OR Today - December 2016 by MD Publishing

SPOTLIGHT ON

PAMELA ELZY PAGE 58

TAKE GOOD CARE

CONTINUING EDUCATION

HAND HYGIENE PAGE 36

NURSES • SURGICAL TECHS • NURSE MANAGERS

NUTRITION

BRUSSELS SPROUTS PAGE 66

DECEMBER 2016

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TeamSTEPPS Team Strategies and Tools to Enhance Performance and Patient Safety

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OR TODAY | December 2016

TEAMSTEPPS There is increased emphasis on patient safety at all levels of the health care delivery system. Some health care organizations are implementing a program developed with input from the Department of Defense as part of their efforts to improve patient safety. Referred to as TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety), this evidence-based framework is designed to improve health care professionals’ teamwork and communication skills as they relate to improving patient safety.

SPOTLIGHT ON: PAMELA ELZY Pamela Elzy is a system-wide director of clinical education. It’s been a long climb to the position she’s earned through years of schooling and dedication to the advancement of her peers as well as herself. For Elzy that experience has yielded a degree of clarity about the field. She still credits her OR background as a new graduate with helping her understand nursing at its most basic level.

OR Today (Vol. 16, Issue #10) December 2016 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. © 2016

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December 2016 | OR TODAY

CONTENTS

departments

PUBLISHER

John M. Krieg | john@mdpublishing.com

VICE PRESIDENT

Kristin Leavoy | kristin@mdpublishing.com

31 13

EDITOR

John Wallace | jwallace@mdpublishing.com

ART DEPARTMENT Jonathan Riley Jessica Laurain Kara Pelley

ACCOUNT EXECUTIVES

Warren Kaufman | warren@mdpublishing.com Jayme McKelvey | jayme@mdpublishing.com

Chandin Kinkade | chandin@mdpublishing.com

ACCOUNTING Kim Callahan

WEB SERVICES

INDUSTRY INSIGHTS 11 16 18 22

News & Notes AAAHC Update OR Culture Clorox Advice

IN THE OR 24 27 28 36

Taylor Martin Cindy Galindo Alicia Dent Adam Pickney

CIRCULATION Lisa Cover Laura Mullen

Suite Talk Market Analysis Product Showroom CE Article

OUT OF THE OR 60 Health 62 Fitness 66 Nutrition 68 Recipe 71 Pinboard 74 Index

OR TODAY | December 2016

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

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INDUSTRY INSIGHTS NEWS & NOTES

NEWS & NOTES

KEY SURGICAL AWARDED AGREEMENT WITH PREMIER INC. Key Surgical has been awarded a group purchasing agreement for instrument cleaners and enzymatics with Premier Inc. The new agreement allows Premier members, at their discretion, to take advantage of special pricing and terms pre-negotiated by Premier for instrument cleaning brushes and enzymatics. The complete line of surgical instrument cleaning brushes from Key Surgical includes everything from brushes designed for cleaning inner channels/lumens of surgical instruments to external cleaning of box locks and hinges to

brushes intended specifically for endoscope cleaning. The brushes feature several bristle materials and handle types/styles to keep up with various/changing needs. In addition to brushes used in the process of decontamination, Key Surgical also carries brushes that can be sterilized and used in the operating room to keep instruments, such as rasps and saws, free of debris during a procedure. Additionally, Key Surgical’s brush cleaning line includes products designed for clean verification. •

AAAHC LAUNCHES INDUSTRY-FIRST QUALITY IMPROVEMENT DIY RESOURCE The Accreditation Association for Ambulatory Health Care (AAAHC) released its first-ever Illuminating Quality Improvement toolkit, a robust bundle of behind-the-scenes resources previously available only through in-person courses. The comprehensive kit provides step-bystep guidance to execute QI studies that can in turn drive improved outcomes and boost patient satisfaction. “Quality improvement studies are an essential step toward achieving accreditation in this industry, but they can be intimidating for the time-stretched professional,” said Cheryl Pistone, RN, MA, MBA, clinical director of ambulatory operations for AAAHC. “This toolkit is the self-study version of a half-day course, allowing users to review and absorb the information on their own schedule.” The information and resources in the Illuminating Quality Improvement toolkit are based on a WWW.ORTODAY.COM

facilitator-led seminar offered by AAAHC at accreditation conferences. Designed to be used on-site in a health care organization, the resource provides a userfriendly guide to the QI component of the AAAHC accreditation process. Designed to assist those looking to be accredited, the kit offers value beyond AAAHCaccrediting organizations to any ambulatory health care provider seeking to identify disparities and improve outcomes. The Illuminating QI toolkit is a complete set of information and templates users can complete and refer to in assessing quality activities for continuing relevance and identifying when they have the potential to launch meaningful improvement studies. The bundle includes a worksheet for identifying possible study topics, explanations on how to develop measurable performance goals and exercises to help users look at

finished studies and evaluate them. The packet also aligns with the 10 elements of AAAHC Standards for Quality Improvement studies, offering modules that explain how to conduct a complete Quality Improvement study that demonstrates compliance with the Standards. By following the comprehensive guides, worksheets and tools in the QI toolkit, health care organizations can avoid pitfalls that may hamper efforts to meet accreditation Standards – such as constructing a study with unrealistic goals or submitting a study that is missing a key component. • The Illuminating QI Toolkit is available for $125 at www.aaahc.org/publications. December 2016 | OR TODAY

INDUSTRY INSIGHTS NEWS & NOTES

STAFF REPORTS

BD, VANCIVE MEDICAL TECHNOLOGIES LAUNCH VASCULAR DRESSINGS WITH CHG ANTIMICROBIAL BD (Becton, Dickinson and Company) and Vancive Medical Technologies, an Avery Dennison business, have launched a line of transparent vascular dressings with chlorhexidine gluconate (CHG) antimicrobial preservative that are designed to enhance patient care and be easy for clinicians to apply and remove. The new BD ChloraShield dressings, which feature BeneHold CHG, an innovative adhesive technology from Vancive Medical Technologies, comfortably secure the dressing to the skin, absorb

fluids and protect the site from external contaminants. The CHG incorporated within the adhesive preserves the dressing from microbial growth, making them well-suited for catheter insertion sites. The Infusion Nurses Society recently released guidelines recommending the use of CHG dressings. BD is the exclusive distributor of the dressings worldwide. “The combination of vascular access expertise from BD, infection prevention expertise from the CareFusion acquisition and CHG adhesive technology from Vancive

Medical Technologies creates a powerful combination for a new vascular access product,” said Stephen Hartley, global vice president of Infection Prevention for BD. “The new ChloraShield IV dressings complete BD’s portfolio to offer a comprehensive set of products for vascular access procedures, including skin prep, catheters, connectors and flush products.” BD ChloraShield dressings are available in a variety of designs including bordered and non-bordered as well as sizes commonly used for peripheral IVs and PICCs. •

SURGICAL CHECKLIST BOARDS PREVENT ‘NEVER EVENT’ ERRORS The Checklist Boards Corporation has announced the successful installation of Surgical Checklist Boards at their 500th client hospital. “We are pleased to announce Checklist Boards’ products have met our health care industry goal to reduce medical procedure risk by preventing errors and saving lives. We receive positive feedback from our clients concerning readmissions, cost savings and improved patient safety,” Rick Taylor, President of the Checklist Boards Corporation, reports. Nathan Mast, Patient Safety Officer at Humility of Mary Health Partners of Central Ohio reports a 31 percent reduction in readmissions and a savings of $2 million after the installation of Checklist Boards Corporation products. “We use Checklist Boards in our surgical suites. The Joint 12

OR TODAY | December 2016

Commission noted them as a Best Practice,” Sandra Washington, Chief Nursing Officer Department of Veterans Affairs reports. A Checklist Board is easy to see and easy to use. The large, interactive checklist has line items that the surgical team confirms as complete. The Right Patient, Right Procedure, and Right Side are only the beginning. Depending on the surgery or invasive procedure, up to 25 line items are included. Each Checklist Board is custom made to the hospital’s exact specifications and may include Time-Out confirmations for before, during and after procedures. Today, 500 hospitals use Time-Out Surgical Checklist Boards before, during and after every procedure. •

WWW.ORTODAY.COM

NEWS & NOTES

MEDLINE ANNOUNCES PINK GLOVE DANCE VIDEO WINNERS This year, physicians, administrators, nurses, breast cancer survivors and community members from 16 different states donned pink exam gloves and created dance videos for breast cancer awareness. It was part of the sixth annual Medline Pink Glove Dance Competition. The votes are in and University Medical Center of El Paso is the grand-prize winner. Receiving 18,276 votes, the most votes overall, El Paso’s only not-for-profit, community-owned hospital and health care system has won a $15,000 donation from Medline to Sobreviviendo el Cancer de Seno (Surviving Breast Cancer) Infusion Center. Furthermore, El Paso raised an additional $3,500 for their breast cancer charity of choice to fulfill the competition fundraising requirement.

“Winning the Medline Pink Glove Dance Competition is a victory for all of El Paso, especially for the many women in our community affected by breast cancer,” said Jacob Cintron, President and CEO of University Medical Center of El Paso. “From inception to completion of our video, volunteer support from throughout our hospital and community poured in to create a message of hope and encouragement. We are confident there will come a day when a cure will be found and contests such as these will not be needed. Until then, however, we are honored to have taken another step toward that eventual victory through this wonderful and generous contest.” • VISIT www.pinkglovedance.com to view this year’s winning videos.

CLOROX HEALTHCARE INTRODUCES NEXT GENERATION OF BLEACH Clorox Healthcare has announced the introduction of Clorox Healthcare Fuzion Cleaner Disinfectant. Fuzion combines bleach efficacy against tough-tokill pathogens with the aesthetics required for broad use throughout health care facilities. Fuzion is Environmental Protection Agency (EPA) registered to kill Clostridium difficile (C. difficile) spores in two minutes and 35 other pathogens in one minute. “At Clorox Healthcare, we are constantly looking for ways to expand the breadth and depth of our industry-leading bleach portfolio to meet the needs of health care facilities and equip end users with the tools they need to safeguard patient environments,” says Lynda Lurie, Director – Marketing, Clorox Healthcare. “Health care facilities need the right disinfectants to help keep patients safe from infection-causing pathogens. With Fuzion, they no longer need to make tradeoffs between efficacy, odor and surface compatibility.” “Fuzion uses innovative new technology to improve surface compatibility and reduce residue,” says Hedi Modaressi, Department Manager – R&D, Clorox Healthcare. “The solution contains sodium hypochlorite and a neutralizer which, when combined, form a pH-neutral hypochlorous acid – a highly effective form of bleach. Once the two-minute WWW.ORTODAY.COM

contact time is reached, the neutralizer breaks down the bleach solution into a very small amount of sodium chloride and water with minimal residue, eliminating the need for a rinsing step.” This approach makes Fuzion tough on pathogens, yet easy on surfaces and practical for everyday use across a wide variety of health care surfaces and settings. These features, combined with the ease of use of a one-step cleaner and disinfectant represent the next generation of disinfectants and an entirely new user experience designed for efficacy and satisfaction. • December 2016 | OR TODAY

INDUSTRY INSIGHTS NEWS & NOTES

HEALTHMARK INDUSTRIES OFFERS GOWN WITH THUMB LOOP Healthmark Industries has announced the addition of Gown with Thumb Loop to its Personal Protection Equipment (PPE) line. OSHA’s Bloodborne Pathogens Standard (29 CFR 1910.1030) requires employers to protect workers who are occupationally exposed to blood and other potentially infectious materials, which is why Healthmark developed a single-use full frontal barrier gown for health care professionals. The Gown features lightweight latex-free blue recyclable polyolefin that is manufactured in the USA. It is 4 mil thick, is 50 inches in length and has full-length sleeves with a thumb loop cuff style, along with a tie back closure type to secure the garment. • VISIT www.hmark.com for more information.

TJC LAUNCHES ONLINE RESOURCE CENTER TO PREVENT WORKPLACE VIOLENCE The Joint Commission has launched an online resource center dedicated to preventing workplace violence in health care settings. The resource center, “Workplace Violence Prevention Resources,” provides a broad range of resources for health care organizations, health care professionals and the general public. The Joint Commission developed the resource center in response to statistics showing higher rates of workplace violence in health care compared to other settings. Joint Commission accredited health care organizations and advisory committee members – including nurses, physicians, pharmacists, risk managers and other professionals with hands-on experience addressing worker and patient safety – also identified the need for additional resources to help mitigate workplace violence, which includes any verbal, written or physical aggression against health care professionals, patients, visitors or others in a setting where health care is delivered. “Many of us in health care have witnessed or experienced workplace violence firsthand,” said Ann Scott Blouin, RN, PhD, FACHE, executive vice president of Customer Relations, The Joint Commission. “Workers in health care are five times more likely to be victims of nonfatal assaults or violent acts than the average worker in all other occupations, according to the Bureau of Labor Statistics. As a result, it is critical that we share key resources with those in the health care community 14

OR TODAY | December 2016

to help them prepare for and address, as well as hopefully prevent, this type of unfortunate situation from taking place.” Workplace Violence Prevention Resources includes easy-to-access policies, procedures, guidelines, research, case studies, white papers, toolkits and other materials focused on workplace violence prevention and preparedness. Topics span violent and criminal event preparedness and prevention, active shooter situations that occur in the health care setting, workplace safety measures, behavioral threat management and emergency operations planning, and incivility and bullying. The collaborative resources come from The Joint Commission, federal and state agencies, professional associations and health care organizations. Designed as a living library, the resource center encourages contributors and others to share their materials for inclusion on an ongoing basis. The resource center aligns with The Joint Commission’s mission and vision to continuously improve patient safety and quality of care, as well as its alliance with the Occupational Safety and Health Administration to protect health care workers’ health and safety. • FOR MORE INFORMATION, visit https://www. jointcommission.org/workplace_violence.aspx. WWW.ORTODAY.COM

NIHON KOHDEN INTRODUCES NEW BEDSIDE MONITOR Nihon Kohden has launched its BSM-3500, the latest advancement in its line of bedside monitors. Designed to meet the precise needs of ambulatory surgery and specialty centers, the BSM-3500 comes fully optimized with all features – both premium and standard – ready to use at a moment’s notice, bringing among the highest standards of care to low acuity settings. “Hospitals and health systems know that not every patient requires intensive care or use of a high-acuity bed, but they also know patients in low-acuity areas still need to be monitored, no matter how minor a

procedure may seem,” said Dr. Wilson P. Constantine, CEO of Nihon Kohden America. “By using Nihon Kohden’s line of quality, reliable monitors that are developed with our premium-as-standard philosophy, health care providers know their patients will be taken care of, no matter where they are in a health system.” In addition to a range of standard monitoring features, the BSM-3500 offers a number of capabilities to ensure care in low acuity settings. These include the ability to spot real-time mini trends for early detection of vital sign variability

during outpatient procedures. In addition, the new monitor works with Nihon Kohden’s proprietary cap-ONE Mainstream CO2 Sensor Kit, which is the world’s first wearable mainstream CO2 sensor for non-intubated patients. As with all Nihon Kohden monitoring systems, the BSM-3500 is also designed to seamlessly integrate with electronic medical records systems. •

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December 2016 | OR TODAY

INDUSTRY IN THE OR INSIGHTS AAAHC UPDATE

BY BRIAN E. SZUMSKY

WINNING WITH SURGICAL CHECKLISTS

hat do airline pilots and medical teams have in common? Answer: The use of checklists. This is not a new idea. It goes back to the 1930s when the U.S. Army Air Corps was testing the B-17 bomber. Due to the number of accidents attributed to “pilot error,” the Corps was on the verge of abandoning the model as “too much plane for one person to fly.” Then they came up with the idea of implementing a pilot’s checklist to make sure all required steps were executed. And the rest, as they say, is history.

PILOTING MEDICAL CHECKLISTS From a health care perspective, the use of checklists is a more recent innovation. In 2007, the World Health Organization (WHO) launched the Second Global Patient Safety Challenge, Safe Surgery Saves Lives. An international group of experts, including anesthetists, operating theatre nurses, surgeons, safety experts, and patients was assembled and charged with developing a solution to the problem of unsafe surgery. In 2009, as a result of the international team’s efforts, the WHO Surgical Safety Checklist was released. The same year, Dr. Atul Gawande published “The Checklist Manifesto: How to Get Things Right.” In it, he argues that expanding knowledge leads to increased specialization which leads to greater need for simple solutions to insure access to information. Gawande posits that checklists are just such a solution and are applicable across many fields including medicine, finance, business, and government. Similar to their use in aviation, in a surgical setting all members of the procedure team have access to the checklist of items that are addressed: before the administration of anesthesia (sign in), before the initial incision (time 16

OR TODAY | December 2016

out), and before the patient leaves the OR (sign out). In addition, team members are encouraged to point out a missed step in real time. This system of checks and balances has obvious benefits: more eyes on the process help decrease the possibility of avoidable human error. CHECKLISTS ADDRESS MORE THAN PROCEDURAL ISSUES What may be less obvious are the results of using checklists on patient and provider satisfaction. Studies from a number of U.S and international facilities show that when patients are aware that checklists are being used, the overall level of their stress decreases and the level of their satisfaction increases. Communication between providers and patients then becomes a key component in higher levels of satisfaction. When providers invite patients into the process by sharing the information that checklists will be used and by communicating that patient participation will be requested there is a reassuring effect. Pre-operatively, a well-prepared patient will have an understanding of the procedure and outcomes. Similarly, a satisfied patient is more likely to follow plans of care and treatment.

Not only does increased two-way communication and the use of checklists raise satisfaction levels for patients but also for providers. According to a 2015 article (Shapiro, et. al., AORN 2015 Sep; 102(3):290), a study conducted with 35 patients and 52 providers showed 94 percent of patients and 83 percent of providers found a checklist to be beneficial. In their responses, patients observed that checklists “increase medical knowledge, alleviate anxiety and help them prepare for postoperative recovery.” These findings also equate the use of checklists with less human error and fewer discrepancies among the procedure team. In 2014, after a team of nurses and surgeons evaluated discrepancies, wrong site surgeries, near misses, team communication, and patient satisfaction, The Center for Outpatient Surgery in Tinton Falls, New Jersey implemented preoperative, preincision, and postoperative checklists. Following implementation, the data collected for 998 procedures performed identified zero discrepancies between team members, and zero wrong site, wrong side, and wrong patient surgeries (AORN, 2016 Jun; 103(6):617-22). The AAAHC Standards for risk WWW.ORTODAY.COM

AAAHC UPDATE

edefining Pressure lcer Prevention management (Chapter 5, Subchapter II of the Accreditation Handbook for Ambulatory Health Care) speak directly to this issue of patient safety, stating, “an accreditable organization develops and maintains a program of risk management […] designed to protect the welfare of the organization’s patients [and employees].” Checklists have been shown to advance the intent of this Standard; however, there are caveats. USING CHECKLISTS OPTIMALLY The key, according to the research, is that the successful use of checklists relies heavily on how they are implemented. When members of the surgical team are acting in unison, only then will lists have the ability to positively affect outcomes. This requires that everyone on the surgical team has bought into the importance and effectiveness of checklists as a quality improvement and risk management tool. When even one member is not fully invested, there can be a negative impact on the ability of the staff to act as a team. Per Russ, et al (Annals of Surgery, 258(6), 856-871) “the evidence suggests that safety checklists improve the perceived quality of OR teamwork and communication and reduce observable errors relating to poor team skills […] However, the evidence would also suggest that when used suboptimally or when individuals have not bought in to the process, checklists may conversely have a negative impact on the function of the team.”

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WIN-WIN Collectively, data and anecdotal evidence suggest that an integrated approach to health care, one focused on teamwork, effective communication, and the use of checklists, has benefits for health care providers and patients. When used optimally, checklists have been connected to improved outcomes, a result that provides benefits to the organization, including decreased risk of litigation and higher scores on patient satisfaction surveys. A win-win for patient and facility. ABOUT THE AUTHOR Brian E. Szumsky is the communications project manager within the AAAHC Marketing and Communication department. He has been with the company since 2015 and has worked with the consulting arm (Healthcare Consultants International) and the AAAHC Institute for Quality Improvement. In addition to managing communications for AAAHC, Szumsky is an adjunct instructor of composition and literature at the college level. WWW.ORTODAY.COM

December 2016 | OR TODAY

INDUSTRY INSIGHTS BY ANN MARIE PETTIS, RN, BSN, CIC, FAPIC, DIRECTOR OF INFECTION PREVENTION, UNIVERSITY OF ROCHESTER MEDICAL CENTER

OR CULTURE

IS IT THE KEY TO IMPROVING SKIN ANTISEPSIS?

any different health care professionals may come in contact with that one patient in the operating room (OR) before their surgery including nurses, residents, surgeons, and possibly environmental service workers. Due to the vast amount of touch points, a culture shift may be necessary if the goal is to have optimal communication between all members of a health care team.

The lack of communication can lead to the risk of health care associated infections (HAIs) due to the potential of different techniques for best practice in skin antisepsis. With that said, standardization is key to achieve those desirable results for the patient. This issue, and several other infection prevention and control issues, were addressed at a virtual roundtable sponsored by Becton Dickinson (BD), earlier this year. There was panel-wide agreement about an ongoing need to raise awareness of issues related to skin antisepsis since HAIs are becoming the main reason for emergency room visits and re-admissions. COMMUNICATION BARRIERS During the panel discussion, each of us was able to cite examples of when professional silos prevented health care providers (HCPs) from communicating effectively regarding best practices for skin antisepsis and product application. Despite the growing number of hospitals and health care systems utilizing dedicated skin preparation teams, it remains commonplace for surgical residents or surgeons to perform skin antisepsis. Situations where surgeons would only agree to use one particular 18

OR TODAY | December 2016

skin prep product with the application style they had always used, simply because “they had always done it that way” were frequently encountered. When the status quo is maintained rather than encouraging a culture paradigm shift in the OR, then evidencebased practices may not be readily adopted. A study from the American College of Surgeons found that postoperative infection rates decreased by 33 percent when a dedicated team of “front-line” providers had primary responsibility for peri-operative procedures. Enhanced sterile techniques for skin and fascial closure were also implemented in this study.

PROMOTING CHANGE THROUGH DATA Although the example above represents just a single study, it does demonstrate how scientific evidence can be the harbinger of positive change. During the roundtable, the panelists agreed that standardization is a major key to the successful reduction of HAIs, and that variation cannot be controlled when communication breaks down in the OR. Do the perioperative nurses feel comfortable educating or challenging the lead surgeon? Can they provide direct correction to a resident applying a product incorrectly or does hierarchy and dysfunctional communication in the OR make that unlikely? Every year, more than 75 million surgical procedures are performed in the U.S., basic infection prevention strategies such as hand hygiene, etc. must be taken seriously. A study by Beyfus et.al., published in the American Journal of Infection Control, found that HCPs failed to perform hand hygiene 37 percent of the time, even after having policies in place regarding these practices. Fostering open communication supported by robust, outcomes-focused data would go a long way towards creating a team-based approach where WWW.ORTODAY.COM

everyone feels empowered, without fear of retribution, to speak up about practice. Ideally, data would be collected to determine post-procedure outcomes which are also shared between institutions if a patient is readmitted to a different health care facility due to health care associated infections. Today, the ability to collect this type of data is limited because electronic health records are not yet integrated enough to track patients across far flung facilities or competing health systems. This is a serious challenge since more than onethird of all readmissions occur at a different hospital than where surgery was performed. As a result, critical outcome information is not tracked. INVESTING IN OUTCOMES The panel concluded the roundtable by discussing how effective communication of outcome data to providers can influence a culture shift in the OR. Highquality HAI data must be readily available to all key stakeholders on an ongoing basis. Health care facilities, researchers and the C-suite must invest time and resources into better understanding how skin antisepsis products (and variability in protocols) affect outcomes. Parties negotiating purchasing and protocol decisions can make more informed choices when armed with data. In conclusion, every surgical HCP should advocate for excellent and standardized skin antisepsis. Ultimately, patient safety must always take precedence over egos or “we’ve always done it this way” rigidity. As HCPs, we must seek out continuing education and hold each other accountable when re-direction about application or product use is warranted. Every time we interact with a patient we must use the best evidence-based infection prevention and control practices to mitigate the risks of HAIs. DISCLAIMER: The development of this piece was supported by Becton Dickinson. WWW.ORTODAY.COM

SOURCES Merkow et al. (2015). Underlying Reasons Associated With Hospital Readmission Following Surgery in the United States. The Journal of the American Medical Association, 313(5), 483-495. doi:10.1001/ jama.2014.18614 Accessed on May 24, 2016 Wick et al. (2012). Implementation of a Surgical Comprehensive Unit-Based Safety Program to Reduce Surgical Site Infections. Journal of the American College of Surgeons, 215(2), 193-200. doi:10.1016/j.jamcollsurg.2012.03.017 Stulberg JJ, Delaney CP, Neuhauser DV, Aron DC, Fu P, Koroukian SM. (2010) Adherence to surgical care improvement project measures and the association with postoperative infections. JAMA Jun 23;303(24):2479-85. Statistical Brief #188. Agency for Healthcare Research & Quality. http://www.hcup-us.ahrq.gov Accessed May 19, 2016 United States Centers for Disease Control and Prevention (CDC). Fast Stats: Inpatient Surgery. http://www.cdc. gov/nchs/fastats/inpatient-surgery.htm. Accessed May 19, 2016 Beyfus, TA, Dawson, NL, Danner, CH, “The use of passive visual stimuli to enhance compliance with handwashing in a perioperative setting” “http:// www.sciencedirect.com “Go to American Journal of Infection Control on ScienceDirect” American Journal of Infection Control, “http://www. sciencedirect.com “Go to table of contents for this volume/issue” Volume 44, Issue 5, 1 May 2016, Pages 496–499, “http://www. sciencedirect.com/ Brooke et al (2015). Readmission destination and risk of mortality after major surgery: An observational cohort study [Abstract]. The Lancet, 386(9996), 884-895.

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INDUSTRY INSIGHTS CLOROX ADVICE

BY KENT STIMSON, SUPPORT OPERATIONS MANAGER, DANBURY HOSPITAL, DANBURY CT

THE HEALTHCAREASSOCIATED INFECTION CHALLENGE

ealthcare facilities face a number of challenges when it comes to safeguarding the patient environment. While manual cleaning and disinfection is a crucial step to reducing pathogens that may cause healthcare-associated infections (HAIs), we felt that a more comprehensive approach to environmental infection prevention would better assist our facility in the fight against pathogens and the growing threat of antibiotic resistance. At Danbury Hospital in Connecticut, we continuously review and re-assess processes to ensure the provision of an infection-free environment for our patients. The implementation of three Clorox Healthcare® Optimum-UV® Systems has assisted in achieving this, and has become an important component of our environmental services infection prevention efforts to reduce infections and provide better patient outcomes.

EDUCATION AND UV IMPLEMENTATION

When we implemented the Clorox Healthcare® Optimum-UV® System in 2015, it was important to us that our team members understood why this technology should be used to bolster our already strong infection prevention program. UV-C energy kills persistent pathogens, including those of top concern such as Clostridium difficile (C. difficile), carbapenem-resistant enterobac22

OR TODAY | December 2016

teriaceae (CRE) and Methicillinresistant Staphylococcus aureus (MRSA). We started education about the devices early on, using our daily team huddles to discuss how the UV disinfection contributes to patient safety and quality of care and service. It was critical to assess and educate the staff that would eventually use the three devices. We took a core group of employees that are involved with discharge cleaning (both patient unit environmental services employees, as well as supervisory personnel) and brought them in with the sales representative, so that they could be involved in the training process and really see, first hand, how easy it is to use. UV WORKFLOW

I don’t feel that adding the UV technology was a separate process, but rather an extension of what we already do, and a further commitment to patient safety. We did not

dedicate just one person to the UV machine, but rather integrated it into our existing facility-wide processes and workflows. The UV Light unit was initially purchased for our OR procedural rooms, but has since expanded to our Interventional Radiology and CTSCAN procedural rooms. Along with discharge cleans of all contact isolations, we also strive to provide monthly “preventative” service to all 30 rooms in our ICU and Step Down patient units. Overall, the response has been very positive. Our staff sees it as a great addition to our cleaning and disinfection processes. They have seen how the UV-C technology improves our patients’ safety by offering an extra layer of protection, and killing microorganisms in high-risk settings and areas of the healthcare environment that may otherwise be missed or insufficiently addressed. The Clorox Healthcare® Optimum-UV® System is a critical component to our program, and is another means of ensuring a safe and infection-free environment to our patients at Danbury Hospital. Employee engagement and sharing the big picture on how the measures we are taking positively impact the patient experience has helped make all the difference. WWW.ORTODAY.COM

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IN THE OR SUITE TALK

STAFF REPORTS

SUITE TALK

Conversations from the OR Nationâ&#x20AC;&#x2122;s Listserv

ESWL (Extracorporeal Shock Wave Lithotripsy) Is there a safe limit to the number of ESWL procedures that can be done in a day? Some facilities have an ESWL machine brought in for procedures, and the operator/driver of the machine can only work so many hours and be driving for so many hours without being considered unsafe. Are there any small facilities that have run into this dilemma? The surgeons always want to schedule as many as they can, then they take longer than expected, and it can lead to a very long day for the operator/driver. A: We are a small facility and do up to five per day. We have not run into any issues. A: No issues here with â&#x20AC;&#x153;over serviceâ&#x20AC;? hours.

A: I have never had that problem and we did ESWLs one day per week and all the urologists were scheduled on that day so we did more than five.

HARDWARE DEPOSITION Is it acceptable for patients to bring home hardware removed from their bodies? If so, the hardware needs to be decontaminated, but does it need to be sterilized? A: We send everything to pathology. If the patient desires to get the hardware, we let pathology know and we have the patient contact them. We do not give the patient anything. A: We give patients their hardware after we wash and sterile with a quick flash cycle. A: Patients could have it, but the doctor needs to give it to the patient.

OR TODAY | December 2016

A: Our policy is that the device must first go to pathology and then can be decontaminated. The physician must write an order requesting the device be given to the patient. This creates an evidentiary trail if anything comes of it. Since the patient paid to have the device put in, legally the device belongs to the patient. The patient must sign a waiver if the device goes to anyone else, such as the representative or someone doing research.

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SUITE TALK

CENTRAL STERILE PROCESSING I have just added Central Sterile Processing to my group to develop an orientation and competency program. Does anyone have Central Sterile Processing material they can share?

A: No, but that’s something that would be very valuable to share! A: I am in the process or re-doing ours so I would be very interested in others’ input as well. A: I would also be interested in any orientation and competency information anyone can share. A: AAMI is a great place to start.

THESE POSTS ARE FROM OR NATION’S LISTSERV FOR MORE INFORMATION OR TO JOIN THE CONVERSATION, VISIT WWW.THEORNATION.COM.

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SAFELY RETRIEVE REUSABLE SHARPS WITH AN SST SYSTEM A simple & effective way to protect personnel, patients and the environment from contaminated sharps The SST System provides for safe handling and transportation of soiled reusable instruments in compliance with OSHA Guidelines. SST’s are three-part container systems: Solid base tray, SteriStrainer drain basket and cover. Placed near the procedure site, the tray system is used to collect the instruments. Covered, it is then safely transported to the decontamination site. There the cover is removed, and the Steri-Strainer is lifted out of the solution and the decontamination process safely begins.

Cover biohazard symbols on your SST Systems with our new 4”x 4” Removable Clean Label

Manufactured to convey key information to healthcare professionals, the clean label is intended to conceal and cover the biohazard symbol on SST systems when transporting clean medical instruments. The 4x4 inch design includes a removable adhesive backing. Prior to use, ensure the application surface area is dry and simply apply the label with ﬁrm thumb pressure.

TRANSPORTATION IDENTIFICATION TAG 2 in 1 Removable Label For Effective Communication Designed for compliance with OSHA standard CFR 1910.1030, this 3.125” x 5.125” label includes one perforated tab, a green top tab with “CLEAN” a ﬂuorescent orange/red bottom tab with “DIRTY”, and the removable OSHA approved “Biohazard Label” adhesive backing. Available with or without the checklist shown.

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IN THE OR MARKET ANALYSIS

STAFF REPORT

INSTRUMENT STORAGE, TRANSPORT MARKETS UP

urgical instruments must remain sterile as they are moved from central sterile processing to the operating room. Trays and carts are among the tools used to maintain the cleanliness of instruments as they are delivered to the operating room. Moving used instruments to an area to be cleaned as soon as possible after a procedure is another factor all health care facilities consider when it comes to how they transport these tools.

The surgical instrument transport device market and the surgical instrument storage market are both expected to experience continued growth with the surgical equipment market. Increases in the number of minimally invasive procedures as well as an aging population are powering growth. The global surgical equipment market, which impacts the surgical instrument transport device market, is expected to grow at a CAGR (Compound Annual Growth Rate) of 4.2 percent from 2013 to 2019. The global surgical equipment market is expected to grow to $11.28 billion by 2019, according to a research report released by Transparency Market Research. The growth in the global surgical equipment market will help fuel continued growth in the surgical instrument transport and storage markets. More advanced surgical tools often require specialized trays and other devices to maintain sterile instruments. This need for specialization, common for robotic WWW.ORTODAY.COM

The global surgical equipment market is expected to grow to $11.28 billion by 2019, according to a research report released by Transparency Market Research. surgical instruments, is a growing segment of the market. “The key driver for the global surgical equipment market is an increase in demand for sophisticated surgical tools that help perform minimally invasive surgeries,” according to a news release from Business Wire. “The report says that this demand has increased due to a

growing number of accidents – road and other accidents – that require quick surgical assistance. Another factor is an increasing geriatric population, which requires a high level of medical and surgical attention.” Medical carts and cabinets play an important role in the health care industry. They provide safe storage and transport options for a variety of medical equipment and supplies, including imaging equipment, surgical instruments, medications and more. The medical carts and cabinets market is a part of the larger medical furniture market and is expected to experience continued growth in the coming years. The Global Medical Furniture Market is mainly driven by population aging. This market was valued at $2.17 billion in 2013 and is expected to reach $3 billion by 2018, at a CAGR of 7.2 percent. The medical furniture market is the largest segment of $2.1 billion home health care market,” according to MicroMarket Monitor. December 2016 | OR TODAY

IN THE OR PRODUCT SHOWROOM

TRANSPORTATION IDENTIFICATION LABEL HEALTHMARK INDUSTRIES The Transportation Identification Label is the first of its kind designed for compliance with OSHA standard CFR 1910.1030. It features one perforated tab, a green top tab with “CLEAN” in black text, a fluorescent orange/red bottom tab with “DIRTY” in black text, and the removable OSHA approved “Biohazard Label” adhesive backing. It labels transporting materials considered a biohazard, while acting as an essential communication tool in the process. Furthermore it has a checklist for all departments to ensure adequate delivery of the case cart or container in question. Identification is made easy with this new innovative label.

OR TODAY | December 2016

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PRODUCT SHOWROOM

SCOPE BASKETS KEY SURGICAL New Scope Baskets from Key Surgical are the perfect containment device to use in the sterilization process of rigid scopes. Constructed of durable stainless steel, the baskets feature fixed silicon brackets that help hold a rigid scope in place during sterilization and transportation. A fully removable lid allows for easy placement of the scope in the basket. The lid slides into place on the basket and locks with an easy-to-use locking mechanism. Available in various sizes. The largest basket includes a small mesh basket to hold scope accessories. Compatible with steam, EtO, and gas plasma sterilization. Visit www.keysurgical.com for more information.

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December 2016 | OR TODAY

IN THE OR PRODUCT SHOWROOM

STAINLESS STEEL CASE CARTS MAC MEDICAL INC. MAC Medical Inc. manufactures a full line of stainless steel case carts that feature fully welded construction for strength and durability. Choose from several designs including open and closed case carts, and our new ergonomically friendly vertical handle case carts for instrument storage and transport. Our engineering capabilities allow us to custom design a specific case cart to satisfy any need your facility may have. To place an order, contact our customer service department at 877-828-9975.

OR TODAY | December 2016

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PRODUCT SHOWROOM

LIGHTWEIGHT ALUMINUM MEDICAL CARTS MEDLINE Medline’s aluminum carts are 30 percent lighter (that is up to a 38-pound difference) than standard steel carts making them easier to maneuver throughout a facility. The four vertical corner mounting tracks also make it easier to mount and adjust accessories without using predrilled holes. Medline’s lightweight aluminum medical carts offer a dual-shelf for additional workspace and five available locking systems to meet the health care worker’s needs. Carts feature ABS plastic molded top with cutaway front and easily adjustable dual push handles. The five-inch premium easy roll casters mount to Medline’s high impact plastic stabilizer base.

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December 2016 | OR TODAY

IN THE OR PRODUCT SHOWROOM

INSTRUSAFE INSTRUMENT PROTECTION TRAYS SUMMIT MEDICAL Take your organization and protection of instrument sets to the next level with InstruSafe Instrument Protection Trays. The customizable trays – made of durable, highly perforated aluminum and silicone instrument holders – lock down delicate instruments with 360 degrees of cushioned protection during sterilization, transportation, storage and the OR. InstruSafe trays are made with you in mind – constructed with strong, quality materials to reduce breakage and frequent replacement, as well as to meet your unique instrument set needs. With a variety of FDA 510(k) sterilization cycle clearances, these trays are a smart, easy upgrade for use with both wrap and rigid containers.

OR TODAY | December 2016

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Stainless Steel Case Carts Durable. Versatile. Customizable.

Open Case Carts

Closed Case Carts

Vertical Handle Case Carts Ergonomically

Friendly

MAC Medical, Inc. manufactures a full line of Open and Closed Case Carts. Choose from several standard designs or provide your specifications and we will custom build one for you. For more information or to place an order, contact our customer service department at 618-476-3550 or 877-828-9975, or by email at sales@macmedical.com. We also manufacture the following products:

Corporate Office 325 West Main Street Belleville, IL 62220 Manufacturing Plant 820 South Mulberry Street Millstadt, IL 62260 Phone: 618-476-3550 Toll Free: 877-828-9975 Fax: 618-476-3337 sales@macmedical.com www.macmedical.com

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the trays are micro mesh. our selection is anything but micro.

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s i ze d t o g e t t h e j o b d o n e. Bi g t r ay s. S m a l l t r ay s. Tr ay s w i t h l i d s. Tr ay s w i t h d ro p h a n d l e s. Tr ay s t h e

N o m a t t e r t h e s i z e o f t h e s t e r i l i z a t i o n j o b , t h e r e’s a Ke y S u r g i c a l M i c r o M e s h Tr a y t h a t ’s p e r f e c t l y

IN THE OR CONTINUING EDUCATION CE568C

OR TODAY | December 2016

BY NANCYMARIE PHILLIPS, PHD, RN, RNFA, CNOR(E)

WWW.ORTODAY.COM

CONTINUING EDUCATION CE568C

KEEP IT CLEAN:

Hand Hygiene and Skin Antisepsis

n the 1960s and 1970s, nursing students were often taught how to manage contaminated objects with their bare hands. This included cleaning patients who were incontinent and counting bloody sponges. In surgery, the scrub nurse would hand off a sponge forceps from the active surgical field, complete with biologic contamination, to the barehanded circulating nurse during sponge counts. Hands often came in contact with microbe-laden material, and the answer was simply handwashing. Nonsterile gloves were not readily available for dirty tasks.

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

The goal of this skin hygiene continuing education program is to provide healthcare professionals with information about the relationship between skin and the transference of pathogenic microorganisms. After studying the information presented here, you will be able to: • Explain the pros and cons of using gloves as personal protective equipment during patient care • Describe three natural features of skin that can support or hinder the transference and growth of microorganisms on the caregiver and patient • Explain how hand hygiene and skin antisepsis work in combination to prevent infection

HISTORICAL BACKGROUND In 1846, physician Ignaz Semmelweis posited the dangers of microbial transfer from contaminated hands to patients in the obstetric suite of Vienna General Hospital.1 Many postpartum patients of his day died of puerperal fever (e.g., caused by Clostridium sordellii) before he put forth his theories about handwashing and its benefit to safe patient care. Some physicians of his time regarded his theories as nonsense and openly mocked him. Semmelweis noted that more resident physicians’ patients died than did patients of midwives. The key factor was that the residents were not washing their hands after they performed autopsies on women who died from postpartum sepsis and before they attended to other patients’ deliveries. The use of chlorine during handwashing lowered the maternal mortality rate. Physician Oliver Wendell Holmes Sr. proposed the same theory about handwashing and significantly reduced maternal sepsis and mortality in the United States. Retrospective studies of Semmelweis’ data have shown that handwashing between patient contacts reduced the incidence of infection and lowered the mortality rate. GLOVES AND SKIN ANTISEPSIS Today, gloves of all varieties are available in patient care areas for healthcare professionals of all disciplines. Although

WWW.ORTODAY.COM

clinicians wear exam gloves during patient care for self-protection, gloves are not a panacea for dealing with evolving “super bugs” of the 21st century. No glove is 100% impervious. Micropores are present on all glove surfaces.1 The dirty hands of many people reach into the same box of nonsterile exam gloves for personal protection and transmit microorganisms to the box opening and its contents. The opening of the box is exposed to microorganisms on the bare skin of everyone who reaches inside for gloves. As the exam gloves are withdrawn, they come in contact with the contaminated box opening. Microbial contamination can be spread without conscious knowledge.1 The microbial load on any surface is capable of causing postoperative complications, such as infection, wound dehiscence or systemic morbidity. Research reveals that prevention of cross-contamination and surgical site infection consists of appropriate skin antisepsis for both the patient and healthcare professionals across all disciplines. Hand hygiene and skin antisepsis are not singular processes and are effective only during the moment they are performed. Each contact with different areas of the patient’s body and the patient care environment (e.g., bed rails, blood pressure cuff, clothing and stethoscope) requires cleansing of the hands and device, or changing of gloves to December 2016 | OR TODAY

IN THE OR CONTINUING EDUCATION CE568C prevent deposition of new bacteria. In essence, providers of various disciplines can transfer bacteria from one part of the patient’s body to another because each body part has its own level of bioload. Moving resident flora to another part of the body creates a pathogenic potential for the patient. Caregivers feel a false sense of security when they don exam gloves and wear them for prolonged periods, performing multiple tasks without removing and changing them. Moisture and heat builds under the gloves, creating favorable living conditions for bacterial reproduction and endospore reactivation. The surface of a glove picks up microorganisms from the environment and deposits them wherever it makes contact. Gloves do not always protect the patient and may, in fact, provide a transfer vehicle for portable pathogens. Whether at the surgical site or on the hands of the caregiver, skin is laden inherently with resident and transient flora. Inadequate hand hygiene allows opportunistic pathogens in varying life stages to transfer between patients and other surfaces during everyday activities. Studies monitoring handwashing reveal that many people do not wash their hands properly after using the toilet or diapering a baby. This manifests in the OR, where body substances abound, and the risk for transference is a serious concern. Hand hygiene and skin antisepsis in surgery depend on using products according to the manufacturer’s recommendations. The products must be used correctly and provide microbial kill to be effective. Another consideration is the safety of the product. RECLASSIFICATION OF ANTISEPTIC SOLUTIONS The Food and Drug Administration (FDA) is in process of reclassifying antiseptic solutions used in healthcare as personnel hand washes, personnel hand rubs, surgical hand rubs, surgical hand scrubs and preoperative skin preparations for 38

OR TODAY | December 2016

patients.2 Antiseptic solutions are classified as generally accepted as safe (GRAS) and/or generally accepted as effective (GRAE). Consideration is given to whether the product is applied and remains on the skin (“leave on”) or if the product is rinsed off with water. Absorption through the skin is a concern. Studies have shown that systemic exposure is greater than previously thought with prolonged use. Surgical personnel may be at risk when using the “leave on” products daily during a period of six months.2 Recent studies have shown that prolonged exposure may pose risk to those who are exposed continually to the chemical ingredients contained in antiseptic solutions. In preparation for generating the final rule, research has shown the presence of the chemicals in the blood, urine and tissues of the users. The classifications will also encompass developmental and reproductive toxicity (DART), hormonal effects, toxicity and carcinogenic potential, and progressive antimicrobial resistance. The ability to isolate the chemicals at previously undetected lower levels has raised concern. The chemical triclosan is a common ingredient in consumer and healthcare products. It has a hormonal effect that has been isolated in urine, cord blood and breast milk. Animal studies show thyroid and reproductive changes (estrogenic and androgenic) in newborn and young test mammalian subjects. It is unknown if a maternal exchange has taken place or if an actual DNA gene alteration has occurred.2 Triclosan, originally categorized as a pesticide, is found commonly in products such as fabrics, cosmetics, toothpaste, many antiseptic soaps, toys and sutures. Measurable elevated blood alcohol levels have been found in surgical personnel, who use alcohol-based surgical hand rubs. Advanced technology and newer testing methods have raised many questions that surpass general safety and effectiveness established by the FDA in 1994 when the original antiseptic rule was adopted.2

CONTEMPORARY ISSUES The risk of death from multisystem organ failure after surgery is doubled if the patient becomes septic after surgery. Skin antisepsis is one way to minimize the risk of infection at the surgical site, but it must be paired with adequate hand hygiene of the surgical team to be effective. Members of the healthcare professional team must collaborate to provide hand hygiene and skin antisepsis, the primary steps in preventing surgical-site infections in all surgical procedures. In 2008, Medicare started to deny reimbursement to surgical facilities for preventable mediastinitis resulting from contamination during cardiac surgery. Surgical technique and the entire team’s maintenance of a sterile environment during procedures are major factors in preventing infection. Facilities have addressed some of the issues associated with microbial transfer by the healthcare teams by the installation of motion-sensor hand gel dispensers and no-touch paper towel dispensers. PHYSIOLOGIC FACTORS IN ASEPSIS The skin is a protective barrier that, when intact, minimizes the host’s exposure to UV rays of the sun and prevents absorption of certain toxins, chemicals and penetration by microorganisms. It serves as a thermoregulatory guardian and sensory organ. Anatomically, all the functions of the skin have a synergistic role in the wellness of the body. But some of the functional structures designed to protect the host from infection can create opportunistic avenues for microorganisms to enter the body surreptitiously. Let’s explore three physiologic protective factors associated with human skin that can be problematic. First is the “intactness” factor of the skin as a whole. The surface of healthy intact skin does not provide favorable living conditions for the resident bacteria on the skin surface. WWW.ORTODAY.COM

PRODUCTS FOR SKIN ANTISEPSIS AND HAND HYGIENE CHEMICAL PROPERTIES

PRODUCT

USE IN SKIN ANTISEPSIS

CONSIDERATIONS

Povidone iodine solution

10% (1% available iodine) or 17.5% (1.7% available iodine) povidone iodine

Sometimes referred to as “paint.” Used full strength. Tuck towels in at patient’s sides to prevent pooling. Broad-spectrum Commonly used on patient’s skin after scrub with microbicide. Used in detergent form (e.g., two-step prep). Do not heat patient skin antisepsis. before use. Heat causes evaporation and increases the chemical strength.

Povidone iodine scrub

7.5% (1.7% available iodine) povidone iodine in detergent soap

Broad-spectrum microbicide. Can be used as surgical hand scrub.

Povidone iodine spray

5% (0.5% available iodine) or 10% (1% available iodine) povidone iodine

Broad-spectrum Fast, even application; minimal risk of pooling. Used microbicide. Used in alone. Prevent aerosolization in the sterile patient skin antisepsis. environment.

Povidone iodine gel

10% povidone iodine (1.0% available iodine)

Broad-spectrum Fast application; minimal or no risk of pooling. Used microbicide. Used in alone. patient skin antisepsis.

Iodine povacrylex

Iodine povacrylex in 74% isopropyl alcohol. (0.7% available iodine)

Used as a rapid, one-step skin prep. Resists removal as Broad-spectrum a lasting barrier during surgery and for several days microbicide. Used in postoperatively. Alcohol base is flammable and must patient skin antisepsis. be completely dry before drapes are applied.

Chlorhexidine 4% chlorhexidine gluconate gluconate in 70% tincture isopropyl alcohol

Used as a rapid, one-step skin prep. Alcohol base is Broad-spectrum flammable and must be completely dry before drapes microbicide. Used in are applied. Can cause corneal, ear and neural patient skin antisepsis. damage.

Chlorhexidine 2.5% chlorhexidine gluconate gluconate in scrub detergent soap

Broad-spectrum microbicide. Used in patient skin antisepsis. Can be used as surgical hand scrub

Chlorhexidine 0.1% chlorhexidine gluconate gluconate spray

Fast, even application; minimal risk of pooling. Used Broad-spectrum alone. Can cause corneal, ear and neural damage. microbicide. Used in patient skin antisepsis. Prevent aerosolization in the sterile environment.

Diluted with sterile water or saline before use. Tuck towels in at patient’s sides to prevent pooling. Do not heat before use. Heat causes evaporation and increases the chemical strength.

Diluted with sterile water or saline before use. Tuck towels in at patient’s sides to prevent pooling. Used alone. Residual antibacterial effects for four to six hours. Can cause corneal, ear and neural damage. Do not use on mucous membranes.

Chloroxylenol scrub

3% chloroxylenol, 3% cocamidopropyl PG-dimonium chloride phosphate in detergent soap

Broad-spectrum microbicide. Used in Diluted with sterile water or saline before use. Tuck patient skin antisepsis. towels in at patient’s sides to prevent pooling. Iodine Can be used as and chlorhexidine free. surgical hand scrub.

PCMX

0.3% chlorometaxylenol

Bactericidal. Used in Diluted with sterile water or saline before use. Tuck patient skin antisepsis. towels in at patient’s sides to prevent pooling. Residual Can be used as antibacterial effects. Iodine and chlorhexidine free. surgical hand scrub.

Concentrations of 60% to 95%

Bactericidal in 30 seconds and inhibits viruses in two minutes as surgical hand hygiene gel.

Alcohol

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Used on hands with no visible soil or biologic contamination. Most brands contain emollients, such as aloe vera. Alcohol does not penetrate biologic material and does not provide lasting antimicrobial effects. Can cause corneal and nerve damage. Flammable.

December 2016 | OR TODAY

IN THE OR CONTINUING EDUCATION CE568C Balance in the numbers of resident bacteria helps prevent transient bacteria from accumulating. The normal epidermal surface is somewhat dry, salty and avascular with a low pH. This is not a friendly surface for bacterial colonization. But the skin as a physical barrier is easily breached. Small tears or perforations in the skin leave the host vulnerable to microbial entry, thereby changing the survivability factor in favor of transient bacterial growth. Examples of simple breaks include body piercings; hangnails; pimples; and tiny injuries, such as paper cuts. The intentional incising of the patient’s skin can provide a portal of entry for any living microorganism (e.g., methicillinresistant Staphylococcus aureus [MRSA] or vancomycin-resistant Enterococci) or dormant bacterial endospore (e.g., Bacillus or Clostridium classes). Second, consider the structure of the skin and its physiologic appendages. Most skin surfaces have hair-bearing follicles, which include the ducts of sebaceous holocrine glands (i.e., oil glands). The face, chest and scalp have the highest number of holocrine glands. The sebum, or oil contained in these glands, is not sterile and contains amino acids and lipids that are nutritious for microorganisms. The follicle provides a locus for microbial growth and transfer across the surface of the hair as it exits the skin surface. Obstruction of oil glands and sequestering of colonizing microorganisms can cause inflammation and an abscess. Two types of sudoriferous (i.e., sweat) glands, apocrine and eccrine, accompany sebaceous glands in different body locations and offer additional nutritional media and moisture for the growth of S. aureus and Corynebacterium. (Staph grows well in the skin environment and can become resistant.) Release of sweat from apocrine glands in the armpits and groin and from eccrine glands over the remainder of the body surface is part of the thermoregulatory process of the skin. Odors produced in the hair-bearing areas 40 OR TODAY | December 2016

of the body are the result of bacterial growth and degradation. Microbial growth can be augmented by the use of skin-lubricating lotions that can inactivate many antiseptic skin products. The third consideration is the flexibility and mobility of the skin’s surface. Generally, skin is pliable. Manipulation of the oil and sweat glands increases discharges onto the surface of the skin. A susceptible recipient can be contaminated by pathogens transferred by these body substances if the skin is not intact. Surface cells desquamate daily, and 10% of shed cells carry viable bacteria. Dry, cracked skin sheds more epithelial cells, decreasing microbial growth inhibiters. Increased numbers of living microorganisms or bacterial endospores are transferred to patients or objects in the environment. ANTISEPTIC CONSIDERATIONS Ineffective handwashing may be part of the problem. Further investigation is warranted concerning the use of antiseptic soaps in all settings. Overuse of antiseptic soaps, especially at home, may be causing increased resistance in certain bacteria. Products such as dishwashing detergent, deodorant, shampoo and toothpaste used in the home contain 0.15% to 0.3% triclosan as a bactericide. Triclosan blocks lipid synthesis in E. coli by inhibiting the hormonal activity of certain enzymes. Studies have shown that continued use of antiseptic products has prompted the proliferation of drug- and antisepticresistant strains of microorganisms in the natural environment. The targeted bacteria are not killed because of inadequate contact time with the bactericide; they continue to reproduce, genetically transmitting resistant plasmids — bacterial DNA molecules capable of self-replication — to the next generation. Pseudomonas aeruginosa has been shown to develop resistance to antibiotics, such as ciprofloxacin (Cipro), after exposure to triclosan.2 Not

all bacteria respond in kind, but some experts suggest that triclosan and other antimicrobials are overused in household products and may result in antibiotic and antiseptic resistance in the natural environment. Skin damaged by repeated washing loses the anatomic flexibility and surface protection of the natural epidermis. Washing damaged skin is not as effective as washing healthy skin.3 As skin health declines, resistant microorganisms colonize the surface. Handwashing increases skin damage and can augment transference of bacteria during patient care. One researcher reports that postscrubbing irritation persisted for several days and the skin did not return to a healthy state for 17 days. Decreased numbers of natural flora on the hands of long-term antiseptic users is followed by decreased resistance to topical infections. Loss of resident flora indicates a shift in skin pH and decline in natural barrier protection. Damaged skin maintains and sheds higher numbers of bacteria. (The pH of intact skin is not good for many skin microbes to overpopulate.) IN SURGERY Many healthcare workers across various disciplines continue to have poor hand hygiene despite best-practice evidence about microbial transfer between individuals. The GRAS/GRAE status of all antiseptic solutions is under investigation, and the results of studies often yield conflicting results.2 (See table on previous page) Patient adherence to presurgical showers with antiseptics is inconsistent. One facility had patients bathe upon arrival in the preoperative holding area using prewarmed no-rinse wipes impregnated with 2% chlorhexidine gluconate antiseptic. The usual concentration for the chlorhexidine gluconate surgical soap is 4%. Because it remained in contact with the skin until the initial skin incision, the lower concentration of the chlorhexidine WWW.ORTODAY.COM

CONTINUING EDUCATION CE568C

ENDOSPORE-FORMING BACTERIA gluconate was effective at reducing bacterial counts, particularly in the hair-bearing regions of the groin and axillae. (In addition, minimal handling of the skin around hair shafts, such as clipping, decreases the risk of infection.) Although no other products were compared, the facility reported a 66% reduction in surgical site infections attributed to use of the chlorhexidine gluconate during the pilot study. A review of preoperative bathing or showering with 4% chlorhexidine gluconate did not show any benefit over cleaning the skin with any antiseptic, even common household soap. The 2% chlorhexidine gluconate no-rinse wipe may have been beneficial because of the mild mechanical exfoliation associated with applying the wipe to the skin and the chemical residue absorbed by epidermal cells. Prewarming the chlorhexidine gluconate cloth to body temperature contributed to patient comfort and adherence. As far as patients’ skin antisepsis, healthcare professionals as a team should consider the duration of chemical contact, the use of adherent antimicrobial drapes (incise sheets) and one-step preps. Plastic adherent drapes with iodophor or other antimicrobial properties minimize microbial transfer during the surgical procedure, but may cause breakdown of the protective epidermal surface when they are removed at the end of the case. Iodophor (also safe and effective for neuro preps) and alcohol-based one-step preps are applied to the skin and are intended to remain on the patient’s skin for several days postoperatively. Natural epidermal shedding of the skin is supported by the antiseptic coating. Chlorhexidine gluconate is known to bind with the stratum corneum of the epithelium, providing six hours of antimicrobial effect. Attempts to rub one-step prep material off the skin prematurely will cause the loss of natural epidermal protective activity. If removal is necessary, an alcohol-based removal solution is commercially available from the manufacturer. THE SURGICAL TEAM Cognitive variables ranging from one’s personality to attitudes and beliefs influence a person’s practice of hand hygiene and should be discussed collaboratively among all disciplines. Healthcare professionals should perform hand hygiene in different ways using different products according to the situation.4 Antiseptic soap and warm tap water should be used when arriving on duty, before meals, for removing visible soil and before leaving the surgical suite for home. Gel rubs with an alcohol base are used when hands are not visibly soiled or when patient skin or equipment has been handled.5 Gel rubs can irritate the skin and are flammable; however, many gel rubs contain emollients to minimize skin breakdown. The gel rub remains in contact with the skin, offering prolonged chemical action against microorganisms similar to the no-rinse chlorhexidine gluconate wipes.5 WWW.ORTODAY.COM

Phylum Firmicutes (means tough skin) Class: Bacilli (aerobic) Genus: Bacillus (gram-positive rods) Pathogenic Bacillus B. anthracis (anthrax) B. cereus (food poisoning) Nonpathogenic Bacillus (heat resistant: used in steam sterilization testing) B. subtilis B. Geobacillus stearothermophilus (formerly known as genus B) Class: Clostridia (anaerobic) gram-positive rods Genus: Clostridium Pathogenic C. perfringens (gangrene, food poisoning) C. difficile (several forms of colitis) C. tetani (tetanus) C. botulinum (botulism) C. sordellii (toxic shock, gynecologic infections) Genus: Helicobacter gram-positive coccus (passed orally into GI tract) H. pylori (gastric and intestinal ulcers)

Surgical hand scrubs before gowning and gloving include antiseptic detergent and a sponge-brush apparatus. The spongebrush mechanically removes skin detris. The detergent component decreases the surface tension of the skin as the antiseptic properties chemically destroy bacteria. The sponge surface causes less skin irritation than the brush portion of the sponge-brush apparatus and is recommended for use on the thinner parts of the hands and arms. Surgical hand and arm scrubbing should include one of the following methods: counted stroke scrub, anatomic scrub by area or timed scrub. Healthcare professionals should clean their fingernails using a nail pick and antiseptic soap under running water. Artificial nails harbor microorganisms and are not permitted in surgical hygiene. Nail polish that is unchipped and less than four days old is acceptable.4 Gel antiseptic rubs are appropriate for use after removing surgical gloves. However, powdered gloves can leave residue on the hands that cause irritation, and the residue should be washed off with soap and water. Gel antiseptic rubs do not remove debris or soil; therefore, hand washing with an antiseptic product is necessary for adequate hand hygiene.6 Skin is never rendered sterile, but controlling microbial load at an irreducible minimum is important for both the patient and caregiver. December 2016 | OR TODAY

IN THE OR

Nonsterile members of the surgical team wear gloves during routine patient care as a component of personal protective equipment. Sterile gloves are used commonly in place of nonsterile exam gloves because they conform to the contours of the hand and feel like a second skin for intubating and suctioning patients. Unfortunately, many nonsterile members of the anesthesia team wear the same pair of gloves throughout the entire surgical case after being exposed to patient body substances during intubation. Gloves can become comfortable and feel natural to the wearer. For example, some anesthesia personnel adjust monitors and press keys on a computer keyboard wearing the same gloves used for oropharyngeal procedures and then inject medications, such as propofol (Diprivan), into the patient’s IV.2 The same computer keyboard is used or monitor button pressed several times during the day by many anesthesia personnel who, in turn, render patient care with or without gloves. Transference of living microorganisms or bacterial endospores between surfaces in the OR and the patient is a demonstrated reality. Any residual microbial contamination can be transferred from the inanimate surface to the patient and possibly to injectable medication. Studies have shown that certain microbes can persist on surfaces more than 24 hours and can be transferred from gloved or nongloved hands to multiple surfaces. Dried bacteria can form resistant endospores as self-protection and later reanimate and replicate themselves by binary fission when conditions again become favorable, such as entry into a host. Examples of endospore-forming bacteria of particular concern include several genera of Bacillus and Clostridium (e.g., Bacillus cereus, Clostridium difficile and Clostridium perfringens). (See examples of endospore-forming bacteria on the previous page.) 42

OR TODAY | December 2016

EXAMPLES OF ENDOSPOREFORMING BACTERIA Endospore-forming bacteria are gramstain positive. Endospores are formed in response to environmental changes on skin and inanimate surfaces that do not support active bacterial growth and reproduction. The process takes about eight hours and is known as sporulation. Endospores are protective capsules that form inside bacteria to resist ultraviolet and gamma radiation, temperature changes, desiccation and many chemicals in the environment; they cause the outer covering of the bacterial cell to shed. When living conditions are favorable, the endospore reanimates and reproduces by binary fission because the genetic material of the bacterium has been preserved. Gloved hands carry a larger microbial load because of the nature of the glove material’s texture. The most common bacteria isolated from keyboards were coagulase-negative staphylococci, bacillus and MRSA. Best practices indicate that gloves should be removed after any procedure, and hands should be washed or treated with an alcohol-based gel rub.6 Healthcare professionals as a team should perform hand hygiene several times during patient care if they are handling multiple areas of the patient’s body or touching multiple items throughout the patient care environment. Gloves are never 100% impervious, and the wearer could be contaminated during patient contact. A study in Australia testing the porosity of surgical gloves proved that all gloves tested were porous enough to transfer bacteria from the wearer’s hands to the patient and vice versa. Proper skin antisepsis and hand hygiene can minimize surgical site infections, and healthcare professionals across disciplines should collaborate to enhance adherence. Skin antisepsis includes surgical techniques, such as the use of antimicrobial adherent incise drapes and antiseptic solutions that bind with skin cells.2,4 Hand hygiene benefits the member of the surgical team as well as the patient. Knowing which product and

method to use is essential to preventing surgical site infections. Given the microporosity of surgical gloves, healthcare professionals as a team must use skin antiseptic products appropriately so they will provide an effective microbial kill and minimize microbial transfer between wearer and patient. Nancymarie Phillips, PhD, RN, RNFA, CNOR, is professor of perioperative education at Lakeland Community College, Kirtland, Ohio. References 1. Phillips NM. Berry and Kohn’s Operating Room Technique. 12th ed. St. Louis, MO: Elsevier; 2012. 2. Safety and effectiveness of health care antiseptics: topical antimicrobial drug products for over-the-counter human use; proposed amendment of the tentative final monograph; reopening of administrative record. A proposed rule by the Food and Drug Administration on 05/01/2015. Federal Register Web site. https://www.federalregister.gov/ articles/2015/05/01/2015-10174/safetyand-effectiveness-of-health-careantiseptics-topical-antimicrobial-drugproducts-for#h-52. Published May 1, 2015. Accessed May 29, 2015. 3. Guidelines for Perioperative Practice. Denver, CO: The Association of PeriOperative Registered Nurses. 2015. 4. Spruce L. Back to basics: hand hygiene and surgical antisepsis. AORN J. 2013;98(5):449-457. doi: 10.1016/j. aorn.2013.08.017. 5. Howard JD, Jowett C, Faoagali J, McKenzie B. New method for assessing hand disinfection shows that preoperative alcohol/chlorhexidine rub is as effective as a traditional scrub. J Hosp Infect. 2014;88(2):78-83. doi: 10.1016/j. jhin.2014.06.013. 6. Macinga DR, Edmonds SL, Campbell E, McCormack RR. Comparative efficacy of alcohol-based surgical scrubs: the importance of formulation. AORN J. 2014;100(6):641-650. doi: 10.1016/j. aorn.2014.03.013. WWW.ORTODAY.COM

CLINICAL VIGNETTE Hannah was admitted to a community hospital for treatment of increased intracranial pressure caused by a tumor that obstructed the flow of cerebral spinal fluid. She was taken to the OR for placement of a ventriculostomy for external drainage of the cerebral spinal fluid. In the OR, the hair around the portal site was clipped. Her remaining hair was secured away from the sterile field. A two-step iodophor prep was performed. Chlorhexidine gluconate is neurotoxic and was not used. The sterile team scrubbed with iodophor and used sterile technique for gowning and gloving. They used an iodophor incise sheet as part of the draping procedure. Irrigation was done with room temperature sterile lactated Ringer’s solution. Antibiotic prophylaxis was not used before, during or after the surgical procedure. The cerebral spinal fluid was collected for baseline culture and sensitivity; it was negative. On postoperative day two, Hannah’s temperature was 102 F, and the cerebral spinal fluid appeared slightly cloudy. The cerebral spinal fluid cultures grew Staphylococcus aureus. During her morning care, the nurses aides had manipulated the three-way stopcock attached to her ventriculostomy port without first using adequate hand hygiene, causing an ascending catheter-associated infection. Hannah received antibiotics intrathecally, and her cerebral spinal fluid cultures resolved. By postoperative Day 5, her cerebral spinal fluid cultures were negative, and her body temperature had returned to normal. 1. The surgical team performed Hannah’s skin prep without a complete head shave. How was this beneficial to the patient’s outcome? a. The risk of permanent baldness is reduced when only small sections of the area are shaved. b. Minimal shaving reduces the risk of skin abrasion created by clippers or razor. c. Leaving hair around the incision permits prolonged contact of the antiseptic prep solution. d. The remaining hair was used to retract the scalp for greater visibility. 2. How did the surgeon determine that the infection was not present at the time of the surgical procedure? a. Baseline cultures were taken intraoperatively and were negative. b. The surgical team performed hand surgical scrubs with chlorhexidine gluconate. c. Antibiotics were not used during the procedure. d. The causative microorganism is not native to the skin. 3. What was the most likely reason for Hannah’s infection? a. The team used poor surgical technique. b. The daily care staff ’s hands were soiled. c. The surgical team was not double-gloved. d. The direct care staff had upper respiratory infections. 4. Why was iodophor the solution of choice for Hannah’s surgical prep? a. Iodophor renders the skin sterile. b. Her hair was freshly washed. c. Iodophor is safe and effective for neuro preps. d. Iodophor was more cost-effective to use.

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 6/30/2017. 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 OnCourse Learning is accredited by the American Nurses Credentialing Center (ANCC), the Accreditation Council for Pharmacy Education (ACPE), and the Accreditation Council for Continuing Medical Education (ACCME), to provide continuing education for the healthcare team. OnCourse Learning is also accredited by the Florida Board of Nursing, District of Columbia Board of Nursing, and Georgia Board of Nursing (provider # 50-1489). OnCourse Learning is approved by the California Board of Registered Nursing, provider # CEP16588. 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

4. Correct Answer: C- Chlorhexidine gluconate is neurotoxic, and the risk of contact with the neurologic system of the patient was significant.

2. Correct Answer: A- Baseline cultures were taken at the time of the procedure, and infection was not present.

3. Correct Answer: . B- Inadequate hand hygiene of personnel providing daily care was the cause of the infection.

1. Correct Answer: B- Minimal handling of the skin around hair shafts decreases the risk of infection.

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December 2016 | OR TODAY

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CORPORATE PROFILE

MAC

Medical, Inc. concentrates in manufacturing top quality medical equipment including Warming Cabinets, Stretchers, Sinks, Tables, Cabinetry, Case Carts, IV Stands, Mayo Stands, and many other stainless steel products. Founded in 1998 by Dennis and Stacey Cooper, the company has grown to more than 120 full-time employees operating in a 100,000 square foot manufacturing facility and 8,200 square foot corporate oﬃce. Both facilities are located in Southern Illinois making this an ideal place for centralized distribution to the entire United States. Not limited to the United States, MAC Medical has product in over 20 countries worldwide. Founded as a solutions-based company, MAC Medical still maintains that as its core competency. With no project too large or too small, MAC Medical is committed to providing solutions for customer needs with its service and American-made products. OR Today magazine recently learned more from MAC Medical President Dennis Cooper.

Can you share a little bit about your company’s history and how you achieved success? Cooper: Since our inception as a small team in 1998, our company has grown to over 120 full-time employees with exponential growth in the past few years. We continue to utilize state-of-the-art equipment such as a 3D CAD solid modeling system, a fully automated fabrication department, and employing highly skilled craftsman making it possible to produce medical equipment unparalleled in the marketplace. We wouldn’t be where we are without the strategic relationships of our domestic and international partners. 46

OR TODAY | December 2016

What are some advantages that your company has over the competition? Cooper: Our competitive advantage has always been the ability to customize products to any specific customer need. Whether it’s a small table or a large bank of custom cabinets, we can find a solution.

Cooper: With our concentration on customer service and manufacturing the highest quality products available, we are always committed to providing solutions for customer needs. Whether it’s an extremely complex product or nearly impossible shipment timeframe, we are always ready to do what it takes to ensure the customer is taken care of.

What are some challenges that your company faced last year? How were you able to overcome them? Cooper: We continue to be presented with project challenges that sometimes seem almost impossible at first glance. I can’t say enough about our experienced in-house engineers and customer service team who dig deep, find solutions, and ultimately figure out a way to complete those unique projects. That’s a testament to the continued success at MAC Medical.

How do you explain your company’s core competencies and unique selling points?

What product or service that your company oﬀers are you most excited about right now? Cooper: MAC Medical recently launched its newly redesigned D-Series (Data Logging) Blanket & Fluid Warming Cabinets. These are the user-friendliest temperature recording devices on the market today. They are equipped with independent, digitally controlled heating chambers that offer actual temperature and set point displays along with simple plug and play data download that requires no additional software. There are 27 standard models to choose from with a sleek new appearance. Also available as a premium WWW.ORTODAY.COM

SPECIAL ADVERTISING SECTION

“Our competitive advantage has always been the ability to customize projects to any specific customer need.” upgrade are the TS-Series (Touch Screen) Warming Cabinets. These Ethernet/Wi-Fi enabled warmers offer smart technology by allowing remote connectivity to your warmer (via smart phone app), giving you control wherever you are. We are also excited about our newly redesigned PT1001 General Transport Stretcher. This stretcher allows for easy and comfortable patient transfer with a weight capacity of up to 750 pounds. Economical and versatile, the PT1001 is an ideal solution for any department where cost-efficient quality is required.

Can you explain the process of creating one of your products? Cooper: We start with a need, whether we recognize a medical facility in need of a product or a

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customer comes to us with a specific product request. Once that need is identified our engineering staff takes over with product development by working out a plan and designing a proof of concept, which can take several revisions. From there we have the product built based on the final approved engineered drawings. If this is going to be a new product offering we then test; retest, and quality check the new product to make sure it passes our rigorous standards. Once approved it’s in the hands of our in-house marketing department to do a full product launch through outbound and inbound channels, educate our distributors and customers, and ultimately track its vitality.

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

Cooper: We continue to help our customers grow and meet any complex requirement they may have. We adapt to the ever-changing market and economic conditions ensuring we maintain the core of MAC Medical.

Can you share some company success stories with our readers – one time that you “saved the day” for a customer? Recently, MAC Medical was confronted with one of those challenging projects with an educational laboratory (primarily used for residence training). This was a new construction where the general contractor was replaced mid project causing a delay with project management. We were challenged with the most complex build to date to be completed in the original

December 2016 | OR TODAY

CORPORATE PROFILE

timeframe leaving us with virtually no time to finish design and build the project. MAC Medical was able to deliver a fully customized setup of sinks, tables, cabinets and shelving on time. Cooper added that this is a prime example of a project that we were happy to take on. Just because a project seems impossible doesn’t mean it is. We are extremely happy this worked out for all parties involved. There’s nothing more rewarding than a satisfied customer and ultimately this gives our next generation of doctors an up-to-date facility where they can learn and practice.

Can you tell us more about recent changes to your company, inventory, services, etc.? Cooper: We are proud of our newly redesigned website www. macmedical.com that launched earlier this year. The clean new design reflects our commitment to the growing needs of our customers along with building upon technology to address present and future business needs. Visitors are welcomed with simple navigation, new and expanded product line content, literature resources, price request capabilities, and search functionality. In addition, the new site is completely responsive and mobile-friendly. In addition, we have a new updated product catalog now available with over 50 pages of product information to

browse. For a copy of our new catalog, contact customer service, or you can simply download a digital version on our website. We also have a new Quick Ship Program to meet urgent project needs. With fast and reliable 1-2 day shipments, this new program provides a responsive approach for time-sensitive projects. The available products for Quick Ship continues to expand.

Can you tell me about your staﬀ ? Cooper: MAC Medical is proud to employ a staff dedicated to customer service. Our employees are truly the heart and soul of our business. They are proud to take part in helping our customers succeed. All of our staff goes above and beyond. I can’t say enough about our team as a whole, they truly are appreciated.

What is most important to you about the way you do business? Cooper: Our motto since the beginning has been “Customer needs are our first priority.” Without our customers we wouldn’t have a business, so it’s important that we take care of those who take care of us. I think as long as we continue to live out that motto, MAC Medical will continue to find success.

OR TODAY | December 2016

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Quality built, American made

Medical Equipment

MAC Medical, Inc. manufactures the highest quality medical equipment available. Our engineering capabilities allow us to custom design any specific product your facility may have. With no project too large or too small for our capability, we are committed to providing solutions for your custom needs with our American made products. Some of our products include: • Warming Cabinets

• Prep & Pack Workstations

Corporate Office 325 West Main Street Belleville, IL 62220

• Transport & Eye Stretchers • Linen Hampers • Surgical Scrub Sinks • Kick Buckets • Processing Sinks • Cabinetry • Tables

• Step Stools • Wall Shelves • Pass Through Windows

• Carts • IV Stands • Mayo Stands

• Peg Boards • MR Conditional Products • Any other customized

• Solution Stands

Manufacturing Plant 820 South Mulberry Street Millstadt, IL 62260 Phone: 618-476-3550 Toll Free: 877-828-9975 Fax: 618-476-3337 sales@macmedical.com www.macmedical.com

stainless steel need

For more information, contact our customer service department at 618-476-3550 or 877-828-9975, or by email at sales@macmedical.com.

Customer needs are our first priority. Check out our new redesigned website

www.macmedical.com

When you consider the high degree of complexity involved in becoming a competent perioperative nurse, itâ&#x20AC;&#x2122;s surprising how little specialized OR training is included in standard nursing program

Team S t r a t e g i e s a n d T o o l s tcurricula. o E n hThis a nc e makes OR P e r f or m a nc e a n d P a t i e nnurse t Straining a f e t yone of the biggest challenges facing BY DON SADLER

the industry today.

ecently, there has been an increased emphasis on patient safety at all levels of the health care deliver y system. Some health care organizations are implementing a program developed with input from the Depar tment of Defense as par t of their effor ts to improve patient safety. R e f e r r e d t o a s Te a m S T E P P S ( Te a m S t r a t e g i e s a n d To o l s t o E n h a n c e P e r f o r mance and Patient Safety), this evidence-based framework is designed to improve health care professionalsâ&#x20AC;&#x2122; teamwork and communication skills as they r e l a t e t o i m p r o v i n g p a t i e n t s a f e t y.

TeamSTEPPS Team Strategies and Tools to Enhance Performance and Patient Safety

“

“The goal is to implement and evaluate new patient safety initiatives, or to change, evaluate or enhance existing initiatives.” Ellice Mellinger, MS, BSN, RN, CNOR, a Senior Perioperative Education Specialist with the Association of periOperative Registered Nurses (AORN)

A COMMON LANGUAGE

According to Ellice Mellinger, MS, BSN, RN, CNOR, a senior perioperative education specialist with the Association of periOperative Registered Nurses (AORN), the TeamSTEPPS program provides a common language or vocabulary to promote effective team skills and communication. “These skills are especially important in the fast-paced and often stressful environment of the perioperative services area,” she says. TeamSTEPPS is designed to teach Master Trainers a framework of skills they can take back to their health care organizations and share with personnel there. “The goal is to implement and evaluate new patient safety initiatives, or to change, evaluate or 52

OR TODAY | December 2016

enhance existing initiatives,” says Mellinger. The TeamSTEPPS program also provides tools that can be used to evaluate and measure the changes that have already been implemented, as well as monitor whether or not these changes are effective and sustainable, says Mellinger. For example, wrong-site surgery and retained surgical items are two of the most frequently reported preventable errors in the OR. Mellinger says research has concluded that ineffective communication is one of the leading causes of these and other sentinel, near-miss and adverse OR events. Mellinger explains in more detail how TeamSTEPPS tools can be used to help prevent wrong-site surgery. “Some departments struggle with the OR team not completing actions that are outlined in their policies for each patient’s preprocedure activities. TeamSTEPPs assessment tools can help identify a course of action to improve the pre-procedure verification process throughout the preoperative process,” she says. ROOTED IN SCIENCE

TeamSTEPPS was developed jointly by the Department of Defense’s Patient Safety Program and the Agency for Healthcare Research and Quality (AHRQ). According to the AHRQ (AHRQ. gov), it is scientifically rooted in more than 20 years of research and lessons from the application of teamwork principles. The AHRQ says there are four specific ways that TeamSTEPPS provides higher quality and safer patient care: • Produces highly effective medical teams that optimize WWW.ORTODAY.COM

the use of information, people and resources to achieve the best clinical outcomes for patients. • Increases team awareness and clarifies team roles and responsibilities. • Resolves conflicts and improves information sharing. • Eliminates barriers to quality and safety. According to the AHRQ, there are three distinct phases in the TeamSTEPPS delivery system: 1. Pre-training assessment for site readiness – This consists of identifying opportunities for improvements in patient safety, determining the readiness of the health care organization (e.g., leadership support) for change, identifying potential barriers to implementing change, and determining if resources are in place to successfully support the initiative. 2. Planning, training and implementation – Options include implementation of all TeamSTEPPS tools and strategies throughout the entire organization, a phasedin approach that targets specific units or departments, or selection of individual tools introduced at specific intervals (this is referred to as a “dosing strategy”). 3. Implementation and sustainment – The key objectives here are to ensure that opportunities exist to implement the TeamSTEPPS tools and strategies that have been taught, practice and receive feedback on skills, and provide WWW.ORTODAY.COM

continual reinforcement of the TeamSTEPPS principles. FOUR BASIC SKILLS

The TeamSTEPPS program is based on a framework that’s comprised of four skills: leadership, situation monitoring, mutual support and communication. Following are more details on each of these skills to help you implement the TeamSTEPPS program at your health care organization. There are two types of TeamSTEPPS leaders: Designated leaders and Situational leaders. Regardless of which type of TeamSTEPPS leader an individual may be, he or she should be able to accomplish a number of specific steps, including the following: • Articulate clear goals. • Make decisions through the collective input of team members. • Empower team members to speak up and challenge lead-

ership, when appropriate. • Actively promote and facilitate good teamwork. • Resolve conflicts among team members skillfully. The TeamSTEPPS program includes several specific team events designed to help boost leadership skills. These include: Team Brief: This is a short planning session that should take place prior to team formation. The goal of the team brief is to assign essential roles, establish expectations and climate, and anticipate outcomes and likely contingencies. Team Huddle: This is a type of ad hoc planning used for problem-solving. It helps reestablish situational awareness, reinforce plans already in place, and assess whether or not it’s necessary to adjust the plan. Team Debrief: This is an informal information exchange

“TeamSTEPPs assessment tools can help identify a course of action to improve the preprocedure verification process throughout the preoperative process.” – Ellice Mellinger

December 2016 | OR TODAY

TeamSTEPPS Team Strategies and Tools to Enhance Performance and Patient Safety

session designed to improve team performance and effectiveness. Team feedback will help drive future process improvements. Situation monitoring is the process of health care team members continually scanning and assessing what’s going on around them to maintain situational awareness. This is defined by TeamSTEPPS as “knowing what is going on around you and knowing the conditions that affect your work.” TeamSTEPPS uses the acronym STEPS to describe situation monitoring: Status of the patient, Team members, Environment, and Progress toward the goal. Also covered under situation monitoring are cross monitoring – an error reduction strategy that involves team members monitoring each other’s actions to provide a safety net within the team – and shared mental models. These result from each team member maintaining situational awareness and sharing relevant facts with the entire team. One form of mutual support in TeamSTEPPS is referred to as task assistance. Here, team members protect each other from work overload situations, put all offers and requests for assistance in the context of patient safety, and foster a climate where it’s expected that assistance will be actively sought and offered. Finally, TeamSTEPPS defines effective communication as complete, clear, brief and timely. It includes a technique called SBARQ for communicating critical information concerning a patient’s condition that requires immediate attention and action: Situation: What’s going on with the patient? 54

OR TODAY | December 2016

Background: What is the clinical background or context? Assessment: What do you think the problem is? Recommendation and Request: What would you do to correct the problem? Questions: What questions do team members have? IMPLEMENTING TEAMSTEPPS TOOLS

Mellinger identifies a number of different ways OR personnel can implement TeamSTEPPS tools and strategies to improve patient safety, including the following: • Learn how to be an effective team member; • Speak up about patient safety concerns; • Communicate professionally to resolve conflicts; • Increase efficiency in perioperative processes; and • Assess and track the progress of quality improvement processes for patient safety. One thing Mellinger especially likes about TeamSTEPPS is the fact that it is not prescriptive. “There are so many tools and strategies available in TeamSTEPPS,” she says. “TeamSTEPPS offers many evidence-based tools that complement the team structures in every OR,” Mellinger adds. “Using these tools encourages a common language and consistency and clarity in communication practices.” According to Mellinger, AORN is developing a new video and study guide titled Perioperative Team Dynamics and Communication that incorporates TeamSTEPPS tools and strategies. “This educational product should be available for purchase by the end of the year,” she says.

FOR MORE DETAILS, visit AORN online at www.aorn.org.

“

“TeamSTEPPS offers many evidencebased tools that complement the team structures in every OR. Using these tools encourages a common language and consistency and clarity in communication practices.” – Ellice Mellinger

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Spotlight On: Pamela Elzy By Matt Skoufalos

Pamela Elzy remembers the day her nursing

career began as the day she told her mother she’d secured a scholarship to the University of Louisville … to be a history teacher. “My mother said, ‘Don’t be ridiculous; I’ve signed you up for nursing school,’ ” Elzy said. “I have to say, it’s one of those things where mom was correct.” A survivor of the Great Depression, her mother was the oldest “of many siblings,” and the only one to have worked prior to marrying, Elzy said. She knew that nurses made money and was worried that her daughter wouldn’t be able to support a family on a teacher’s salary.

As it turned out, nursing “is something I was drawn to,” Elzy said, “and I really have not looked back.” “I still read a lot of history,” she said. “I just don’t teach it.” Elzy got her letter of acceptance from the Saint Joseph’s School of Nursing in Louisville the same day the Courier-Journal reported that the school was closing. The nearby Kentucky Baptist School of Nursing offered to take on any students displaced by the shutdown, and, much to her Catholic father’s regret, that’s where Elzy went. “It was a very difficult discussion, but mom was insistent on this course of action,” she recalled. “I got a stunning nursing education.”

The three-and-a-half-year diploma program at Kentucky Baptist offered a three-month clinical surgery rotation among its assignments, and Elzy fell in love with the operating room. At the end of school, seniors were allowed to choose their assignments for the last three months of school, and she headed back to the OR. By graduation, she’d put six months of surgery experience on her resume. Elzy’s education had been funded by a scholarship from the Jewish Hospital Foundation, which included a two-year contract at the Jewish Hospital of Louisville upon graduation. When she appeared before the scholarship group with the backing of a family friend, the director of nursing told Elzy her grades were good enough to pursue a bachelor’s degree in the field. “I can remember in my 17-yearold mind, saying, ‘I don’t want to teach,’ ” Elzy said. “I’ve been eating those words a thousand times.” Elzy was given an OR assign-

As it turned out, nursing is something I was drawn to and I really have not looked back. 58

OR TODAY | December 2016

WWW.ORTODAY.COM

ment at Jewish Hospital, which she recalls as “a wonderful climate for developing as a person and as a professional.” She thrived for years in the role, but her next nursing director hammered home the point made by his predecessor, telling her, “If anyone’s interested in management in my hospital, you’ve got to have a bachelor’s degree.” So, Elzy spent the next six years earning her BSN part-time while also working part-time. As promised, that led to an OR supervisory role in which Elzy spent another decade before earning her master’s degree in hospital leadership at Webster University in St. Louis. Four years later, she missed the OR so much that she took another position as the director for surgery and recovery at a Level II trauma center. By the time Elzy had reduced her role into an evenings-and-weekends detail as a charge nurse in order to spend more time raising her daughter, her responsibilities had expanded to include not only surgery and recovery but also the same-day surgery unit, nursing education, labor and delivery, and a satellite labor and delivery clinic. Along the way, Elzy discovered she had a knack for formulating staff education and gathering hospital policies and procedures. She was invited to take over as an interim perioperative nursing educator at the University of Louisville Hospital – an experience she described as akin to building an airplane in mid-flight. She eventually inherited the position full-time, and was promoted to the director of the clinical education department. Two years later, Elzy earned WWW.ORTODAY.COM

the opportunity to develop and implement a clinical informatics program. Along the way, she completed an online MSN and a doctorate in nursing, which jibed with the institutional changes that followed after the hospital was merged with Kentucky One as a division of Catholic Health Initiatives. Elzy became the system-wide director of clinical education. It’s been a long climb to the position she’s earned through years of schooling and dedication to the advancement of her peers as well as herself, and to Elzy, that experience has yielded a degree of clarity about the field. She still credits her OR background as a new graduate with helping her understand nursing at its most basic level. “Complexity, advocacy, teamwork – all of those things you have to be successful at to work as a nurse in the operating room – this is what we’re asking of our new grads now, and many of them are having so much trouble doing that,” Elzy said. “I learned early on it was not about what I did, it was about how I interacted with all of the people that were in this operating room to care for this patient. To me, that was a lifelong learning opportunity. I am really, really sorry that our nursing students don’t get more opportunities to embrace their role before they have to decide what to do with their lives.” “I miss it a lot, but I’m 63 and I don’t think I could work 12 hours in a lead outfit anymore,” she said. “This opportunity we have when we’re young to experience different things; the OR is a place to ground yourself in these vital pieces of nursing understanding.”

“I learned early on it was not about what I did. It was about how I interacted with all of the people that were in this operating room to care for this patient.” December 2016 | OR TODAY

OUT OF THE OR HEALTH

BY MARILYNN PRESTON

ON TURNING 40 NOT ME, SILLY - THE COLUMN!

o I dare write a column celebrating 40 years of writing this column? "Why not?" I answer, striking the power pose. I've put in my 10,000-plus-plus hours. I've become an expert in healthy living, not to mention time spent on healthy dying, a booming industry just now coming about. I've done other things in my professional life – from winning Emmys for a sports and adventure series to co-hosting a dueling-TV-critics show a la Siskel and Ebert – but no work I've done has the track record of this old thing, the longest-running syndicated fitness column in America.s. Longevity counts. Happy anniversary to me. When I created Energy Express, my full-time job was writing features and reviewing TV, film and theater for the Chicago Tribune. All the medical columns in newspapers were about headache cures and hemorrhoids. Fitness was just beginning to creep into the consciousness of the nation, right up there with CB radio and needlepoint. It was 1976. Jane Fonda was going for the burn, jumping jacks were in style, only tough guys belonged to gyms, and yoga and tofu were considered interchangeable terms. Things have changed – so much so, I decided to interview my own most personal trainer for the past many decades. That would be me.

60 OR TODAY | December 2016

Q: WHAT'S THE SINGLE BIGGEST CHANGE YOU'VE SEEN IN FITNESS IN THE LAST 40 YEARS?

A: That's impossible. Ask me something else. Q: COWARD?

A: OK, then. Fitness isn't just about exercise anymore. It's evolved into something much grander and more important. These days, fitness is all about living a healthier, happier, more balanced, more loving life, taking into account the powerful mindbody connection, which was not taken seriously in 1976. Forty years ago (yes, I was just learning to tie my shoes), “healthy lifestyle” wasn't even an expres-

sion. Now it's a multibillion-dollar industry that includes fitness trackers, glow-in-the-dark athletic shoes and the Lake Nona project, an entirely new theme park city in – you'll never guess – Orlando, created around the concept of “wellness.” Rumor has it that Minnie and Donald are shopping for a condo. Over the years, I've seen wellness and fitness fuse into one, emphasizing physical exercise, mental clarity, smart eating, strength training, relaxation, stress reduction, adventure travel, yoga and tofu and almost everything sold at Whole Foods. Organic is everywhere. As for jumping jacks, forget it. It turns out they can really screw up your back. Q: SHOULD EVERYONE EXERCISE?

A: No! Only women and men and girls and boys who want to feel better, live longer, have more energy and fewer reasons to complain. Everyday physical activity – in modest amounts, enough to get the heart pumping and the joy juices flowing – helps you navigate the path to a healthier, happier, longer and more joyful life. Period, the end. WWW.ORTODAY.COM

HEALTH

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Contact us for your Bulb Direct Catalog! sales@bulbdirect.com 800-772-5267 Q: SO WHY DID THEY NEARLY STOP ALL P.E. CLASSES IN SCHOOLS ALL ACROSS THE COUNTRY?

A: Crazy child abusers! This is one of the most sickening developments in the last 40 years. What we have done to our children! It's no wonder that school kids are fatter, more troubled and more likely to have heart disease, diabetes and attention problems. We took away their gym time, force-fed them all sorts of toxic food and drinks, and now we sit back and watch the drug companies sell kids sleeping pills, digestive aids and antidepressants in record numbers. I pray it doesn't take another 40 years to untangle the mess. Q: WHY DO SOUND ANGRY?

A: Let's just say deeply disappointed. Because anger is one of those negative emotions that take us down the lesser path of pimples or low back pain – depending on your age. Q: WHAT ARE THE THREE BEST FITNESS TRENDS OF THE PAST 40 YEARS?

A. Just three? That's torture. There is so much to celebrate. One, the profound connection between body and mind is mainstream now. Two, millions of people are open to healing therapies that include the best of the East and the West. Three, girls and women have every opportunity to soar – in sports, in life, in spite of the patriarchy that has normalized gender bias. But I digress.

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MARILYNN PRESTON is the creator of Energy Express, the longest-running syndicated fitness column in the country. She has a website, marilynnpreston.com, and welcomes reader questions, which can be sent to MyEnergyExpress@aol.com. WWW.ORTODAY.COM

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December 2016 | OR TODAY

OUT OUT OF THE OR OR FITNESS HEALTH

BY BY MATTHEW AUTHORSOLAN NAME HARVARD HEALTH LETTERS

THE RISE OF PUSHUPS

he morning of my 50th birthday in May I did something I had not tried in a long time. I dropped to the floor and did 50 pushups, one for each year. I had to break it up into sets and the last few where shaky, but I did it. And it felt great.

As a new member to the 50-plus club I realized this bread-and-butter exercise still works wonders as a snapshot of your fitness. “How many you can do at one time offers a real-time measurement of your strength and muscular endurance and is an easy tool to help you improve,” says Edward Phillips, M.D., assistant professor of Physical Medicine and Rehabilitation at Harvard Medical School. “You can do them anywhere and at any time. All you need is your bodyweight and a few minutes.”

as needed. “By adjusting the speed you perform a pushup, the angle of your body, and even hand placement, you can add more or less intensity, or focus on specific muscles,” says Phillips. A study published in the February 2016 issue of the Journal of Physical Therapy Science found that the chest muscle activity was greater when pushups were performed with the hands placed halfway inward from their normal position. Hands placed outward work the triceps more.

THE PERFECT EXERCISE The pushup engages your body from top to bottom. It works several muscle groups at once: the arms, chest, abdomen (core), hips and legs. Pushups also can be modified

THE PERFECT FORM To maximize what pushups can offer you should perform them correctly. • Begin in a full plank position with your arms extended, palms

OR TODAY | December 2016

flat and just below shoulder level, feet together or about 12 inches apart, resting on the balls of your feet. • Keep your back straight and your weight evenly distributed. • Look down and lower your body until your elbows are at 90 degrees (or go to the floor to rest, if needed) and then push back up to complete one rep. Try to take two seconds to go down and one second to go up. If this is too difficult, perform from a hands and knees position. You can also do inclined pushups where you place your hands on a counter or wall and lean forward at a 45-degree angle. “You can still engage the core and work your arms and chest, while WWW.ORTODAY.COM

HEALTH

you place less weight on the wrists and shoulders,” says Phillips. With a regular pushup, you lift about 50 to 75 percent of your body weight. (The actual percentage varies depending on the person’s body shape and weight.) Modifications like knee and inclined pushups use about 36 percent to 45 percent of your body weight. ESTABLISH A FOUNDATION To find your starting point, perform as many pushups as you can while keeping good form. It could be 10, five or even two. Focus on hitting this

WWW.ORTODAY.COM

number at first with a rest day between sessions. As your strength improves, add more reps, or move up to a full pushup position (if you’ve been bending at the knees or doing pushups against a wall) or build up to doing two to three sets. Because they provide instant feedback, pushups can be a great motivator. Pushup challenges are trendy. Can you do a certain number in a week, or in 30 days? Can you perform 15 to 20 nonstop? “Challenges are a fun way to set up mini, short-term goals, which many men need to stay focused,” says Phillips.

Create your own pushup challenge and see if you can reach it. Begin small and once you achieve it, set the bar higher. My challenge is to do 50 pushups every day for the entire year. So far, so good. I knock them out before I brush my teeth in the morning, and can now do 30 nonstop. Pushups have taught me that when it comes to improving my fitness, I can still rise to the occasion. EatingWell is a magazine and website devoted to healthy eating as a way of life. Online at www.eatingwell.com

December 2016 | OR TODAY

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OUT OF THE OR NUTRITION

BY ENVIRONMENTAL BY AUTHOR NUTRITION NAME

SHOUT-OUT TO BRUSSELS SPROUTS

russels sprouts can get a bad rap, especially from kids. But there’s more to these little veggies than meets the eye.

THE FOLKLORE

Preceded by a less than delicious reputation, Brussels sprouts have been famously refused by children and labeled as smelling of sulphur. Even ancient folklore says the very first sprouts grew from bitter tears. Brussels sprouts were first cultivated near Brussels, Belgium in the thirteenth century. Belgian folklore has it that eating them at the beginning of a meal will ward off drunkenness. Despite their storied past, Brussels sprouts are unsung heroes among vegetables. Properly prepared, these tiny green globes pack as much sweet (yes, sweet!), intense flavor as they do health benefits. 66

OR TODAY | December 2016

THE FACTS

Brussels sprouts (Brassica oleracea var. gemmifera) are clearly related to cabbage, but they’re also kin to other cruciferous vegetables, including broccoli, kale, and cauliflower. They grow in groups of 20 to 40 along a stalk that stretches about three feet tall. Each sprout is a one-to two-inch diameter replica of a green cabbage. There are many hybrid varieties, such as Jade Cross, Confidant, and Ruby Crunch, which is purple. Brussels sprouts are packed with powerful antioxidants. A half-cup serving delivers 12 percent Daily Value (DV) of vitamin A and 81 percent DV of vitamin C. Combined with 137 percent DV of vitamin K and a plentiful dose of

glucosinolates – important, healthpromoting plant chemicals – Brussels sprouts are known for potential cancer prevention properties. THE FINDINGS

Brussels sprouts are rich in glucosinolates, which have been shown to attack cancer cells. Individuals who consume a diet rich in cruciferous vegetables, such as Brussels sprouts, have lower risk of developing cancer, according to a 2015 review of studies published in Current Pharmacology Reports. Brussels sprouts also may play a promising role in the prevention and treatment of cardiovascular disease, according to emerging evidence in a 2015 BioMed Research International. Brussels sprouts contain sulforaphane, a compound derived from glucosinolates, which may work in combination with other plant chemicals, including anthocyanins and WWW.ORTODAY.COM

NUTRITION

NO MORE

Wheel obstructions DESPITE THEIR STORIED PAST, BRUSSELS SPROUTS ARE UNSUNG HEROES AMONG VEGETABLES. carotenoids, to help lower blood pressure, cholesterol and other heart risk factors. THE FINER POINTS

Late September through February is the season for Brussels sprouts. Picked after the first frost, they will be at peak flavor. Smaller sprouts are sweeter than larger (which may taste more like cabbage). Purchase them on or off the stalk, but select tight, firm sprouts with healthy green (not yellowed) leaves. Refrigerate them unwashed and uncut in a sealed plastic bag up to two weeks. Trim the stems, remove loose outer leaves, and leave them whole, cut in half or shredded. Enjoy shredded in a salad, or give sprouts a quick steam, boil or roast with a little salt, pepper and olive oil. â&#x20AC;&#x201C; Reprinted with permission from Environmental Nutrition. WWW.ORTODAY.COM

December 2016 | OR TODAY

OUT OF THE OR RECIPE

BY DIANE ROSSEN WORTHINGTON, TRIBUNE CONTENT AGENCY ENTRÉE

SIMPLE SOUP OFFERS

COZY COMFORT IN COOL WEATHER

All of us are all watching our spending these days, so when you can make up a main course soup that is this delicious and inexpensive it is worth celebrating.

T asty Tips

•C ooking time for beans can vary depending upon their age, so cook the beans longer if necessary. • This can be made through Step 4 up to one day ahead, covered and refrigerated. • For garnishing, use a very fruity olive oil to bring out the flavors of the soup. • Try a grated pecorino cheese instead of the Parmesan. • If you can find fresh basil add a few tablespoons to the soup as it cooks.

OR TODAY | December 2016

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RECIPE

White beans, an array of garden vegetables and stale bread are the cornerstone ingredients in this peasant Tuscan vegetable soup. Stale bread is a staple in Tuscan cooking and a clever way to use up leftover bread. The soup requires at least a day in advance before it is ready to enjoy, so plan accordingly. It’s the soup I yearn for when the weather turns cool. Ribollita means “reboiled” in Italian, or “twice cooked.” You can use

either Tuscan bread that has no salt or a French baguette. If you don’t have leftover bread, just toast the bread slices. The bread slices are added after the soup has cooked and then refrigerated overnight. The next day it is “reboiled” (actually simmered) and drizzled with a lovely, fruity extra-virgin olive and a sprinkling of aged Parmesan cheese just before serving. The first time I ever tasted this make-ahead

soup I was excited by the intense layers of vegetable flavor enriched by a rich white bean puree. I have made many versions of this classic soup, but all of them include either cavolo nero, a black Tuscan cabbage or kale (a satisfactory substitute). This is my favorite recipe for this comforting, vegetarian, one-dish meal. The poached egg is optional. All that is needed is a red wine like a chianti, super Tuscan red, Argentine malbec or a California zinfandel. Enjoy.

DIRECTIONS: 1. Cover the beans with cold water and soak overnight. If you prefer to do a quick soak method, bring the beans and water to a boil and cook for 2 minutes, cover and let stand for 1 hour. Drain the soaked beans and set aside. 2. In a very large soup pot (8-quart casserole works well) combine the beans, 12 cups of water, garlic and sage. Bring to a simmer over medium-highheat. Reduce the heat to low and simmer for about 1 1/2 to 2 hours or until the beans are tender. Cool. Remove 1 cup of beans and reserve. With a hand blender puree the beans in the cooking liquid. Remove to a large bowl and reserve. 3. In the same pot add 1/4 cup oil on medium heat. Add the onions and saué for about 12 minutes or until nicely softened and lightly browned. Add the carrots, celery, eggplant, potatoes, cabbage chard and kale. Toss all the vegetables to evenly coat them. Add the tomatoes, salt and pepper and cover, cooking about 20 more minutes or until the greens have wilted. (You can toss them a few times to encourage even cooking.) WWW.ORTODAY.COM

4. A dd the pureed beans and cook, covered, for another 40 minutes or until nicely thickened. Add the reserved beans and taste for seasoning. Add the bread slices and cook another 10 minutes or until the bread is soaked through. Cool and refrigerate 5. W hen ready to serve the next day reheat on low heat for about 1/2 hour or until the soup is nicely thickened. Taste for seasoning. (Serve with or without a poached egg.) 6. F or the poached eggs: Fill a large skillet 2/3 full of water and bring to a boil. Reduce the heat and add vinegar. Break each egg into a custard cup, and carefully drop the eggs in very gently; simmer for about 3 minutes or until desired degree of doneness. (I like my egg runny) Carefully remove eggs from pan using a slotted spoon. 7. T o serve: Ladle the soup into soup bowls and place an optional egg in the center of each bowl. Drizzle on a few teaspoons of olive oil. Sprinkle with some Parmesan cheese and serve immediately.

Ribollita Serves 8 1 pound dried cannellini beans 3 cloves garlic 5 fresh sage leaves 1/4 cup olive oil 2 onions, coarsely chopped 3 carrots, peeled and sliced 3 stalks celery, sliced 1 medium eggplant, peeled and chopped into 1/2-inch pieces 2 medium russet potatoes, peeled and thickly sliced 1/2 small savoy cabbage, cored and coarsely chopped 1 bunch red swiss chard, coarsely chopped 1 bunch cavolo nero or kale, coarsely chopped 1 can (14 1/2 ounce) crushed tomatoes Kosher salt Freshly ground pepper 12 day-old slices Tuscan or French bread, toasted, if necessary 8 large eggs, optional 1 tablespoon white vinegar, optional Extra-virgin olive oil Freshly grated Parmesan cheese

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. December 2016 | OR TODAY

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HOW TO OVERCOME YOUR EXERCISE EXCUSES It’s easy to come up with reasons why you can’t exercise – but sometimes you spend more time arguing with yourself than it takes to fit in an exercise session. The easiest way to overcome your exercise excuses is to be prepared for them. Identify the reasons you most often give (yourself) for not being able to exercise – and think of a few ways to work around them. Here are some tips for overcoming exercise excuses. The excuse: “I don’t have enough time.” Try these solutions: • Break exercise into smaller segments. Try for three 10-minute segments a day, and you might find it’s easier to fit into your schedule than one 30-minute session. • Multitask. Do stretches while watching TV, or crunches during the commercial breaks. • Adjust your schedule. Say, get up a half-hour earlier to walk, or take a

shorter lunch break so you can fit in a quick walk before going back to work. • Make it a nonnegotiable routine. Block off a time each day for exercise, so you (and friends and family) can plan around it. If you need to write it in your planner to make it happen, do it! The excuse: “I’m too embarrassed to exercise.” Try these solutions: • Bring a friend along for moral support. Walk in a neighborhood where you’re not likely to run into anyone you know. • Work out at home with an exercise DVD. • Try a gym that feels comfortable and friendly. Most welcome all sizes and fitness levels. The excuse: “Exercise is too hard.” Try these solutions: • Take it slow and steady. Start with a comfortable amount of activity and add a little more each day. • Try walking as exercise. It’s already

part of your day, so just try to add a few extra steps when you can. Park farther from the store entrance, or do your errands around town on foot, rather than driving. • Listen to your body. Don’t exercise to the point of exhaustion, and make sure you alternate harder efforts with rest days and workouts during which you can easily talk with a workout partner without gasping for breath. • Keep going. If you’ve got minor aches, take it easier the next day but don’t stop altogether. Gentle movement helps sore muscles recover. – EatingWell.com

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HOST AND HOSTESS GIFTS EVERYONE WILL LOVE Every season is party season, but when the latter half of the year rolls in so do the party invitations. If you’ll be attending one or more parties this year, chances are you’ll not arrive empty handed. It’s polite to thank your host or hostess with a token of your appreciation, and you want your gift to be something useful, delightful and memorable. At the same time, you don’t have to spend a bundle to impress your host or hostess. Here are ideas for host or hostess gifts that are sure to show party-throwers you consider them the “host (or hostess) with the most,” while convincing them you’re the best guest ever:

Congratulations to Jeanette Chietero, and the Ramapo Valley Surgical Center!

If your host is a wine lover and you’re not confident about choosing a bottle, one option is to put together a bag of accessories. Present your host with a quality wine bottle opener, personalized stopper or even a set of lovely wine glasses. M&Ms are a great party treat and in honor of the candy’s 75th anniversary, Danish fashion designer Camilla Staerk collaborated with the brand to present specially designed packages of plain and peanut M&Ms. M&Ms by Staerk Designer Collection are exclusively available in Target stores. Packages come in shareable and personal sizes featuring elegant animal print designs that will look great displayed in any home. However, they’re only available for a limited time.

Know a host who always whips up the most dazzling menus? You can celebrate your host’s culinary skills by giving artfully packaged gourmet sea salts, organic seasonings or ethnic spices. Anyone who lives in a busy household can find themselves hunting for something to write with - and unable to find a pen or notepad. Put together a selection of pretty pens, paired with magnet-backed notepads, and present in a pretty tote. The next time your hostess is planning a get-together, she’ll remember who gave her the pen and paper she’s using to draft her guest list!

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December 2016 | OR TODAY

INDEX ALPHABETICAL 3M Healthcare ……………………………………………… 9 AAAHC ……………………………………………………… 65 AIV Inc. ……………………………………………………… 15 AORN Works ……………………………………………… 4 Belimed Inc. …………………………………………………17 Boss Instruments, LTD. …………………………… 10 Bulb Direct Holding, LLC. ……………………… 61 C Change Surgical …………………………………… 45 Checklist Boards Corp. …………………………… 73 Cincinnati Sub-Zero, Inc. ………………………… 63 Clorox ………………………………………………………… 23 Dabir Surfaces………………………………………………17 Doctors Depot ………………………………………… 57

Enthermics Medical Systems, Inc. ………… 20 GelPro ………………………………………………………… 25 Gopher Medical ………………………………………… 61 Healthmark Industries……………………………… 26 Innovative Medical Products, Inc. ………… BC Innovative Research Labs ……………………… 67 Interpower Corporation …………………………… 5 Jet Medical Electronics …………………………… 70 Key Surgical, Inc. ………………………………… 34-35 MAC Medical ………………………………… 33, 46-49 MD Technologies ……………………………………… 64 Medi-Kid Co. ……………………………………………… 64 Medwrench………………………………………………… 73

Pacific Medical LLC …………………………………… 6 Palermo Health Care ……………………………… 70 Paragon Service …………………………………………21 Ruhof Corporation ……………………………………2-3 Summit Medical, Inc ………………………………… 55 Steris IMS ………………………………………………… IBC Surgical Power ………………………………………… 64 TBJ, Inc. ……………………………………………………… 56 Tru-D. ………………………………………………………… 73 USOC Medical …………………………………………… 44

ACCREDITATION AAAHC ……………………………………………………… 65

HAND/ARM POSITIONERS Innovative Medical Products, Inc ………… BC

PRESSURE ULCER MANAGEMENT Dabir Surfaces………………………………………………17

ANESTHESIA Checklist Boards Corp. …………………………… 73 Doctors Depot ………………………………………… 57 Innovative Research Labs ……………………… 67 Gopher Medical ………………………………………… 61 Paragon Service …………………………………………21

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

RADIOLOGY Checklist Boards Corp. …………………………… 73

INFECTION CONTROL/PREVENTION Belimed Inc. …………………………………………………17 Clorox ………………………………………………………… 23 Palermo Health Care ……………………………… 70 Ruhof Corporation ……………………………………2-3 Summit Medical, Inc ………………………………… 55 Tru-D. ………………………………………………………… 73

REPAIR SERVICES Pacific Medical LLC …………………………………… 6

INDEX CATEGORICAL

APPAREL Healthmark Industries……………………………… 26 ASSOCIATIONS AAAHC ……………………………………………………… 65 AORN Works ……………………………………………… 4 BEDS Innovative Medical Products, Inc ………… BC CARDIOLOGY C Change Surgical …………………………………… 45 Gopher Medical ………………………………………… 61 CARTS/CABINETS Enthermics Medical Systems, Inc. ………… 20 Cincinnati Sub-Zero, Inc. ………………………… 63 MAC Medical ………………………………… 33, 46-49 TBJ, Inc. ……………………………………………………… 56 CLEANING SUPPLIES Ruhof Corporation ……………………………………2-3 CLAMPS Innovative Medical Products, Inc ………… BC DISINFECTANTS Clorox ………………………………………………………… 23 Palermo Health Care ……………………………… 70 DISPOSABLES Pacific Medical LLC …………………………………… 6 ENDOSCOPY Bulb Direct Holding, LLC. ……………………… 61 Clorox ………………………………………………………… 23 MD Technologies ……………………………………… 64 Ruhof Corporation ……………………………………2-3 Summit Medical, Inc ………………………………… 55 GEL PADS GelPro ………………………………………………………… 25 Innovative Medical Products, Inc ………… BC GENERAL AIV Inc. ……………………………………………………… Checklist Boards Corp. …………………………… GelPro ………………………………………………………… Surgical Power …………………………………………

OR TODAY | December 2016

15 73 25 64

INSTRUMENT STORAGE/TRANSPORT Belimed Inc. …………………………………………………17 Key Surgical, Inc. ………………………………… 34-35

REPLACEMENT PARTS Bulb Direct Holding, LLC. ……………………… 61 RESPIRATORY Innovative Research Labs ……………………… 67 SAFETY GEAR Key Surgical, Inc. ………………………………… 34-35

KNEE SYSTEMS Innovative Medical Products, Inc ………… BC

SHOULDER RECONSTRUCTION Innovative Medical Products, Inc ………… BC

LASERS Checklist Boards Corp. …………………………… 73

SIDE RAIL SOCKETS Innovative Medical Products, Inc ………… BC

LEG POSITIONERS Innovative Medical Products, Inc ………… BC

STERILIZATION 3M Healthcare ……………………………………………… 9 Belimed Inc. …………………………………………………17 Key Surgical, Inc. ………………………………… 34-35

MONITORS Doctors Depot ………………………………………… 57 Jet Medical Electronics …………………………… 70 USOC Medical …………………………………………… 44 ONLINE RESOURCES Medwrench………………………………………………… 73 OR TABLES/ ACCESSORIES Innovative Medical Products, Inc ………… BC ORTHOPEDIC Surgical Power ………………………………………… 64 OTHER AIV Inc. ……………………………………………………… 15 Medi-Kid Co. ……………………………………………… 64 Tru-D. ………………………………………………………… 73 PATIENT DATA MANGAMENT MAC Medical ………………………………… 33, 46-49 PATIENT MONITORING Gopher Medical ………………………………………… 61 Pacific Medical LLC …………………………………… 6 USOC Medical …………………………………………… 44 POSITIONERS/IMMOBILIZERS Innovative Medical Products, Inc ……………………………………………… BC

SURGICAL Boss Instruments, LTD. …………………………… 10 Bulb Direct Holding, LLC. ……………………… 61 Checklist Boards Corp. …………………………… 73 Key Surgical, Inc. ………………………………… 34-35 MD Technologies ……………………………………… 64 Ruhof Corporation ……………………………………2-3 Summit Medical, Inc ………………………………… 55 Surgical Power ………………………………………… 64 SUPPORTS Innovative Medical Products, Inc ………… BC TELEMETRY USOC Medical …………………………………………… 44 TUBES Bulb Direct Holding, LLC. ……………………… 61 WARMERS Belimed Inc. …………………………………………………17 Cincinnati Sub-Zero, Inc. ………………………… 63 Enthermics Medical Systems, Inc. ………… 20 MAC Medical ………………………………… 33, 46-49 WASTE MANAGEMENT TBJ, Inc. ……………………………………………………… 56

POWER COMPONETS Interpower Corporation …………………………… 5 WWW.ORTODAY.COM

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