh is th f o s ce n The conseque any other in n a th m o ro g n ti ra e p greater in the o area of the hospital.

nurses

wa nted

aďŹ&#x192;ng rrent OR st u c h it w g n eali t lie ahead RATEGY: D llenges tha ONGED ST a R h c -P e O th W r T A : ng fo focuses on and prepari roach that p challenges p es, and a rs d nu e g ve n ti o-pro riopera tw pe a d s e e ifi ir al u q qu re ining hiring and reta f to maximize efficiency. 1 attracting, af st g in your exist 2 scheduling

OR TODAY | July/August 2015

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and Scheduling Strategies BY DON SADLER

he looming shortage of registered nurses in the U.S. has been well publicized. This shortage has been attributed to a number of different factors, including the retirement of many baby boomer nurses and the need for more health care services as the U.S. population ages.

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The consequences of this shortage could be greater in the operating room than in any other area of the hospital. “There’s a tsunami of change that’s coming at us,” says ChrysMarie Suby, RN, MS, the president and CEO of the Labor Management Institute. “Right now, we’re watching as the wave approaches the shore. It’s not here yet, but it will be soon.”

July/August 2015 | OR TODAY

and Scheduling Strategies

SOBERING STATS Suby cites a number of statistics that should be eye-opening to hospital and OR leaders. For example, about two-thirds of perioperative nurse leaders are over 50 years old and one-fifth are over 60. Also, 37 percent say they plan to retire within the next three years and 65 percent plan to retire by 2022. In addition, about half of all OR leaders say they are having problems recruiting perioperative nurses – and two-thirds expect to encounter problems over the next five years due to the age of their staff. The Institute of Medicine’s landmark report “The Future of Nursing” recommended that the number of baccalaureate-prepared nurses in the workforce should be increased to 80 percent, and the population of nurses with doctoral degrees should be doubled. The current nursing workforce falls far short of these goals, the report noted, with only 55 percent of registered nurses prepared at the baccalaureate or graduate degree level. Finally, the Bureau of Labor Statistics projects a need of 525,000 replacement RNs in the workforce between now and 2022. This is on top of the 527,000 projected new RN job openings during this timeframe. According to Suby, these statistics should be especially alarming for perioperative leaders because of the lack of perioperative training that most RNs receive in school. “There aren’t enough new nurses coming into the workforce who are

OR TODAY | July/August 2015

“

Once you have allocated block time to a surgeon or group, you’ve committed to having your staff and resources available to them at that time, so you should only allocate block time when it can be used effectively. This is especially crucial when you’re dealing with staff shortages. ” — Michelle Jackson

ready to enter the perioperative environment,” she says. Rachel Le Mahieu, RN, MSN, CNOR, RNFA, the director surgical services at Spring Valley Hospital in Las Vegas, Nevada, concurs. “There’s a steep learning curve for new nurses entering the OR,” she says. “Technology is advancing so fast that there’s a lot for them to take in, and training new OR nurses is a lengthy process.”

Le Mahieu estimates that it takes between six months and a year for new OR nurses to become comfortable in the job, at least two years for them to become proficient, and about five years for them to become experts. “It’s getting harder and harder to find qualified perioperative staff because there’s so much for them to learn,” says Le Mahieu. “This is especially true for specialty niche nurses: I’ve had two cardiovascular OR nurse positions open for over a year now.” A TWO-PRONGED STRATEGY Dealing with current OR staffing challenges and preparing for the challenges that lie ahead requires a two-pronged approach that focuses on: 1) attracting, hiring and retaining qualified perioperative nurses, and 2) scheduling your existing staff to maximize efficiency. Suby stresses the need to recruit nurses who are coming out of school into the perioperative field. “Too often, the focus is on critical care and emergency nursing, rather than on perioperative nursing,” she says. “Once new perioperative nurses have been hired, they need to be partnered with experienced OR nurses in formal mentoring programs.” Le Mahieu believes that solid training and support are essential to getting new perioperative nurses up to speed fast so they can contribute in the OR as quickly as possible. “It’s important to have a strong perioperative residency program so

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“Your scheduling practices should always accommodate your budget for full-time employees. When the schedule is detached from the budget, staff needs can be inflated by two or three people per shift. This results in unnecessary added expenses and staff floating.” — ChrysMarie Suby

you can ‘grow your own’ perioperative nurses,” she says. Creating the right workplace culture and environment is critical to retaining OR nurses once you’ve hired them. “This includes providing strong support to perioperative nurses in the OR environment,” says Le Mahieu. “For example, they need to know that OR leadership will have their backs if they have to stand up to a physician.” “If perioperative nurses don’t have the support they need to do their jobs, they’re not going to stay – no matter how well-paid they are,” Le Mahieu adds. Both Suby and Le Mahieu believe that hospitals should go above and beyond when it comes to perks and other benefits in order to retain perioperative nurses. These perks include things like tuition forgiveness and reimbursement, bonuses for developing new skills, continuing education opportunities, and flexibility in scheduling. OR SCHEDULING STRATEGIES The second prong of a strategy for dealing with staff shortages is scheduling OR staff for maximum efficiency. “Your scheduling practices should always accommodate your budget for full-time employees,” says Suby. “When the schedule is detached from the budget, staff needs can be inflated by two or three people per shift. This results in unnecessary added expenses and staff floating.” Most hospitals use block scheduling to allocate staff, facilities and WWW.ORTODAY.COM

resources on specific days at specific times to surgeons and surgical groups. Surgeons and groups can then schedule their cases accordingly. “Once you have allocated block time to a surgeon or group, you’ve committed to having your staff and resources available to them at that time,” says Michelle Jackson, the surgical scheduling systems supervisor for the Boise, Idaho campus of the St. Luke’s Health System. “So you should only allocate block time when it can be used effectively. This is especially crucial when you’re dealing with staff shortages.” Jackson manages scheduling for 60 ORs in six different facilities that handle more than 30,000 cases a year. In 2010, she helped launch an initiative designed to improve blocks utilization at her facility, which had an unmanaged system of block scheduling at the time with no monitoring or systematic approach. The initiative created a multidisciplinary block committee comprised of surgeons, perioperative managers and other key OR staff. Committee members were tasked with making decisions about policies governing utilization expectations, how unused block will be released, and what the consequences will be when blocks are not utilized most effectively. “If surgeons aren’t using their blocks effectively, they’re tying up resources that could be used by other surgeons and groups,” Jackson says. “This is why it’s so important to have a block management system that details procedures

holders must follow if they need to make changes to their blocks.” Since the initiative was started, block utilization at the St. Luke’s Health System campuses where it’s used has increased from the low-70 percent range to the mid-90 percent range, exceeding the average target for all physicians. Among the keys to this success, notes Jackson, have been obtaining high-level hospital support for block management and building strong partnerships with surgeons. She defines high-level support as the chief of surgery, COO, CFO or even CEO. “Without this support, the task is impossible,” says Jackson. She adds that implementing block management was something that was done with the surgeons, not to them. “We honed in on surgeons who were frustrated with the process when we opened up the scheduling committee,” Jackson says. Le Mahieu says her hospital has implemented what she calls modified block scheduling so that schedules are adapted to how surgeons are actually using their block. “We try not to block more than 75 percent of available OR time to save the remaining 25 percent for growth and add-on cases,” she says. Suby notes that with ORs contributing up to half or more of the typical hospital’s revenue, effective OR scheduling is more critical than ever. “You need to know your numbers and manage your dollars to make sure your ORs are running at peak efficiency at all times,” she says. July/August 2015 | OR TODAY

OR TODAY LIVE! CONFERENCE PREVIEW

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OR TODAY | July/August 2015

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Multisorb Technologies, Inc. Booth: 204 325 Harlem Road Buffalo, NY 14224 www.multisorb.com

St. Luke’s Health System Booth: 206 190 E. Bannock St. Boise, ID 83712 www.stlukesonline.org

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ENTRANCE INTERESTED IN EXHIBITING? LIMITED SPACE IS AVAILABLE. Visit ORTodayLive.com today to reserve a booth or call Bethany Williams at 800-906-3373.

July/August 2015 | OR TODAY

ABOUT HELPING PEOPLE SPOTLIGHT ON: PAMELA MOSS, RNC, BA

OR TODAY | July/August 2015

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wasn’t until after Pamela Moss graduated college with a psychology degree that she came to feel like that field might not be the best fit for her. “I just didn’t have the passion for it,” Moss said. “Psych has a lot of recidivism, where people just keep coming back,” she said. “There’s very few opportunities to actually help improve someone’s situation because there’s so many more socioeconomic factors” contributing to their problems. Those motivational hurdles – plus the feeling that she wouldn’t hit her earning potential without investing another two years in a master’s degree – led Moss to consider alternatives. She came to realize she’d always been surrounded by nurses in her life, and began to recognize how the field offers a wondrous variety of appointments, whether at the bedside in direct care, or at an informaticist’s workstation. Then her sister saw a newspaper ad for a nursing assistant training program at Hunterdon Medical Center in Flemington, New Jersey. “They had a program where nursing assistants become nurses,” Moss said. “They were going to help pay for that process, and there was a sign-on bonus as well. It was a really good opportunity.” For three years, Moss worked as a nursing assistant in a step-down unit, caring primarily for cardiac patients. When she got the opportunity to work in the cardiac catheterization lab, Moss found out that she also enjoyed assisting on angioplasties, stents, and the treatment of cardiac arrest patients. Working with a talented group of interventionalists gave her even more of an appreciation for the field of cardiac care, but Moss knew she’d found her niche when she saw how well her patients treated her. “My first week in the cath lab, one of the patients actually sent me flowers, which I thought was exceptionally sweet and wonderful,” Moss said. The husband of another patient with a chronic illness donated money in her name to the Hunterdon Medical Center. WWW.ORTODAY.COM

July/August 2015 | OR TODAY

SPOTLIGHT ON: PAMELA MOSS, RNC, BA

Then there were the moments of lifesaving, like the 50-year-old man who came into her care already intubated and suffering from a heart attack. Moss and her team used an Impella device to withdraw blood from his left ventricle during a critical period of his injury, and he was able to make a recovery. “I would encourage anybody who wants to pursue nursing to do it. The ﬁeld is changing, where we’re being looked at less as caregivers and more as providers.” — Pamela Moss, RNC, BA

“The person who came in was somebody that you think wasn’t going to make it,” she said. “He was doing so well [that] he was, in a week and a half, able to walk out of the hospital as if nothing [had] really happened to him.” “I really have the opportunity to help save someone’s life,” Moss said. “I don’t take that lightly. I enjoy the fact that I was lucky enough and fortunate enough to be in this type of nursing. I’m always learning something new. It’s exciting; it’s very stimulating intellectually.” Soon Moss had an opportunity to work in another cath lab, where she learned how to perform primary angioplasties. Today she works at the 200-bed New York Presbyterian/Lawrence Hospital in Bronxville, N.Y. After 10 years in the field, she’s preparing to earn a BSN or MSN, and plans to continue in cardiac care. 56

OR TODAY | July/August 2015

“Heart disease is the number one killer of all Americans,” Moss said. “The improvements in the medication, in the devices, allow for a much longer lifespan than previously.” “Dying from congestive heart failure is not an easy way to go,” she said. “It’s a long-term disease that keeps people from doing daily activities.” Although there aren’t specific elements of her psychiatric education that Moss misses, she occasionally has moments when she recalls elements of that background, usually when working to calm an anxious patient before a procedure. But by changing careers, the person whose psyche she’s most improved has been her own, Moss said. In making the decision to go back to school, Moss discovered that she is capable of tackling a challenge she might not have had the confidence to approach as a younger person.

“In my late teens and early twenties, I didn’t believe I was smart enough to get into nursing because of all the science of it,” she said. “When I was 31, it was a question of, ‘How hard are you willing to work to make it happen?’ That’s part of the challenge for anybody who thinks they might not be smart enough.” “Nursing school is still one of the hardest things that I had to do in my life,” she said. “You just continue to work hard, no matter what failures you have – and I’ve had plenty. It was really hard, and it was hard not to want to throw in the towel.” “I’ve never been more proud of myself than when I graduated nursing school,” Moss said. “The field really does allow you to go anywhere and do anything, and that opportunity is worth the struggle of nursing school.” On a week-on, week-off schedule, Moss has ample time to enjoy her hobbies – visiting art museums and the movies; going to yoga class or for a bike ride; cooking new foods with friends – and her favorite, which is travel. She’s headed to Dubai later this year, a trip she’s anticipating highly. All these opportunities are much more easily available to her thanks to the unique schedule and lifestyle that her nursing career has afforded her. “I would encourage anybody who wants to pursue nursing to do it,” she said. “The field is changing, where we’re being looked at less as caregivers and more as providers. We’re an active part of the health care team, [and] that really is part of being on the first line, looking after the patient, and being able to care for them.” WWW.ORTODAY.COM

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OUT OF THE OR HEALTH

BY HEIDI MCINDOO, MS, RD

VEGGIE

ROUNDUP

hen it comes to making sound nutrition choices, many would like it to be black and white. This food is good; this food is bad. This fruit is the worst; this vegetable is the best. However, healthy eating isn’t all black and white. Eating nutritiously is all about selecting a variety of wholesome foods. When it comes to vegetables, certainly all are good for you, but some are stronger in specific nutritional contributions. A nutrient-rich diet that protects against disease is packed with a variety of different vegetables.

veggies & pasta sauce

According to the USDA Dietary Guidelines, adults should consume 2 to 3 cups of vegetables daily, depending on age and gender. Unfortunately, many Americans aren’t reaching that goal. Getting the recommended amount of vegetables per day can help improve your overall health by lowering your risk of certain cancers, high blood pressure and cardiovascular disease. Vegetables, rich in fiber, also can help boost your digestive health and promote a healthier weight. And of course, eating your veggies helps you pack your diet with essential nutrients and antioxidant compounds. WWW.ORTODAY.COM

sandwhich stacking

If you’re trying to get more vegetables into your diet, try these tips. SANDWICH STACKING: If your sandwich is usually just bread, meat and cheese, consider adding a healthy layer of vegetables. In addition to the usual tomato and lettuce, try baby spinach, roasted red peppers, and shredded carrots. SOUP’S ON! Vegetable soups or pasta sauces are great vehicles to boost your vegetable intake. Add chopped peppers, carrots, mushrooms, zucchini and more to the pot as it simmers.

soups on!

CASSEROLE FILLERS: Macaroni and cheese, chili and other one-pot meals are delicious with extra vegetables mixed in, such as bell peppers, broccoli, corn or tomatoes.

– Environmental Nutrition is the awardwinning independent newsletter written by nutrition experts dedicated to providing readers up-to-date, accurate information about health and nutrition in clear, concise English. For more information, visit www.environmentalnutrition.com. July/August 2015 | OR TODAY

OUT OF THE OR FITNESS

BY CAROLINE KAUFMAN, M.S., R.D.N.

BEING UNDERWEIGHT IS RISKY BUSINESS

hile headlines often sound the alarm on the dangers of being overweight, less attention is given to the two percent of U.S. adults who are underweight. Their ranks may be smaller, but the health risks that affect many people who are underweight – a body mass index (BMI) below 18.5 – are significant. HEALTH RISKS FROM LOW BODY WEIGHT INCLUDE:

Increased risk of osteoporosis and fractures. Thin, small-boned women have an increased risk of osteoporosis, particularly if they are undernourished. Vitamin and mineral deficiencies contribute to hip fracture because they speed up bone loss, contribute to impaired coordination, and reduce the body’s ability to protect itself during a fall. The National Osteoporosis Foundation reports that 20 percent of seniors who break a hip die within one year

60 OR TODAY | July/August 2015

from problems related to the broken bone itself or the surgery to repair it. Many of those who survive a fall require long-term care.

Increased risk of death from chronic obstructive pulmonary disease (COPD). Underweight patients had a 1.7 times higher risk of death from COPD compared to people with a normal BMI, according to an abstract presented at the 2011 European Respiratory Society’s Annual Congress in Amsterdam.

Increased risk of death from surgery. According to a 2012 study in JAMA Surgery, of the nearly 200,000 patients who underwent major surgery, those with a BMI under age 23.1 were 40 percent more likely to die within 30 days of the surgery compared to overweight patients (BMI of 25-29.9). BEYOND WEIGHT Though an underweight BMI may compromise your health, newer research reveals that it may not tell the whole story. Other factors may

be better indicators of health, such as casual walking speed and muscle strength, according to Zhaoping Li, Ph.D., M.D., Chief of the Division of Clinical Nutrition at the David Geffen School of Medicine at UCLA. BMI vs. percent body fat: For post-menopausal women and Asian women, who have a genetic predisposition for abdominal obesity even when they have a low or normal BMI, percentage of body fat is better at predicting health risks than BMI, according to Li. For example, many women weigh the same before and after menopause, but they lose muscle and gain abdominal fat (belly fat). Unlike fat in other parts of the body, belly fat causes inflammation that contributes to chronic diseases like heart disease and diabetes. What contributes to being underweight? Outside of cancer, chronic lung disease and heart failure, common causes include: 1. Underlying medical conditions, such as hypothyroidism and eating disorders WWW.ORTODAY.COM

FITNESS

JACKPOT! MDEXPO IS HEADING TO VEGAS!

2. Not eating enough food. 3. Heavy alcohol or drug use. 4. Conditions that affect your body’s ability to absorb nutrients, such as irritable bowel disease or Crohn’s disease. 5. Depression and anxiety. 6. Certain medications, particularly antidepressants, blood pressure and osteoporosis medications, which may decrease appetite, and aspirin and ibuprofen, which can upset your stomach. 7. Barriers to buying, transporting, or cooking food, which can include anything from breaking a bone to financial hardship. STEPS TO HEALTHY WEIGHT GAIN Are you having trouble gaining weight because you’re tired and don’t have an appetite? You’re not alone. Those are the two most challenging obstacles to overcome, says Lori Zanini, RD, CDE, spokesperson for the Academy of Nutrition and Dietetics. • MAKE MINI MEALS. Don’t worry about sitting down for large, daunting dinners. Instead, eat small meals every 2-3 hours. • START SMALL. Start meals with foods that pack a lot of nutrients and calories into small servings, like eggs, peanut butter, avocados, nuts and seeds.

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• GET STRONG. Do weight-bearing exercises, like strength training yoga, tai chi, or brisk walking at least three times a week. Since muscle weighs more than fat, these exercises help you gain weight, plus they’ll help you boost energy levels and protect bones. • DRINK YOUR CALORIES. Get in on the smoothie and juice trend! To boost nutrition and add extra calories, throw in avocado, dry oats, nut or seed butters, tofu, pre-cooked rice, protein powder, cottage cheese, milk powder, or yogurt. It’s faster and feels less filling to drink calories rather than chew them. • ADD EXTRAS. No matter what you’re making, add something high-calorie and nutritious to the mix. Pour extra olive or canola oil into the pan when you’re cooking vegetables, sprinkle nuts or sesame seeds on top of cooked dishes, add avocado slices to a sandwich, and sprinkle granola over yogurt. • STASH YOUR SNACKS. Keep snacks everywhere so you always have an opportunity to eat a mini-meal. Leave granola bars in the car, trail mix at work, and energy bars in your bag.

Reprinted with permission from Environmental Nutrition, a monthly publication of Belvoir Media Group, LLC. 800-829-5384. www.EnvironmentalNutrition.com.

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OUT OF THE OR NUTRITION

BY CAMERON HUDDLESTON, KIPLINGER PERSONAL FINANCE

YOU CAN BUY ORGANIC FOOD WITHOUT BUSTING YOUR BUDGET

ention organic food to shoppers and they often respond that it’s too expensive. For the most part, they’re right. A recent Consumer Reports study found that organic foods cost 47 percent more, on average, than conventional foods. As such, it’s not surprising that Whole Foods, the grocer most associated with organic and natural food offerings, is often referred to as “Whole Paycheck.” To combat that reputation, the company just announced that it will be launching a chain of less expensive stores aimed at price-conscious Millennial shoppers. But Whole Foods didn’t specify when it was opening the new stores or where they’d be located. So what can you do in the meantime if you want to buy organic for less? For starters, it’s important to understand that prices on many organic items can be the same as or even lower than the prices on their conventional counterparts.

OR TODAY | July/August 2015

The Consumer Reports study found this to be true on several organic products, including lettuce, carrots, maple syrup and olive oil. Kiplinger’s independent research found that even Whole Foods has surprisingly low prices on certain organic items including organic milk, chicken broth and peanut butter. In other words, saving money on organic foods doesn’t just come down to what you buy but where you buy it. Try shopping at these places to keep costs down:

ALDI This low-cost supermarket chain originated in Germany and now operates about 1,400 locations in the U.S. Aldi keeps its prices low because of its no-frills approach – you have to bag your own groceries, for example – and its lineup of exclusive brands. The organic selection isn’t extensive, but the items that are available tend to be priced lower than similar products at supermarkets and Whole Foods. For example, a 25-ounce jar or organic marinara sauce at Aldi’s is between 50 cents $2 less than similar sauces at other grocers we checked.

TRADER JOE’S This quirky grocery chain, with more than 400 locations across the U.S., is known for its low prices. Many of its organic offerings are bargains compared with similar products at supermarkets and organic grocers. Fruits and vegetables, beef, yogurt and coffee are among its top organic deals. For example, we found that a 6-ounce package of organic spinach was $2 less at Trader Joe’s than at several supermarkets we checked.

WAL-MART The mega-retailer has used its size and scale to make organic affordable, says Wal-mart spokesperson Molly Blakeman. Wal-mart stocks 1,600 organic grocery items, including a line of packaged goods from the Wild Oats brand, which once was a chain of natural food stores that was bought by Whole Foods. About 3,800 Wal-mart stores have at least 30 Wild Oats products and 2,200 stores have more than 70 of the brand’s items, Blakeman WWW.ORTODAY.COM

NUTRITION

says. The prices are on par with similar conventional items and at least 25 percent lower, on average, than national organic brands, she says. Among products in the line are rice, pasta, crackers, cookies and olive oil. Wal-mart also offers 50 organic produce items under its Marketside brand; however, we found that Aldi and Trader Joe’s tend to have lower prices on organic fruits and vegetables. WAREHOUSE CLUBS You’ll pay $45 or more a year to join a warehouse club such as Costco, BJ’s or Sam’s Club. But you can recoup the annual fee with the savings you’ll get by buying warehouse clubs’ discounted bulk items, especially organic fare. For example, BJ’s organic chicken breasts are about $1 to $3 less per pound than at the other stores we

WWW.ORTODAY.COM

checked; a 26-ounce jar of organic peanut butter costs about the same as 16-ounce jars at other stores; and organic maple syrup costs about half as much per ounce. BJ’s carries a total of 150 organic items, and both BJ’s and Sam’s Club offer free one-day passes if you want to check out the organic offerings before committing to a membership. BJ’s is currently offering a free 60-day trial membership if you sign up by July 5. It’s worth noting that to take full advantage of warehouse clubs’ discount pricing, you need to be able to consume the entire amount of your bulk purchases before those items spoil or expire.

vendor at the same market, it’s hard to claim that this option is one of the best places across the board to buy organic on a budget. Plus, although you might find an abundance of naturally grown or raised produce, you likely won’t find many, or any, items that are actually certified organic, which requires meeting requirements set by the U.S. Department of Agriculture. Nonetheless, it’s worth doing some comparison shopping of your own at your local farmers market to see how its prices stack up. There’s a good chance you’ll find that it won’t cost you more than shopping at the supermarket, and might cost less.

FARMERS MARKETS Because prices can vary greatly from market to market and even vendor to

– Environmental Nutrition

July/August 2015 | OR TODAY

OUT OF THE OR RECIPE

BY DIANE ROSSEN WORTHINGTON

A SERIOUSLY SIMPLE CLASSIC

OR TODAY | July/August 2015

WWW.ORTODAY.COM

RECIPE

love grilled chicken breasts, but they can turn out dry and somewhat flavorless. I have a couple of different techniques I like to use to avoid these pitfalls. Make sure to grill the chicken on medium-high heat quickly so it doesn’t have time to dry out. Cook the breasts with the skin on for a juicier result. Marinate the chicken for up to two hours before cooking to add flavor without changing the texture of the chicken. The only caveat to this is,

while marinating, if you are using a sticky-sweet barbecue sauce, just season the breasts and rub them with oil before cooking. Wait until five minutes before the chicken is done to brush on the sweet sauce so it doesn’t remain over the flame long enough to burn. Finally, make sure that the breasts are of uniform thickness for even cooking by pounding them between sheets of waxed paper. This recipe works perfectly with lean chicken breasts, and the sauce is a Seriously Simple classic that I serve often. It is a variation on the internationally popular chimichurri sauce

that appears on grilled meats in Argentina. It is as common there as ketchup is here. I added sweet white balsamic vinegar to the mixture, but you could also use sherry or champagne vinegar if you like. The basics of chimichurri sauce are parsley, lots of garlic, vinegar and olive oil. You can make your own signature variety with the addition of compatible ingredients. Some ideas include adding capers, shredded carrots, celery, red bell pepper and even anchovies. Some ingredients remain uncooked while others meld together when left simmering for a few minutes.

GRILLED CHICKEN BREASTS WITH HERBED GREEN SAUCE Serves 4-6

SAUCE: 5 medium garlic cloves, peeled and dark ends 1 1/4 1/4 3/4 3/4 1/4 1/4 1 1/4 •

removed small bunch Italian parsley, stems removed cup fresh basil leaves cup fresh dill leaves teaspoon dried oregano cup olive oil cup white balsamic, sherry or other white vinegar cup water or chicken stock teaspoon lemon zest teaspoon crushed hot pepper flakes, or to taste Salt and freshly ground black pepper to taste

MARINADE: 3 tablespoons Herbed Green Sauce 2 tablespoons olive oil 3 whole medium chicken breasts, halved,

In a food processor, fitted with the metal blade, mince the garlic. Add the parsley, basil, dill and oregano, and process until finely chopped. Add the oil, vinegar, water, lemon zest and seasonings, and process. Taste for seasoning. It should be very flavorful and spicy. Adjust if necessary, and set aside. Combine the marinade ingredients in a small mixing bowl and mix until smooth. Taste for seasoning. Place the chicken breasts in a zip-lock bag and pour in the marinade. Make sure the marinade is evenly distributed. Zip the bag and refrigerate for 1/2 to 4 hours. Prepare the barbecue for medium-heat grilling. Remove the chicken from the marinade and grill about 3 inches from the flame for 7 to 10 minutes on each side or until no pink color is showing. Place on a platter and serve with the sauce on the side.

boned and flattened

ADVANCE PREPARATION:

The sauce can be made up to five days ahead, covered and refrigerated. Just make sure to remove it from the refrigerator a half hour before serving. WWW.ORTODAY.COM

Diane Rossen Worthington is an authority on new American cooking. She is the author of 18 cookbooks, including “Seriously Simple Parties,” and a James Beard Award-winning radio show host. You can contact her at www.seriouslysimple.com. July/August 2015 | OR TODAY

OUT OF THE OR PINBOARD

PINBOARD

The News and Photos That Caught Our Eye This Month

OR TODAY

CONTESTS • JULY/AUGUST • OR Today is extending the June contest! Snap a selfie while on vacation with your copy of OR Today and you could win FREE lunch for your department. Email the photo along with your name, title and contact information to jwallace@mdpublishing. com. Every entry wins a $5 gift card, but remember that the most creative photo wins a pizza party!

THE WINNER GETS LUNCH FOR THE ENTIRE TEAM!

Win Lunch! 66

OR TODAY | July/August 2015

{

EACH SUBMISSION WINS A $5 GIFT CARD!

Pass the Pistachios RESEARCHERS LINK PISTACHIOS TO LOWER BLOOD PRESSURE

Pistachio nuts, singled out among other nuts, seem to have the strongest effect on reducing blood pressure in adults. This is according to a recent review and scientific analysis of 21 clinical trials, all carried out between 1958 and 2013. The review appears online in The American Journal of Clinical Nutrition, a publication of the American Society for Nutrition. The researchers concluded that nut consumption can reduce blood pressure and particularly systolic blood pressure. Of the nuts studied, pistachios seemed to have the strongest effect in reducing both systolic and diastolic blood pressure. •

WWW.ORTODAY.COM

PINBOARD

“The very ﬁrst requirement in a hospital is that it should do the sick no harm.” – Saint Basil

HOT BREAKFAST IS A MORNING WIN

The verdict is in: breakfast matters. In fact, 93 percent of Americans agree breakfast is the most important meal of the day, according to International Food Information Council Foundation, 2011 Food & Health Survey. For a wholesome, convenient breakfast consider El Monterey Signature Breakfast Burritos, including Egg, Sausage & Cheese; Egg & Bacon; Egg, Sausage Cheese & Potato; Egg, Cheese & Jalapeño; and the new Meat Lovers, made with egg, sausage, bacon and cheese. Each burrito is a source of protein, made with ingredients like scrambled eggs, cheddar cheese, sausage and fresh-baked flour tortillas. And, the burritos can be ready in just three and a half minutes in the microwave, making them an easy breakfast for people on the go. •

photo provide

d by el mont erey

Breakfast Mat ters

TRAVEL HEALTHY AND PROTECT YOUR BACK

Heady anticipation of summer travel plans can mask the fact that travel itself can leave our backs – which often bear the brunt of heavy luggage – vulnerable to injury, according to Daveed Frazier, MD, an orthopedic spine surgeon at Atlantic Spine Center.

Travel Safe

WWW.ORTODAY.COM

Here are some tips to avoid back pain: • Bending at the knees and using leg muscles to lift bags, rather than bending at the waist. • Avoiding twisting the lower back while lifting bags. • Distributing weight evenly on each side of the body • Carrying shoulder bags on alternate shoulders for short periods of time to avoid stressing one side of the back. • Renting a pushcart to move through stations and airports. • Taking advantage of curbside check-in at the airport so you don’t have to handle your bags yourself.

July/August 2015 | OR TODAY

OR TODAY | July/August 2015

WWW.ORTODAY.COM

Your Medical Product Support Network. Reasons to join MedWrench: 1. Get ANSWERS to tough medical equipment issues. 2. SHARE knowledge by providing solutions to others. 3. STAY CURRENT with new products and equipment news. 4. Find QUALITY vendors and service providers. Â 5. Create your own MY BENCH for quick access to product resources.

FREE to join! www.MedWrench.com WWW.ORTODAY.COM

July/August 2015 | OR TODAY

INDEX ALPHABETICAL AAAHC…………………………………………………………………15

Government Liquidation…………………………………IBC

Palmero Health Care……………………………………… 58

Bio-Medical Equipment Service Co.…………… 32

Healthmark Industries…………………………………… 22

Paragon Service……………………………………………… 42

Bryton Corporation………………………………………… 26

Innovative Medical Products, Inc………………… 72

Polar Products, Inc………………………………………………21

C Change Surgical……………………………………………… 9

Jet Medical Electronics………………………………………21

Ruhof Corporation…………………………………………… 2-3

Curbell Medical Products, Inc.………………………… 5

Kapp Surgical Instruments, Inc.…………………… 25

Sage Services…………………………………………………… 63

Dabir Surfaces……………………………………………………15

Key Surgical, Inc.………………………………………………… 4

Surgical Power………………………………………………… 32

Doctors Depot………………………………………………… 57

MD Technologies……………………………………………… 58

TBJ, Inc.……………………………………………………………… 33

Enthermics Medical Systems, Inc.………………… 43

MedWrench……………………………………………………… 69

Tru-D……………………………………………………………………… 6

GelPro…………………………………………………………… 44-47

Pacific Medical LLC……………………………………………14

INDEX CATEGORICAL ACCREDITATION AAAHC…………………………………………………………………15 ANESTHESIA Doctors Depot………………………………………………… 57 Paragon Service……………………………………………… 42

Government Liquidation…………………………………IBC MedWrench……………………………………………………… 69 Surgical Power………………………………………………… 32 HAND/ARM POSITIONERS Innovative Medical Products, Inc………………… 72

APPAREL Healthmark Industries…………………………………… 22

HIP SYSTEMS Innovative Medical Products, Inc………………… 72

ASSOCIATIONS AAAHC…………………………………………………………………15

INFECTION CONTROL/PREVENTION Government Liquidation…………………………………IBC Palmero Health Care……………………………………… 58 Ruhof Corporation…………………………………………… 2-3 Tru-D……………………………………………………………………… 6

AUCTIONS Government Liquidation…………………………………IBC MedWrench……………………………………………………… 69 BEDS Innovative Medical Products, Inc………………… 72 CARDIAC SURGERY C Change Surgical……………………………………………… 9 CABLES/LEADS Sage Services…………………………………………………… 63 CLEANING SUPPLIES Ruhof Corporation…………………………………………… 2-3 CLAMPS Innovative Medical Products, Inc………………… 72 DISPOSABLES Government Liquidation…………………………………IBC Kapp Surgical Instruments, Inc.…………………… 25 Sage Services…………………………………………………… 63 ENDOSCOPY Government Liquidation…………………………………IBC Kapp Surgical Instruments, Inc.…………………… 25 MD Technologies……………………………………………… 58 Ruhof Corporation…………………………………………… 2-3 TBJ, Inc.……………………………………………………………… 33 GEL PADS Innovative Medical Products, Inc………………… 72 GENERAL GelPro…………………………………………………………… 44-47

OR TODAY | July/August 2015

INSTRUMENTS Government Liquidation…………………………………IBC INTERNET RESOURCES MedWrench……………………………………………………… 69 KNEE SYSTEMS Innovative Medical Products, Inc………………… 72 LABROATORY TBJ, Inc.……………………………………………………………… 33 LEG POSITIONERS Innovative Medical Products, Inc………………… 72 MONITORS Jet Medical Electronics………………………………………21 OR TABLES/ ACCESSORIES Bryton Corporation………………………………………… 26 Dabir Surfaces……………………………………………………15 Innovative Medical Products, Inc………………… 72

POSITIONING AIDS Innovative Medical Products, Inc………………… 72 POSITIONERS/IMMOBILIZERS Innovative Medical Products, Inc………………… 72 RADIOLOGY REPAIR SERVICES Bio-Medical Equipment Service Co.…………… 32 Pacific Medical LLC……………………………………………14 SHOULDER RECONSTRUCTION Innovative Medical Products, Inc………………… 72 SIDE RAIL SOCKETS Innovative Medical Products, Inc………………… 72 SOCIAL MEDIA MedWrench……………………………………………………… 69 STERILIZATION Key Surgical, Inc.………………………………………………… 4 TBJ, Inc.……………………………………………………………… 33 Tru-D……………………………………………………………………… 6 SURGICAL AAAHC…………………………………………………………………15 Kapp Surgical Instruments, Inc.…………………… 25 MD Technologies……………………………………………… 58 Polar Products, Inc………………………………………………21 Surgical Power………………………………………………… 32 SURGICAL SUPPLIES Government Liquidation…………………………………IBC Ruhof Corporation…………………………………………… 2-3 SURPLUS MEDICAL Government Liquidation…………………………………IBC

ORTHOPEDIC Surgical Power………………………………………………… 32

SUPPORTS Innovative Medical Products, Inc………………… 72

PATIENT AIDS Innovative Medical Products, Inc………………… 72

TEMPERATURE MANAGEMENT C Change Surgical……………………………………………… 9

PATIENT MONITORING Bio-Medical Equipment Service Co.…………… 32 Curbell Medical Products, Inc.………………………… 5 Pacific Medical LLC……………………………………………14

WARMERS Enthermics Medical Systems, Inc.………………… 43

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