OR Today - January/February 2017 by MD Publishing

SPOTLIGHT ON

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CONTINUING EDUCATION

C. DIFFICILE PAGE 24

TAKE GOOD CARE NURSES • SURGICAL TECHS • NURSE MANAGERS

FITNESS

LESSONS LEARNED PAGE 50

JANUARY/FEBRUARY 2017

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CONTENTS

features

THE REAL RISKS: SURGICAL SMOKE An estimated 500,000 health care workers are exposed to potentially dangerous surgical smoke each year. However, many health care professionals are unaware of the risks. OR Today takes a closer look at surgical smoke.

OR TODAY | January/February 2017

SPOTLIGHT ON: BONNIE CONKLIN SULLIVAN Bonnie Conklin Sullivan played college lacrosse, became a coach and then decided to follow in her mother’s footsteps and became a nurse. She now enjoys working at a community hospital in her hometown.

OR Today (Vol. 17, Issue #1) January/February 2017 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. © 2017

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January/February 2017 | OR TODAY

CONTENTS

departments

PUBLISHER

John M. Krieg | john@mdpublishing.com

VICE PRESIDENT

Kristin Leavoy | kristin@mdpublishing.com

34 11

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 News & Notes 16 AAAHC Update 20 ASCA Update

IN THE OR 22 24 33 34

CIRCULATION Lisa Cover Laura Mullen

Suite Talk CE Article Market Analysis Product Showroom

OUT OF THE OR 48 Health 50 Fitness 52 Nutrition 54 Recipe 56 Pinboard 58 Index

Taylor Martin Cindy Galindo Adam Pickney

OR TODAY | January/February 2017

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INDUSTRY INSIGHTS NEWS & NOTES

3M INTRODUCES C. DIFF SOLUTION TABLETS

POSTER ABSTRACT PRESENTS TRU-D ROBOT EFFECTIVENESS

Hospitals can pose potential risks to patients and staff through the threat of infections caused by pathogens such as MRSA, E. coli and C. difficile (C. diff.). To combat the rise of C. diff infections at hospital facilities, 3M recently launched 3M C. diff Solution Tablets, providing a proven, effective alternative to bleach and peracetic acid disinfectants. Now available for use in the U.S., the new product delivers on effectiveness, efficiency and value. “We are excited to provide our customers with an effective solution for the battle against C. diff,” said Adrian Cook, product marketer for chemicals at 3M Commercial Solutions Division. “The reduction and prevention of infections is an important focus for our customers and we look forward to continuing our work in ensuring safe environments.” In addition to the new product launch, 3M Commercial Solutions Division also announced the expansion of its Flow Control System product line through the introduction of four additional chemical offerings including: 3M Quat Disinfectant Cleaner Concentrate 5A; 3M Neutral Quat Disinfectant Cleaner Concentrate 23A; Scotchgard Pretreatment Cleaner Concentrate 28A; and 3M Bathroom Cleaner Concentrate 44A.• WWW.ORTODAY.COM

In a poster abstract presented at IDWeek 2016, researchers presented findings on the effectiveness of Tru-D in reducing patient infections. Short for “total room ultraviolet disinfection,” Tru-D guarantees complete room disinfection operating from a single position with a single cycle of UVC light energy. According to the researchers, in the past 15 years, much has been discovered on the role of the environment in the transmission of infectious diseases. In fact, more recently, researchers have discovered that the use of antibiotics can promote C. diff proliferation and the number of C. diff spores that are shed into the local environment. Therefore, it has been determined that disinfection of all surfaces in a health care facility is critical in reducing multidrug-resistant organisms (MRDOs) in the environment. In the poster abstract presented at IDWeek, “Microbial Load on Environmental Surfaces: The Relationship Between Reduced Environmental Contamination and Reduction of Healthcare-Associated Infections,” researchers proved that a combination of manual cleaning and Tru-D’s measured dose UV light energy can lead to a reduction of 94 percent of MDROs and a 35 percent decrease in infection rates. “Sometimes we label areas high risk – tray tables, sink, side rails, call box, chair, etc. – however, no one has ever identified these objects as more likely to be involved in transmission of disease,” said Dr. William A. Rutala, one of the abstract’s researchers in his presentation “Role of the Environmental Surfaces in Disease Transmission: ‘No Touch’ Technologies Reduce HAIs” at the 2016 Association for the Healthcare Environment Conference. “We absolutely do not know what is more high risk, so we have to focus on all surfaces. Given this data, all room surfaces must be disinfected.” Tru-D’s UV disinfection robot ensures total room disinfection, eliminating harmful pathogens such as C. diff, MRSA and VRE in a single cycle from a single position. Used in terminal room disinfection, Tru-D is brought into a room after the EVS staff cleans using traditional methods. Tru-D then operates from a single position and administers a single cycle of UVC light, destroying up to 99.9 percent of pathogens that can remain behind. • January/February 2017 | OR TODAY

INDUSTRY INSIGHTS NEWS & NOTES

ACTION PARTNERS WITH CATCHWIND The world of pediatric medical devices has been enhanced with Catchwind Pediatrics, a membershipbased organization that brings manufacturers, medical professionals, engineers and government officials together to facilitate progress in the market. Action has joined Catchwind to reinforce its commitment to the pediatric market. “Right-sizing products has become increasingly important to our perioperative demographic and keeping children safe from pressure injuries is always our ultimate goal,” says Janet Kaplan, Marketing Director of Action Products, Inc.-Medical Products Group. “We want to share our pediatric knowledge with other relevant companies and partner where we can to move the needle forward,” Kaplan adds. •

DIVERSEY CARE LAUNCHES INTELLICARE HAND HYGIENE Sealed Air’s Diversey Care division has introduced IntelliCare, a new commercial hand hygiene system featuring a hybrid automatic hand care dispenser with both touchless and manual activation. The versatile dispensing system is compatible with Diversey Care liquid/gel and foam products. With hand washing being the single most effective way to prevent the spread of infection, the IntelliCare dispenser seamlessly shifts from touchless to manual mode to deliver uninterrupted hand hygiene once battery power is depleted. Real-time alerts for content refills and battery replacement also promote hand hygiene compliance. IntelliCare dispensers can be used with a variety of hand care formulations, allowing facilities to customize product selection based on environment, site or user needs. •

CENSIS TECHNOLOGIES LAUNCHES NEW WEBSITE Censis Technologies has launched a new website, www.censis.com. The new site is focused on providing a cleaner and more interactive experience for users. The updated site introduces a new way to learn about the solutions offered in the Censis portfolio, using multiple forms of media. With innovative technology and website design tools, the user will now be able to navigate and explore the site using whatever browser or device they choose. In addition to updating the central part of the new website, the Censis customer portal has been redesigned, providing the

OR TODAY | January/February 2017

user a better way to find resources and training materials for their staff. This effort is phase one of a three-phase plan to engage with current and prospective clients utilizing different digital media. Phase two will be unveiled at the annual Censis Technologies Users Conference (CtUC) in August of 2017. “We are excited to offer our customers and the health care industry an enhanced website that provides up-to-date information about surgical asset management,” said Randy Smith, Censis Technologies CEO. “Our team is committed to providing the

health care industry relevant digital resources through videos, eBooks, blog posts, and live online events, all with the goal of supporting the enhancement of patient safety.” •

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NEWS & NOTES

ENCOMPASS GROUP INTRODUCES DISCOVERY COLLECTION Encompass Group LLC has introduced the Discovery Collection of pediatric health care apparel – four fun prints in a variety of gowns, pajama tops and coordinating solid-color pajama pants designed for kids … and their caregivers. The Discovery Collection was created for ages 1 up through 12 years. The easy color coordination within the set allows the caregiver to easily grab the correct size. The 100 percent polyester knit is soft and breathable, built for institutional laundering, and meets all federal flammability regulations for children’s sleepwear. “Because we believe that everyone should feel safe and comfortable in their health care environment, we have developed this new

line of pediatric apparel designed to stir children’s imaginations and help them relax in a health care environment, which can be scary and strange,” said Joe Przepiorka, Vice President, Marketing, Encompass Group, LLC. “The Discovery prints selected by our in-house designer, Denise Formisano, includes Northern Lights, Galileo Guardians, Raining Cats and Dogs, and Stars. All Discovery Comfort Knit fabrication was selected to be comfortable while meeting hospital and institutional laundry standards. The polyester construction is durable for longevity, and also allows for faster drying time in the laundry,” he added. •

BIODEX SURGICAL C-ARM TABLE OFFERS POSITIONING Biodex Medical Systems Inc., has announced the availability of the Surgical C-Arm Table 840. As minimally invasive surgical options have increased over the past decade – with approximately 9 million such procedures performed in the United States in 2013 – surgeons have come to rely on C-arm fluoroscopy devices for a variety of cardiovascular, orthopedic and urology procedures. The new Surgical C-Arm Table 840 from Biodex is a stable, accessible and vibration-free fluoroscopic table that keeps a patient at exactly the right position and angle for cardiovascular procedures. The low-profile base of this radiolucent imaging table from Biodex guarantees C-arm clearance, whether using portable or ceiling-suspended C-arms. It features an extra-large radiolucent area of 71 inches and accommodates patients weighing up to 500 pounds. Proper positioning along three axes is possible with a free-float SmoothGlide tabletop movement of 35 inches head to toe and 10 inches side to side. High-speed actuators assure quick tabletop positioning, including height adjustability from 33.5 to 43.5 inches, an isocentric lateral roll of 0 to ±15 degrees, and Trendelenburg

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motions (and reverse motions) of 0 to 20 degrees. Multiple positioning control access is made possible with mushroom-top, hand and foot controls. The Biodex Surgical C-Arm Table 840 is available with either a contoured or rectangular carbon-fiber tabletop, both with a 2-inch mattress. The contoured tabletop features a face cutout for comfortable prone positioning. A removable, non-radiolucent catheter tray extension provides additional table length to hold catheters within the patient’s sterile field. In order to accommodate a variety of settings, the fluoroscopic table comes standard with AC and battery power options. •

January/February 2017 | OR TODAY

INDUSTRY INSIGHTS NEWS & NOTES

MORE THAN 500 U.S. HOSPITALS USE SURGICOUNT SAFETYSPONGE SYSTEM Stryker has announced that more than 500 hospitals nationwide are using the SurgiCount Safety-Sponge System and have accounted for nearly 200 million surgical sponges around the United States in the past five years. Numerous independent organizations – including The Joint Commission, the Association of periOperative Registered Nurses and the American College of Surgeons – recommend the use of adjunct technology to supplement manual sponge counting to reduce the risk of retained sponges. The SurgiCount Safety-Sponge System is a solution, utilizing uniquely identified sponges and towels to provide a precise, real-time count so the surgical team can close a procedure – and a patient – with confidence. Unlike the traditional manual counting procedure, which relies on a whiteboard that is erased at the end of a procedure, a record of the SurgiCount-verified correct count is maintained in the hospital’s SurgiCount 360 software so that surgeons, nurses and hospital administrators have a permanent record of the verified count. When used in conjunction with the manual counting process, SurgiCount significantly reduces the risk of retained sponges by addressing the problem of false-correct counts. The SurgiCount system is currently in use in hospitals in 43 states, and in an estimated 11 million procedures, the system has never failed to identify a retained sponge. •

HEALTHMARK OFFERS MULTI-PURPOSE LABEL

Healthmark Industries has announced the addition of the Multi-Purpose Equipment Label to its labeling line. It ensures proper labeling for medical equipment to communicate crucial information, addressing one of the many unique challenges health care facilities are tasked with daily. The Multi-Purpose Equipment Label was developed as a way to ensure consistency and identify whether medical equipment is clean, in-use or dirty. The 2-inch x 3-inch label has an easy to use pull-tab style design with an adhesive backing that does not leave residue behind. The brightly colored label provides high visibility to health care professionals, allowing individuals to correctly communicate the status of equipment.•

SUMMIT MEDICAL EXPANDS INSTRUSAFE PORTFOLIO Summit Medical Inc. has launched InstruSafe Care + Maintenance Products. The new product line offers a variety of protection, cleaning and identification solutions such as assorted tip protectors, brushes and identification tapes. The development of this new line expands the reach of its InstruSafe brand and increases the number of solutions it offers customers. “The InstruSafe team is made up of multiple individuals, including myself, that have a great deal of experience in the health care industry, specifically in sterile 14

OR TODAY | January/February 2017

processing departments,” said Marcus Super, director of sales and marketing at Summit Medical. “We are familiar with the frustrations and inefficiencies that occur when the right tools aren’t available to properly care for and maintain your instruments. This is why we released our line of InstruSafe Care + Maintenance Products – to provide sterile processing professionals with the solutions they need to help create a more effective central service process.” The InstruSafe Care + Maintenance Products are meant to serve

as a part of a preventative maintenance plan to help minimize the need to replace costly instruments. •

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INDUSTRY IN THE OR INSIGHTS AAAHC UPDATE

BY BRIAN E. SZUMSKY AND MARCIA PATRICK, RN, CIC

ENVIRONMENTAL CLEANING AS A TOOL FOR

INFECTION PREVENTION

n October 2016, AAAHC published its annual “Quality Roadmap.” Using data compiled from all surveys conducted under 2015 Standards, this year’s report identified that standards from chapter 7, Infection Prevention and Control and Safety, were involved in almost 40 percent of the deficiencies reported in surgical/procedural settings. The introduction to the chapter states, “an accreditable organization … maintains ongoing programs designed to (1) prevent and control infections and communicable diseases and (2) provide a safe and sanitary environment of care.” While deficiencies in these standards can range from improper use of multi-dose vials to expired medications and supplies to inadequate disinfection of equipment, for the purposes of this article, we will focus on environmental cleaning. Organizations accredited by AAAHC are required to have an infection prevention and control risk assessment and related policies in place, so infection outbreaks are expected to be the exception and not the rule. That said, anytime an organization experiences an infection event, there is likely to be quick effort to review and revise policy and/or processes. However, there may be times when human error allows an opportunistic bacterium to infect single or multiple patients. With that in mind, organizations such as the CDC and AORN address these issues with guidelines addressing sterilization, isolation, and physical environment among others. The CDC study identifies five categories of infection control in ASCs as hand hygiene and personal protective equipment, injection safety and medication handling, equipment reprocessing (e.g., sterilization and high-level disinfection), environmental cleaning, and handling of blood glucose monitoring equipment. A 2010 study of 68 U.S. ASCs found that two-thirds had at least one lapse in infection control, and 57 percent were cited for deficiencies in infection control. Findings of this kind raise eyebrows and, more crucially, vigilance

OR TODAY | January/February 2017

regarding how facilities ensure patient safety. While lapses in infection precautions are alarming, they also present an opportunity for change in organizations through consultative guidance and education. WHEN DO WE CLEAN?

Patient treatment areas require cleaning before use and between patient visits. For between-patient cleaning, the surfaces or equipment touched by the patient, and any other surface visibly soiled, must be cleaned with an EPA-registered disinfectant for health care use. Terminal cleaning at the end of the day requires the cleaning of all horizontal surfaces, medical equipment, high touch areas, and floors, again using an EPA-registered disinfectant for health care use. Terminal cleaning is more intensive than the cleaning that occurs between patient visits and must be compliant with the organization’s policies and any applicable State requirements. Beside the recommendations noted above for before and between patient visits and terminal cleaning at the end of the day, AORN has developed guidelines for frequency. See https:// www.aorn.org/websitedata/cearticle/ pdf_file/CEA14517-0001.pdf

WHAT DO WE CLEAN?

Beyond the obvious – materials and equipment that have come into direct patient contact – carpeting, cloth furniture, counter tops, curtains/ drapes, and mattresses should all be subject to regular disinfecting. For example, the American Society for Healthcare Environmental Services of the American Hospital Association recommends that “privacy curtains should be cleaned any time there is visible dust or soil and as a part of the terminal cleaning process whenever an area has been occupied by a patient who has been on contact or droplet precautions. To prevent cross contamination, the privacy curtains should be taken down immediately after an area has been occupied by a patient who has been on isolation precautions, and clean curtains should be hung before the next patient occupies the area” (AORN, 2011). In ambulatory settings, this translates to a written policy and procedure addressing cleaning of privacy curtains that must be followed. Some ambulatory facilities are eliminating privacy curtains in new construction. The exam table is oriented so the foot of the table is not facing the door, and a colored flag or light system is used to indicate the status of the room so staff WWW.ORTODAY.COM

AAAHC UPDATE

DID YOU KNOW? • When transferring cleaning products from one container to another, the second container must include a manufacturer’s label with the expiration date. Most manufacturers will provide smaller labels free of charge. Consultatively, AAAHC discourages the use of spray bottles which may expose the user to aerosolized chemicals. Eight-ounce peri-bottles are a better option. • Scrubs are not acceptable in situations requiring personal protective equipment (PPE). PPE should not permit blood or body fluid to pass through or to reach employee’s work clothes, street clothes, undergarments, skin, eyes, mouth, or other mucus membranes under normal conditions of use. • Corrugated shipping boxes may contain various infestations such as worms, cockroaches and larvae, so they should not be placed in clean or sterile supply rooms. Instead, the contents should be unpacked and the box removed from the premises. While AAAHC Standards do not include such a requirement, surveyors may offer this as a consultative comment. AORN does address this specifically. • A clean linen cart must be covered when transported. Most linen carts have covers with a flap, but it is not necessary for the flap to be down and the sides zipped when the clean linen cart is in its place of use. Persons accessing the linen may duck under the flap, which will come in contact with their hair and clothing. The risk of contamination of the linen from the contaminated flap is much greater than from airborne contamination. Be sure to include this in your linen policy and procedure. Soiled linen hampers are not required to be covered. Include this in your policy and procedure as well.

are not entering when a patient is on the table, unless involved in their care. HOW DO WE CLEAN?

Despite the fact that some health care settings are at low-risk for transmitting infections, it is not acceptable to use overthe-counter products when cleaning surfaces and medical equipment. Regardless of the setting, organizations should use an EPA-registered disinfectant for health care use and follow manufacturer’s instructions for its use in regard to amount, dilution, contact time, safe use, and disposal. (Search EPA registered hospital disinfectants for additional information.) Consultatively, AAAHC and AORN both suggest assembling a multi-disciplinary team to define facilityspecific policies regarding environmental cleaning, including frequency, process and products used. The team selects cleaning chemicals, materials, tools, and equipment; determines cleaning schedules; and devises protocols for responding to potential infection events, such as blood and body substance spills and environmental contamination. It is helpful to have a master list of items to be cleaned including who will clean it, what it will be cleaned with, when cleaning is required, and, if needed, how it will be cleaned. A table format works well for this. The team would also define and ensure proper training of personnel responsible for cleaning. Environmental cleaning is a critical component in creating a safe, pathogen-free facility for patients and staff. The time and detail required to implement an effective IPC program may appear daunting. However, with planning and clear goals, it is manageable. Conversely, the cost to patient and staff safety resulting from an avoidable infection event can be incalculable. Download a free PDF copy of the AAAHC Quality Roadmap 2016 at http://www.aaahc.org/en/institute/Quality-Roadmap/

• Remember that the wet contact time on the disinfectant label must be followed – in some cases, this will require re-wiping a surface so it remains wet for the indicated time.

ABOUT THE AUTHORS Brian E. Szumsky is Communications Project Manager at AAAHC. 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.

• EPA approved pop-up wipes are handy. Again, the wet contact time must be followed. A wipe or bunch of wipes should only be used on a single surface – going from one surface to another can spread contamination. Use one (or more) wipes per surface and discard. Keep the wipes container closed when not in use to prevent the wipes from drying out.

Marcia Patrick, RN, CIC, has over 30 years of experience in infection control, including acute care, ambulatory care, adult and pediatrics in medical centers and community hospitals. She served on the APIC Board of Directors from 2009 to 2012 and helped develop the APIC Ambulatory Surgery Course to meet the 2009 CMS infection control requirements for ambulatory care.

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January/February 2017 | OR TODAY

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INDUSTRY INSIGHTS ASCA UPDATE

BY WILLIAM PRENTICE, ASCA CHIEF EXECUTIVE OFFICER

PLAN NOW TO BE PART OF ASCA 2017 THIS MAY

f you work in or with an ASC, I encourage you to make plans now to join ASCA May 3-6, 2017, for our next annual meeting – ASCA 2017. We will be convening at the Gaylord National Resort & Convention Center at National Harbor, just outside Washington, D.C., and less than 10 miles from Capitol Hill.

The location of this year’s meeting offers some special opportunities. For one, ASCA is inviting everyone at this meeting to visit with their members of Congress and their staff during National Advocacy Day activities built into the meeting program this year. You don’t have to have any experience making these kinds of visits. You just need to indicate that you want to participate when you register for the full meeting. ASCA staff will set your appointments, provide you with information and resources you can use during your meetings and accompany you and your colleagues during your visits on Capitol Hill. This is your chance to tell your representatives in Washington, D.C., about your ASC and advocate for the support you need to be able to continue to provide top-quality care to your patients. Another special opportunity tied to the location of our meeting this year is that we have been able to invite representatives from four federal agencies to join us. You will be able to hear firsthand from officials from the Centers for Medicare & Medicaid Services, the Food and Drug Administration, the Drug Enforcement Administration and the Department of Homeland Security. Topics will range from drug shortages and the disposal 20

OR TODAY | January/February 2017

of controlled substances to preparing for a Medicare survey and protecting your patients and staff from a violent event in your facility. This year’s program also offers you some special opportunities that don’t rely on location. On Saturday morning, a set of 90-minute sessions will give you an opportunity to take a deeper dive into several ASC management topics that are essential to the well-being of your facility. You can choose from sessions on designing and maintaining an effective medication management program; managing claims denials and bundled payments; avoiding violations of the Anti-Kickback Statute, Stark Law and False Claims Act; and more. If you are concerned about complying with the new Life Safety Code Rules, making sure that the human resources policies you have in place provide adequate protection for your staff and your ASC or passing your next accreditation survey, I recommend that you look into the premeeting workshops offered this year. All will be led by experienced ASC professionals who will provide real-world solutions to your everyday challenges and help you keep your patients safe and your ASC compliant. Another special feature of this year’s meeting is a full day of sessions

on infection prevention. With quality of care top of mind in health care today, infection prevention remains a top priority in every health care setting. I expect that you will see multiple sessions on the schedule that day that speak to infection prevention concerns you are facing in your ASC. This intensive infection prevention programming is something that ASCs have asked ASCA to provide, and we are pleased to be able to offer this opportunity as part of ASCA 2017. When you register for ASCA 2017, you get access to more than 60 educational sessions, extensive networking opportunities, the largest ASC exhibit hall of the year and a meeting dedicated exclusively to ASCs. With presentations and conversations focused exclusively on what you do each day, this meeting is your opportunity to take a short break from providing patient care to connect with others in the ASC community and examine emerging trends, new tools and technology, best practices and the future of your ASC. Up to 17 nursing contact hours, 17 administrator education units and 24 AMA PRA Category 1 Credits are available. While I consider this meeting a “must-do” for everyone on staff at an ASC, I also want to extend a special invitation to every physician who treats patients in an ASC. The opportunities that this meeting offers you to find out more about the many ways an ASC supports you in your practice is just one reason. Another is that these are uncertain times in WWW.ORTODAY.COM

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ASCA UPDATE

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health care, and a large part of the future of your ASC and the ASC model of care is in your hands. This meeting will give you, and everyone who participates, an opportunity to get more involved in the activities and conversations taking place now that will define the health care landscape and marketplace of tomorrow. In addition to the many opportunities this meeting provides, Washington, D.C., offers a long list of unique sightseeing opportunities. I encourage you to come early or stay late and invite family and friends to join you in visiting some of the city’s historic and cultural centers. Next door to our host hotel, you will also find extensive shopping opportunities and a new casino that opened late last year. PROOF APPROVED CHANGES You can learn more about ASCA 2017 and NEEDED register at www.ascassociation.org/ASCA2017. I hope to see you in CLIENT SIGN–OFF: Washington, D.C., this May.

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MONTH

IN THE OR SUITE TALK

SUITE TALK

Conversations from the OR Nation’s Listserv

SUCTION MACHINES

Today there are a variety of suction machines. Some of these machines can be used on multiple cases. It is our nature to empty the suction machine between cases. With the new devices today, a machine can be used multiple times before needing to be emptied. The machine must have the volume reset to obtain accurate blood loss for each case. Is your facility encouraging staff to empty the devices between cases or at the end of the day? A: We empty whenever full/ close to full and at end of day. A: We empty between cases.

A: End of the day – it’s too time consuming to empty between cases and the volume can be reset if that is important.

A: We also empty when full or end of day.

POCKET BAG COUNTERS What is your routine for using the pocket bag counters? 1. Just when there is a chance for retention (i.e. an open belly)? 2. On smaller cases are they using the kick buckets? 3. With every case? 4. Does your staff always place the sponges in the count bags from the bottom up to the top? A: We have no policy on using the pocket A: All cases. All in counter bags with final bags. I typically see them used when there show me verification. are 5 or more sponges tossed off the field. I load them from the bottom to the top. That A: What I see is that people use the bag way the bag is stabilized with sponges on when they see fit. No official policy for the bottom and I am not leaning over when to use it. putting my face next to sponges in the top pockets while placing ones in the lower A: We never leave sponges in a kick bucket. pocket. I also see the circulator flip out the We always use the counter bag. If there are blue loop on the lap sponge so it is visible. I only a couple of used sponges, most scrubs think they are a great tool to expedite leave them on their back table and count counting and minimizing the handling of all together. We don’t give any advice on contaminated sponges. how to fill the bags, just so they are visible to both scrub and circulator when needed.

OR TODAY | January/February 2017

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SUITE TALK

PHOTO CONSENT Is everyone having patients sign a consent for photography before arthoscopy or laparoscopy? A: It is included in our general surgical consent that the patient agrees to photos. The patient does not sign a separate one. A: You should have that type of photography stated in your operative consent given the amount of laparoscopic and arthroscopic cases done today.

A: I really need some help here. One side says absolutely and the other says no. So are any of you having patients sign consent for photography for arthroscopy, laparoscopy, colonoscopy, EGD? A: I agree it is in the general consent, along with pathology comments.

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

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IN THE OR CONTINUING EDUCATION CE362-60F

OR TODAY | January/February 2017

BY CONNIE C. CHETTLE, MS, MPH, RN, AND BARBARA BARZOLOSKI-Oâ&#x20AC;&#x2122;CONNOR, MSN, RN

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CONTINUING EDUCATION CE362-60F

C. DIFFICILE

Threatens Hospitalized Patients

n 2000, a new, more virulent epidemic strain of Clostridium difficile emerged and caused us to rethink and revamp our preventive strategies.1 This newly emerged strain of C. difficile (designated BI/NAP1/027) is distinct from the predominant strain that circulated in hospitals in the 1980s and 1990s. It produces 16 times more toxin A and 23 times more toxin B than the earlier strain. BI/ NAP1/027 also carries a gene for an additional virulence factor — a third binary toxin similar to a toxin in Clostridium perfringens.2 This strain of C. difficile causes disease that is more severe, more refractory to therapy and subject to higher rates of relapse.

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

The purpose of this program is to inform healthcare professionals about Clostridium difficile infections in hospitals and long-term care facilities and to offer strategies for reducing the spread of this pathogen. After studying the information presented here, you will be able to: • Give three reasons why it is difficult to control transmission of C. difficile in hospitals and long-term care facilities • Explain at least four ways the patient-to-patient spread of C. difficile can be prevented • Discuss the two major risk factors for infections with C. difficile

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As the rates of BI/NAP1/027 increase in healthcare facilities throughout the United States, we are faced with the difficult challenge of keeping patients from becoming infected with these potentially severe — and sometimes fatal — bacteria. Armed with knowledge about C. difficile’s transmission and adequate infection control measures, we can meet the challenge of helping fight this difficult pathogen. C. difficile, a gram-positive, anaerobic, spore-forming bacteria, is the major cause of nosocomial diarrhea. The organism is infectious and is transmitted via the fecal-oral route. It colonizes in the intestinal tract of humans after normal intestinal flora have been disrupted by antibiotic therapy. Depending on host factors, the outcome of colonization can range from asymptomatic carriage to severe diarrhea, pseudomembranous colitis, toxic megacolon, leukemoid reactions, severe hypoalbuminemia, intestinal perforation, requirement for colectomy, shock and death from secondary sepsis.3 The number of cases of nosocomial C. difficile, as well as the proportion of cases with severe and fatal complications, has been increasing. Each year in the United States, nearly 10% of patients

hospitalized for more than two weeks become infected with the pathogen at a cost estimated to exceed $4.9 billion.1 C. difficile infections can lengthen a patient’s hospital stay by 2.8 to 5.5 days, with average extra costs reaching as high as $3,006 to $15,937 per episode.4,5 In addition, patients with the BI/ NAP1/027 strain of C. difficile have significantly higher mortality rates.6 Hospital-acquired MRSA infections have been decreasing in the U.S. since 2007, while C. difficile infections (CDI) have been increasing.7 For example, from 2000 to 2005, the rate of hospitalization because of CDI increased about 23% per year, and in a study conducted at 28 community hospitals from January 2008 to December 2009, hospital-acquired CDI occurred 25% more often than MRSA infections.7 C. difficile has also moved out of hospitals into the community, and infections are being diagnosed in younger and healthier people. Community-associated disease now accounts for 20% to 27% of CDI cases.7 WHO’S AT RISK?

Although asymptomatic colonization by C. difficile can occur, more often when this normal flora is disrupted and resistance is imJanuary/February 2017 | OR TODAY

IN THE OR CONTINUING EDUCATION CE362-60F paired, exposure allows the pathogen to establish itself in the colon. Disruption of normal intestinal flora is usually caused by exposure to antibiotics.7 Even an exposure to a single dose of antibiotic, given for preoperative prophylaxis, has been linked to C. difficile infection.6 Almost all antibiotics now in use have been associated with CDI. This includes metronidazole (Flagyl) and vancomycin (Vancocin), the primary drugs used to treat CDI. The antibiotics most frequently associated with CDI, however, are cephalosporins, ampicillin (Principen) and clindamycin (Cleocin).4 The use of fluoroquinolones has been strongly correlated with the emergence of the B1/NAP1/027 strain. Data from a meta-analysis show that third-generation cephalosporins are the strongest risk factor, with fluoroquinolones being most strongly related to the BI/NAP1/027 strain.8 In addition, medication to reduce gastric acid production (H-2 blockers and proton pump inhibitors) has been linked to increased risk of CDI. Stomach acidity provides some protection against C. difficile bacteria when the organism is ingested.4 Nearly all CDIs occur as a result of fecal-oral transmission by human vectors or by contact with a contaminated environment. The contamination occurs when patients with CDI diarrhea or asymptomatic carriers of C. difficile shed the bacteria into their surroundings.6 Although the vegetative form generally dies within 24 hours after being shed, C. difficile bacteria can change to a dormant form called a spore. In this form, C. difficile is highly resistant to cleaning and disinfection measures and can survive for months on environmental surfaces.6 One study found spore contamination in 49% of rooms occupied by patients with diarrhea, 26

OR TODAY | January/February 2017

29% of rooms occupied by infected patients without diarrhea.6 Patients have a high risk of infection or colonization when they are admitted to C. difficile-contaminated rooms and cared for by staff with C. difficilecontaminated hands.6 In other studies, C. difficile spores have been recovered from bathtubs, bedpans, bedside rails, bedside tables, call buttons, door handles, equipment used to obtain vital signs or perform physical assessments, faucets, handrails, IV pumps, light switches, sinks, telephones, toilets, walkers and wheelchairs. Spores have also been recovered from clothing and stethoscopes of healthcare workers caring for infected patients.6 RISK FACTORS FOR CDI INCLUDE:

• Exposure to antimicrobials • Age older than 65 • Severe underlying illnesses • Duration of hospitalization • GI surgery and procedures • Feeding tubes, stool softeners, GI stimulants, antiperistaltic drugs and enemas • Antacids and proton pump inhibitors (acid suppressants used to treat peptic ulcers and esophageal reflux), such as lansoprazole (Prevacid), esomeprazole magnesium (Nexium) and omeprazole (Prilosec) • The use of rectal thermometers4-6

HOW INFECTION DEVELOPS

Fewer than 3% of healthy adults carry C. difficile as part of their normal intestinal flora.7 When infections occur, they are the result of ingesting C. difficile spores found in the environment. Studies to determine the infective dose of C. difficile with antibiotic-treated animals indicate that ingesting as few as two spores may be enough to cause disease.9

Ingested spores of C. difficile can survive gastric acid and readily pass through the stomach. When the spores are exposed to bile acids in the small intestines, they germinate and produce two potent enterotoxins: toxin A and toxin B. Both toxins then seriously damage the lining of the colon (mucosa), resulting in inflammation, hemorrhage and necrosis.10 About half of the patients who become colonized with C. difficile do not develop symptoms.4 For those who do, symptoms can appear as early as one day after exposure to antibiotics or up to three months after antibiotic therapy has been completed.4 For mild to moderate CDI, the most common symptom is lower abdominal cramping pain without fever. In these cases, diarrhea is usually mild, with up to 10 loose, watery stools per day.10 For moderate to severe cases of CDI (colitis without pseudomembrane formation), symptoms are profuse watery or mucoid, greenish, foul-smelling diarrhea (10 to 15 stools per day) that may contain blood. In addition, abdominal distention, anorexia, cramps, fever, leukocytosis, malaise and nausea often occur, and dehydration is common. Diarrhea can be unexpected and explosive, resulting in significant shedding of C. difficile spores into the environment. Very severe cases of CDI (pseudomembranous colitis) present with the same clinical symptoms as severe colitis; however, endoscopic examination of the colon in these cases shows inflamed mucosa studded with raised yellow and off-white plaques. The plaques often cover large portions of the mucosa and easily slough off, giving rise to the term “pseudomembrane.”10 Fulminant pseudomembranous colitis with prolonged ileus, megacolon and perforation can occur. WWW.ORTODAY.COM

CONTINUING EDUCATION CE362-60F

Diarrhea may occur from paralytic ileus and an enlarged dilated colon (toxic megacolon). The only symptoms may be a high fever, severe lower or diffuse abdominal pain, tenderness, distention and a moderate or marked leukocytosis. There may be signs and symptoms of bowel perforation with severe point tenderness and rebound tenderness. Abdominal rigidity, involuntary guarding and reduced bowel sounds may also occur. For patients with fulminant pseudomembranous colitis, aggressive therapeutic interventions including emergent colectomy are necessary to prevent morbidity and mortality.4 Recurrent CDI occurs in 6% to 25% of successfully treated patients one week to two months after treatment.5 Although the exact reasons for relapse are unclear, it may be because of a reinfection with C. difficile or to noneradicated spores in the colon. Both vancomycin and metronidazole can kill the vegetative (growing, reproducing) form of C. difficile, but neither kills the spores that can germinate after treatment and before the normal colonic flora are restored. Unfortunately, after treatment for the first relapse, some patients will have further recurrences.4 Relapses may also occur because of new C. difficile infections. There are limited data to support the use of probiotics â&#x20AC;&#x201D; nonpathogenic bacteria, such as Saccharomyces boulardii and Lactobacillus GG â&#x20AC;&#x201D; to prevent primary CDI as well as a potential risk of bloodstream infection.4,5 PINPOINTING C. DIFFICILE

Diagnosis of C. difficile is based on clinical symptoms supported by endoscopic findings and/or stool testing for the presence of the pathogen or toxins. C. difficile infection should be suspected in any WWW.ORTODAY.COM

patient with diarrhea who has received antibiotics in the last three months or whose diarrhea begins 72 hours after hospitalization.4 C. difficile toxin in a stool sample is unstable, yet many rapid laboratory tests target these toxins for identification of infection. One common laboratory test in hospitals to diagnose C. difficile-associated disease is the enzyme-linked immunosorbent assay, which checks for toxins A and/or B. Laboratory tests of this type can provide results in only a few hours. The test is hampered, however, by its suboptimal sensitivity of 63% to 94%.5 A twostep test using enzyme immunoassay detection of glutamate dehydrogenase, a C. difficile common antigen, and then a cell cytotoxicity assay or toxigenic culture to confirm glutamate dehydrogenase-positive stool specimens provides more accurate results. Polymerase chain reaction testing is rapid and sensitive.5 The most sensitive manner of identification appears to be specimen culture followed by identification of the toxigenic isolate, but this may require several days for completion. At present, there is no diagnostic strategy which is 100% accurate in identifying infection with C. difficile, and diagnosis must also take clinical suspicion into consideration.5 WHICH THERAPY IS BEST?

CDI may resolve itself in patients with mild disease by simply discontinuing the precipitating antibiotic without specific anti-C. difficile therapy. The decision to treat is based on the severity of the symptoms.5 For patients with moderate to severe diarrhea/colitis, antibiotic therapy is needed to eradicate C. difficile. The antibiotics used for treatment are oral metronidazole (500 mg three times a day for 10 to 14 days) and oral vancomycin (125

mg four times a day for 10 to 14 days).4,5 The two drugs were thought to be equally effective although it now seems that the rates of CDI response to metronidazole are declining. Nevertheless, metronidazole is still the drug of choice for most patients with mild to moderate disease because it is less costly than vancomycin and less likely to promote emergence of vancomycinresistant enterococci. For severe disease, oral vancomycin should be used in combination with IV metronidazole. As a caution, metronidazole should not be used beyond the first recurrence of CDI or for longterm therapy because of its potential for cumulative neurotoxicity.5 The Food and Drug Administration has approved fidaxomicin (Dificid), a poorly absorbed macrocyclic antibiotic, as a treatment for C. difficile. While Dificid compares to vancomycin in effectiveness for treating CDI, its advantage is that it has less effect on fecal flora, which reduces the recurrence rate. Unfortunately, reoccurrence rates in drug trials were reduced only in non-BI/ NAPI/027 strains of CDI.11 Antidiarrheal agents, such as diphenoxylate hydrochloride and atropine sulfate (Lomotil) or loperamide (Imodium), and narcotic analgesics should be avoided. These agents may delay clearance of toxin from the colon and cause additional colon injury, which may lead to ileus and toxic dilation. Patients who develop fulminant colitis require admission to the ICU and may need an emergency colectomy because of severe ileus with dilated colon or impending perforation.4 Fecal bacteriotherapy, or fecal transplant, is the transfer of donor gut bacteria in feces to the bowel of a CDI patient.6 This potential therapeutic option restores the balance of normal flora in the GI tract of the patient January/February 2017 | OR TODAY

IN THE OR CONTINUING EDUCATION CE362-60F with C. difficile. Before transplant, donor stool is tested for pathogens. It is then transplanted into recipient via a retention enema, colonoscopy or nasogastric tube. Some systematic studies have found the success to be greater than 92%.6 FIGHTING INFECTION

Preventing infections with C. difficile in hospitals and long-term care facilities is a challenge for a number of reasons. Many hospitalized patients are treated with antibiotics, which makes them more susceptible to colonization or infection with C. difficile. Asymptomatic colonized patients who are fecal excretors (have C. difficile in their feces) may be an important hidden reservoir of the bacteria. The bacteria/spores excreted by these patients can be transmitted throughout a facility on contaminated hands of healthcare workers and on shared patient-care equipment. There is no way to determine how many asymptomatic carriers are present in a hospital or the colonization rate with C. difficile because it is not appropriate to test all patients. It is known that when patients become colonized, at least two-thirds do not develop clinical symptoms. What is not known is whether colonization is temporary or permanent. Treatment of asymptomatic patients to eradicate carrier status is also not recommended.4,5 Many common hospital disinfectants cannot kill the C. difficile spores found in rooms of colonized or infected patients; however, diluted sodium hypochlorite (bleach) or an EPA-approved sporicidal disinfectant is effective for cleaning contaminated surfaces in patient rooms.4 Other methods include “touch-free” cleaning with automated equipment, such as ultraviolet radiation technology and hydrogen peroxide vapor.6 The alcohol gel hand rubs (sanitizers) used in many hospitals to 28

OR TODAY | January/February 2017

disinfect hands do not kill C. difficile spores and neither does soap and water. Although there are no studies that have shown an increase in C. difficile with the use of hand sanitizer or a decrease with the use of soap and water, it has been shown that soap and water is more effective in removing spores from the hands.6 During outbreaks, soap and water are recommended preferentially for handwashing when caring for suspected or confirmed patients. Healthcare workers should also wear clean, nonsterile gloves when caring for patients and when touching patient items.4,6 We must be sure to take the precautions below to prevent the spread of C. difficile:4-6 • Antibiotics associated with high rates of CDI should be avoided. • All healthcare workers, including dietary, housekeeping and maintenance, should receive information about the transmission of C. difficile and precautions to interrupt transmission. • As soon as CDI is suspected or identified, patients should be placed on contact precautions in a private room with a private bathroom. If private rooms are not available, patients can be placed in rooms with other patients with CDI (cohorted). If bathrooms are shared with noninfected patients, an individual commode chair should be used. • Signs or placards indicating the precautions should be placed on the door of any room with a suspected or confirmed CDI patient. • Healthcare workers should use gowns and gloves for all contact with suspected or infected

patients. Gowns and gloves should be put on before entering the room of confirmed patients and removed upon exiting. This practice prevents healthcare workers from carrying the pathogen on their clothes to other patients. • When indicated, healthcare workers should wash their hands with soap and water for at least 15 seconds to remove C. difficile spores. • Disposable or dedicated equipment should be used for each suspected or confirmed CDI patient. Patient-care equipment, such as blood pressure cuffs, stethoscopes and thermometers, should remain in the patient’s room and not shared with other patients. Patient rooms and medical equipment should receive careful cleaning/disinfection with an agent capable of destroying C. difficile and its spores. Hypochlorite-based disinfectants or household bleach (1/4 cup household bleach to 1 gallon of water) can be used to disinfect environmental surfaces. Warning: Never mix chlorine bleach solution with other cleaning solutions or detergents containing ammonia; this mixture may produce highly toxic vapors. An EPA-approved sporicidal disinfectant may be used according to manufacturer’s directions. • Rooms should be cleaned thoroughly with attention to hightouch surfaces as per policy and when a CDI patient is discharged. Throw away all disposable items that cannot be disinfected. Because of the increased incidence and severity of CDI, the Centers for Disease Control and Prevention has WWW.ORTODAY.COM

CONTINUING EDUCATION CE362-60F

recommended direct surveillance and reporting of healthcare-associated CDI. To implement surveillance, the following definitions have been developed.

OnCourse Learning guarantees this educational program free from bias. Connie C. Chettle, MS, MPH, RN, is an epidemiologist living in St. George, Utah. Barbara Barzoloski-O’Connor, MSN, RN, CIC, is the infection-control manager at Howard County General Hospital in Columbia, Md.

REFERENCES 1. Antibiotic resistance threats in the United States, 2013. Centers for Disease Control and Prevention Web site. http:// www.cdc.gov/drugresistance/threatreport-2013. Updated July 17, 2014. Accessed November 22, 2015. 2. Sekulovic O, Meessen-Piard M, Fortier L. Prophage-stimulated toxin production in Clostridium difficile NAP1/027 lysogens. J Bacteriol. 2011;(193(11):27262734. http://www.ncbi.nlm.nih.gov/pmc/ articles/PMC3133130. Accessed November 22, 2015. 3. Deshpande A, Pimentel R, Choure A. Antibiotic-associated diarrhea and Clostridium difficile. Cleveland Clinic Center for Continuing Education Web site. http://www.clevelandclinicmeded.com/ medicalpubs/diseasemanagement/ gastroenterology/antibiotic-associateddiarrhea/Default.htm. Published June 2014. Accessed November 22, 2015. 4. Dubberke ER, Carling P, Carrici R, et al. Strategies to prevent Clostridium difficile infections in acute care hospitals: 2014 update. SHEA/ISDA Practice WWW.ORTODAY.COM

Case Definition for CDI6 • Diarrhea: Unformed stools that take the shape of the specimen collection container — or toxic megacolon — abnormal dilation of the large intestine documented radiologically, and — • Stool sample — positive assay for C. difficile toxin A and/or B, or a positive stool culture with a toxin-producing C. difficile organism • Pseudomembranous colitis seen during endoscopic examination or surgery • Pseudomembranous colitis seen during histopathological examination Definition of CDI Recurrence • Two episodes of CDI in the same patient that occur fewer than eight weeks apart are considered a relapse. It is not possible in clinical practice to determine whether the second occurrence is a relapse with the same strain or a reinfection with a different strain. Definition of Severe CDI Severe CDI: Patients who meet any of the criteria below within 30 days after CDI diagnosis: • History of admission to an ICU for complications associated with CDI (e.g., shock requiring vasopressor therapy) • Surgery (colectomy) for toxic megacolon, perforation or refractory colitis • Death caused by CDI within 30 days after symptom onset (e.g., listed on death certificate or recorded in medical record by clinician caring for patient) Hospitals need to remain on guard for this virulent strain of C. difficile. All healthcare professionals play a vital role in preventing transmission of this pathogen to our patients when we pay careful attention to infection control measures and ensure that everyone in contact with infected patients follows contact (barrier) precautions.

Recommendation. ICHE. 2014;35(6):628645. doi: http://dx.doi. org/10.1086/522262.

Clinical-Practice-Guidelines-for-Clostridium-difficile-Infection-in-Adults-2010. aspx. Accessed November 22, 2015.

5. Cohen SH, Gerding DN, Johnson S, et al. Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infect Control Hosp Epidemiol. 2010;31(5):431-450. http:// www.shea-online.org/View/ArticleId/11/

6. APIC implementation guide: guide to preventing Clostridium difficile infections (2013). Association for Professionals in Infection Control and Epidemiology Web site. www.apic.org/ implementationguides. Accessed November 22, 2015. 7. Lessa FC, Gould CV, McDonald LC. January/February 2017 | OR TODAY

IN THE OR

CLINICAL VIGNETTE A 67-year-old man was admitted to the hospital with pneumonia and an acute exacerbation of his asthma. He was placed on oxygen, treated with a beta-adrenergic agonist and started on systemic corticosteroids. He also started a 10-day course of moxifloxacin (Avelox). While hospitalized, he continued taking his medication for blood pressure, lisinopril (Zestril), and for ulcers, lansoprazole (Prevacid). After six days in the hospital, the patient was well enough to go home. He was told to taper his asthma medication as directed and to continue taking the moxifloxacin for four additional days. Five weeks postdischarge, after three days of severe abdominal cramps and eight to nine watery, greenish foul-smelling stools each day, the patient presented to the ED. Stool specimens tested positive for C. difficile and the patient was readmitted to the hospital. 1. Which risk factor for CDI did the patient have? a. Age older than 65 and severe underlying illnesses b. Previous hospitalization and proton pump inhibiters c. Avelox, proton pump inhibitors and hospitalization d. All of the above 2. When the patient was admitted to the floor, the nurse who was to care for him paged the infection-control nurse to ask which precautions she should take to prevent transmitting C. difficile to her other patients. The infection-control nurse told her to: a. Disinfect her hands after each patient encounter with the waterless, alcohol-based hand sanitizer b. Wipe down the electronic rectal thermometer and blood pressure cuff used on the C. difficile patient with a quaternary ammonia compound (hospital disinfectant) before using equipment on her other patients c. Wash her hands with soap and water for at least 15 seconds to remove C. difficile spores physically d. Keep the door to the patient room closed so airborne spores will not spread throughout the hospital 3. The nurse wanted more information about CDI. When the patientâ&#x20AC;&#x2122;s physician came to the floor, she asked if he would talk to the nurses about CDI at a staff meeting later that afternoon. At the staff meeting, the physician told the nurses that: a. A new, more virulent strain of C. difficile (BI/NAP1/027) has emerged in the 2000. This strain produces 16 times more toxin A and 23 times more toxin B than the strains in the 1980s and 1990s. b. The new strain colonizes the respiratory system after normal flora has been disrupted by antibiotic therapy. It causes the lungs to fill with fluid, leading to shock and death. c. More than 90% of patients carry C. difficile as part of their normal intestinal flora. d. Patients with C. difficile need special handling to prevent transmission of the bacteria to other patients. Nurses should put on gowns, gloves and N-95 respirators before entering the room of infected patients. Before leaving the room, they should carefully disinfect their hands with waterless, alcohol-based hand sanitizers. 4. At the staff meeting, one of the nurses asked the physician to explain why diarrhea caused by C. difficile (BI/NAP1/027) is more worrisome than diarrhea caused by other microbes. Which reason given by the physician is correct? a. Patients with fulminant pseudomembranous colitis due to CDI may need an emergency colectomy because of severe ileus or impending perforation. b. There is no effective treatment for CDI. c. CDI is readily transmissible through the airborne route. d. C. difficile is difficult to distinguish from other GI microbes.

OR TODAY | January/February 2017

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CONTINUING EDUCATION CE362-60F

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.

Current status of Clostridium difficile infection epidemiology. CID. 2012;55(suppl 2):S65-S70. http://cid.oxfordjournals.org/content/55/suppl_2/S65.full. Accessed November 22, 2015. 8. Slimings C, Riley TV. Antibiotics and hospital-acquired Clostridium difficile infection: Update of systematic review and meta-analysis. J Antimicrob Chemother. 2014.;69(4):881891. http://jac.oxfordjournals.org/content/69/4/881.long. Accessed November 22, 2015. 9. Otter J. What does it take to prevent the transmission of C. difficile from environmental surfaces? Micro Blog Web site. http://www.micro-blog.info/2013/02/what-does-it-taketo-prevent-the-transmission-of-c-difficile-from-environmental-surfaces. Published February 25, 2013. Accessed November 22, 2015. 10. Loo VG. Current Concepts in Clostridium difficile infection: a focus on severe disease: a Continuing Medical Education Self-Study Newsletter Providing Expert Perspective on CDI. Voorhees, NJ: Robert Michael Education Institute and Postgraduate Institute for Medicine; 2008. 11. Louie TJ, Miller MA, Mullane KM, et al. Fidaxomicin versus vancomycin for clostridium difficile infection. N Engl J Med. 2011;364:422-431. doi: 10.1056/NEJMoa0910812.

CLINICAL VIGNETTE ANSWER KEY

4. Correct Answer: A —CDI can result in the need for emergency colectomy as it may cause severe ileus and lead to bowel perforation. 3. Correct Answer: A — The new strain of C. difficile appeared in 2000. The disease caused by the strain is more severe and more refractory to therapy. It also has a higher relapse rate. 2. Correct Answer: C — Alcohol-based hand sanitizers are not effective against spore-forming bacteria and soap and water are often recommended for spore removal. 1. Correct Answer: D — All are risk factors for CDI, including age, severe underlying illnesses and the use of proton pump inhibitors, such as lansoprazole. Also, in the United States, 10% of patients (3 million) hospitalized for more than two weeks become infected with C. difficile. Exposure to antibioitcs is a risk factor for developing CDI. WWW.ORTODAY.COM

DEADLINE Courses must be completed by 12/31/2017. 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.

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January/February 2017 | OR TODAY

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IN THE OR MARKET ANALYSIS

STAFF REPORT

HEATH CARE PPE SEGMENT PART OF LARGER MARKET

recently unveiled report on the global personal protective equipment market includes various segments of the market, including health care. The overall PPE market is projected to reach $52.4 billion by 2020, with a compound annual growth rate (CAGR) of 6.8 percent between 2015 and 2020, according to MarketsandMarkets. “North America dominated the PPE market in 2014. The U.S. is the key market for PPE in the region. The growing demand for PPE in construction and manufacturing and oil and gas segments is driving the market for PPE in the region,” according to MarketsandMarkets. However, the health care sector is a strong part of the global PPE market. “Asia-Pacific is the fastest-growing market for PPE during the projected period. The ensuing increase in investments and rise in the number of new manufacturing establishments is anticipated to witness Asia-Pacific emerge into a prime driver of growth for the PPE market. Furthermore, the health care segment is expected to witness decent growth during the forecast period,” MarketsandMarkets reports. “This is due to the rising concern for safety from body fluid contamination and chemicals in the region.” Grand View Research also predicts market growth. “The global personal protective equipment demand was valued at $38.38 billion in 2015 and is expected to reach $68.69 billion by 2024, growing at a CAGR of 6.7 percent from 2016 to 2024,” according to Grand View Research. The medical textiles market, which

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includes products and materials for PPE, is also forecast to see growth. “The global medical textiles market is expected to reach $20.23 billion by 2022,” according to a report by Grand View Research Inc. “The rise in the number of elderly population, ongoing technological advancements and increase in health consciousness are fueling the growth of global medical textiles market.”

The overall PPE

market is projected to reach $52.4 billion by 2020, with a compound annual growth rate (CAGR) of 6.8 percent between 2015 and 2020. “Burgeoning health concerns necessitating the criticality of awareness for better health care practices coupled with rising disposable income are expected to augment the demand for medical textiles. Growing medical and hygiene sectors and health conscious population of the

developing economies are projected to drive the demand for medical textiles market over the forecast period,” the report states. “The non-woven segment is expected to grow at a CAGR of over 5 percent from 2015 to 2022. Nonwoven fabrics are used in the myriad of applications extending from wound dressings, adhesive tapes, cotton pads, disposable surgical clothing, bandages,” according to a report by Grand View Research Inc. “Rising application of these products in the health care sector is expected to drive market growth.” Another market also impacts the overall health care segment of the global PPE market. According to analyses from Life Science Intelligence, the U.S., European, Asia-Pacific and rest-of-world (ROW) markets for surgical drapes, gowns, gloves, masks and fluid management products are forecasted to reach $11.3 billion in sales in 2020. “These markets are being fueled by global trends in surgical procedure volumes, aggressive strategies by product suppliers to improve safety and limit the risk of infection, and ongoing efforts to reduce health care costs,” according to Life Science Intelligence. “Market headwinds include continued financial constraints on health care systems, and downward pricing pressures. The U.S. represents the largest market for these products, although countries in the Asia-Pacific and ROW regions are expected to generate the fastest growth rates through 2020, due to their large potential and presence of local manufacturers offering low-cost product lines.” January/February 2017 | OR TODAY

IN THE OR PRODUCT SHOWROOM

SAFECARE THREE-ARMHOLE ISOLATION GOWNS ENCOMPASS GROUP New SafeCare Three-Arm-Hole Isolation Gowns feature a wrap-around design which does away with the need for ties and provides a generous, comfortable fit. The front, arms, and back are all made of a yellow, 99% polyester/1% carbon fabric to provide protection all around. Wearers can put the gown on and take it off without having to deal with ties. White stockinette cuffs are lint-free. These new SafeCare gowns are quick drying, highly functional, and easy to don and doff. For more information, contact Encompass at info@encompassgroup.net.

OR TODAY | January/February 2017

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PRODUCT SHOWROOM

SAF-T HEALTHCARE APPAREL PRIME MEDICAL Keep the color. Kill the germs! SAF-T is the only line of healthcare apparel designed to be washed in chlorine bleach without any fading… but that’s not all. SAF-T is made with BioSmart, a patented fabric technology that binds chlorine. With each wash in EPA-registered bleach, the fabric is shielded with chlorine molecules which will kill 99.9% of pathogens while the garments are in use. Made in the USA, SAF-T delivers powerful protection. For more information, visit SAF-T-Scrubs.com.

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January/February 2017 | OR TODAY

IN THE OR PRODUCT SHOWROOM

GOWN WITH THUMB LOOP HEALTHMARK INDUSTRIES 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 we’ve 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.

OR TODAY | January/February 2017

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PRODUCT SHOWROOM

PREMIUM COMFORT SURGICAL CAP MEDLINE Medlineâ&#x20AC;&#x2122;s new Premium Comfort Surgical Cap provides health care workers with more confidence in the care they deliver. The latest design delivers full coverage, from the back of the neck to sideburn area, is one size fits most to provide all-day breathable comfort and a secure fit, and offers a quality, longer-lasting design that creates less waste than bouffant caps. With no elastic band in front, the cap wonâ&#x20AC;&#x2122;t leave a mark. Medline has partnered with perioperative leaders in the field to ensure the cap is compliant with hospital protocols for infection prevention.

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January/February 2017 | OR TODAY

THE REAL RISKS :

BY DON SADLER Would you be surprised if someone told you that being in an operating room for a full day could expose you to the same amount of smoke plume as smoking more than a pack of cigarettes? Itâ&#x20AC;&#x2122;s true. An estimated 500,000 health care workers are exposed to potentially dangerous surgical smoke each year. Unfortunately, many OR nurses are unaware of the harm that inhaling surgical smoke could be causing to their health.

T H E R EAL RISKS: SUR G ICAL S MO KE

WHAT CAUSES SURGICAL SMOKE? Any procedure that uses an energy-generating device will produce some amount of surgical smoke. These devices include electrosurgical units (ESU), lasers, electrocautery and ultrasonic devices, and powered instruments such as bone saws and drills. “Surgical smoke is the by-product of using these energy-generating devices that raise intracellular temperatures to 100 degrees Celsius (212 degrees Fahrenheit) or higher,” says Mary J. Ogg, MSN, RN, CNOR, Senior Perioperative Practice Specialist with the Association of periOperative Registered Nurses (AORN). “When the tissue vaporizes, this produces surgical smoke,” says Ogg. “Surgical smoke contains toxic gases and biological/viral products from tissue destruction,” says Beth S. Slater, RN, MEd, CNOR, IS Specialist/Educator, Surgical Services with UPMC Horizon in Greenville, Pennsylvania. “All OR team members and patients are exposed to the respiratory intake of this potentially harmful smoke.” Ogg lists a number of hazards that surgical smoke poses to patients. These include a lack of visibility during laparoscopic procedures, delays during the procedure to clear the smoke, increased levels of carbon monoxide, and port-site metastasis. According to G Thomas Ruiz, M.D., an OB-GYN in Orange County, California, an estimated 85 percent of the 24 million procedures performed annually in the U.S. use electrocautery. “Perioperative nurses have twice the incidence of many respiratory problems as the general public, and few doubt there’s a connection between this and

40 OR TODAY | January/February 2017

Mary J. Ogg MSN, RN, CNOR, Senior Perioperative Practice Specialist with the Association of periOperative Registered Nurses

their long-term exposure to surgical smoke,” says Ruiz. “The problems encountered with surgical smoke aren’t always readily apparent,” says Slater. “But who’s to say that respiratory illnesses or irritation suffered by OR personnel haven’t been precipitated by exposure to surgical smoke?” PRIORITY POLLUTANTS Even though surgical smoke is mostly water vapor, Ruiz says it contains more than 150 chemicals, including 16 that are listed as “priority pollutants” by the EPA. “When you’re vaporizing tissue, you can also vaporize and transmit viruses and disease, including cancer,” says Ruiz. “There have been reported cases of surgeons contracting the viruses of their patients during surgery.” In discussing the dangers of surgical plume, most people talk about biological contaminants like infectious bacteria and viruses,

says Ren Scott-Feagle, MSN/ Ed, BSHS/M, RN, CNOR, Clinical Educator for Surgical Services in the Clinical Education Department at the University Medical Center of Southern Nevada in Las Vegas. “However, many staff fail to also recognize the dangers of chemical and micro-particle residue,” she says. Scott-Feagle says she has participated in procedures that resulted in an excessive amount of surgical plume that not only intermittently obstructed the surgical field, “but also caused some staff to cough and even complain of nausea post-operatively,” she says. PROMOTING A SAFE AND HEALTHY WORKPLACE There are currently no specific OSHA standards for laser/electrosurgery plume hazards, according to Scott-Feagle. “However, health care organizations have a responsibility to promote a safe and healthy workplace,” she says. Eliminating the dangers of surgical smoke in the OR require both changes in OR practices and the use of technology, says Ogg. “On the equipment side are smoke evacuators, disposable tubings, filters, ESU pencils with tubing and in-line filters,” she says. “The best way to remove smoke plume from the OR is to use some kind of smoke evacuation device,” adds Ruiz. “There are several different approaches, but the most effective are those that remove smoke as close to the source as possible, like electrocautery devices with suction at the tip.” “Certainly, changing to a smoke evacuation system that includes a filtration system is the easiest and most cost-efficient way to remove smoke from the OR,” Slater says.

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“ The biggest obstacle to eliminating surgical smoke isn’t access to technology solutions – it’s changing the status quo.” G Thomas Ruiz, M.D. According to Robert Scroggins, BSN, RN, CMLSO, Clinical Programs Manager with Buffalo Filter, which designs and manufactures surgical smoke evacuation systems, hospitals and staff are looking for cost-effective solutions to evacuate surgical smoke from the operating room in an effort to keep patients and staff safe. “For example, new designs in surgical smoke evacuation pencils offer surgeons electro-cautery with smoke evacuation that feature compact, slim ergonomic designs,” he says. “There are also a myriad of smoke evacuator choices – from freestanding devices to those integrated into booms.” And for laparoscopic surgery, there are solutions that easily attach to standard trocars and utilize readily available suction systems providing noiseless operation, he adds. “With all these technology options, there is no reason that surgical smoke should not be filtered and evacuated from the operating room,” says Scroggins. CHANGING OR PRACTICES As for changes in OR practices, Ogg stresses that smoke evacuation must be used for every procedure that generates smoke, regardless of how

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much smoke is generated. “The effects of smoke inhalation are cumulative, so no matter the amount, it is imperative to evacuate the smoke,” she says. Ogg recognizes that with any change to OR practices there are barriers to adoption. “Identifying the barriers to surgical smoke evacuation allows the health care organization to develop relevant strategies and interventions to improve evacuation,” she says. Ruiz has seen these barriers to adoption of smoke evacuation devices first-hand. “The biggest obstacle to eliminating surgical smoke isn’t access to technology solutions – it’s changing the status quo,” he says.

Robert Scroggins BSN, RN, CMLSO, Clinical Programs Manager with Buffalo Filter

“Many surgeons don’t like change, especially when it involves how we perform a procedure,” Ruiz adds. “But we as surgeons should be the ones driving this change. If we display leadership, this will provide health care organization with the motivation to adopt these devices.”

THE AORN GO CLEAR AWARD Ogg says that AORN has partnered with Medtronic through the AORN Foundation to create the AORN Go Clear Award. “This program is a comprehensive approach to protecting patient and worker safety by promoting a smokefree environment wherever surgical smoke is generated,” says Ogg. For facilities that have not implemented smoke evacuation or that only evacuate smoke occasionally, the AORN GO Clear program includes all the tools and protocols needed to start or enhance smoke evacuation practices. It breaks smoke evacuation down into a 10-step process. “The program includes an implementation manual explaining in detail how to accomplish each step, as well as supplemental resources such as templates for competencies, policies and procedures, and a product evaluation,” says Ogg. “In designing the program, AORN has developed all types of resources for successful adoption and implementation of smoke evacuation processes.” Ogg lists a number of benefits facilities may realize by participating in the AORN GO Clear program, including the following: • Attract and retain the best clinicians due to a healthier, smoke-free environment. • Ensure the safety of all surgical patients by protecting them from the hazards of surgical smoke. • Provide education for perioperative team members on the risks of surgical smoke and teach implementation methods for smoke evacuation. • Increase smoke evacuation compliance on all surgical smoke generating procedures. To learn more about the AORN GO Clear program, visit aorn.org/GoClear.

January/February 2017 | OR TODAY

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Surgical smoke is only part of the story Unmask the truths Standard surgical masks are limited in their abilities to ﬁlter out surgical smoke particles which could contain harmful bacteria, viruses and pollutants.1

Neptune E-SEP Smoke Evacuation Pencil Like you, we’re in the business of protecting people – more speciﬁcally you and your patients. The Neptune E-SEP Pencil gets in between you and smoke plume by removing it directly at the source2 providing the performance and protection that’s comfortable for everyone. • Helps fulﬁll clinical guidelines surrounding surgical smoke hazards2-6 • Natural grip and feel; slim and lightweight at only 14 grams/.5 oz • 2-in-one monopolar solution Download our whitepaper at neptunewastemanagement.com/esep, or contact your Surgical sales representative to learn more.

SPOTLIGHT IN THE OR BONNIE CONKLIN SULLIVAN

From Lacrosse

to Labor and Delivery

Spotlight On: Bonnie Conklin Sullivan By Matt Skoufalos

orn and raised in Suffern, New York, Bonnie Conklin Sullivan grew up the daughter of a nurse and granddaughter of a medical receptionist. A gifted lacrosse player, she captained her team at George Mason University as a defender-midfielder while earning her bachelor’s degree in kinesiology and exercise science. Conklin Sullivan went on to coach NCAA-Division I lacrosse at James Madison University, but as much as she loved the game, she worried that she wouldn’t be able to raise a family while coaching. “Back then there weren’t many female coaches getting married and having children,” she said. “I looked for the next best thing: coming from a nursing family, I thought, ‘I’m going to coach women to have babies.’ ” Conklin Sullivan decided to move home and pursue a nursing degree from Rockland Community College; upon graduating in 2003, she was soon picked up by NewYork-Presbyterian Hospital, and has worked in labor and delivery ever since. She’s since moved back to Suffern to work at Good Samaritan Hospital, a move that Conklin Sullivan said illustrated the distinctions between working at a high-volume teaching hospital and at a smaller, community hospital. Although “both are great environ-

44 OR TODAY | January/February 2017

ments,” nurses in community hospitals must be versatile and self-sufficient, she said. “We don’t have in-house obstetrical doctors,” Conklin Sullivan said. “Patient care is more critical. You’re required to put your thinking cap on and be on top of your nursing skills, soup to nuts, all the time.” The intensity level can be different, too, she said. The Weill Cornell Medical Center’s Level I NICU receives high-risk pregnancy cases, whereas Good Samaritan often transports such women and their babies to a center like Cornell. In labor and delivery, some patients will seek a boutique standard of care, and because so much of patient feedback affects their rating, hospitals cultivate

patient experience, which happens at the bedside. “It’s much more of a priority to make sure patients understand what’s going on, that they’re satisfied with their care, and that their questions are being answered,” Conklin Sullivan said. “Patient education is more detailed, patient responses, and how much they want to learn, has really come a long way.” As a result, she said, demands placed on nurses increase consistently, sometimes not in a way that’s commensurate with their compensation or opportunity to earn more: even with overtime, nurses who want to stay in patient care won’t achieve the wage scale of those who earn advanced degrees and seek leadership roles. But for Conklin Sullivan, the job is all about working with patients, and a higher-level assignment could take that away from her. “The only way you can make more money is going back to school and being a manager or a nursing supervisor,” she said. “They don’t have patient care, and I love that contact with patients and that interaction.” Interaction is a big part of what WWW.ORTODAY.COM

SPOTLIGHT ON: BONNIE CONKLIN SULLIVAN

“ Being in sports and always being a part of a team has helped me, and that’s helped me in my nursing field. I love helping other nurses and I love when other nurses help me.” Conklin Sullivan loves about her occupation. As a former college lacrosse player and coach, the concept of teamwork and group effort resonates deeply with her. She fondly recalls “huddles” with the staff at NewYork-Presbyterian as helping keep members of the unit on the same page before and after surgical interventions, emergency cases, and other interactions. The cohesion such an approach instills within members of the staff lasts long after their patients are disWWW.ORTODAY.COM

charged, she said. “They made sure everybody on the unit was aware of what’s going on,” Conklin Sullivan said. “Everybody on the floor knew what was going on in every room. It was such a team concept, and I loved it. That’s vital to patient care.” “Being in sports and always being a part of a team has helped me, and that’s helped me in my nursing field,” she said. “I love helping other nurses and I love when other nurses help me.” Conklin Sullivan feels a shared value of teamwork among her colleagues at Good Samaritan as well. Whether it’s five minutes before her shift change and a delivery case is admitted, or she’s headed out the door and a colleague suddenly faces an emergent need, they all support one another. “I’ll never see another nurse admit a patient alone,” she said. “You want someone to help you when you’re struggling; you’ve got to help others as well. The night shift at Good Sam, that’s what we pride ourselves on. I’ve never been alone. Someone peeks their head in

and says, ‘I’m here for you.’ ” “Those words go so far for me because I feel like I have help outside the door,” Conklin Sullivan said, “and that makes me give better patient care. I’m not stressed. I’m not nervous. And, I’m a competitive person. I want the best delivery, the safest delivery, the best care, and I want that patient to feel like they got the best. It’s the same concept.” Just as strong as her competitive spirit are Conklin Sullivan’s instincts as a coach and her training in kinesiology. Knowledge of body mechanics and the psychology of high-stress situations come in handy when she’s coaching birthing techniques or working as a lactation consultant. In both circumstances, she provides personal care and shares moments of intensity – and Conklin Sullivan doesn’t think she’d ever pursue a role in leadership if it means she’d have to give that up. “This is the ultimate goal,” Conklin Sullivan said, “being in with a patient in labor who pushed to deliver her dream. It’s my dream. I don’t want any more.” January/February 2017 | OR TODAY

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OUT OF THE OR HEALTH

BY PREMIUM HEALTH NEWS SERVICE

WALKING MEETINGS

COULD GIVE WORKERS LONGER, HEALTHIER LIVES

hanging just one seated meeting per week at work into a walking meeting increased the work-related physical activity levels of white-collar workers by 10 minutes, according to a new study published by public health researchers at the University of Miami Miller School of Medicine.s.

The study suggests a possible new health promotion approach to improving the health of millions of white-collar workers who spend most of their workdays sitting in chairs. "The Walking Meeting" the study also supports the American Health Association's physical activity recommendations of 150 minutes per week of moderateintensity physical activity for adults, or about 30 minutes each weekday. "There are limited opportunities for physical activity at work. This "walking meeting" pilot study provides early evidence that white-collar workers find it feasible and acceptable to convert 48

OR TODAY | January/February 2017

a traditional seated meeting into a walking meeting," said the study's principal investigator Alberto J. Caban-Martinez, D.O., Ph.D., M.P.H., assistant professor of public health sciences. "Physical activity interventions such as the walking meeting protocol that encourage walking and raise levels of physical activity in the workplace are needed to counter the negative health effects of sedentary behavior." For part of the study, participants, who were white-collar workers recruited from the University of Miami, wore accelerometers to measure physical activity levels during the workday over a three-week period. They

also followed a "walking meeting protocol" that included guidance for leading meetings and taking notes while walking. The average combined moderate/vigorous physical activity reported by participants increased from 107 minutes in the first week to 114 minutes in the second week and to 117 minutes in week three of the study. "Walking is known to have tremendous health benefits," said the study's lead author and project director, Hannah Kling, M.P.H., a graduate of UM's Department of Public Health Sciences. "Having sedentary, white-collar workers consider walking meetings feasible suggests that this intervention has the potential to positively influence the health of many individuals." Previous studies have proven that engaging in moderate exercise, which includes brisk walking for as little as 15 minutes per day, can add up to three years of life expectancy. WWW.ORTODAY.COM

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January/February 2017 | OR TODAY

OUT OF THE OR FITNESS

BY MARILYNN PRESTON

BEST LESSON OF THE LAST 40 YEARS? YOU ARE RESPONSIBLE FOR...

began in my previous column what I plan to finish now: a look back over 40 years of writing this syndicated column and advising about what it means to live a healthy, happy, vibrant life, free of stress, strong and lean, conscious and carefree, joyful every moment, no fried foods, ever. Forget that, dear readers. It’s an impossible goal that sets you up for failure. Nobody gets through life without upsets and setbacks. Even the good life is predictably unpredictable, and so are some of the developments I’ve seen over the last 40 years. Here are a couple of the best, followed by three I wish would vacate the building tomorrow: HOLISTIC MEDICINE HAS TAKEN HOLD

I mentioned this unstoppable force for positive change previously, and I hope to mention it about a million more times before I retire to the forest. The mind-body connection is mainstream now, and millions of consumers of U.S. health care are waking up to what an overmedicated and undernourished country we have become. We Americans still have an expensive and mediocre health care system compared with other developed 50 OR TODAY | January/February 2017

countries, but I’ve seen notable progress. We the people, in order to form a more perfect union between our physical fitness and our mental fitness, are seeking out proven practices of the East in record numbers, spending time with yoga masters, body workers, qi gong practitioners, acupuncturists and others who help us activate our inner healer. Many of the practices make us healthier, and some don’t, just like Western medicine, where 97 percent of funding in the U.S. goes to pay for medical services and almost nothing

– three cents of every U.S. health care dollar – is spent on patient education and prevention. It’s shameful. No one dies from an overdose of ginger tea, whereas improper treatment by doctors and hospitals is the third-leading cause of death in America. Third! Rhymes with absurd. Prescription drugs are also killing Americans in record numbers, and the billions of dollars spent treating the side effects of these drugs is outrageous. The moral of this developing story? Be vigilant. Be informed. And even more important – in fact, most WWW.ORTODAY.COM

FITNESS

important – be responsible for your own health and wellness. Others in the healing professions can and will help and guide, but you’re in charge. You will live longer and better if you set your own health goals and back them up with self-discovery, self-monitoring and accountability. OUR BRAINS KEEP LEARNING

it’s past time to end those persuasive and dangerous ads on TV, in newspapers and magazines, on the radio and Internet. Even the American Medical Association has argued for a ban, but the ads continue, and the results are sickening, as people insist on taking drugs they don’t need, that they misuse, that kill them. It shouldn’t take 40 years to get Congress to act. How about 40 days?

Thank God for neuroscience. Over the last 40 years, researchers have used hard science and brain imagery to confirm something we didn’t know – Marilynn Preston is the creator before: our brains are neuro-plastic of Energy Express, the longestgeniuses and never stop growing. running syndicated fitness column APPROVED NEEDED Neurons do die, butPROOF others come to life, inCHANGES the country. She has a website, and you can make sparks fly and new marilynnpreston.com, and CLIENT SIGN–OFF: neural connections right up to the end. welcomes reader questions, which PLEASE CONFIRM THEsent FOLLOWING ARE CORRECT At which point the battery dies and we THAT can be to MyEnergyExpress@ LOGO PHONE NUMBER WEBSITE ADDRESS flatline into the mystery. aol.com. Meanwhile, here are three trends of the last 40 years that it’s time to kill off:

PRESCRIPTION DRUGS ARE ALSO KILLING AMERICANS IN RECORD NUMBERS, AND THE BILLIONS OF DOLLARS SPENT

PROOF S

TREATING THE SIDE EFFECTS OF THESE DRUGS IS OUTRAGEOUS. SPELLING GRAMMAR

TRIM 4.5”

REST IS A SIGN OF WEAKNESS

It’s time to stop mocking people for getting the rest they need for their bodies and minds to recover from the stresses of the day. People who go around bragging that they get by on four hours of rest a night are sleepdeprived. SUGAR IS BENIGN

TRIM 4.5”

Sugar is toxic at 22 teaspoons a day, which is the amount the average American consumes. Yikes! It is a leading cause of obesity, heart disease, diabetes and – this just in – Alzheimer’s. We recently discovered that Big Sugar paid off Harvard doctors to minimize the dangers of sugar and to instead lead Americans to believe that saturated fat is the enemy. It’s not. Processed food is. Oops. ASK YOUR DOCTOR IF YOU NEED THIS DRUG

Only America and New Zealand allow drug companies to advertise directly to consumers. It’s not such a problem in a country where sheep (who rarely watch TV) outnumber people 22 to 1. But here WWW.ORTODAY.COM

January/February 2017 | OR TODAY

OUT OF THE OR NUTRITION

BY KALEY TODD, M.S., R.D.N.

TRY NUTS FOR A HEALTHY WEIGHT

or years, nuts – dense in calories and fat – were considered off limits for people looking to shed a few pounds. However, in the last two decades research has uncovered numerous health benefits of tree nuts, including almonds, walnuts, pistachios, pecans, hazelnuts, and cashews, for heart health and brain protection. Now those benefits even extend to achieving a healthy weight, as research shows that consuming nuts can actually help people lose pounds and keep them off. NUTS FOR A HEALTHY WEIGHT Results from research suggest that adults who consume nuts regularly may have a lower body weight compared to those who don’t regularly eat nuts. A 2014 Loma Linda University study found that high consumers of tree nuts had the lowest prevalence of obesity compared to those with low nut consumption. And another study published in the American Journal of Clinical Nutrition compared the body weight of nut-enriched diets to similar control diets without

OR TODAY | January/February 2017

STUDIES ALSO HAVE SUGGESTED THAT NUTS CAN BOOST METABOLISM. nuts, and found that intake of nuts did not increase body weight, waist circumference or body mass index. Other research links nut consumption with less weight gain over long periods of time.

WHY DO NUTS HELP? Nuts are calorie-dense but are comprised of nutrient-rich components, including good fats, vitamins, minerals, protein and fiber, which makes them high in satiety value, resulting in reduced overall calorie consumption. Studies also have suggested that nuts can boost metabolism. In addition, nuts have fewer calories than previously thought. Research on pistachios and almonds shows that the calories absorbed by the body are lower than once thought, because the complex matrix of whole nuts makes their fat content resistant to absorption. This means you are not taking in the full amount of calories found in nuts. Keep in mind that overindulging in nuts can still cause you to pack on pounds. So, practice portion control by keeping consumption to approximately a handful or an ounce (160 to 180 calories) daily. WWW.ORTODAY.COM

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January/February 2017 | OR TODAY

OUT OF THE OR RECIPE

OR TODAY | January/February 2017

BY LIA HUBER EATINGWELL

WWW.ORTODAY.COM

RECIPE

OATS ARE NOT JUST FOR BREAKFAST!

n this play on shrimp and grits, we simmered oats with scallions and cheese for a savory, creamy dish reminiscent of risotto. Youâ&#x20AC;&#x2122;ll even get your veggies with the sauteed baby spinach on the side. Serve with hot sauce and a glass of unoaked chardonnay, we simmered oats with scallions and cheese for a savory, creamy dish reminiscent of risotto. Youâ&#x20AC;&#x2122;ll even get your veggies with the sauteed baby spinach on the side. Serve with hot sauce and a glass of unoaked chardonnay.

Two-Pepper Shrimp with Creamy Pecorino Oats Serves 8 Serving Size: 4-5 shrimp, 1/2 cup oats, and 1/2 cup spinach Active Time: 30 minutes Total Time: 30 minutes

DIRECTIONS:

1. H eat 2 teaspoons oil and 1 teaspoon butter in a medium saucepan over medium heat until the butter is melted. Add scallion whites and cook, stirring occasionally, until softened, 2 to 3 minutes. 2. A dd oats and stir for 1 minute, then add water and 1/4 teaspoon each salt and pepper. Bring to a boil, then reduce heat to a simmer; cook, stirring often, until creamy, 8 to 10 minutes. 3. Meanwhile, sprinkle shrimp with cayenne and the remaining 1/4 teaspoon pepper. Heat 1 tablespoon oil in a large skillet over medium-high heat. Add the shrimp and cook until just

opaque, 2 to 4 minutes per side. Transfer to a clean bowl; cover to keep warm. 4. A dd the remaining 1 teaspoon oil and 1 teaspoon butter to the skillet. Add half the spinach; cook, stirring, until slightly wilted, about 1 minute. Add the remaining spinach and cook, stirring, until wilted, 2 to 3 minutes more. Add hot sauce and the remaining 1/4 teaspoon salt. 5. S tir cheese and the remaining 1 teaspoon butter into the oats. 6. Serve the oats with the spinach and shrimp. Sprinkle with the scallion greens.

Ingredients: 1 pound dried cannellini beans 6 teaspoons extra-virgin olive oil, divided 3 teaspoons butter, divided 6 scallions, white and light green parts sliced, divided 1 cup old-fashioned rolled oats 2 cups water 1/2 teaspoon salt, divided 1/2 teaspoon ground pepper, divided 1 pound raw shrimp (16 to 20 count), peeled and deveined 1/8 teaspoon cayenne pepper, or to taste 1 pound baby spinach 1/4 teaspoon hot sauce, or to taste 1/2 cup grated Pecorino or Parmesan cheese

RECIPE NUTRITION:

Per serving: 342 calories; 15g fat (5g sat, 7g mono); 199mg cholesterol; 20g carbohydrate; 0 g added sugars; 2g total sugars; 34g protein; 5g fiber; 678mg sodium; 1014mg potassium. WWW.ORTODAY.COM

EatingWell is a magazine and website devoted to healthy eating as a way of life. Online at www.eatingwell.com. January/February 2017 | OR TODAY

OUT OF THE OR PINBOARD

PINBOARD

The News and Photos That Caught Our Eye This Month

OR TODAY

CONTESTS • JAN/FEB • Email us a photo of yourself or a colleague reading a copy of OR Today magazine to be entered to win a $50 Subway gift card! Snap a photo with your phone and email it to Editor@MDPublishing.com to enter. It’s that easy! Good luck!

BOOK UNVEILS TOP PRIORITIES NURSES MUST KNOW To have a voice in their profession, nurses must first know the most relevant discussion topics. In their new book, “The Power of Ten, 2nd Edition: A Conversational Approach to Tackling the Top Ten Priorities in Nursing,” OnCourse Learning’s Jennifer Mensik, PhD, MBA, RN, NEA-BC, FAAN, and national nurse leader Susan B. Hassmiller, PhD, RN, FAAN, provide a road map for those conversations to begin. “Our hope is that everyone reads this book and takes one action item from it that they feel passionate about and helps to make that change occur,” said Mensik, the executive director for nursing, medicine and pharmacy education

OR TODAY | January/February 2017

Susan B. Hassmiller

{ Jennifer Mensik

programs for OnCourse Learning. “We believe that this will be very influential in advancing our profession.” The authors surveyed more than 50 national and international nurse leaders on the issues most impacting the nursing profession. From that feedback, they presented the top 10 issues through essays, quotes, action items, discussion points and data. The book was published by the Honor Society of Nursing, Sigma Theta Tau International, and is available for purchase online. The authors will donate royalties from the book equally to American Red Cross nursing programs and the American Nurses Foundation.

Win Lunch! THE WINNER GETS A $50 SUBWAY GIFT CARD

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ARE YOU IN THE KNOW?

GOPURE WATER PURIFICATION POD PROVIDES WATER ON-THE-GO Bloc Enterprises LLC has launched the PuriBloc GoPure pod – the first portable and continuous water enhancement device featuring PuriBloc water quality improvement technology. Convenient, reusable, and designed for dropping in any water bottle or small water container, the GoPure pod introduces a revolutionary and natural water purification process that constantly cleans and enhances potable tap water for nurses and busy professionals. FOR MORE INFORMATION, visit www.blocenterprises.com

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PINBOARD

OR TODAY NOVEMBER

CONTEST ENTRIES

Cindy Mask, CST, FAST, AA, BAAS Program Director, Surgical Technology

“ I read OR Today magazine to stay up-to-date with the new equipment, technology, and processes that may be available. I also read it to see how other facilities are Lavonia W functioning alker, RN, BSN, CNOR, Sur gical Serv so that I can ices compare it with my facility and take back anything that may help my fellow colleagues and staff members. I LOVE OR Today magazine!” - L avonia Walker, RN, BSN, CNOR, Surgical Services - ODS Head Nurse, General/ Plastics/Neuro/Dermatology, University of Arkansas for Medical Sciences

• PAST WINNER • “ Thank you so much for the $50 Subway gift card I won. I took a picture of my coworkers and I enjoying our 6-foot subs in celebration. This is the ambulatory surgery unit at the Hospital of Central Connecticut in New Britain, CT.” Dianna Taraskewich, BSN, RN, CNOR

Mark Wujek, CBET, at Women & Children’s Hospital of Buffalo, Kaleida Health System, was a hit at the Reverse Halloween Parade. Biomed was at the “tail end” of the parade. – Mark Wujek, CBET Women & Children’s Hospital of Buffalo Kaleida Health System

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January/February 2017 | OR TODAY

INDEX ALPHABETICAL AAAHC………………………………………………………… 18 ASCA…………………………………………………………… 48 AIV Inc.………………………………………………………… 53 AORN Works………………………………………………… 5 Arthroplastics, Inc.……………………………………… 23 Belimed Inc.………………………………………………… 49 Calzuro.com……………………………………………… IBC C Change Surgical………………………………………… 9 Checklist Boards Corp.……………………………… 53 Cincinnati Sub-Zero, Inc.…………………………… 42

Cygnus Medical…………………………………………… 15 Dabir Surfaces…………………………………………… 49 D.A. Surgical…………………………………………………… 4 Encompass Group……………………………………… 55 GelPro…………………………………………………………… 49 Healthmark Industries……………………………… 32 Innovative Medical Products, Inc.…………… BC Jet Medical Electronics……………………………… 51 Kaap Surgical Insturments……………………………21 MD Technologies………………………………………… 19

Medi-Kid Co.……………………………………………………21 Pacific Medical LLC……………………………………… 6 Palermo Health Care………………………………… 18 Paragon Service………………………………………… 47 Ruhof Corporation………………………………………2-3 Stryker…………………………………………………………… 43 TBJ, Inc.………………………………………………………… 10 Tru-D.…………………………………………………………… 46

GENERAL AIV Inc.………………………………………………………… 53 Checklist Boards Corp.……………………………… 53 GelPro…………………………………………………………… 49

Innovative Medical Products, Inc…………… BC

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

RADIOLOGY Checklist Boards Corp.……………………………… 53

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

REPAIR SERVICES Cygnus Medical…………………………………………… 15 Pacific Medical LLC……………………………………… 6

INDEX CATEGORICAL ACCREDITATION AAAHC………………………………………………………… 18 ANESTHESIA Checklist Boards Corp.……………………………… 53 Paragon Service………………………………………… 47 APPAREL Healthmark Industries……………………………… 32 ASSOCIATIONS AAAHC………………………………………………………… 18 AORN Works………………………………………………… 5 ASCA…………………………………………………………… 48 BEDS Innovative Medical Products, Inc…………… BC CARDIOLOGY C Change Surgical………………………………………… 9 CARTS/CABINETS Cincinnati Sub-Zero, Inc.…………………………… 42 Cygnus Medical…………………………………………… 15 TBJ, Inc.………………………………………………………… 10

INFECTION CONTROL/PREVENTION Belimed Inc.………………………………………………… 49 Cygnus Medical…………………………………………… 15 Encompass Group……………………………………… 55 Palermo Health Care………………………………… 18 Ruhof Corporation………………………………………2-3 Tru-D.…………………………………………………………… 46 INSTRUMENT STORAGE/TRANSPORT Belimed Inc.………………………………………………… 49 Cygnus Medical…………………………………………… 15 KNEE SYSTEMS Innovative Medical Products, Inc…………… BC

PRESSURE ULCER MANAGEMENT Dabir Surfaces…………………………………………… 49

SAFETY GEAR Calzuro.com……………………………………………… IBC SHOULDER RECONSTRUCTION Innovative Medical Products, Inc…………… BC SIDE RAIL SOCKETS Innovative Medical Products, Inc…………… BC STERILIZATION Belimed Inc.………………………………………………… 49 Cygnus Medical…………………………………………… 15

CLEANING SUPPLIES Ruhof Corporation………………………………………2-3

LASERS Checklist Boards Corp.……………………………… 53

CLAMPS Innovative Medical Products, Inc…………… BC

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

SURGICAL Checklist Boards Corp.……………………………… 53 Cygnus Medical…………………………………………… 15 Kaap Surgical Insturments……………………………21 MD Technologies………………………………………… 19 Ruhof Corporation………………………………………2-3

DISINFECTANTS Cygnus Medical…………………………………………… 15 Palermo Health Care………………………………… 18

MONITORS Jet Medical Electronics……………………………… 51

SUPPORTS Innovative Medical Products, Inc…………… BC

OR TABLES/ ACCESSORIES D.A. Surgical…………………………………………………… 4 Innovative Medical Products, Inc…………… BC

TELEMETRY USOC Medical……………………………………………… 41

DISPOSABLES Kaap Surgical Insturments……………………………21 Pacific Medical LLC……………………………………… 6 ENDOSCOPY Cygnus Medical…………………………………………… 15 Kaap Surgical Insturments……………………………21 MD Technologies………………………………………… 19 Ruhof Corporation………………………………………2-3 FALL PREVENTION Arthroplastics, Inc.……………………………………… 23 Encompass Group……………………………………… 55 FOOTWEAR Calzuro.com……………………………………………… IBC GEL PADS GelPro…………………………………………………………… 49 Innovative Medical Products, Inc…………… BC

OR TODAY | January/February 2017

OTHER AIV Inc.………………………………………………………… 53 Arthroplastics, Inc.……………………………………… 23 Cygnus Medical…………………………………………… 15 Medi-Kid Co.……………………………………………………21 Tru-D.…………………………………………………………… 46 PATIENT MONITORING Pacific Medical LLC……………………………………… 6 PATIENT WARMING Encompass Group……………………………………… 55

TEMPERATURE MANAGEMENT Cincinnati Sub-Zero, Inc.…………………………… 42 Encompass Group……………………………………… 55 WARMERS Belimed Inc.………………………………………………… 49 Cincinnati Sub-Zero, Inc.…………………………… 42 WASTE MANAGEMENT Stryker…………………………………………………………… 43 TBJ, Inc.………………………………………………………… 10

POSITIONERS/IMMOBILIZERS Cygnus Medical…………………………………………… 15 D.A. Surgical…………………………………………………… 4 Medi-Kid Co.……………………………………………………21

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